Albucasis Cauterization

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In order to explain how such an interesting and innovative diagnostic and therapeutic system as that involving the outer ear remained unknown until about 50 years ago, we need to take a few steps back through the history of medicine, first to ancient times when a wide variety of animal and human ailments were cured using iron and fire. Cauterization was well known to Hippocrates (460-380 bc), who wrote in his last aphorism (section VII, no. 87), 'quaecunque medicamentis non cur-antur, ferrum curat, quae ferro non curantur, ignis curat, quae igne non curantur, ea incurabilia sunt' ('those diseases which are not cured by medicines are cured by the scalpel; those which are not cured by the scalpel are cured by fire; those which are not cured by fire can be considered incurable').

The great surgeons Avicenna (980-1037) and Abu al-Qasim, also known as Albucasis (d. c.1013), were particularly skilled in cauterization, and in selecting the appropriate instruments and techniques. Albucasis stated in the first book of his work,1 dedicated entirely to cauterization: 'the cautery excels the drug by the rapidity of its success, the strength of its action, and the potency of its powers'. However, he admonished his pupils:

no one should attempt this operation unless he has had long training and practice in the use of the cautery, and is fully acquainted with the various human temperaments, and the character of the complaints in themselves; their causes, symptoms, and duration.

He removed some prejudices which still existed in this period:

the Ancients disagreed also as to the fit time for cautery, affirming that spring was the best. Myself, I say that the cautery is suitable at all times; for whatever harm may arise from the season of the operation is utterly outdone by the benefit deriving from the cauterization itself; especially if the cautery is applied to pains that are severe, grievous, and swift, brooking no delay, because of the fear that the consequences may be more grave than the slight harm from the season.

His opinion was that:

the actual cautery and its superiority over cauterization with chemical caustics is one of the secrets of medicine. For fire is a simple substance having no action except upon the actual part cauterized; nor does it do more than slightly harm any adjacent part. But the effect of cauterization with caustic may spread to parts at a distance from that burnt; and also in the part cauterized it may give rise to a disease difficult to cure or even fatal.

In the centuries to follow, the methods used were termed 'actual cautery' and 'potential cautery'. These indicated, respectively, treatment with red-hot iron and local application of caustics.

In Albucasis's time many parts of the body and several diseases were treated with cauterization, for example pleurisy, chest complaints, liver abscesses, diseases of the spleen, dropsy, piles and anal fistula, painful menstruation and infertility, toothache, migraine, sciatic pain, etc. In Chapter 5 of his book Albucasis described the following treatment for earache:

when the ear gets a pain from the cold and is treated with laxatives and other medicine as mentioned in its section and the pain nevertheless persists, heat the cautery termed punctate. Then after it has been heated prick with it in a circle right round the ear, or around both if there is pain in both, after the place has been marked with ink; the cauterizations being a little away from the ear. Let the cauterization be often punctures or thereabouts round. Then dress the places till healed.

Albucasis at work is depicted in a series of miniatures accompanying the Latin translation of his text (Fig. 1.1).

The method of cauterization spread throughout Europe, and many physicians applied the actual mi cuircncrtb mdiPiUicTm.i£C:>ft:

Fig. 1.1 Albucasis applying the cautery in a case of earache. Miniature from Abu'l Qasim Halaf Ibn Abbas al-Zahrawi, Chirurgia, second half of 14th century. (Reproduced with the permission of the Wellcome Institute for the History of Medicine, London.)

otte n no inmnicrur tolo: tu'c ig^ can wnu <7iUnr>qMii>nn7T.if puai c*I> cftKi

Fig. 1.1 Albucasis applying the cautery in a case of earache. Miniature from Abu'l Qasim Halaf Ibn Abbas al-Zahrawi, Chirurgia, second half of 14th century. (Reproduced with the permission of the Wellcome Institute for the History of Medicine, London.)

cautery until well into the 19th century. In France, the country in which the practice of cauterization had most support and was most widespread, it was used in the hospitals of all the principal towns, and the person who in 1811 best summarized the history of the actual cautery and best described the technique was a Frenchman, Pierre-Francois Percy (1754-1825), a surgeon at the court of Napoleon, who had had considerable experience on the battlefield. Percy2 ordered at least 10 instruments of different dimensions and shapes to be forged for various uses. The heated instruments were inserted into a special wooden handle (Fig. 1.2).

The instruments were classified into three groups:

1. cauteres objectifs - brought close to the part to be treated but not into contact with it (used, for example, for bleeding piles or nosebleeds)

2. cauteres transcurrens - touched the affected part rapidly and superficially (used, for example,

Zahrawi Miniature
Fig. 1.2 Percy's ten cauteries with handle on the left. (Reproduced with the permission of the Wellcome Institute for the History of Medicine, London.)

for delicate tissues such as the lips and eyelids but also for rheumatism and sciatica) 3. cauteres inherens - applied and held in place for more or less time, to act deeper.

In England the practice of ironing the painful part with a laundress's iron (the skin being protected by being covered with a piece of thin flannel or brown paper) had long been in vogue for various types of pain. However, it was only after 1830 that physicians such as Henry William Fuller3 and James Syme4 proposed the use of the actual cautery for lumbago, stiff neck and other forms of 'muscular rheumatism', which at that time included sciatica.

An exceptional case report comes from one of the great surgeons of the history of medicine, Joseph Lister. Having qualified in London, Lister went to Scotland, where in 1854 he became Syme's house-surgeon at the Edinburgh hospital. During his stay he probably witnessed patients being treated with the actual cautery, as in the following case:5

Case IV. - Disease between the Atlas and Axis: Actual Cautery applied with great benefit.

Thomas Smith, aet. 27, admitted the 20th of June, 1854. Generally enjoyed good health till eighteen months ago, when a stiffness of the neck came on without any assignable cause, with pain when he turned round his head on the pillow; the pain increased greatly, and deprived him altogether of sleep for seven weeks, during which time he lost three stone in weight. There was severe pain in the head as well as in the neck, aggravated to an extreme degree by either nodding or turning of the head, particularly the latter, which, indeed, he at last never did without turning the rest of the body also. He applied to numerous medical men in Birmingham, where he lives; and blisters and caustic issues were repeatedly applied to the back of the neck, but never gave more than very slight and very transient relief, and he says that from the commencement of his complaint he never had one minute's freedom from pain, except during sleep, till he came here.

At this time he was, according to his own account, about as bad as he had been at all. His countenance wore a peculiar expression of mingled suffering and apprehension, as Mr. Syme expressed it. He complained of severe pain in the neck and head, aggravated by any sudden movement, so that there was a great constraint about all his actions. He always kept his head bolt upright except when in bed, and could neither lie down nor get up without supporting his head with his hands; he never turned his head without the rest of the body, but gentle nodding was not very painful. There was great swelling of the upper part of the neck, and he could only open his mouth a little way; deglutition was extremely difficult, and a remarkable prominence of the bodies of the upper cervical vertebrae was to be felt in the pharynx.

On the day after the admission, Mr. Syme applied the actual cautery over the spinous processes of the upper cervical vertebrae; the man was not under chloroform, and said he hardly knew whether the pain was greater even at the moment than what he had experienced from caustic issues, and immediately afterwards he told us that he did not feel the pain of the burn at all. Next day he found less pain in moving the head, and in two or three days his countenance assumed a cheerful aspect. A steady daily improvement has since taken place in his symptoms, and at the present time (the 15th of July) he has no pain whatever when he sits at rest, and can also use strong and active exertion without uneasiness, and no longer requires to support his head in lying down or rising; he can turn his head round pretty freely and look up to the ceiling, and it is only in sudden movements ofthe neck that he feels any pain at all. The swelling of the neck has greatly subsided, and he can open his jaws wide, and swallow with comparative facility. The sore on the neck is almost healed, and he talks of leaving the hospital in a few days as cured.

Remarks. - The above cases speak for themselves; and I might add several others, that exemplify in an equally striking manner the beneficial effects of the actual cautery in certain forms of articular disease. It will be observed that is by no means so painful a remedy as is generally supposed, and also that its good effects are more than can be attributed to the mere discharge of pus from the sore which it produces, seeing that a great improvement commonly occurs within a few hours of its application, and long before suppuration is established.

It is now many years since the use of this means of counter-irritation was introduced into Great Britain by Mr. Syme; but although a constant series of successful cases have since continued to demonstrate its value to those who have witnessed his practice, yet I am satisfied that it has not hitherto been sufficiently generally appreciated. Case IV is an example of its efficacy against a mostfor-midable disease, where caustic issues had been long tried in vain. I believe many limbs and lives have been sacrificed that might have been saved by the actual cautery, and by it alone; and having been myself very strongly impressed with the importance of the subject, I should be truly glad if any surgeon who may have hitherto overlooked it, should be induced by the above report to inquire more closely into its merits.

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