Chapter XV: Book VI: Sect. I.—preface to the Surgical Part (1)

Having divided the treatise on the surgical matters into what relates to manual operations on the flesh, and the account of fractures and dislocations of bones, we shall begin with what relates to the flesh, observing there our accustomed brevity. Beginning therefore, again with the upper parts, we shall first give an account of the operations on the head, more particularly of the burning of the vertex.

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COMMENTARY. This book contains the most complete system of operative surgery which has come down to us from ancient times. We shall have occasion also to refer frequently to Celsus, who, in the last two books of his work, has treated of surgical operations with considerable accuracy. Our author appears to have been wholly unacquainted with him; but when did a Greek writer ever acknowledge himself under obligations to a Roman? Haly Abbas, in the 9th book of his ‘Practica,’ copies almost everything from Paulus. Albucasis gives more original matter on surgery than any other Arabian author, and yet, as will be seen from our commentary, he is indebted for whole chapters to Paulus. In the ‘Continens’ of Rhases, that precious repository of ancient opinions on medical subjects, if there be any surgical information not to be found in our author, it is mostly derived from Antyllus and Archigenes. As to the other authorities, although we will occasionally have to explain their opinions upon particular subjects, no one has treated of surgery in a systematical manner; for even Avicenna, who treats so fully of everything else connected with medicine, is defective in his account of surgical operations; and the descriptions which he does give of them are almost all borrowed from our author. The account of fractures and dislocations given by Hippocrates and his commentator Galen may be pronounced almost complete; but the information which they supply upon most other surgical subjects is scanty.

SECT. II.—ON BURNING OF THE HEAD FOR OPHTHALMIA, DYSPNŒA, AND ELEPHANTIASIS.

In ophthalmia, occasioned by a defluxion from above, and in dyspnœa, produced by a redundance of a recrementitious humour which is sent from the head down to the chest, and by lodging there proves injurious to the parts contained in it, they burn the middle of the head in this manner. Having first shaven the parts about the vertex, they apply cauteries shaped like olive-kernels and burn the skin down to the bone, scraping the bone after the falling off of the eschar. Some by burning even the bone itself make a small scale exfoliate from it, in order to allow the humours of the head to perspire and be evacuated the more readily; and for this purpose they keep the ulcer open for some time and then allow it to cicatrize. In treating elephantiasis some burn five eschars in the head, one anteriorly above the part called the bregma; another, below this, a little above the forehead, at the extremity of the hairs; another, at the part called the occiput; two others at the parts called the squamous plates, above the ears, one on the right side and another on the left; and thus, by the removal of several scales, they procure the evaporation and discharge of the collection of thick humours in the deep-seated parts of the head, and prevent the sight from being injured. They also apply another cautery on the spleen, in order to remedy the prime organ in the formation of the melancholic humour by the eschar formed in the skin.

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COMMENTARY. See Hippocrates (de Visu); Aretæus (de curat. Morb. Chron. i, 1); Celsus (iii, 23, and vi, 6); Cælius Aurelianus (Morb. Acut. i, i, and Morb. Chron. i, 4); Aëtius (vi, 50); Actuarius (Meth. Med. iii, 2); Rhases (Cont. xxvii, 1, 24); Albucasis (Chirurg. i); Mesue (de Ægr. Capitis); Avicenna (iii, 1); Haly Abbas (Pract. ix, 69); Avenzoar (I, 9, 17).

The use of the actual cautery in surgical practice is often alluded to by the classical authors. See a collection of these passages in Dr. Blomfield’s edition of the ‘Agamemnon’ of Æschylus (822.) Consult also Gataker’s ‘Marcus Antoninus’ (v. 193); and Boissonade’s ‘Anecdota Græca’ (vol. ii, p. 311.) A very elaborate and sensible account of the use of the cautery in the practice of surgery is given by Vegetius. (Malomed. i, 28.)

Hippocrates, or whoever was the author of the work referred to above, applied the cautery to the head very freely in diseases of the eyes and other complaints.

Aretæus directs us, in cases of cephalæa and epilepsy, to perforate the bone as far as the diploe, and afterwards to burn it until the dura mater is separated from the bone. He admits, however, that it is a harsh remedy.

Celsus directs us, as an ultimum remedium in epileptic cases, to form issues with a burning iron upon the occiput and at the juncture of the first vertebra with the head.

Aëtius speaks of burning the head in nearly the same terms as our author. He directs us to avoid the muscular parts. Actuarius does the same.

Cælius Aurelianus, however, disapproves of this practice in cases of cephalæa and epilepsy.

The Arabians were even more partial than the Greeks to burning the head in these and other complaints. See in particular Albucasis, whose description is very minute. In cases of cephalæa he recommends the cautery to be applied to the occiput, but cautions against touching the bone lest it produce violent pain. He directs us to be careful to avoid muscles, nerves, and arteries. Avicenna, Rhases, Mesue, and Haly Abbas recommend the operation, in the most unqualified terms, as a powerful remedy in the cases mentioned by our author. Avenzoar, however, condemns the unguarded application of the burning iron to the head.

Guido de Cauliaco recommends the cautery in cases of hydrocephalus (ii, 2, 10). Brunus also applied it for hydrocephalus, (ii, 17.) But see in particular Lanfrancus (III, iii, 18.)

Fabricius ab Aquapendente states that from the most ample experience he had ascertained the good effects of applying the cautery over the sutures of the skull in various complaints, especially asthma, consumption, and all cold defluxions from the head to the chest. He gives a full account of the operation. (Œuvres Chirurg. ii, 1.) But see De Haën. (Rat. Méd. t. iii, p. vi, c. 6.)

SECT. III.—ON HYDROCEPHALUS.

The hydrocephalic affection is so named from the peculiarity of the fluid, it being of a watery consistence. It occurs in infants, owing to their heads being improperly squeezed by midwives during parturition, or from some other obscure cause; or from the rupture of a vessel or vessels, and the extravasated blood being converted into an inert fluid; or from rarefaction, the matter exuding and lodging between the skin and the pericranium. For the fluid is formed either between the pericranium and the skin, or between the pericranium and the bone, or between the bone and the meninx. In those cases, therefore, in which the fluid is formed between the skin and the pericranium, there is a soft tumour, all of one colour, and without pain, accompanied with an elevated swelling, having only a thin substance intervening between it and the fingers, readily yielding and again resuming its form. When it is seated between the pericranium and the bone, all the other appearances are the same, but the swelling is harder, yields more slowly, seems to be felt through thicker substances, and is more painful. When the fluid is seated between the meninx and the bone, there will still be a swelling, but not of so yielding a nature, nor so easily felt, only it yields to the application of strong pressure; for the bones of infants, being recently formed, are of a more yielding nature; and this is more especially the case when, owing to enlargement of the sutures, the fluid escapes outwards. This is readily ascertained from the circumstance, that by pressure of the fluid it retreats to the deep-seated parts. In such cases the pain is greater, the whole head is distended, the forehead projects outwards, the eyes are fixed and shed tears frequently. In these cases we reprobate any surgical interference, although some remove a piece of the bone by trepanning, as will be described in the section on fractures of the bones of the head. But if the fluid be formed between the skin and the pericranium, and the swelling be small, we may make one transverse incision through the middle. But if the fluid is seated between the pericranium and the bone, and the tumour is large, we make two incisions intersecting one another in the middle; or if it is still larger we may make three imitating the form of the Greek letter Η. After the operation, having evacuated the fluid and applied suitable compresses, we bind it up, and soak it with wine and oil until the third day; after which, having loosed the bandages, we may cure it by the application of pledgets; or, if the bone is long of incarnating we may scrape it lightly.

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COMMENTARY. See Hippocrates (de Morbis, ii, 15); Celsus (iv, 2); Aëtius (vi, 1); Galeni (ut aiunt) Isagoge; Antyllus (apud Nicetam); Avicenna (iii, 1; iv, 2); Avenzoar (I, 9, 17); Albucasis (Chirurg. ii, 1); Haly Abbas (Pract. ix, 16); Rhases (Contin. xxvii; and ad Mansor. ii, 25.)

Hippocrates gives an interesting account of water in the brain, the symptoms of which, as described by him, are pain in the opening of the head and temples, rigor, fever, double vision, impatience of sounds, vomiting of phlegm, &c. He recommends emetics, caputpurgia, and afterwards purgatives. He also makes mention of hellebore and sternutatories, and even directs us to perforate the skull, or, in other words, to trephine it.

Celsus describes only the hydrocephalus externus. He recommends us to use stimulant applications to the head, such as sinapisms, and if this treatment does not succeed, he directs us to use the scalpel. The case, otherwise, is to be treated like dropsy, with sudorifics, exercise, friction, and diuretics.

Our author’s description is mostly abridged from Aëtius, who gives an extract from Leonidas. Even when the fluid is collected within the skull he directs us to let it out, provided it is in such quantity as to occasion a separation of the suture.

The account of the disease, given by Antyllus, in the Collection of Nicetas is nearly the same as our author’s. He speaks favorably of the operation only in cases in which the water is collected externally to the bone.

In the ‘Isagoge,’ generally ascribed to Galen, it is directed, when the water is collected below the skin on the pericranium, to evacuate it by making two or three straight incisions; and when immediately below the bone, to perforate it; but the case in which the fluid is seated between the membrane and the brain is pronounced to be utterly incurable.

Rhases borrows his account mostly from Antyllus and our author. Upon his own authority, however, he recommends bandages with compresses. He also approves of applying the actual cautery over the sutures. He further recommends friction and burning the temporal veins.

Avicenna borrows freely from Aëtius and our author, and supplies no new views of practice. When water is collected in the anterior ventricles of the brain, Avenzoar, although in general no advocate for the actual cautery, directs us to apply it over the sutures.

Albucasis says that he had only known hydrocephalus internus in infancy, and in every case it had proved fatal. However, he describes the operation of evacuating the collection in much the same terms as the Greeks. He warns the operator to avoid wounding an artery, lest the evacuation of blood should occasion immediate death. Alsaharavius mentions the frequent occurrence of the disease in sheep. Haly’s treatment is the same as our author’s.

The hydrocephalus externus is now scarcely mentioned, and the existence of such a case has been even questioned. Van Swieten allows the reality of it, but says that it is of rare occurrence. (Comment. 1217.) We are disposed to think that the cases described by our author must have been collections of lymph, or pus occasioned by external injuries forming between the integuments and the bone. Modern pathologists admit the reality of collections of serum and pus between the bone and the dura mater. We may further mention that the earlier modern authorities approve of the cautery in the present case. See Guido de Cauliaco (ii, 2, 10.)

The late Baron Larrey was a decided advocate for the application of moxa in this complaint. Henricus Regius directs us to evacuate the water slowly by making a small incision and introducing a silver canula. (Animad. Medic. 13.) Though recent experience does not give much encouragement to the operation, it sometimes happens that it is attended with success.

Fabricius gives the same account of these cases as the ancients. (Œuv. Chir. ii. 22.)

SECT. IV.—ON ARTERIOTOMY.

In chronic defluxions of the eyes, and in the affection of vertigo, we are in the practice of dividing the arteries behind the ears. Having, therefore, shaven the hind part of the head, and marked with the fingers the position of the artery, which is easily discovered by its pulsation, and then having marked out the line of an incision two fingers in length with black ink, we cut down to the bone. When this does not succeed we must measure a distance of three fingers’ breadth from the ears, and then operate by making a transverse division of the artery until blood flow _per saltum_, and the instrument strike the bone. After a moderate evacuation of blood, the pericranium is to be divided, lest it become inflamed from the distension; and having scraped the bone we apply a wedge-like tent of linen to the wounds, and accomplish the cure by pledgets. But if, after all, the bone remain bare, we must have recourse to scraping it in like manner.

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COMMENTARY. Our author’s description is mostly abridged from Aëtius (vi, 90), who copies from Severus.

This operation is minutely described by Albucasis. (Chirurg. ii, 2.) He directs us to shave the head, and rub the parts behind the ears with a rough cloth until the arteries become visible. The course of the vessels is to be marked with ink, and they are to be divided with a sharp scalpel, the incision penetrating down to the bone. He says, however, that if the surgeon choose, he may introduce the scalpel below the vessel, and cut upwards. The length of the incision is to be two fingers’ breadth. Blood, he remarks, springs from an artery per saltum. About six ounces, more or less, may be taken.

The operation is likewise mentioned by Avicenna (Cantic. iv,) and Averrhoes (in Cantic.); by Rhases (ad Mansor. vii, 21); and is described in exactly the same terms as our author’s by Haly Abbas. (Pract. ix, 4.)

SECT. V.—ON ANGIOLOGY, OR SECTION OF THE TEMPORAL VESSELS, AND ON BURNING THE SAME.

In hemicrania and in chronic or acute defluxions, when the eyes are affected with a hot and acrid defluxion, so as to occasion heat of the temporal muscles with swelling, every one approves of angiology for the cure of them. Having, therefore, first shaven the hairs of the temples, and noted the part with our fingers, we must use warm fomentations, and apply a bandage round the neck; and, when the vessels become visible, having marked their course with ink, we must draw the skin aside with our left hand or the fingers of an assistant, and make a superficial incision along the vessel; then cutting quite through, and stretching the parts with hooks, and exposing the vessel by means of the instruments used in operations on membranous parts, we must raise it up when it is separated all around. If it be small, having stretched and twisted it with a blind hook, we may divide it through, so as to be able to seize upon part of it. But if it be large, we must apply a double ligature under it with a needle, either a piece of raw flax, or some other strong thing; and, in the first place, making a straight opening into the vessel with a scalpel used in venesection, and taking away a moderate quantity of blood, we must tie the ligatures at both extremities of the exposed vessel, and cutting the intermediate part, we may remove it either immediately, or at the time of loosing the dressings. Some, without dividing the vessels at all, burn them to a sufficient depth with burning-irons shaped like olive-kernels. After the operation we must use pledgets of dry charpie, and put on an oblong compress (_splenium_) with a bandage. After the removal of these dressings, we must accomplish the cure by incarnating powders, applications on pledgets, and cicatrizing remedies; the threads and ligatures having previously dropped out from putrefaction.

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COMMENTARY. The author of the Hippocratic treatise (de Morbis in Homine, c. 49) recommends us to open the temporal veins for obstinate headaches; and, if this does not effect a cure, he directs us to burn them.

Celsus describes both operations very distinctly. He directs us to apply a ligature round the neck, so as to make the vessels swell, and then, having marked the course of the vessels with ink, to remove the ligature, and open the veins. When a sufficient quantity of blood is discharged, the part is to be burnt with slender irons cautiously about the temples, for fear of wounding the temporal muscles, but more boldly between the forehead and the vertex, so as to produce exfoliation of a scale of the bone. He also speaks favorably of cutting the vessels in the temples and upper part of the head. (vii, 7.)

Aëtius gives nearly the same description as our author. The part which relates to the burning is taken from Leonidas (vii, 93.)

Angiology is briefly described in the ‘Isagoge’ of Galen. A minute description is given by Albucasis. He recommends the operation as a remedy for inveterate cases of hemicrania, catarrh, and cephalæa. He directs us to shave the hairs about the temples, and to continue to do so until the artery appears. It is known, he remarks, by its pulsation. When it does not readily make its appearance, he recommends us to apply a cloth round the patient’s head, and to rub the place with a rough towel. Then, he says, take a scalpel, and make an incision so as to lay bare the artery, which seize with a hook, and separate from the surrounding parts, and if the vessel is small, cut out a proper piece of it, and allow from three to six ounces of blood to flow. But if the vessel is large, bind it in two places with strong silk threads, or strips of raw cloth (_alhohod_), so that it may not drop out before the wound is consolidated. Then cut out the part between the two ligatures. He directs us to dress the wound as recommended by our author. He also mentions the operation of burning the temporal veins as being one that is less serious than angiology. (Chirurg. ii, 3.)

Jesu Haly’s account of the operations of tying and burning the temporal arteries is very distinct. (iii, 25.)

Haly Abbas describes the operations of cutting out and burning the temporal vessels in nearly the same terms as our author. (Pract. ix, 70.)

Rhases mentions that the celebrated Archigenes recommended the temporal veins to be burnt for epilepsy. (Contin. i.)

The veterinary surgeons burnt the temporal veins in diseases of cattle. See Vegetius (Mulomed. ii, 16.)

We are inclined to think that it was the temporal veins and not the arteries which were cut out and burnt by the Greek surgeons in this operation. It will be seen, however, that the Arabians direct us to cut out a portion of the artery; at least this is sufficiently clear in the description of Albucasis, for he states decidedly that the vessel to be secured will be recognized by its pulsation, and he further recommends us to apply beforehand a ligature about the head, and not about the neck as directed by our author, whereby it is obvious that the arteries and not the veins would become distended; these observations apply also to Jesu Haly’s description. As Celsus, like our author, directs the ligature to be applied round the neck (cervix ante modice deliganda est), we may suppose that his operation related to the veins. From his using the word venæ indeed no inference can be drawn, as he applies it indiscriminately to arteries and veins. We are at a loss what to determine respecting the description given by Haly Abbas, for although the vessel that is secured be called arteria, the ligature or strip of cloth is directed to be applied round the collum. Where the mistake lies in this case we cannot venture to conjecture, and leave it to be found out by some person who has access to the MS. of the original. For our part we may exclaim with a celebrated German scholar,—“Felices sæpe prædicavimus Bochartum, Plempium, Celsium, Hydium, Casirium, quibus usus codicum Arabicorum concessus erat.” (Sprengel, Rei Herbariæ Historia, i, 239.)

Fabricius ab Aquapendente describes the operation as relating to the veins (Œuv. Chir. ii, 3.) Tagliacozzi, however, seems to refer it to the arteries. It thus appears that there is a good deal of uncertainty regarding this ancient operation.

SECT. VI.—ON HYPOSPATHISMUS.

This surgical operation derived its name from the kind of instrument used in it. We have recourse to it when a copious and hot defluxion is determined to the eyes. The face is ruddy, and about the forehead there is a sensation as of worms or ants passing along it. Having therefore first shaven the hairs about the forehead, we must permit the lower jaw to move, and avoiding the place where the temporal muscles are seen to act, we are to make three straight and parallel incisions on the forehead, each having the length of two fingers, and descending to the bone, and being at the distance of about three fingers’ breadth from one another. After the incision we apply the instrument called hypospathister, and extend the division from the left temple to the middle incision, dividing all the intermediate substance along with the pericranium; then we push a spatula from the middle one to the rest, and applying the point of a sharp-pointed knife to the first division, so that its sharp side may be turned to the flesh within the skin, and the blunt one to the bone, we push it as far as the middle division, cutting through all the vessels which descend from the head to the eyes, but not comprehending the external skin. And again we push it from the middle to the last incision, cutting through the vessels in like manner. After a moderate evacuation of blood, having squeezed out the coagula, and made three twisted tents, we are to put one into each division, and applying a compress soaked in water, we must secure it with a bandage. Next day we bathe not only the ulcers, but likewise the temporal muscles, and the ears with wine and oil, on account of the inflammation; and on the third day having removed the dressings, we must have recourse to copious affusion, and afterwards complete the cure suitably with tents out of basilicon dissolved in rose-oil.

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COMMENTARY. See Aëtius (vii, 92); Albucasis (Chirurg. ii, 4); Haly Abbas (Pract. ix, 7.) This operation is better described by our author than by any of the others. Celsus, although he describes several grave operations for the relief of defluxions on the eyes, makes no mention of it. Aëtius barely alludes to it in general terms. It must have been a very formidable operation, and for that reason perhaps, has been entirely abandoned in moderate times. Even Albucasis speaks of it as being an operation which was performed by the ancients; from which language we may suppose that it had been given up in his time. His description of it is evidently taken from our author. Haly Abbas describes the operation very distinctly. Three longitudinal incisions at the distance of three fingers’ breadth from one another are to be made in the forehead down to the bone, then a knife, or some such instrument, is to be introduced so as to divide the parts between the longitudinal incisions, sparing only the outer skin.

SECT. VII.—ON PERISCYPHISMUS.

When many deep-seated vessels send a copious defluxion to the eyes, we have recourse to the operation called periscyphismus. These cases are attended with such symptoms as these: in the first place you will find the patient’s eyes atrophied and small, weak of sight, the canthi corroded, and the eyelids ulcerated, the hairs falling off, with a discharge of very thin, acrid, and hot tears; there is a deep-seated pain in the head of an acute and violent character, and there is frequent sneezing. Having first shaved the head as aforesaid, and avoiding the place where the temporal muscles play, we make a transverse incision, beginning at the left temple and ending at the other. The incision must have its terminations where there are no muscles, its direction being a little above the forehead, and we must avoid the coronal suture. Leonidas directs the incision to be made along the middle of the forehead. When the bone is laid bare we may keep the parts asunder with tents and plenty of pledgets, and bind the extremities of the division; and, as we formerly stated, bathe with wine and oil. After loosing them, if the inflammation is on the decline, we may scrape the bone until it begin to incarnate, and accomplish the cure by a mode of practice calculated to promote incarnation, using the incarnative powders; among which is that containing of wheaten flour, p. ij; of colophonian rosin, p. j; and that called the cephalic, and those incarnatives prepared from pumice-stone. For, when the skin is thickened by a dense cicatrix, and the mouths of the vessels constricted, the defluxion is prevented from being determined to the eyes as before.

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COMMENTARY. See Aëtius (vii, 93); Pseudo Galen (Isagoge); Albucasis (Chirurg. ii, 5); Haly Abbas (Pract. ix, 18.)

It is evident that this operation is neither more nor less than a complete division of the integuments of the head from temple to temple; of course it must even have been more dangerous than the operation treated of in the last section. Aëtius, Haly Abbas, and Albucasis describe it in the same terms as our author. The periscyphismus and hypospathismus are briefly noticed in the ‘Isagoge.’

Fabricius ab Aquapendente treats of these operations among those of the ancients, _qui ne sont plus en usage_ (Œ. C. ii, iv); even Tagliacozzi speaks of them as being cruel and dangerous. However, a surgical operation, similar in principle, called the “long issue of the scalp,” is still practised in certain hospitals of Great Britain. See the ‘Transactions of the Provincial Association,’ (vol. xi.)

SECT. VIII.—ON SUTURE OF THE UPPER EYELID, AND OTHER MODES OF OPERATING FOR TRICHIASIS.

Distichiasis is a preternatural growth of hairs, superadded to the natural order of hairs of the eyelids; and derives its origin from a defluxion, when there happens to be a flow upon the part of a humour which is not pungent or acrid; for that which is more acrid, saltish, or otherwise pungent, when it lodges in these parts, consumes the natural series of hairs. For this state then we sometimes have recourse to the suture of the upper eyelid, and sometimes also for phalangosis when the eyelid inclines inward, the phalanx or row of the hairs being inverted; and sometimes for relaxation of the eyelid, when the natural row of hairs hurts the ball of the eye. Having placed the patient on a seat, either before us or on the left hand, we turn the upper eyelid outwards, and, if it has long hairs, we take hold of them between the index-finger and thumb of the left hand; but if they are very short we push a needle having a thread, through the middle of the tarsus from within outwards; then stretching the eyelid with the left hand by means of his thread, with the point of a scalpel held in the right hand, having folded out the eyelid and everted it, behind the thread we make the under-incision within the hairs which irritate the eye, extending from the larger canthus to the smaller, along the tarsus. After this subsection, having extracted the thread, and putting a small compress under the thumb of the left hand, we stretch the eyebrow upwards. Then arranging other small compresses on the canthi at the extremities, we direct the assistant who stands behind to stretch the eyelid by means of them. Then by means of the scalpel used for sutures we make the first incision, called the veruted (shaped like a verutum or short dart) a little above the hairs, which are in their natural state, extending from canthus to canthus, and penetrating only the depth of the skin; and afterwards we perform the incision called the lunated, beginning at the same place as the former, and carrying it upwards to such a height as to comprehend the whole redundant skin, and ending in like manner as it did. Thus the whole skin comprehended within the incisions will have the shape of a myrtle leaf, of which portion, having perforated the angle on the right hand with a hook (tenaculum), we dissect away the whole skin: then washing away the clots with a sponge, we unite the lips of the incision by three or four sutures, beginning at the middle, and passing the needle itself through the under-section. The thread should be made of wool; and having cut away the superfluity of the thread, not close to the sutures, but so as to leave a superfluity of three fingers’ breadth, we stretch this remainder along the forehead and fasten it by means of any of the agglutinative plasters. But the hairs of the eyelid are to be freed from the sutures with the point of a needle. Such is the common and safe mode of performing this surgical operation. Some avoid the dissection of the skin, and therefore after the under-incision, having stretched the redundant skin by means of the forceps used in operations on the eyelids, they cut it off with a scalpel, and apply sutures as described above. But if the irritation from the hairs is produced only by a part of the eyelid, it will be proper to confine the operation to that part. Then soaking the compresses in oxycrate, and laying them on the part, we secure them with bandages, continuing to moisten the dressings with diluted oxycrate until the third day; after which we remove them, and cutting away the superfluous parts of the threads, we anoint the eyelids either with saffron, glaucium, or some of the anti-inflammatory collyria, such as that formed of saffron and roses. But if the sutures inflame, we apply some one of the softening plasters, and soothe the eye by an injection of eggs mixed with milk. When the ligatures slacken we cut and extract them. I know a certain person who having made the dissection of the skin of the eyelid, as mentioned above, did not have recourse to sutures, but effected the cure with a healing ointment. For when the wound cicatrised, the eyelid being somewhat contracted, forced the hairs to incline outwards. In like manner, another person not practising the dissection of the eyelid, nor the two external incisions, but only making the under-incision, stretched with his fingers or by a hook the fold of the eyelid, two reeds or plates of the same length as the eyelid, and as broad as for venesection, he twisted a ligature round it at both its extremities; and thus the whole skin behind not being nourished, and on that account being deprived of life, fell off within ten, or at most fifteen days along with the reeds or plates, so as to leave scarcely any scar.

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COMMENTARY. On suture of the upper eyelid, and other methods of operating for distichiasis, see Hippocrates (de Victu acut. 66); Aëtius (vii, 71, 72); Celsus (vii, 7); Albucasis (Chir. ii, 11); Rhases (Divis. i, 30; ad Mansor. ix, 26; Contin. ii, 3); Avicenna (iii, iii, 3, 32); Avenzoar (i, 8, 6); Serapion (ii, 7); Mesue (ii, 18); Jesu Hali (ii, 10); Canamusali (vi, 26); Haly Abbas (Pract. ix, 19); Vegetius (Mulom. ii, 15.)

The description of the operation given by Aëtius from Leonidas being nearly the same as that described by our author, we shall confine ourselves to an abridged account of it, and merely make a few remarks to illustrate the description of Paulus. In order to facilitate the operation, he recommends the operator to have two assistants instead of one, as directed by our author. He also recommends him, in the first place, to mark with ink the portion of skin which requires to be cut out. He then directs him to make the under-incision, by which he seems to have meant an incision within the ciliary hairs along the tarsus, and extending from canthus to canthus. He recommends it to be made pretty deep, and even in certain cases suggests the propriety of making two under-incisions, one as above described within the ciliary hairs, in order to relax the tarsus; and the other upon the preternatural hairs. He next directs first a transverse incision to be made along the eyelid above the ciliary hairs, and then a lunated one beginning and ending like the other, after which the skin, thus separated, is to be dissected out. He recommends the edges to be united by means of five sutures, one in the middle and two at each extremity of the incisions. The other steps of the operation are exactly the same as those described by our author, and cannot be misunderstood. Hippocrates describes an operation for trichiasis, which Heister thought the same as that recommended by Aëtius, but the description is so obscure that we must confess our inability to explain it.

Celsus describes three methods of cure for trichiasis. 1. By burning the roots of the hairs. 2. The anabrochismus, which will be explained in the 13th section. 3. The anarrhaphè or suture, as described by Aëtius and our author. As the steps of the operation described by him are almost exactly the same as those of Aëtius, we need not dwell upon the explanation of them. Lest, however, there should be any misapprehension about the under-incision, we shall give his directions about it in his own language: “præter hoc, in superiore palpebrâ sub pilis ipsis incidenda linea est ut ab inferiore parte diducti pili sursum spectant; idque si levis inclinatio est, solum satis est.” Instead of five sutures, as directed by Aëtius, he recommends only three.

Albucasis states that there are four modes of curing trichiasis. 1. By the actual cautery. 2. By the potential cautery. 3. By incision and the suture, which operation he describes at great length. He directs us in the first place to evert the eyelid, either by taking hold of the ciliary hairs, or by passing a needle, armed with a hair, through the tarsus, and raising the eyelid with it. He then, like the others, directs us to make the under-incision within the ciliary hairs, from the greater canthus to the smaller, to cut out the redundant skin of the eyelid, and unite the surfaces with sutures. In short, his operation is exactly the same as our author’s. He mentions, however, another method of making the incision by elevating the redundant fold of the skin with hooks or a trident, and cutting it off with a pair of scissors. 4. The fourth method consists of making the under-incision, as in the last operation, and then twisting the redundant skin firmly about reeds or small pieces of wood until it mortifies: after which the wound is to be cured upon general principles.

Serapion’s account of the operation is defective, and need not be particularly noticed. Canamasuli directs us to cut out the hairs and burn the part with a cautery of gold.

Avicenna merely mentions, in very general terms, that the cure may be accomplished by agglutinative applications, by the cautery, or by excision.

Mesue briefly describes four modes of cure: 1. By means of agglutinants. 2. By passing a needle, armed with a hair, through the tarsus, as will be explained in the 13th section. 3. By plucking out the hairs and cauterising the part. 4. By applying medicines calculated to prevent the renewal of the hairs after they have been plucked out.

Jesu Hali’s description of these operations is very circumstantial; he speaks of cutting out the piece of skin with a fine pair of scissors.

Rhases states that the cure of trichiasis may be effected by burning the roots of the hairs with a red-hot needle, or by making the excision of the superfluous skin of the eyelid. He also makes mention of the treatment by agglutinants. In his great work, the ‘Continens,’ he briefly notices the four operations described by Albucasis. He appears to have approved very much of the burning. He also describes the operation with the reeds or pieces of wood.

Avenzoar mentions four methods of curing inversion of the ciliary hairs. 1. By everting the upper eyelid and securing it with agglutinants until the roots of the hairs have been cauterised with a rod of gold. This method he does not approve of. 2. By extirpating the offending hairs and applying the blood of a bat to the places from which they were torn. 3. By making an excision of the superfluous skin of the eyelid, and afterwards applying sutures. He alludes, we suppose, to the operation of Aëtius. 4. By twisting the skin about small reeds or tubes, in the manner described by our author and Albucasis.

Haly Abbas accurately describes the four following operations: 1. By excision and the suture. He directs the under-incision not to be made deep. 2. By twisting the hairs into the fold of a silk thread and flattening it to the forehead. 3. By the actual cautery. 4. By the potential cautery.

We will give the description of the veterinary surgeon, Vegetius, in his own words: “Non longe a pilis ab interiori parte scalpello plagam dabis in cute palpebræ, post forficibus per longum ad mensuram oculi fasciolam præcides, et impositis fibulis consucs palpebram foris versus, ut oculus sine deformitate recipiat visum et gratiam naturalem.”

It is to be remarked that Albucasis, Jesu Hali, and Vegetius speak of cutting out the superfluous skin of the eyelid with a pair of scissors, as was done by Scarpa.

All the ancient operations for trichiasis are described by Guido de Cauliaco (vi, 2.) The mode of cure by twisting the skin about small reeds until the parts slough is still generally practised in China. The Chinese surgeons grasp the fold between two slips of bamboo, which being tightly fastened at their ends perform the office of a ligature.

SECT. IX.—ON BURNING OF THE EYELIDS BY MEDICINES.

The burning of the eyelids with caustic medicines was reprobated, in a word, by all the ancients, lest the acrimony of the application should prove injurious to the eyes; and because when the burning was carried to too great an extent the affection called lagophthalmos was produced, in which case the eyelids cannot be shut, and the vision is apt to be injured by everything that comes in the way. But since many who suffer from the irritation of the ciliary hairs are not able to endure even the name of the operation by suture, we are compelled from necessity, against our will, to have recourse to burning by medicine. The following is a composition of that kind: of quicklime, p. ij; of Gallic or common soap, p. ij; and some add of aphronitrum, p. iv. These things being pounded with strained ley, or soap ley, or some other ley, as that of figs or of oaks, and being mixed with the urine of a young man not come to maturity, we apply to the eyelid, upon the knob of a specillum, the part touched having the shape of a myrtle leaf; and we burn to the extent comprehended in the operation by suture. The skin being burnt at the first application, we remove so much of it with a sponge, and apply the medicine a second time, allowing it to remain until the part blacken; and if it does not blacken we apply it a third time. When the skin is blackened and the eschar also formed, we must clean away the medicine and have recourse to bathing and washing until the eschar drop off; after which it will be proper to complete the cure by means of pledgets of charpie and emollient collyria.

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COMMENTARY. None of the other authorities describe this method of cure so minutely as our author, except Haly Abbas, who evidently copies from him. (Pract. ix, 71.) Rhases and Albucasis, however, also mention the operation. They direct us to burn the part with a preparation of quicklime and soap, with the addition of some caustic lixivia, _or_ leys. These ancient leys, _or_ lixivian ashes, appear to have been preparations of potass more or less pure. We need scarcely remark that these applications must have resembled the caustic paste, now used for forming issues. The method of treatment here described is, in principle, much the same as that performed by Quadri with sulphuric acid. A caustic paste very similar to that now used is described by Guy of Caulico. (vii, 1.)

The strained ley, of which mention is made by Paulus, was probably the same as the calx colata of Cælius Aurelianus. (Tard. Pass, v, 1.) It appears to have been an impure preparation of potass with the addition of some lime. It is the same, we suppose, as the πρωτόστακτον mentioned in the Third Book of this work. The calx colata would seem to have been identical with the Vienna paste now used in the treatment of varix. A composition for burning the eyelids, mentioned by Jesu Hali, contains lime, prepared beans, nitre, and sal ammoniac, formed into a paste with the water of soap and pure myrrh. Jesu, however, does not much approve of this method of treatment.

SECT. X.—ON LAGOPHTHALMOS OR HARE-EYE.

Those persons are said to have hare-eyes who have the eyelids drawn upwards. This complaint arises either naturally or from the cicatrix of a wound, and this may have occurred spontaneously, or from the operations of the suture or burning (as just mentioned) having been improperly performed; in which case even a moderate relief can only be accomplished when the eyelid is sufficiently thick. For we must divide the cicatrix, and having separated the lips with a tent, use bandages until the cure is completed, avoiding such things as are very desiccative, and having recourse to those which are fatty and relaxing, such as the juice of fenugreek poured on the part, and the ointment prepared with four ingredients called basilicon, applied on a tent.

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COMMENTARY. See Celsus (vii, 7); Aëtius (vii, 71); Albucasis (Chirurg. ii, 13); Avicenna (iii, 3, 3, 12); Haly Abbas (Pract. ix, 20); Rhases (Cont. ii, 4.)

Celsus directs us to make a lunated incision below the eyebrows, the horns of the incision being turned downwards, and care being taken not to wound the muscles. A tent or pledget of lint is to be put into this incision to prevent the edges of it from uniting. This simple operation is described in nearly the same terms by Aëtius, Albucasis, Avicenna, Haly Abbas, and Rhases.

Fabricius ab Aquapendente informs us that the operation had fallen into disuse in his time. It is now sometimes practised. See Scultet, (Arsen. de Chirurg. Tab. xxxiv, 8.)

SECT. XI.—ON THE SUTURE OF THE UNDER EYELID, AND THE BURNING OF IT BY MEDICINES.

The under eyelid is subject to the same complaints from the ciliary hairs as the upper; for, when larger than natural, it is everted; and it is subject likewise to phalangosis and distichiasis. We must, therefore, perform the operation of the suture in the same manner as for the upper eyelid, but in an inverted order, beginning with the _lunated_ incision on account of the obstruction occasioned by the blood, and then making the _veruted_. But the _under-incision_ is to be omitted altogether, because the lower eyelid, by its natural weight, is readily everted. The rest of the treatment to be completed as in the suture of the upper eyelid, except that the extremities of the ligatures are not to be glued to the forehead. If in this case the patient is averse to an operation, and prefers burning by medicines, you have already got a description of this process.

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COMMENTARY. This section requires no commentary.

SECT. XII.—ON ECTROPION, OR EVERSION OF THE LOWER EYELID.

Ectropion of the under lid is occasioned by the same causes as lagophthalmos of the upper, only that it does not occur naturally, but arises sometimes from relaxation produced by medicines possessed of this property, which have been applied for inflammation; and sometimes the eversion is occasioned by the suture or burning having been improperly performed. Taking, therefore, a needle, armed with a double thread, we perforate the fleshy mass, pushing it through from the left canthus to the right, and then by means of the thread fastened to both of its extremities, we stretch the skin with the needle, and cut down upon it with a scalpel, removing the needle at the same time. Then, if the eyelid resume its proper shape and is turned inwards, this operation will be sufficient. But if the eversion continue after the removal of the flesh, we apply the back of the specillum to the divided eyelid; and on the inside of the eyelid, having made two incisions, beginning at the two angles of the incision formerly made, and terminating in an acute point, and meeting together like the Greek Λ, we remove this substance, so that its acute point may be below at the eye, and the broad above at what is called the tarsus. Afterwards we unite the separated parts with a needle containing a woollen thread, being satisfied with two sutures. But if the ectropion be occasioned by the operation of the suture or burning we make a simple incision along the first cicatrix below the hairs of the tarsi, and having separated its lips, we fill up the wound with pledgets, using the same methods as for lagophthalmos (except fomentations) until the parts which have been stitched unite.

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COMMENTARY. See Aëtius (vii, 74); Celsus (vii, 7); Albucasis (Chirurg. ii, 14); Haly Abbas (Pract. ix, 20.)

Aëtius gives a full account of the treatment of ectropion from Demosthenes and Antyllus. When the disease is occasioned by fungous flesh on the inner membrane of the eyelid, he recommends us to burn it down with escharotics, such as misy, chalcitis, &c. (See the Third Book.) He describes the surgical operation in the following terms:—when the fleshy excrescences are very large they are to be dissected out with a scalpel, and the part touched with burnt copper or the like. When the eversion is greater, he directs us to perform an operation upon the inner part of the eyelid, making two incisions, which unite below like the Greek letter Λ, and afterwards dissecting out this lambdoid or triangular piece, and along with it the flesh below, which, he remarks, is not cartilaginous like the upper eyelid, but taking care to preserve the skin untouched. The edges of the incisions are then to be united by one suture at the eyelids. When the ectropion is occasioned by an external cicatrix, we are to operate upon the inner surface of the eyelid in the manner just now described, only avoiding to make deep incisions, and uniting the edges of the incisions as before directed. Then stretching the cicatrix with a hook, and pushing a needle armed with a double thread, under the thickened flesh from the smaller canthus to the larger, we are to cut down upon the needle and divide the thickened flesh. A pledget of lint is then to be put into the external incision, and a compress, moistened with cold water, applied with a bandage. He directs us to avoid warm fomentations until the ligatures drop out. When ectropion arises from the excrescence called encanthis, he recommends us to dissect it out. When the disease is occasioned by paralysis, or arises from too large a portion of the eyelid having been cut out in the operation for entropion, he pronounces it to be incurable. It is also said to be incurable when occasioned by the sloughing of carbuncles.

Celsus says that ectropion arises either from an operation for inversion improperly performed or from old age. In the former case he directs us to make an incision like that for lagophthalmos, only with this difference, that the horns of it are to be turned to the jaws (maxillas) and not to the eye. When it arises from old age he recommends us to burn the excrescence with a slender piece of iron, and then to anoint it with honey.

Albucasis describes the operation in nearly the same terms as Aëtius. Thus, he directs us to pass a needle armed with a double thread, below the fleshy excrescence from the left canthus to the right, and stretching it by means of the threads to cut it out with a broad scalpel. If this incision does not relieve the eyelid, he directs us to take the specillum (radius) and applying it to the incision, to evert the eyelid with it, and then to make two incisions in the inner surface of the eyelid so that they may meet at an angle below, like the Greek letter Λ. Then this triangular portion is to be dissected out, and the edges united by a suture with a woollen thread. When the disease arises from a cicatrix he directs us to divide it, and then to keep the lips of the wound separate by the application of a pledget. He concludes with the remark that, as the disease puts on various forms, a prudent surgeon will show his skill by restoring the parts to their natural state.

Haly Abbas evidently borrows his description from Aëtius or our author.

The operation here described is very similar to the one practised by the late Sir William Adams. In the days of Fabricius this operation was condemned as cruel and troublesome. It will be remarked that the V operation of modern times is a modification of the operation now described.

SECT. XIII.—ON ANABROCHISMUS AND BURNING WITH IRON.

When the hairs which irritate the eye are not numerous, but only one, two, or at most, three, close to one another, we approve of the operation called anabrochismus. Taking, therefore, a very slender needle, we pass through its ear (eye?) a woman’s hair or a fine flaxen thread, and unite the two extremities together in such a manner that the thread or hair which is passed through may have a double loop; and we pass another such thread or hair through the loop, and pushing the needle through the tarsus where the preternatural hairs appear, we introduce the hair or hairs into the loop by means of an ear-specillum, and draw it upwards. And if the hair of the eyelash be fixed in it, we draw up the loop; but if one or more, fall out, we again, by means of the one at first introduced, draw down the loop, and once more introducing a hair or hairs, draw them upwards. But if there is only one slender hair that irritates the eye we draw up another of the ciliary hairs along with it, anointing them with gum or some other glutinous substance, and bending them until they unite to the skin. Some preferring burning to the operation of anabrochismus, turn the eyelid outwards, and with a hair-forceps dragging out the offending hair, if there is but one, or two, or three; if there be as many, they apply a double-headed specillum, or an ear-specillum, or some such small instrument heated, to the place whence the hair or hairs were removed. For the skin being thus constricted, no other hair is produced.

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COMMENTARY. We will give Celsus’s description of this operation in his own words: “Quidam aiunt, acu transui juxta pilos exteriorem partem palpebræ debere, eamque transmitti duplicem capillum muliebrem ducentem, atque ubi acus transiit, in ipsius capilli sinum, qua duplicatur, pilum esse conjiciendum, et per eum in superiorem palpebræ partem attrahendum, ibique corpori agglutinandum, et imponendum medicamentum quo foramen glutinetur; sic enim fore, ut is pilus in exteriorem partem postea spectet.” However, he does not much approve of the operation. He also describes the operation of cauterising the roots of the hairs. (vii, 7.)