Cælius Aurelianus says that Asclepiades performed the operation in cases of cynanche; but he himself disapproves of it. (De Morb. Acut. i, 7.) We may mention further in this place that Avicenna, Avenzoar, Haly Abbas, Mesue, and Rhases express themselves rather favorably of the operation in urgent cases of cynanche. From the circumstance mentioned by Pollux of cynanche, that it mostly attacks children, we are inclined to think that the ancients meant the croup by it.
None of the Greek authorities, except our author, have left a description of the operation. Psellus, however, mentions it in such a manner as would lead us to infer that the operation had not been lost sight of in his time, i. e. “Laryngotomy is a certain surgical operation.”
Avicenna and Albucasis merely copy our author’s description, and appear to have never seen the operation performed. To show, however, that the windpipe may be opened without occasioning death, Albucasis relates the case of a female who cut her trachea while attempting to commit suicide; in which case, by sewing up the wound, he effected a cure without difficulty. (Chirurg. ii, 13.)
Rhases mentions that, in cases of cynanche which threaten instant death, a certain physician, Ancilisius (Antyllus?) recommends the surgeon to open the windpipe. His description of the operation is as follows: The patient’s head being kept back the skin is to be divided, and the sides of it separated by means of threads, so as to expose the windpipe, which is to be opened by making an incision in the membrane which connects two of the rings together. After the abcess bursts the wound is to be sewed up. (Cont. vii, 2.)
Haly Abbas likewise describes the operation accurately. He directs us to make an incision in the skin, and to separate the edges with hooks so as to expose the windpipe, which is to be opened between two cartilages. (Pract. ix, 38.)
The modern history of the operation is given in Van Sweiten’s Comment. (814); Mémoires de l’Acad. Royale (ii); and Cooper’s Surgical Dictionary. See a complete history of the operation by Sprengel. (Hist. de la Méd. 18, 6.) He says, that Anthony Benivieni, a surgeon of Florence, is the first after Antyllus who is known for certain to have performed the operation.
SECT. XXXIV.—ON ABSCESS.
That the abscess is a corruption and transmutation of the flesh or fleshy parts, and what are its modes of formation, and how many kinds of abcesses there are, we have sufficiently explained in the [Fourth Book]. Now we have only to treat of the operation upon it. If it be completely changed to pus, which we ascertain from the pains, fever (if any was formerly present), redness, pulsation, and the other symptoms of inflammation being diminished, from the swelling assuming a sharp point, and from pus being felt under the fingers upon pressure, more especially if the abscess be superficial, in that case we may proceed to the operation. But if it is not felt to the touch, nor is elevated to a point, owing to its being deep-seated, we must attend to the other symptoms before operating. It is to be understood, however, that before the conversion to pus is completed, we sometimes open abscesses when they are unripe, on account of their being near joints or vital parts, lest, by their continued putrefaction, a ligament or some necessary part should be corrupted by it. And Hippocrates directs us to open abscesses about the anus before they are completely ripened, for fear of their perforating the intestine. In opening them we must not, in all cases, make the incisions in the same manner, but observe the natural lines—as on the face; and the growth of the hairs—as on the head, and taking as much care as possible not to occasion deformity. Straight incisions are to be made in the legs, as in the muscles and tendons; and nerves, arteries, and vital parts are to be avoided, taking care of their safety by sometimes making a straight incision and sometimes a transverse one into the abscess, according to the circumstances of each case. When the abscesses are small we make one incision, but when they are larger we make more, always dividing the thinner parts, and those which are most convenient for the escape of the matter. When the swelling is much raised up to a point, unconcocted, thin, and devoid of vitality, we must cut out a piece either like a triangle, or like a myrtle leaf, or of some other angular figure, because the circular is unfavorable to cicatrization. Those which are not pointed we open by a simple incision, and when we find a sinus, if the part is fleshy and the skin proper for uniting, we only make such incisions into the part as will allow the matter to be discharged; but if it be thin and very devoid of flesh we make a simple incision along its whole length; and after this simple incision, if the parts on each side appear thin and not fleshy we must pare them off. After the operation, having first sponged the part, if the abscess be small, and if only one incision has been made, we may use a simple pledget, but if it be large, and there be many incisions, we draw through them a fillet which can be easily extracted; and when the part has been cut out we fill it in like manner with lint. If a hemorrhage take place we must use cold water or oxycrate, and if the bleeding continue we may sprinkle upon the part finely powdered chalcitis, which we may also have recourse to often when the part is gangrenous and flaccid. In winter, and when the parts are nervous, we may soak oblong pledgets in wine and oil and apply them; and in summer, when the parts are fleshy, we may soak these applications in water and oil, or in the same cold wine and oil, and binding them, on the following day we may bathe with the same fluids; but on the third day, having loosed the dressings and sponged the parts, we may use the application called tetrapharmacon on a pledget, and if there be no inflammation present we may apply the same wash for the preservation of the pledget; but if there be inflammation, we must apply a digestive cataplasm, having first poured water on the parts. When the inflammation abates we may effect the cure by promoting suppuration and incarnation. Sinuses are to be cured by agglutinative remedies, as has been said, in the [Fourth Book], on sinuses.
Commentary. All the authors quoted under [this head in the Fourth Book] may be consulted.
Celsus is more than usually prolix in laying down the rules for the surgical treatment of abcesses. Before the abscess harden, he directs us to make incisions in the skin, and apply a cupping instrument, in order to remove any symptoms of inflammation which may have been present, or, in other words, to procure resolution. Sometimes, however, as he explains, the matter is collected in a cyst (tunica), in which case it is not to be supposed that the contents of the abscess can be removed by a cupping instrument. When the pus ripens it is seldom proper to let it out if seated in the armpits, or groins; nor when the collection is superficial, or in the flesh; and it is better, as he prudently directs, to apply cataplasms until the pus make an opening for itself. When it is judged necessary to open an abscess, he recommends us, if not seated in a nervous part, to perform the operation with a red-hot iron, because a small opening made in this manner will remain longer open. Abscesses in nervous parts are to be opened with a scalpel. In making an incision, the form and size of it are to be considered. In general the openings are to be made as small as possible; but large sinuses require larger incisions, and sometimes two or three are necessary: when the skin is livid or diseased it sometimes must be cut off to further the cure. In this case an opening is to be made of the shape of a myrtle-leaf. When the pus is evacuated, if in the armpit or groins, no pledget is to be used, but a sponge out of wine is to be applied. In other places, a little honey is first to be used; then agglutinative medicines; and above these likewise, if necessary, a sponge squeezed out of wine. (vii, 2.)