ii, 64.) Guido de Cauliaco directs us to draw the prepuce forwards, and
cut it off; after which the bleeding is to be stopped with powders, or
the cautery. (vi, 2.)
SECT. LVIII.—OF THYMI ON THE PENIS.
Thymi are fleshy excrescences, forming sometimes upon the glans, and
sometimes upon the prepuce; and some of them are malignant, and some are
not. Those which are of a mild nature it will be proper to pare away with
the edge of a scalpel, and sprinkle the part with chalcitis; but when
malignant, the part must be burned after they are removed. If there be
thymi on both sides of the prepuce, some internal and others external,
we must not attempt all at the same time, lest by mistake we should cut
off the prepuce, which is thin; but we must first cut off the internal,
and, when they are healed, we may next attempt the external. Some of the
moderns effect a cure by cutting them off with a pair of scissors, and by
binding them with a horse-hair; as, in like manner, some burn them with
the cold cautery.
* * * * *
COMMENTARY. Albucasis copies our author’s description. (Chirurg. ii, 56.)
When the tumour is of a malignant nature, he particularly approves of
using the actual cautery. These intractable tumours on the genital member
are now frequently met with.
SECT. LIX.—ON CATHETERISM, AND INJECTION OF THE BLADDER.
When the urine is suppressed in the bladder, owing to some obstruction,
such as a coagulum, or stones, or from any other cause, we have recourse
to catheterism for the removal of it. Wherefore, taking a catheter
proportionate to the age and sex we prepare the instrument for use. The
mode of preparation is this: having bound a little wool round with a
thread, and introduced the thread with a sharp rush into the pipe of the
catheter, we adapt the wool to the opening at the head of the catheter,
and having cut off the projecting parts of the wool with a pair of
scissors, we put the catheter into oil. Having then placed the patient
on a convenient seat, and used fomentations, if nothing prohibit, we
take the catheter and introduce it at first direct down to the base of
the penis, then we must draw the privy parts upwards to the umbilicus,
(for at this place there is a curvature of the passage,) and thus push
the instrument forwards. When in the perineum it approaches the anus,
we must bend the member with the instrument in it down to its natural
position, for from the perineum to the bladder the passage is upwards;
and we must push the instrument forwards until it reach the cavity of
the bladder. We afterwards take out the thread fastened into the opening
of the catheter, in order that the urine being attracted by the wool may
follow, as happens in syphons. Such is the method of introducing the
catheter. But since we have often occasion to wash an ulcerated bladder,
if an ear-syringe be sufficient to throw in the injection it may be
used, and is to be introduced in the manner described above. But if we
cannot succeed with it we may fix a skin or the bladder of an ox to the
catheter, and throw in the injection through its opening.
* * * * *
COMMENTARY. Although we have treated succinctly of strangury and
retention of urine in the Third Book, it may be proper, before explaining
the ancient methods of introducing the catheter, to give some further
account of the causes of these complaints, and the opinions entertained
by the physiologists with regard to the functional offices of the urinary
organs. Galen states that the bladder is possessed of two faculties, a
retentive and an expulsive, both of which arise from muscular power;
that the retentive resides in the neck of the bladder, and is of the
voluntary kind of powers; but that the expulsive belongs to the class of
natural or involuntary powers, being of the same kind as the peristaltic
faculty of the intestines. When a person, then, makes water voluntarily,
it is by suspending the voluntary action of the sphincter vesicæ, that is
to say, of the retentive faculty of the bladder, whereby the expulsive
or peristaltic powers are brought into action, and the contents of the
bladder are thereby evacuated. He properly adds, however, that this
involuntary or expulsive faculty may be assisted by the action of the
voluntary muscles which surround the bladder, especially the recti
muscles of the abdomen. Retention of urine, therefore, may arise from the
loss of either of these faculties. The expulsive faculty is most commonly
lost, either from over-distension of the bladder, as when its contents
have been allowed to accumulate too far, or from injury of the spinal
marrow which supplies it with nerves. Rhases remarks that when retention
of urine proceeds from debility of the expulsive faculty, the bladder may
be evacuated by merely making pressure above the pubes.
According to Rhases, retention of urine arising from derangement of
the retentive faculty, that is to say, from its no longer being under
the control of the will, may be occasioned by inflammation, by some
swelling, such as a fleshy tumour forming in the meatus urinarius, or by
the presence of some foreign body, such as a stone, a clot of blood, or
the like. He alludes several times to this fleshy tumour in the passage,
by which he probably means either an enlargement of the prostate gland,
or stricture of the urethra. He calls it a very intractable case. For
a fuller exposition of the ingenious speculations and opinions stated
above, see Galen (De Locis Affectis, iv, 4); Rhases (Contin. i and xxiii.)
Celsus describes very accurately the operation of catheterism. The tube
or catheter, he says, should be made of copper, and the male catheter
ought to be somewhat bent, smooth, and neither too large nor too small
for the passage. The length of the largest male catheter should be 15
inches, of the middle-sized 12, and of the smallest 9; the largest
female catheter should he 9, and the smallest 6 inches. The patient is
to be laid on his back, and the surgeon standing by his right side, and
holding the penis in his left hand, is to introduce with his right the
catheter into the urinary passage; and when it reaches the neck of the
bladder, the instrument along with the penis is to be bent downwards and
introduced into the bladder. When the water is evacuated the catheter
is to be extracted. The female passage, he remarks, is shorter, and is
discovered by a sort of mammary protuberance above the vagina, by which
he evidently means to describe the clitoris. The operation, he adds, in
this case is less difficult. (vii, 26.)
The operation is mentioned by Aëtius and other of the Greek authorities,
but none of them describe it fully but Paulus.
Albucasis recommends a catheter made of silver. His account of the
operation is evidently borrowed from our author. He describes and gives
a drawing of an instrument for throwing injections of oil and water into
the bladder when inflamed. It is a tube of silver or copper having the
bladder of a ram attached to it. (Chirurg. ii, 59.)
Avicenna and Serapion mention the operation but do not describe it
minutely. Haly Abbas directs us to make the patient sit and to pour warm
water and oil upon the penis. This is evidently recommended with a view
of producing relaxation. The ordinary steps of the operation are very
properly described by him. (Pract. ix, 45.)
Rhases gives a fuller account of catheterism, and all the circumstances
connected therewith, than any other ancient author. He very properly
forbids the catheter to be introduced when the retention arises from
inflammation at the neck of the bladder. (Ad Mansor. ix, 73.) He first
gives Antyllus’s description of the operation, which is very accurate,
but similar to our author’s. He recommends us, before attempting the
introduction of the instrument, to put the patient into a warm bath, or
to apply hot fomentations to the parts. He then directs us to lubricate
the instrument with oil or thick mucilage, and to introduce it into the
passage until it arrives at the under extremity of the penis, when it is
to be gently pushed upwards in the direction of the navel, turning it
to one side or another according as it encounters obstruction. He states
that it is best to have the openings of the catheter in its sides as they
are less likely to be obstructed by clots than when in the extremity. He
also mentions that he was sometimes in the practice of using a ductile
instrument of lead which accommodated itself to the passage.
Both Serapion and Rhases mention the operation of puncturing the bladder.
Rhases says that when there is retention of the urine and the bladder is
inflamed, if the case be urgent, and there be reason to apprehend that
the introduction of the catheter would aggravate the symptoms, it may be
proper to make an incision in the perineum into the side of the bladder,
and to draw off the urine with a canula. Both add, however, that there is
danger of the wound not closing. (Cont. xxiii, 2.)
The ancients seem to have fancied that it was necessary to fill up the
internal cavity of the catheter with wool, or some such substance, in
order to produce a vacuum when drawn out, believing that the catheter
in this case acted upon the principle of the syphon. See Alexander
Aphrodisiensis (Prob. ii, 59.) It is singular that they should have
fallen into this mistake, when Galen, as we have mentioned above, had
so clearly explained that the evacuation of the bladder is accomplished
by the action of its expulsive powers whenever its retentive faculty is
suspended or overcome. The earlier writers on surgery likewise adopt
the notion that the cavity of the instrument requires to be filled up
with wool. See Guido de Cauliaco (vi, 2.) They describe stricture of
the urethra under the names of _hypersarcosis_ and _caruncula in meatu
urinario_. See Henricus Regius (An. Med. 44.)
SECT. LX.—ON CALCULUS.
The cause of the formation of stones, and that in children they are
formed most readily in the bladder, and in adults in the kidneys,—all
this having been explained in another place, we now proceed to the
method of performing lithotomy, but shall first give the symptoms of
stones lodged in the bladder. The patients then void urine of a watery
consistence with a sandy sediment; and from constant itching the member
is now relaxed and again stretched in an uncommon degree, because, owing
to the irritation, they are perpetually handling it, more especially in
the case of children. When the stone falls into the neck of the bladder
a sudden retention of urine takes place. Of those cut for the stone,
children to the age of fourteen are the best subjects for the operation,
on account of the softness of their bodies: old men are difficult to cure
because ulcers of their bodies do not readily heal; and the intermediate
ages have an intermediate chance of recovery. And again, those who have
larger stones recover best because they have become habituated to the
inflammation, whereas those who have smaller recover with difficulty
for the opposite cause. These things being so, when we proceed to the
operation, we first have recourse to shaking the patient, sometimes by
means of assistants, and sometimes by making him jump from a height, in
order that the stone may be forced down to the neck of the bladder. We
have then to place him sitting in an erect posture, with his hands under
his thighs, in order that the bladder may be forced down into a small
space. If then we ascertain by feeling externally that the stone with
the shaking has fallen down to the perineum, we proceed immediately to
the operation; but if it has not descended, we must introduce the index
finger of the left hand well oiled, or, if an adult, the middle also,
into the anus, and with the fingers in a supine direction we search with
them for the stone, and, bringing it down gradually to the neck of the
bladder, we fix it there, pushing it out with the finger or fingers when
so fixed; and having given directions to the assistant to press down
the bladder with his hands, and ordering another assistant to raise the
testicles in his right hand, and with the other to stretch the perineum
to the other side from that upon which the incision is to be made, we
take the instrument called a lithotome, and between the anus and the
testicles, not, however, in the middle of the perineum, but on one side,
towards the left buttock, we make an oblique incision, cutting down
direct upon the stone where it protrudes, so that the external incision
may be wider, but the internal not larger than just to allow the stone to
fall through it. Sometimes, from the pressure of the finger or fingers at
the anus, the stone starts out readily at the same time that the incision
is made, without requiring extraction; but if it does not start out of
itself we must extract it with the forceps called the stone-extractor.
After the removal of the stone, having stopped the bleeding by manna of
frankincense and aloes, comfrey, misy, and such like styptic powders, and
having dipped wool or compresses in wine and oil, we apply them; and also
apply the bandages for calculous diseases, namely, that having six legs.
But if there be any apprehension of hemorrhage we must apply a compress
which had been soaked in oxycrate, or water and rose-oil, and placing
the patient in a reclining posture, bathe the parts frequently. After
the third day, having loosed the bandages, and poured much water and oil
into the wound, we may dress it with the ointment called tetrapharmacon
(basilicon) on a pledget, removing them and dressing often on account of
the acrimony of the urine. If inflammation come on, we must have recourse
to the cataplasms and fomentations proper for it. And we may also inject
into the bladder oil of roses, oil of camomile, or butter, unless some
inflammation prevent. In like manner, if the sore become spreading, or
otherwise malignant, we must suit the applications to the state of it.
When the ulcer is freed from inflammation we may loose the dressings, and
use diachylon plaster to the groins and bottom of the belly. During the
whole time of the treatment, the thighs must be bound together, which
contributes to the cure with the other remedies. If the stone, being
small, fall into the penis, and cannot be voided with the urine, we may
draw the prepuce strongly forwards, and bind it at the extremity of the
glans. We must next apply another ligature round the penis behind the
member, making the constriction at its extremity next the bladder, and
then make an incision down upon the stone, and bending the penis we eject
the stone, and undoing the ligatures we clear away the coagula from the
wound. The posterior ligature is applied lest the calculus should retreat
backwards, and the anterior, in order that, when untied, after the
extraction of the stone, the skin of the prepuce may slide backwards and
cover the incision.
* * * * *
COMMENTARY. We will now attempt to explain all the ancient descriptions
of lithotomy.
Hippocrates in his _Oath_ binds his pupils not to perform this operation,
but to leave it to those who made it their business. It appears then
that in his days lithotomy was a separate branch of the profession.
Celsus is the earliest author who describes lithotomy, although it is
probable that he merely explained the method of operating in Alexandria,
the surgeons of which city had acquired great celebrity in performing
this operation. He forbids the operation, except after every other remedy
had failed; and in children between the ages of nine and fourteen, and
in the season of spring. The patient is to be kept upon a spare diet
beforehand; and when the operation is about to be performed, he is to
be directed to walk, so as to bring down the stone to the neck of the
bladder, which is to be ascertained by introducing a finger into the
anus. Then a strong and experienced person, sitting on a high seat, is
to take the patient and hold him secure, his buttocks being placed upon
the assistant’s knee, and his legs being drawn in and his hands placed
on them and held there. But if the patient be strong he is to be held
by two assistants, one on each side, upon two seats placed beside one
another, and they are to be directed to press upon his shoulders with
their breasts, so as to force down the bladder. Two other assistants are
to be at hand, to prevent any risk of the former two losing their hold.
The surgeon having pared his nails, is to introduce gently first the
index and then the middle finger into the anus, whilst with the right
he makes pressure upon the abdomen, and in this way the stone is to be
secured at the neck of the bladder. The shape of the stone is to be
considered, and it is to be pressed down so as to favour its exit. These
matters being properly arranged, a lunated incision is to be made over
the neck of the bladder near the anus down to the neck of the bladder,
the horns of the incision inclining a little towards the (left?) buttock;
then at that part where the incision is bent round (at the curvature of
the incision?) even under the skin, another transverse incision is to be
made, by which the neck is to be opened, and the urinary passage dilated,
the opening being somewhat larger than the stone. When the stone is small
it may be propelled and drawn out by the fingers; but if large, it is to
be extracted by a hook or crotchet made for that purpose. This hook is of
a semi-circular form, smooth externally, and rough on the inside. By the
help of it the stone is to be taken out dexterously, attention being paid
to the shape of it. He mentions that Ammonius the lithotomist was in
the practice of breaking down the stone into pieces when it was so large
that it could not be extracted without tearing the neck of the bladder.
He states that the operation is seldom required in the case of females,
but that if the stone be large it may sometimes be necessary. The fingers
are to be introduced into the vagina, as they are into the rectum of
males, and then, if the patient be a girl, an incision is to be made
under the left edge (of the labia pudendi?); but if in an adult female, a
transverse incision is to be made on both sides between the urethra and
os pubis.
The above is but an abridgment of the Celsian description, which, it must
be admitted, is attended with considerable difficulties. We shall give
the passage in which he describes the form and place of the incisions.
“Incidi super vesicæ cervicem juxta anum cutis plaga lunata usque ad
cervicem vesicæ debet, cornibus ad _coxas_ spectantibus paulum: deinde
eâ parte, qua resima plaga est, etiamnum sub cute altera transversa
plaga facienda est, qua cervix aperiatur; donec urinæ iter pateat, sic,
ut plaga paulo major, quam calculus sit.” Sprengel renders the words
“cornibus ad coxas spectantibus paulum” by “dont les angles regardant les
aines;” but _coxæ_ signifies properly not the groins, but the _nates_,
viz., the buttocks, or perhaps the hips. (Celsus viii, 1.) In the English
translation of M. Foubert’s paper on Lithotomy, in the ‘Memoirs of the
French Academy of Surgery,’ these words are more correctly rendered, “the
extremities of which incision must be in some measure directed towards
the thighs.” Dr. Milligan, however, in his edition of Celsus, proposes
to read _coxam_, by which he supposes that Celsus understood the _coxa
sinistra_. He adds: “hinc liquet, cornua plagæ Celsianæ, ut hodiernæ,
coxam sinistram respexisse.” We are inclined to adopt this conjecture,
as it makes the Celsian description agree with that of our author and
his Arabian copyists, all of whom direct the first incision to be made
towards the left _nates_. The words “qua resima plaga est,” must signify,
we suppose, the curvature in the middle of the incision where the two
horns unite. M. Foubert reads “qua strictior ima plaga est,” but we
suspect without any proper authority from MSS.
We may be permitted to remark that the advantages of the semi-lunar
incision are pointed out by Bromfield, and the Celsian operation was
generally practised by the late Baron Dupuytren of Paris.
Aëtius and other of the Greek authorities allude frequently to the
operation, but none of them describe it minutely except Paulus. Our
author’s statement, that there is less danger from the extraction of
large than of small stones, is at variance, we believe, with modern
experience. Aretæus states that small stones are most easily extracted.
He was, however, no advocate for the operation at all, except in extreme
cases. He speaks of cutting “the neck of the bladder.” (Morb. Acut.
Curat, ii, 9.) Does he not allude to attempts at lithotrity in the
following passage?—ὄυτε γὰρ (λίθος μέγας) θρύπτεται, ἢ πόσι, ἤ φαρμάκῳ, ἢ
αμφιθρυπτοιτο, ὂυτε ἀσινέως τέμνεται. (Morb. Chron. ii, 4.) Which passage
may be thus translated: “when the stone is large neither lithotrity, or
lithotripsy, nor lithotomy, can be practised safely.” Theophilus, in his
‘Commentary on the Aphorisms of Hippocrates,’ states that in lithotomy it
is not the bladder, properly speaking, but the neck of the bladder, which
is muscular, that is cut.
We now proceed to the Arabians. Albucasis, after detailing the symptoms
in much the same terms as our author, goes on to describe the operation
as follows. Having cleared out the bowels with a clyster, the patient
is to be shaken so as to make the stone descend, and he is then to be
secured in the arms of an assistant, with his hands under his _nates_.
The surgeon is then to press upon the perineum, and, if the stone be
felt, the operation is to be proceeded with; but otherwise, the index
finger of the left hand, if the patient be a child, and the middle if an
adult, is to be introduced into the anus, and the stone is thereby to
be gradually brought down to the neck of the bladder. Having pushed it
outwards to the place where you mean to make your incision, an assistant
is to be directed to press down the bladder from above the pubes, while
another draws up the testicles with the one hand, and with the other
stretches the skin under them. Then with a proper scalpel the operator
is to make an incision between the anus and the testicles, not in the
middle, but towards the left _nates_, straight upon the stone which is to
be pressed out by the finger. Let the incision be transverse (oblique?),
large externally, but internally of the size of the stone. If the stone
does not then start out, the operator must seize upon it with a forceps,
or a hook having a lunated extremity. If there be more than one stone,
the largest is to be extracted first, and then the others may be easily
removed. When the stone is large he directs us to break it down with a
forceps. His directions respecting the treatment afterwards are similar
to those of Paulus. When the stone sticks in the urethra he recommends
us to cut down upon it. His description of the operation on women is
likewise similar to our author’s, but more circumstantial. Having got a
dexterous midwife, or some proper person to introduce her finger into the
rectum or vagina, and press the stone down to the left hip, the operator
is to make first a small incision over it, and afterwards, by the help of
a sound or specillum, it is to be enlarged so as to allow a passage for
the stone. (Chirurg. ii, 60, 61.)
Avicenna’s description is nearly the same as that of Albucasis, but not
so minute. He directs the surgeon to introduce a finger into the anus,
if the patient be a male, but into the vagina if a woman who is not a
virgin, and to push the stone outwards, so as to make it protrude. He is
then to cut down upon it, making an incision proportionate to the size of
the stone; but if the stone be very large, the incision must not be made
of the same size, but it is to be grasped in a forceps and broken into
pieces. If inflammation come on after the operation, he recommends him to
have recourse to clysters, the warm bath, and venesection, and a piece
of cloth dipped in oil of roses and some vinegar is to be applied to the
part. The bad symptoms after the operation are said to be violent pain in
the part and under the navel, coldness of the extremities, prostration
of strength, loss of appetite, and, at last, singultus and involuntary
discharges from the bowels. (iii, xix, 1, 7.)
The description given by Haly Abbas being nearly the same as that
of Albucasis, need not be noticed here but very briefly. He prefers
performing the operation in infancy, but permits it to be done at all
ages. For the reason assigned by our author he states that recovery is
most likely to take place when the stone is large. Like the others, he
directs the surgeon to introduce either the fore-finger alone, or it
and the middle finger into the anus, behind the stone, and to push it
outwards, and then the operator is to cut down upon it, making the
incision between the testes and the anus, yet not in the middle, but
towards the left side. When the incision is carried down to the stone it
will sometimes start out from the pressure of the fingers in the anus;
but otherwise, it is to be seized upon with a forceps and extracted. If
inflammation come on he recommends us to apply a cataplasm, and to throw
into the bladder an injection consisting of oil of roses and of camomile,
or of melted butter. (Practic. ix, 46.)
Rhases gives from preceding authors several descriptions of lithotomy,
but as they closely resemble our author’s, we shall treat of them only
in a cursory manner. In his first description he directs the surgeon to
place the patient with his hands fastened to his ankles so as to press
down the bladder. When the stone does not descend properly, so as to
be felt externally, he recommends him to introduce one or more fingers
into the rectum and push it outwards; and then while an assistant
draws up the testicles the operator is to make a transverse (oblique?)
incision, larger externally, but internally only of such a size as to
allow the stone to pass out. If the stone does not come out readily it
is to be extracted with an instrument, and the hemorrhage checked with
a composition of aloes, frankincense, and vitriol. When the patient is
a child he recommends the operator to place him upon the knees of an
assistant, and to make pressure on the abdomen so as to force down the
bladder. He forbids the operation when the stone cannot be brought down
to the neck of the bladder. When the stone is large he directs it to
be broken into pieces before extraction. His next description is taken
from the celebrated Antyllus, but as it scarcely differs at all from the
preceding one, we shall merely select a few remarks. When the stone is
smooth, round, and small, he directs the surgeon to push it down to the
neck of the bladder by means of a finger introduced into the rectum, and
to make an incision down upon it; after which the stone is to be forced
out. When pain supervenes after the operation, he recommends him to
place the patient in a bath medicated with camomile, linseed, mallows,
&c.; or if it be summer, and there be any disposition to hemorrhage, to
place him in a vessel filled with strong vinegar. When it is ascertained
that there are clots of blood in the bladder obstructing the urine, he
directs the surgeon to introduce a finger by the incision, and extract
them gradually. His next description is from an author named Sarad, whom
he frequently quotes in other parts of his works. He directs the operator
to introduce a finger into the rectum and push the stone outwards to the
left side of the perineum, removed about the size of a grain of barley
from the raphe (_daram_), and then to make an incision into the neck of
the bladder. He afterwards gives a very circumstantial account of the
operation from another author called Athuriscus. He particularly directs
the operator to make an incision in the left side of the perineum and
to open the neck of the bladder, as a wound of the body of the bladder
seldom unites. When the stone is large he recommends him to seize it
with strong pincers and break it into pieces. When a stone sticks in
the urethra he directs him to tie one ligature behind it and to secure
the prepuce before the glans with another, and then to cut down upon
the stone. He gives very minute directions about the after treatment,
recommending especially the removal of any clots which obstruct the
passage. (Cont. xxiii.)
The practice of lithotomy appears to have been reckoned a disreputable
occupation among the Arabians, for Avenzoar mentions it as an operation
which an upright and respectable man would not witness, far less perform.
(ii, 2, 7.)
As there are some doubts regarding the form of the incisions in the
ancient methods of performing lithotomy, we will now give the words of
some of the Arabian translators. Stephanus Antiochensis, the translator
of Haly Abbas, has the following words: “Inter testes anumque finde et
non in mediâ viâ sed in sinistri lateris parte ab intestinis, sitque
_perallela_ fissura, et ab exterioribus larga, ab interioribus non.”
The translator of Albucasis expresses himself thus: “Finde in eo quod
est inter anum et testiculos et non in medio, ad latus natis sinistræ:
fiat sectio _transversa_.” The following are the words of Avicenna’s
translator: “Cave ne scindas super commissuram quum sit malum, commissura
enim secundum veritatem est locus mortalis. Amplius fac super ipsum
(lapidem?) scissuram tendentem ad _transversum_, studendo ut cadat
scissura in collo vesicæ.” The translator of Rhases expresses himself in
the following terms: “Scinde super lapidem cum instrumento _camadan_;
et scissura debet fieri _transversa_, et sit exterior caro larga et in
interiori vesicæ stricta.”
Yet notwithstanding all this we are inclined to think that the incision
was _oblique_ and not _transverse_; for our author, whom they all follow,
directs us to make the incision oblique (λοξὸς), and it is further
clear that a transverse one would not answer the purpose so well. No
dependence can be put in the accuracy of these barbarous translations.
The language of Stephanus Antiochensis is particularly obscure. Casiri
justly characterizes the translations of the Arabian authors as being
“_perversiones_ potius quam _versiones_.” (Bibl. Hisp. Arab, i, 266.)
The ancient operation, with scarcely any alterations, is described by
the earlier modern writers on surgery. See Brunus (Chirurg. Magna. ii,
17); and Guido de Cauliaco (Chir. vi, 2.) They direct us to introduce
a finger into the rectum and push the stone outwards; then to make an
incision down upon it on the left side of the raphe. Brunus recommends a
longitudinal incision.
It appears that the ancient operation of lithotomy is still practised
with great success by the native doctors of Hindostan. See ‘Transactions
of the Medical and Physical Society of Calcutta,’ vol. iv. An interesting
case in point, related in the ‘Medical Gazette’ for Feb. 7, 1845, forms a
valuable commentary on the Celsian description of lithotomy. In the year
1827 Mr. Madden the traveller saw it performed in Tyre by an old pilot on
a boy of thirteen years of age. The case did well.
SECT. LXI.—ON THE PARTS ABOUT THE TESTICLES.
As contributing to the understanding of the operations on herniæ, we
shall premise a description of the parts about the testicles. The
testicle itself is a glandular and friable substance, formed for the
production of semen. The substances called parastatæ and cremasteres,
are processes from the membrane of the spinal marrow, descending
along with the arterial vessels in the testicles, by which the semen
is injected into the pudendum; the spermatic vessels are veins from
the vena cava passing to the testicles in a convoluted manner, and by
them the testicles are nourished. The tunica vaginalis (erythroides or
elytroides?) is of a nervous nature; at the convex and anterior part not
adhering, but at the concave and posterior parts united to the testicle,
deriving its origin from the peritoneal coat. This part, where it is
united to the testicle, they call the posterior adhesion. The darti are
membranes connecting the external skin to the tunica vaginalis, being
united to it at the part where it is united behind to the testicle. But
that wrinkled skin which forms an external covering to the testicles is
called the scrotum.
* * * * *
COMMENTARY. Celsus gives a similar description of the parts connected
with the testicles. The testicles themselves, he says, consist of
medullary matter and possess no sensibility of their own, but experience
violent pains and inflammations from the membrane which surrounds them.
They hang from the groins by nerves called cremasters by the Greeks, with
each of which descend two veins and arteries. These are covered by a
thin nervous white coat, without blood, called elytroides by the Greeks.
(This must be the tunica vaginalis of modern anatomists.) Above it is a
stronger tunic which adheres strongly to the inner at its lower part, and
is called dartos by the Greeks. (This appears to be the cremaster muscle
of modern anatomists.) The veins, arteries, and nerves are surrounded by
many small membranes. (By these he seems to have meant the fasciæ from
the aponeurosis of the external oblique muscle.) All these parts are
covered by an external investment called the scrotum. (vii, 18.)
Ruffus Ephesius says that the scrotum is a loose substance in which the
testicles are placed, being in particular fleshy externally; that it
consists of two tunics, the external being corrugated and called dartos,
and the internal being called erythroides (elytroides?). The dartos and
scrotum connect the testicles to the parts above, but the erythroides
(vaginalis?) is united to and surrounds the testicle itself. (De Corporis
Humani partium appellationibus, ii.)
Oribasius describes the cremasters as being two muscles which descend
from the groins and surround the tunica vaginalis. (Anatomica ex Galeno.)
(This is very similar to Cloquet’s description of them.)
Theophilus’s description unfortunately has come down to us very
incomplete. (De Fabricâ Hominis, v, ad finem.)
SECT. LXII.—ON HYDROCELE.
An inert fluid, collected about the parts which are enveloped by the
scrotum, and occasioning a marked swelling there, has obtained this
appellation. The fluid is, for the most part, collected in the tunica
vaginalis around the testicle, at its anterior part; but the affection
is sometimes, though rarely, formed externally to the tunica vaginalis.
Often, however, it is collected in the proper tunic of the testicles,
and surgeons call this affection hydrocele of the tunica adnata. If
the complaint is formed from some preceding cause, such as weakness
of the parts, the blood brought there for the purpose of nourishment
is converted into an inert watery or serous substance. But if it is
occasioned by a blow, a sanguineous or feculent substance constitutes
its contents. The common symptom is a permanent swelling without pain
about the scrotum, not disappearing under any circumstances, yet somewhat
compressible when the collection is small, but not at all compressible
when it is large. When the fluid is collected in the tunica vaginalis the
swelling is globular, but somewhat oblong like an egg; and in these cases
the testicle is not to be felt as being everywhere surrounded with the
fluid. But that which is collected externally to the tunica vaginalis,
is felt as through a small intervening substance. When it is formed in
the adnata, being everywhere circumscribed and globular, the swelling has
the appearance of another testicle. If the fluid be watery, the swelling
is of one colour and transparent; but if it be feculent and bloody, it
appears red or livid; and if these symptoms appear in both parts of
the scrotum, you may be sure that there is a double hernia. We operate
upon it in this manner. Having shaven the pubes and scrotum, unless
the patient be a boy, we lay him in a supine posture upon a bench, and
apply to his buttocks a cloth several times folded, and to the scrotum
a sponge of considerable magnitude, and sitting at the left side of the
patient, we give directions to an assistant sitting at his right side to
draw the genital organs to the other side, and to draw up the skin of
the scrotum to the abdomen. Then taking a scalpel we divide the scrotum
longitudinally from its middle to near the pubes, making the incision
straight and parallel to the raphe which divides the scrotum into two
parts, and extending the incision down to the vaginalis. When the fluid
is in the adnata, we make the incision where the apex of the tunica
adnata makes its appearance, and separating the lips of the incision with
a hook, and having dissected the darti with a knife for hydrocele and a
scalpel, and laid bare the tunica vaginalis, we divide it through the
middle with a lancet for bleeding, more especially in that part where it
is separated from the testicle; and having discharged into some vessel
the whole or most of the fluid, we cut away the vaginalis, especially
its thinnest parts, with hooks. Afterwards, Antyllus uses sutures and
the treatment for recent wounds; but the moderns have recourse to what
is called the incarnative mode of treatment. If the testicle is found in
a state of putrefaction, or otherwise diseased, the vessels which pass
along with the cremaster are to be separately inclosed in a ligature,
the cremaster cut, and the testicle removed. And when there are two
hernias we may operate in the same manner twice, directing the incisions
on both sides at the parts of the scrotum about the loins. After these
things, having introduced the head of a probe through the incision below
at the extremity of the scrotum, and elevating the scrotum upon it, we
make an incision with a sharp-pointed scalpel in a convenient situation
for the discharge of the coagulated blood and pus. By means then of
the head of the probe we introduce an oblong pledget into the upper
incision, and having sponged away the clotted blood, we introduce wool
dipped in oil through the incision down to the testicle; and externally
we may apply other pieces of wool dipped in wine and oil to the scrotum,
hypogastrium, groins, perineum, and loins; and applying a compress three
times folded upon them, and binding them with a six-legged bandage, and
other proper bandages, we place the man in a reclining posture, putting
wool under the scrotum for the sake of ease, and spreading the soft skin
under him to receive the embrocations. We bathe with warm oil until
the third day, after which having loosed the bandages we must use the
ointment tetrapharmacon on a pledget, having changed the oblong one.
Afterwards we may again apply the embrocations proper for inflammation
until the seventh day, after which we have recourse to the medicine
called motophylacion. After the ulcer has been cleaned and moderately
incarnated, and the parts have been bathed, we must remove the oblong
pledget, and have recourse to the subsequent treatment as formerly
described. But if inflammation, hemorrhage, or any such disagreeable
consequence come on, we must, in a word, treat each of these in a
suitable manner, that I may not have occasion to make repetitions. But if
we would rather have recourse to the cautery in cases of hydrocele (as
is the practice of the moderns), we must follow all the directions given
as to what is to be done before and after the operation, and also those
given with regard to the operation itself, omitting only the incision
with a scalpel, and the division for allowing the discharge of its
contents. Wherefore having heated ten or twelve cauteries, shaped like
the Greek letter Γ, and two sword-shaped ones, we must first burn the
scrotum through the middle with the gamma-shaped, and having dissected
away the membranes with a scalpel or blunt hook, we must burn with the
sword-shaped as if cutting. Having laid bare the tunica vaginalis (which
is easily recognized by its whiteness and density) with the extremity of
a gamma-shaped cautery, we evacuate the fluid. Afterwards, when the whole
is laid bare, we stretch it with hooks and remove it with a sword-shaped
cautery.
* * * * *
COMMENTARY. Celsus directs the surgeon, when water is contained in a
hernial tumour, to make an incision in the groin, if the patient be a
child, unless the largeness of the collection prevent; but in adults, and
when the swelling is great, he recommends him to make it in the scrotum.
Then if the incision be in the groin, the coats are to be drawn up there
and the water discharged; but if in the scrotum, and if the disease be
seated there, nothing more is to be done but to evacuate the fluid,
and remove any membranes which may happen to contain it; after which
the parts are to be washed with a solution of salt or soda. When the
fluid is situated under the middle or inner coat (the tunica vaginalis
and tunica albuginea?), all these tunics are to be removed without the
scrotum and cut out. (vii, 21.) Celsus, as well as our author, describes
the hæmatocele or bloody tumour, the existence of which is affirmed by
Heister. (ii, 5, 123.)
Galen alludes incidentally to the evacuation of the fluid in hydrocele.
(Meth. Med. xiv.) Sprengel and Guy de Cauliac affirm that he makes
mention of the seton as a mode of cure; but if this assertion be correct
we have not been able to find out the passage in which he does so.
Aëtius gives a very distinct account of the nature of hydrocele, but his
description of the operation is by no means so accurate as our author’s.
He trusts mostly to astringent and desiccative applications. (xiv, 22.)
Albucasis describes the operation in nearly the same terms as Paulus. His
operation consisted of making an incision in the swelling and dissecting
out the coats of the testicles. The dressings which he recommends are
similar to those mentioned by our author. He also describes the operation
by the cautery in nearly the same terms as Paulus. He adds, that if the
patient be timid and do not choose to submit to these operations, the
surgeon may let out the water either with a scalpel or the instrument
used for tapping in dropsy. He states, however, that after this operation
the water will collect again. (Chirurg. ii, 62.)
Avicenna briefly describes the operation of opening the tumour, and
applying cauteries or strong medicines to the membranes. (iii, xxii, i,
6.)
Haly Abbas directs us to open the tumour, and cut out its tunics, and
then to apply incarnative dressings. This treatment, he adds, the moderns
prefer to the escharotic applications used by the ancients. (Pract. ix,
47.) He also describes the process of burning. (Pract. ix, 79.)
Rhases describes the operation of puncturing the scrotum for hydrocele.
He also speaks of burning the part with a slender rod of iron, and of
cutting out its tunics. (Cont. xxiv.)
The membrane called tunica adnata in our translation is the “ima tunica”
of Celsus, and the “panniculus proprius” of the Arabian translation of
Albucasis, and seems to be the same as the tunica albuginea of modern
anatomists.
Sprengel gives an excellent history of the operation of hydrocele. (Hist.
de la Méd. 18, 8.)
SECT. LXIII.—ON SARCOCELE AND TOPHI OF THE TESTICLES.
When flesh is formed in any part of the bodies which are connected by
the scrotum, it gives rise to the disease called sarcocele. This arises
either from some obscure cause, the testicle being attacked with a
defluxion and becoming indurated, or from a blow, or from unskilful
treatment after the operation for hernia. Its consequences are, a
swelling of the same colour, with hardness; when the swelling is of a
scirrhous nature, it is devoid of colour and sensibility; and when it
is malignant there are sharp pains. When going to operate we place the
patient as in the former case, and make the incisions in like manner; and
if the complaint is occasioned by the growth of a fleshy tumour to the
testicle, we divide the dartos and tunica vaginalis in like manner; then
stretching the testicle and bringing it to the outside of the vaginalis,
we separate the cremaster from the vessels, tie a ligature round the
vessels, and cut the cremaster; then we remove the testicle affected with
the fleshy tumour as a foreign body. But if the fleshy tumour be formed
about any of the coats of the testicle or its vessels, having divided
the scrotum and the membranes lying under the flesh, we must dissect out
the whole fleshy tumour. But if the posterior process (“epididymis”?) be
affected with sarcocele, having dissected all the surrounding parts, we
remove the testicle along with it; for it is impossible for the testicle
to continue without it. If tophi be formed about the testicle and the
tunica vaginalis, they may be distinguished from sarcocele and hydrocele
by their resistance, hardness, and inequality, and are to be operated
upon as sarcocele.
* * * * *
COMMENTARY. Celsus describes and recommends the same operations. He
directs us to divide the nerve by which the testicle is suspended (the
cremaster?), then to tie the veins and arteries at the groin with a
thread, and cut them below the ligature. When a fleshy tumour is formed
between the coats he recommends us to cut it out. (vii, 22, 23.) When the
parts are indurated he forbids us to meddle with them.
Albucasis directs us to separate the cremaster from the vessels, to
tie the vessels, and then remove the testicle from the surrounding
parts. When the disease consists of a fleshy tumour which adheres to the
testicle he directs us to cut it out. After the operation the wound is to
be filled with rose-oil and wine. (Chirurg. ii, 63.) The other Arabians
treat of the operation less minutely, with the exception of Haly Abbas,
who describes it exactly as Albucasis. (Pract. ix, 48.)
SECT. LXIV.—ON CIRSOCELE AND PNEUMATOCELE.
When the vessels about the scrotum or darti are in a varicose condition,
they are called simply varices, but if the nutrient vessels of the
testicles be in a varicose state, the affection is named cirsocele. The
symptoms of it are obvious. There is a collection attended with swelling,
and somewhat curved, of a botryoidal shape, and accompanied with
relaxation of the testicle. It also occasions certain inconveniences,
especially in running, exercising, and walking. We may operate upon it
thus. After putting the patient in a convenient posture, we must lay hold
of the scrotum and push the cremaster to the under part; it is easily
distinguished from the vessels, being more slender, firmer, and elastic,
as being strong and firm; the patient also feels pain upon pressure, and
moreover it is connected with the penis. Having secured the vessels in
the scrotum by our own fingers and those of our assistant, and stretching
them strongly, we press obliquely the point of a scalpel direct upon the
vessels; then having transfixed the parts with hooks and dissected what
lie under the skin, and having exposed the vessels, as mentioned in the
operation of angiology and that for aneurism, and pushing through them a
needle having a double thread, and cutting the loop of the thread, we tie
the ligatures round the vessels where the varices arise and where they
terminate, and make a straight incision in the intermediate space. Having
evacuated the blood collected in the tumour, we apply the treatment for
suppurations until the ligatures with the vessels themselves fall out of
their own accord. Leonides says, that when a few of the vessels which
nourish the testicles are in a varicose state this operation should be
performed, but that when all are affected, the testicle should be cut out
along with them, lest being deprived of its nutrient vessels it should
decay. Pneumatocele being a species of aneurism, Leonides forbids us
to operate upon it for fear of a hemorrhage, which cannot be restrained
from taking place at the time; but, there being two kinds of it, the one
occasioned by the four vessels which nourish the testicle, and the other
by the arteries of the darti and scrotum being affected, the moderns
refrain from meddling with the latter, but operate upon the former. We
distinguish them from one another, inasmuch as that which arises from
the arteries is easily made to disappear upon pressure with the fingers,
whereas that from the nutrient vessels of the testicles, not at all or
with much trouble. We operate upon it as for cirsocele, taking up each of
the veins and securing it with a thread.
* * * * *
COMMENTARY. Celsus thus describes the cirsocele: “Venæ intumescunt;
eæque intortæ conglomeratæque a superiore parte, vel ipsum scrotum
implent, vel mediam tunicam vel imam: interdum etiam sub imâ tunicâ,
circa testiculum nervumque ejus, increscunt.” (vii, 18.) He describes
the operation at great length afterwards. If the varicose tumour is upon
the scrotum he directs us to burn it with slender and sharp irons, which
are to be applied to the veins themselves, but in such a manner as to
burn them alone. Then suitable dressings are to be applied for producing
cicatrization. When the varicose veins are situated above the middle
tunic, an incision is to be made in the groin, the tunic drawn out, and
the veins separated from it with a finger or the handle of a scalpel. The
veins are afterwards to be tied with a thread above and below; then they
are to be cut below, and the testicle restored to its place. When the
disease is situated above the third tunic (tunica albuginea?) the middle
one must be cut out. Then if only two or three veins are in a varicose
state they may be tied, as above directed, at the groin and where they
join the testicle and cut out. When the disease is situated between the
internal coat and the testicle, he says, there is no other remedy but the
removal of the testicle. For this purpose he directs us to secure the
arteries and veins with a thread, divide them, and then to cut the nerve
by which the testicle is suspended (the cremaster?). (vii, 19 and 22.) He
does not treat of pneumatocele. It must be obvious that the pneumatocele
of our author was an aneurismal varix or erectile tissue. We see no good
reason, therefore, for the animadversions which Heister makes upon his
account of it. (See Surgery.)
This operation is briefly noticed in the ‘Isagoge’ of Galen, and ‘Meth.
Med.’ (xiv.)
Albucasis considers it a dangerous operation, but says he will describe
it as it was performed by the ancients. He accordingly gives our author’s
account of it, directing us to dissect the congeries of vessels from
the surrounding parts, to pass a needle, armed with a double thread,
under them, and to tie them above and below; then to make a longitudinal
incision in them, and to evacuate the feculent fluids which they contain.
The wound is afterwards to be dressed with incarnants. If all the vessels
are involved in the disease, he directs us to remove the testicle
altogether. (Chirurg. ii, 64.) He says he never saw the operation
performed for pneumatocele; but that the ancients operated for it in the
same manner as for cirsocele. (66.)
Avicenna and Rhases treat of the pneumatocele, and recommend carminative
applications to it; but they do not describe the surgical operation.
Haly Abbas borrows the description of Paulus. (Pract. ix, 49.)
SECT. LXV.—ON ENTEROCELE, OR INTESTINAL HERNIA.
Enterocele is a descent of the intestine into the scrotum, and is
occasioned either from rupture of the peritoneum which takes place in
the groin, or from stretching of the peritoneum. Both these, I mean
rupture and stretching, are occasioned by previous violence, such as a
blow, a leap, or loud crying, but that from stretching in particular is
connected with relaxation and other weaknesses of the body. The common
symptoms of both are a marked swelling in the scrotum, which is increased
by exercise, heat, retention of the breath, and other exertions; and
its symptoms are, that it goes up slowly upon pressure, and quickly
falls down again, and that while the person affected with it lies in a
recumbent posture it remains in its proper place until he stands again
erect. The retention of fæces in the region of the scrotum often brings
on dangerous symptoms; for it is attended with pain, and sometimes
with rumbling of wind upon pressure. The peculiar symptoms of hernia
from distension are, that it does not occur suddenly, but gradually;
that it falls down occasionally from any ordinary causes; that the
swelling appears equable and deep-seated, the protruded intestine being
surrounded by the peritoneum. In those from rupture the descent at
first is sudden, and happens only from violence; the swelling is very
large, and appears seated superficially immediately under the skin,
owing to the intestines having burst through the peritoneum. If the
omentum alone falls down to the scrotum in rupture of the peritoneum the
affection is called epiplocele, but if intestine descend along with it,
it is named epiploenterocele; and if water be contained in the tunica
vaginalis it receives an appellation compounded from all the three. But
neither these nor the intestinal hernia from rupture of the peritoneum
are proper subjects for surgery, but we operate upon enterocele alone
from distension, in the following manner: after placing the patient in
a recumbent posture, and getting the skin in the groin stretched by an
assistant, we make a transverse incision, cutting as in the operation of
angiology (but some make the incision not transverse but longitudinal),
then having transfixed it with hooks we stretch out the incision to such
a degree as to afford room for the testicle to pass through; then passing
through the inner skin a number of hooks proportionate to the size of
the wound, and dissecting the membranes and fat with a blind hook or
scalpel we cut them across. When the peritoneum is everywhere laid bare,
introducing the index-finger at the back part of the scrotum between
the darti and peritoneum, we free the posterior process (epididymis?);
and then with the right hand doubling its extremity to the inside of
the scrotum, and at the same time stretching the peritoneum in the left
hand, we bring the testicle with the vaginalis tunica to the incision,
and give directions to one assistant to stretch the testicle, whilst
we, having completely cleared the posterior process, ascertain by the
fingers whether a fold of intestine be comprehended in the tunica
vaginalis, and if so we must press it down to the belly; then we take
a large-sized needle containing a doubled thread of ten pieces, and we
pass it through the middle at the extremity of the peritoneum close to
the incision; and cutting the double we make four pieces of them, and
laying them over one another in the form of the Greek letter Χ, we bind
the peritoneum securely, and again twisting round the pieces we secure it
so that none of the nutrient vessels may have a free passage to it lest
any inflammation be occasioned, and we apply another ligature farther
out, less than two fingers’ breadth distant from the former. After making
these ligatures we leave about the size of a finger of the peritoneum,
and cut off the whole all round, removing at the same time the testicle,
then making an incision at the lower part of the scrotum to favour the
discharge, we introduce an oblong pledget, and apply embrocations of oil
and bandages as for hydrocele. We must also make the other applications
as there laid down. I have known some not unskilful surgeons who after
the incision into the tunica vaginalis burnt the extremity of it with
heated cauteries for fear of hemorrhage, as would appear. These after
the operation straightway bathed their patients in a long wooden trough
containing hot water, until the seventh day, repeating this as often
as five times during the period of a day and a night, more especially
with children; and it succeeded wonderfully, for they remained free from
inflammation, and the ligatures fell out speedily along with the parts.
In the intervals between the bathings the afore-mentioned embrocations
were applied. Another surgeon, in addition to the means already
mentioned, rubbed into their back at the time pepper triturated with oil.
* * * * *
COMMENTARY. Celsus recommends us, if the patient be a child, to make
an attempt, in the first place, to effect a cure with bandages. In
more advanced ages, if a large portion of intestine has fallen down,
and if attended with pain and vomiting, which symptoms generally arise
from retention of the fæces, it is clear, he says, that the knife is
not applicable, and that the case is to be remedied by other means. He
recommends venesection in the arm, the tepid bath, warm cataplasms, and
spare diet; but he disapproves of purgatives. This is his treatment of
strangulated hernia. When an operation with the scalpel is resolved
upon, an incision having been made in the groin down to the middle
tunic (tunica vaginalis?), the lips of it are to be separated with the
assistance of hooks, while the surgeon frees the tunic from all the small
membranes (external fascia?). When this tunic is removed, an incision is
to be made from the groin down to the testicle, which is to be carefully
cut out. This process, however, is only applicable when the patient is of
a tender age, and the mischief is moderate. When the patient is a strong
man and the disease greater, the testicle is not to be removed, but is
to be allowed to remain in its place. It is accomplished in this manner:
the groin being opened with a scalpel, in the same manner, down to the
middle tunic, it is to be seized with two hooks, so that an assistant
may prevent the testicle from falling out at the wound; then that tunic
is to be cut downwards with a scalpel, and under it the index-finger of
the left hand is to be pushed down to the bottom of the testicle so as to
force it up to the wound: then the thumb and index-finger of the right
hand separate the vein, artery, nerve, and their tunic, from the upper
tunic. But if any small membranes (fasciæ?) come in the way, they are
to be cut out with a scalpel, until the whole tunic be exposed. Having
cut out what is proper, and replaced the testicle, a somewhat broader
thong of skin is to be removed from the lips of the wound in the groin,
in order to enlarge the wound, and thereby occasion a greater formation
of new flesh. The object of this operation, it will be remarked, is to
produce a firm cicatrix at the external abdominal ring. In cases of
epiplocele, he recommends us either to replace the omentum, or to cause
the death of it by septic medicines, cauteries, or the ligature; or to
cut it out with a pair of scissors, but of this proceeding he does not
much approve, as it may occasion dangerous hemorrhage. (vii, 20, 21.)
Galen briefly states that intestinal and omental herniæ are to be cured
by pressing up the intestine or omentum, removing as much as possible of
the spermatic vessels; or otherwise drawing out the peritoneum, fomenting
it, and then cutting it off. (Isagoge.) He mentions that it was customary
to bleed the patient before the operation when he was plethoric. (De Opt.
sec.)
Aëtius speaks of the operation as being highly dangerous. He forbids
attempts at reduction while the prolapsed parts are affected with
inflammation, tormina, and flatus. (xiv, 23.)
Albucasis’s account of the treatment is quite similar to our author’s.
He states that the disease is occasioned by the descent of a portion
of intestine to the testicle, owing to rupture or distension of the
peritoneum. Sometimes, he says, fæces get into the prolapsed bowels, and
being retained give rise to violent and sometimes fatal symptoms. When
going to operate he directs us, in the first place, to make the patient
reduce the intestine if reducible. Then an incision is to be made along
the whole skin of the testicle, and hooks are to be fixed in the lips of
the wound so as to enlarge it, and allow a passage for the testicle. The
membranes, then, below the skin, are to be dissected, so as to expose
completely the tunica vaginalis (_sifac album._) The index-finger is
then to be introduced between the tunica vaginalis and the second coat
(tunica albuginea?) so as to free the adhesions at the back part of the
testicle. The operator is afterwards to separate the testicle from all
its adhesions and raise it up to the external wound. He must now examine
whether any portion of intestine remain protruded, and if so, it must be
replaced. The operator is then to take a large needle armed with a cord
of ten threads, and having introduced it behind the tunic under the skin
of the testicle (tunica vaginalis?) its extremities are to be cut, and
the threads arranged into four pieces. With them the peritoneum is to be
tightly bound in a crucial form, so as that the nutrient vessels may not
be able to reach it, which will obviate inflammation. Another ligature
is to be applied afterwards at the distance of less than two fingers’
breadth from the former. After applying these two ligatures, about a
finger’s breadth of the peritoneum is to be left, and the rest is then to
be cut all around, and the testicle removed along with it. An incision is
then to be made at the lower part so as to allow an outlet for the blood
and matter. Wool dipped in oil is to be applied afterwards, and bound as
formerly described. Sometimes, he adds, the cautery is applied to the
tunica vaginalis after the incision for fear of hemorrhage. (Chirurg. ii,
65.) He describes minutely the treatment by burning in another place. (i,
47.)
Avicenna recommends the cautery, but does not describe the other
operation. Haly’s description is evidently taken from our author. (Pract.
ix, 50.)
Rhases states correctly that hernia generally arises from dilatation of
the passage which leads from the cavity of the abdomen to the testicle.
In ordinary cases, he says, there is no rupture of the peritoneum. He
states that the contents of the hernial tumour are either intestines or
omentum. The omentum, he adds, is the intestine most commonly found in
ruptures. He says the peritoneum (_sifac_) lines the whole intestines
and surrounds the testicles. Antyllus, from whom he gives a subsequent
extract, states in like manner that the peritoneum descends to the
testicles and forms the tunica elytroides, i. e. vaginalis. Antyllus also
affirms that hernia arises from relaxation of the passage between the
cavity of the abdomen and the testicles. This opinion regarding ruptures
is maintained by several of the authorities quoted by Rhases. (Contin.
xxiv.)
Sprengel says of Rhases: “Sa théorie des hernies proprement dites est
infiniment préférable à celle des Grecs.” (Hist. de la Méd.) The account
which Rhases gives of ruptures is, no doubt, very correct; but there is
every reason to suppose that it was entirely taken from the works of the
Greek surgeons.
The operations practised by the ancients for the radical cure of hernia
cannot but appear to us extremely cruel and hazardous; and yet the danger
attending them must have been less than is generally supposed, otherwise
they could not have been so frequently performed as they were about two
centuries ago. Fabricius ab Aquapendente mentions that a celebrated
rupture doctor of his time informed him that he used to operate upon
200 patients at an average every year. Fabricius, however, prudently
recommends us not to perform the operation except in extreme cases, and
to be content in general with supporting the parts by means of a truss.
The ancients never operated to relieve strangulated hernia.
SECT. LXVI.—ON BUBONOCELE, OR INGUINAL HERNIA.
Enterocele arising from distension commences as bubonocele; for at first
the peritoneum being stretched the relaxed intestine is protruded as far
as the groin, and forms this disease, which the ancients operated upon in
this manner. After making the incision to the extent of three fingers’
breadth transversely across the tumour in the groin, and removing the
membranes and fat, and the peritoneum being exposed in the middle where
it is raised up to a point, let the knob of a probe be applied, by
which the intestines will be pressed deep down. The prominences, then,
of the peritoneum formed on each side of the knob of the probe are to be
united to one another by sutures, and then we extract the probe, neither
cutting the peritoneum nor removing the testicle, nor anything else,
but curing it with the applications for fresh wounds. But since burning
in cases of bubonocele is preferred by most of the moderns it will be
right for us to give an account of this operation. After the man has
undergone moderate exercise, let him cough violently and strain to keep
in his breath; and when the swelling appears at the groin we mark with
black ink or collyrium the place that is to be burned in a triangular
figure, making its transverse line above in the situation of the groin,
and we also make a mark in the middle of the triangle. Having laid the
patient in a recumbent posture we first apply to the mark in the middle
nail-shaped cauteries heated in the fire, afterwards burn the sides of
the triangle with gamma-shaped (Γ) cauteries, and afterward level the
triangle with cauteries shaped like tiles or lentils, an assistant during
the whole process of burning wiping away the ichorous discharges with a
rag; and in those who are of a moderate habit of body the burning should
be carried to such a depth as to touch the fat. But in those who are
lean we must not attend to this mark lest by mistake we should burn the
peritoneum; nor again in those who are grosser and fatter, for in them
the fat appears before a sufficient burning has taken place. We must,
therefore, be rather guided as to its extent by a skilful conjecture.
After the burning, having triturated salts with leeks we apply them to
the eschar, and use the inguinal bandage shaped like the Greek letter Χ.
On the following days we complete the cure with the dressings fitting for
eschars, such as lentils with honey, and the like.
* * * * *
COMMENTARY. Celsus directs us, when the inguinal tumour is moderate in
size, to make one incision; but if larger, he recommends two lines to be
made, so that the middle may be cut out; then, without extracting the
testicle, as advised in certain cases of prolapsed intestines, the veins
are to be bound together and tied where they adhere to the tunics, and
afterwards cut below the knots. (vii, 24.)
Avicenna speaks of astringent applications and the actual cautery, but
disapproves of the incision and suture. (iii, 22, 1.)
The operations of the suture and burning are described by Albucasis
(Chirurg. ii, 67, and i, 47); by Rhases (Cont. xxiv); and by Haly Abbas
(Pract. ix, 52, and ix, 80.) They all evidently copy from our author.
Garengoit affirms that Paulus has made mention of crural hernia, but we
agree with Heister that this is a mistake.
SECT. LXVII.—ON RHACOSIS, OR RELAXATION OF THE SCROTUM.
When the skin about the scrotum is relaxed without the bodies within
being affected, rhacosis is formed, being a most unseemly complaint.
Wherefore Leonides, having placed the man in a recumbent posture, cut off
the redundant skin with a scalpel direct upon some board or some hard
skin, and united the lips of the wound with sutures. But Antyllus, having
first transfixed the redundant skin with three or four ligatures, cut
off what was external to them with a sharp-pointed pair of scissors or
scalpel, and having secured the parts with sutures, effected the cure by
the treatment for recent wounds.
* * * * *
COMMENTARY. Our author’s description of the two modes of performing the
operation is copied by Albucasis. (Chirurg. ii, 68); and by Haly Abbas
(Pract. ix, 53.)
SECT. LXVIII.—ON CASTRATION.
The object of our art being to restore those parts which are in a
preternatural state to their natural, the operation of castration
professes just the reverse. But since we are sometimes compelled
against our will by persons of high rank to perform the operation, we
shall briefly describe the mode of doing it. There are two ways of
performing it, the one by compression, and the other by excision. That
by compression is thus performed: children, still of a tender age, are
placed in a vessel of hot water, and then when the parts are softened in
the bath, the testicles are to be squeezed with the fingers until they
disappear, and, being dissolved, can no longer be felt. The method by
excision is as follows: let the person to be castrated be placed upon a
bench, and the scrotum with the testicles grasped by the fingers of the
left hand, and stretched; two straight incisions are then to be made with
a scalpel, one in each testicle; and when the testicles start up they are
to be dissected around and cut out, having merely left the very thin bond
of connexion between the vessels in their natural state. This method is
preferred to that by compression; for those who have had them squeezed
sometimes have venereal desires, a certain part, as it would appear, of
the testicles having escaped the compression.
* * * * *
COMMENTARY. We have given Celsus’s description of the operation in
the 64th section of this Book. Albucasis describes the operations by
compression and by excision. In the former the testicle is squeezed by
the operator while the patient is seated in hot water. In the other
the spermatic cord is to be first secured with a ligature and then the
testicle cut out. (Chirurg. ii, 69.)
They are likewise described in nearly the same terms by Haly Abbas.
(Pract. ix, 54.) The castration of the inferior animals is mentioned by
Aristotle (Hist. Animal. ix, 50); by Varro (De Re Rustica, iii, 9); by
Columella (De R. R. vi, 26); and by Palladius (De R. R. vi, 7.) Varro
informs us that it was customary to make capons by burning the testicles
of cocks with a red-hot iron. It appears from Juvenal that the surgeons
in his time were often called upon to perform castration. (Sat. vi,
l. 370.) Abulpharagius likewise mentions that the performance of this
operation constituted at one time an important part of the surgical
practice in Bagdad. (Dynast. ix.) But the Emperor Justinian condemned the
operation as being dangerous and often fatal.
Sprengel gives an interesting history of castration. One of the most
important points in this operation is the mode of tying the cord. Some
modern authorities affirm that no bad effects result from putting a
ligature round the whole cord, but others condemn this practice as
bringing on convulsions and tetanus. All admit the difficulty of securing
the artery separately.
SECT. LXIX.—ON HERMAPHRODITES.
This affection derives its name from a combination of the names Hermes
and Aphrodite (Mercury and Venus,) and occasions great deformity to both
sexes. There being four varieties of it, according to Leonides; three of
them occur in men and one in women. In men, sometimes about the perineum
and sometimes about the middle of the scrotum, there is the appearance of
a female pudendum with hair; and in addition to these there is a third
variety, in which the discharge of urine takes place at the scrotum as
from a female pudendum. In women there is often found above the pudendum
and in the situation of the pubes the appearance of a man’s privy parts,
there being three bodies projecting there, one like a penis, and two like
testicles. The third of the male varieties in which the urine is voided
through the scrotum is incurable; but the other three may be cured by
removing the supernumerary bodies and treating the part like sores.
* * * * *
COMMENTARY. This section of our author is copied by Albucasis (Chirurg.
ii, 70); and by Haly Abbas (Pract. ix, 55.) Avicenna briefly mentions
this monstrosity. (iii, 20, 2, 43.)
Guy of Cauliac and Brunus describe it in the same terms as the Arabians.
SECT. LXX.—ON EXTIRPATION OF THE NYMPHA AND CAUDA PUDENDI.
In certain women the nympha (clitoris?) is excessively large and presents
a shameful deformity, insomuch that, as has been related, some women have
had erections of this part like men, and also venereal desires of a like
kind. Wherefore, having placed the woman in a supine posture, and seizing
the redundant portion of the nympha in a forceps we cut it out with a
scalpel, taking care not to cut too deep lest we occasion the complaint
called rhœas. The cauda is a fleshy excrescence arising from the mouth
of the womb, and filling the female pudendum, sometimes even projecting
externally like a tail; and it may be removed in the same manner as the
nympha.
* * * * *
COMMENTARY. That the nympha and clitoris were used anciently as
synonymous terms is evident from Ruffus Ephesius (De Partibus Hominis);
Soranus (c. 6); and Pollux (Onomasticon, ii.) Martial, in more than one
place, makes allusion to unnatural practices connected with an enlarged
clitoris. Aëtius says that it is a small muscular substance situated at
the commissure of the alæ pudendi above the meatus urinarius. He adds,
that when preternaturally enlarged it is to be amputated. Like our
author, he directs us to take hold of the tumour with a forceps and cut
off the protuberance, taking care not to carry the excision too far. He
recommends us to apply a sponge squeezed out of an astringent wine or
cold water, with suitable dressings. He gives the same account of the
cauda as our author. (xvi, 103 and 104.) It was a tumour arising from the
uterus itself. Albucasis merely transcribes our author’s account of these
operations. (Chirurg. ii, 71.) Avicenna briefly recommends us to remove
the enlarged nympha by medicines or the knife. (iii, 22; i, 24.) It would
appear that this operation, like circumcision, is still often practised
in the East.
The chapters of Soranus, in which these operations were treated of, are
unfortunately wanting.
On extirpation of the enlarged clitoris see Heister’s Surgery (ii, 5,
147). The _cauda pudendi_ was probably the cauliflower excrescence of the
os uteri described by late authorities on midwifery.
SECT. LXXI.—ON THYMI, CONDYLOMATA, AND HEMORRHOIDS ABOUT THE FEMALE PARTS
OF GENERATION.
The thymus is an excrescence sometimes red, but sometimes white, for
the most part without pain, and resembling the clusters of thyme. The
condylomata are rugose protuberances; and the hemorrhoids resemble
those about the anus, and, like them, sometimes pour forth blood. Such
excrescences in women, when brought into view and exposed, are to be
seized with a forceps and cut out with the point of a half-spatula.
And we are then to use pounded galls, or fissile alum. For the more
distinguished surgeons do not approve of ligatures in these cases.
* * * * *
COMMENTARY. Aëtius gives a fuller account of these tubercles. He
recommends us to seize them with a forceps and cut them out by the roots.
He directs us not to interfere with such hemorrhoids of the womb as are
varicose and malignant. Those which are hard and do not bleed are to be
cut out at once, but such as are disposed to bleed are to be seized with
a forceps and a ligature put round them before they are cut. Moschion,
however, condemns this practice as being highly dangerous.
Albucasis evidently copies from our author. (Chirurg. ii, 73.)
Haly Abbas briefly directs us to seize these tubercles with a forceps and
cut them out with a pair of scissors. (Pract. ix, 65.)
Rhases, treating of diseases of the uterus, says, “if there be a red
piece of flesh in the mouth of the womb, if situated at its anterior
part, and if it be round, or long, and not attended with pain, some
surgeons cut it off, but I prefer tying it.” (Cont. xxii.) This
description seems to apply to polypus of the womb.
See a full account of the condylomata and hemorrhoids of the womb, by
Lodovicus Mercatus (in the Gynæcia, p. 962.) He remarks that Celsus
and Aëtius call any tubercle arising from inflammation by the name of
condyloma, whereas Paulus applies the term only to callous tubercles of
the uterus. He approves of seizing them with a forceps and cutting them
out.
SECT. LXXII.—ON IMPERFORATE PUDENDUM AND PHIMUS.
Some women have the genital parts imperforate, sometimes naturally,
and sometimes owing to some previous disease. And sometimes it is
deep-seated, sometimes in the alæ pudendi, or in the intermediate
places, and is sometimes occasioned by an adhesion of the parts, and
sometimes by obstruction. The obstructing substance is either flesh or
membrane. The disease occasions great impediment sometimes in coition,
sometimes in conception, or in parturition, and occasionally during the
menstrual purgation, provided the membrane or flesh occasion a complete
obstruction; for in certain cases there is a perforation in the middle.
Having ascertained the cause, either from its being obvious to the
sight, or by introducing the speculum, if it be a simple adhesion only,
it may be separated by a straight incision, made with a scalpel, for
operating upon fistulæ. But if it is an obstruction, having transfixed
the connecting body, whether it be membrane or flesh, with hooks, we
stretch it and divide with a scalpel for fistulæ; and having stopped
the hemorrhage with such applications as are desiccative without
being stimulant, we have then recourse to such medicines as promote
cicatrization, applying a priapus-shaped tent covered with some epulotic
medicine, in those cases especially in which the operation is performed
upon a part not very deep-seated, in order that the parts may not unite
again. And the phimus which is formed at the mouth of the uterus is
operated upon in the same manner.
* * * * *
COMMENTARY. Aristotle makes mention of imperforate vagina. (De Generat.
Animal. iv, 4.) Aëtius treats of these diseases at considerably greater
length than our author, but his practice is nearly the same. Upon the
whole the amount of his directions respecting the treatment is, that when
the obstruction is occasioned by a membrane, it is to be divided and
the lips of the incision prevented from adhering by the introduction of
suitable tents; or, if it is a fleshy body, it is to be dissected out,
and the parts separated by a piece of sponge or tents. (xvi, 96.) The
same operation is described by Soranus. (219.)
The same method of treatment, however, had been previously recommended by
Celsus. Thus, when the obstruction is occasioned by a simple membrane, he
recommends us to divide it by two transverse incisions like the letter
Χ, taking great care not to wound the urinary passage, and then the
membrane is to be cut out. When the obstruction is produced by a fleshy
tumour, he directs us to expose it by making a straight incision; then,
having seized it with a forceps or hook, to dissect it out, and introduce
an oblong tent (λημνίσκος) soaked in vinegar, and apply externally wool
moistened with vinegar. The dressings are to be removed on the third day,
and the sore treated upon general principles. When the wound is healing,
he advises us to introduce a leaden tube smeared with some suitable
ointment to prevent adhesion. (vii, 28.)
Albucasis makes mention of a singular substitute for the leaden tube
recommended by Celsus: “Coeat mulier omni die ut non consolidetur locus
vice alia!!” The same advice is gravely given by Rhases (Cont. xxii),
and by Alsaharavius, who, as we have formerly stated, was probably the
same person as Albucasis. (Pract. xxv, 2, 19.) But when the obstruction
arises from a fleshy tumour, Albucasis recommends us to make use of the
leaden tube. (Chirurg. ii, 72.) Alsaharavius directs us to remove the
obstruction by corrosive medicines or with the knife.
Rhases briefly describes the phimus, and directs us to perforate it with
an instrument of iron, and then to introduce a tent moistened in some
styptic wine.
Haly Abbas states that obstruction of the uterus may arise either
from a natural, that is to say, a congenital impediment, or from the
effects of ulceration. He recommends us to make the midwife clear away
the obstruction with a scalpel or any other convenient instrument. The
Arabians were very delicate in allowing male practitioners to perform
surgical operations about the genital organs of women. (Pract. ix, 66.)
SECT. LXXIII.—ON ABSCESS OF THE WOMB.
When the abscess is situated at the mouth of the womb, so as that it
can be operated upon, we must not be in haste in having recourse to
incision, nor until the disease be ripened, and the inflammation has
increased to its utmost, and the vascular bodies which surround it have
become attenuated, owing to the importance of the uterus in the system.
In operating, the woman should be placed on a seat in a supine posture,
having her legs drawn up to the belly, and her thighs separated from one
another. Let her arms likewise be brought down to her legs and secured
by proper ligatures about the neck. The operator, sitting on her right
side, is to make an examination with a speculum proportionate to her age.
The person using the speculum should measure with a probe the depth of
the woman’s vagina, lest the stalk (fistula) of the speculum being too
long it should happen that the uterus should be pressed upon. If it be
ascertained that the stalk is larger than the vagina, folded compresses
are to be laid upon the alæ pudendi, in order that the speculum may be
placed upon them. The stalk (fistula) is to be introduced, having a
screw at the upper part, and the speculum is to be held by the operator,
but the screw is to be turned by the assistant, so that the laminæ of the
stalk being separated the vagina may be distended. When the abscess is
exposed, if it be soft and thin (which may be ascertained by touching it
with the finger), it is to be divided at the top by a scalpel or needle,
and after the discharge of the pus, a soft oblong tent well smeared with
rose-oil is to be introduced into the incision, or rather external to
the opening into the woman’s vagina, so as not to produce compression.
And externally to the alæ pudendi and the region of the pubes and loins
unwashed wool, or clean wool dipped in oil, is to be applied. On the
third day she is to be placed in a hip-bath of warm oil or water, or of a
decoction of mallows; and having wiped the parts, we introduce the tent
gently into the opening, spread with the ointment tetrapharmacon, either
alone or with clarified honey; its strength, however, ought to be reduced
with butter or oil of roses. The external parts are to be covered with
cataplasms until the inflammation subside and the sore become clean. If
it is got cleansed with difficulty, an injection of the decoction of
iris, of birthwort, or of honey, may be thrown up with an ear-syringe.
The healing process may be promoted by the calamine ointment diluted with
wine and applied upon a pledget. But if the abscess be within the mouth
of the uterus, we must decline operating.
* * * * *
COMMENTARY. A similar description of the method of opening abscesses
in the vagina is given by Aëtius. (xvi, 85.) The only difficulty
in comprehending his description or our author’s arises from our
unacquaintance with the construction of the ancient dioptræ or specula.
Drawings of several sorts of them are given in the surgery of Albucasis
and by Scultet. (Arsenal de Chirurg. tab. 18.) One of the simplest of
them consists of two laminæ or plates so united that by turning a vice or
screw they separated to the proper distance. Albucasis evidently copies
our author’s description. (Chirurg. ii, 71.) The account given by Haly
Abbas is quite similar. (Pract. ix, 57.)
SECT. LXXIV.—ON EMBRYULCIA AND EMBRYOTOMY.
We have described the treatment of difficult labours in the Third Book.
If the process of parturition be not rectified by the means there laid
down, we must proceed to the surgical operation, after having formed
a probable conjecture whether the woman will survive or not; and if
she may be saved, then we are to operate; but if not, we must decline
attempting the operation. Those in a dying state are affected with coma,
lethargy, and loss of muscular motion; they are difficult to rouse, or
if roused by loud cries, they return a feeble answer, and again sink
into a comatose state. Some have convulsive contractions, or subsultus
tendinum, or insensibility to food. The pulse is found to be greatly
inflated, but obscure and feeble. Those who are to recover have none of
these symptoms. Having placed the woman in a supine posture, with her
head rather depressed, her thighs are to be kept elevated by women on
each side, or by certain assistants; or if they are not at hand, her
chest is to be first fastened to the bed by ligatures, so that when the
fœtus is pulled the woman’s body may not follow, and diminish the force
of the pulling. Then the alæ pudendi being separated by an assistant, we
must introduce the left hand lubricated with some unctuous substance,
the fingers being contracted, to the mouth of the uterus, and dilate
it, and having got it relaxed by lubricating it with oil, we seek for
the most convenient place for fastening the hook (embryulcus). The most
convenient places in presentations of the head are—the eyes, the occiput,
the roof of the mouth, the chin, the clavicles, and the parts about the
sides and hypochondrium; and in feet presentations, the bones of the
pubes, the middle of the ribs, or, again, the clavicles. The hook is to
be held in the right hand, and its curvature grasped with the fingers,
and it is to be gently introduced with the left hand, and fixed on
some of the afore-mentioned places, being pushed to the cavity of the
uterus. And another is to be applied opposite to it in order that the
pulling may be straight down and not to one side. Then we are to pull
gently, not only straight-forward but also from side to side, as in the
extraction of teeth; and there ought to be no relaxation of the pulling
in the intervals. Then introducing the index-finger or more fingers
besmeared with fat between the mouth of the womb and the impacted body,
we must lubricate it all around. When the hook comes down properly it
must be changed to a part above, and so on until the fœtus is completely
extracted. When a hand presents, and is so impacted that it cannot be
returned, we must wrap a cloth round it so that it may not slip, and pull
it so far, and when it is properly fallen down it should be cut off at
the shoulder. The same thing is to be done when two hands fall down into
the vagina; and in like manner, when the feet come down, and the rest
of the body does not come along, we must amputate at the groins, and
then endeavour to turn the rest of the body. If the impaction take place
owing to the head being larger than natural, if it be a hydrocephalous
fœtus, we must open its skull with a polypus-scalpel, or a needle, or
a sharp-pointed knife concealed between the fingers, in order that it
may collapse when evacuated; but if it be a naturally large head, we
must open the skull in like manner, and break down its bones with a
tooth-forceps or a bone-forceps, and if the bones project they ought to
be extracted. If, after the head has been delivered, an impediment should
take place at the chest, the parts about the clavicles should be divided
down to the cavity of the thorax with the same instrument, so that the
thorax may collapse when its fluid contents are discharged; but if it
do not collapse we may divide the clavicles and extract them, when the
thorax will collapse. If the belly be inflated, owing to the death of
the child, or its being dropsical, we must evacuate its contents with
the intestines in the same way. In presentations by the feet the wrong
direction may be easily rectified at the mouth of the womb. But if the
fœtus stick at the chest or belly, we must wrap a cloth about it and draw
it down, and making a division in the same manner, evacuate its contents.
If, after the other parts are cut off, the head retreat backwards and
is retained, we must introduce the left hand, and if the mouth of the
womb be open, push up the hand to the cavity of the womb, and having
found the head, bring it down with the fingers fixed in the mouth, and
extract by one or two hooks fixed in it; but when there is inflammation
at the mouth of the womb we must use no violence, but lubricate the parts
with unctuous and fatty applications, and have recourse to hip-baths,
embrocations, and cataplasms, in order that when the mouth is dilated
extraction may be accomplished in the manner described above. Cross
presentations, if they can be rectified, may be treated according to the
afore-mentioned methods; but if not, the whole fœtus must be cut asunder
within, and extracted in pieces, taking care that none of the parts of
it be left behind. After the operation we must have recourse to the
treatment for inflammations of the uterus. If hemorrhage come on, you
have already had the management of it described.
* * * * *
COMMENTARY. There is a curious treatise commonly published along with
the works of Hippocrates on the extraction of the fœtus; but, as it
is not mentioned by Erotian and Galen, it is now generally admitted
not to be genuine. The author of it directs us, when the arm presents,
to pull it down and amputate at the shoulder-joint; after which the
head is to be brought to the proper position and delivery accomplished
accordingly. This is not now the general rule of practice, and yet we
were once compelled by necessity to deliver in this way, after we and an
intelligent assistant had been foiled in all our attempts to turn the
child. We have known of similar cases happening in the practice of other
surgeons; and, in fact, this method of procedure was advocated lately
by a sensible writer in the ‘Edinburgh Medical and Surgical Journal.’
The author of the ancient treatise in question recommends us to bring
down the head in its natural state, if possible, but if this be found
impracticable, to break it down. He directs us to give for drink a white,
sweet, undiluted wine.
Celsus gives an interesting account of this subject, and his practice
is deserving of much consideration. He recommends us, when the position
is unnatural, to turn the child either to the head or the feet; adding,
afterwards, that delivery may generally be accomplished easily enough by
the feet. In arm presentations, he approves of turning to the head, that
is to say, in cases when it is ascertained that the fœtus is dead. If
the head is at hand, a smooth hook with a small point is to be fastened
at the eye, the ear, the mouth, or the forehead, and its body is to be
thus dragged down. This, however, must not be attempted when the mouth of
the womb is not properly dilated. The right hand is to be employed in
dragging down the fœtus, and the left in directing the instrument and the
fœtus. When the body of the fœtus is distended with a fluid, it is to be
let out, and the body brought down with a hook. If the child lie across
and the position cannot be got rectified, the hook is to be inserted
at the armpit, and extraction gradually performed. In extreme cases he
recommends us to cut the neck asunder, and extract the parts separately,
beginning with the head, for fear of its being left in the uterus.
Should such an accident occur, however, he directs us to get the belly
compressed so as to force the head down to the os uteri; after which it
may be extracted with a hook in the manner described above. (Smellie
relates histories of such cases.) When one foot presents, and the breech
sticks at the os uteri, he recommends us, when the other foot cannot be
found, to separate the one which protrudes; after which the body of the
child may be pushed up, and the other leg found and brought down. It is
to be recollected that this practice is only recommended when the child
is dead. He adds, that other difficulties may give rise to the necessity
of performing embryotomy. (vii, 29.)
Aëtius has an interesting chapter on the Extraction of the Dead Fœtus,
copied from the works of Philumenus. His description of embryotomy is
similar to our author’s. He directs us to apply two hooks to certain
parts of the head, such as the eye, mouth, and chin, and thus to drag
down the body. If the head is large or hydrocephalic, he advises us to
open it and evacuate its contents; and if even then it is found to be too
large for the passage, he recommends us to break down the bones of the
skull and remove them with a forceps, after which the instrument is to
be fixed and the fœtus dragged down. If obstruction to the delivery take
place at the chest or the belly, he directs us to evacuate their contents
in like manner. When an arm or both present, he recommends us to amputate
at the shoulder-joint. If the child come down doubled, and the position
cannot be got rectified, he advises us, if the head can be reached, to
break down its bones, and then extract the other parts accordingly; but
if the legs are got at most easily and cannot be brought down, they
are to be amputated at the hip-joint, and then the head will be got
delivered. When the body is so impacted in a doubled state that it cannot
be moved, he directs us to separate the vertebra at the neck, and then
to drag down the lower part of the body; after which the head is to be
sought for by the hand introduced into the uterus, and brought along with
two hooks. (xvi, 23.)
No ancient author has described the operation of embryotomy so accurately
as Soranus; but as his account of the process is lengthy and does not
differ essentially from that of Aëtius, (indeed the latter evidently
copies from Soranus,) we need not seek to give any outline of it. (Op.
51, 52, 53.)
Avicenna takes his chapter on the extraction of the dead fœtus from our
author. (iii, 21, 2, 24.) We have mentioned in the Third Book that he was
acquainted with the forceps.
Albucasis, in like manner, takes his account of embryotomy from Paulus.
He relates a singular case that came under his own knowledge of an
extra-uterine conception; the most remarkable circumstance about which
was, that the bones of the fœtus after a time were discharged at the
umbilicus. The work of Albucasis contains drawings of the instruments
used in his time for obstetrical operations. There are several forcipes
among them, but as they all have teeth, it is to be presumed that they
were used only for delivering the fœtus when dead. It is to be regretted
that he has entirely omitted the forceps mentioned by Avicenna. (See
Chirurg. ii, 76 and 77.)
Rhases directs us when the child’s head is large and cannot be brought
down with fillets, to open it and deliver with hooks. When it is
ascertained that the child is dead, he recommends us to break down the
bones of the head and evacuate the brain. In preternatural presentations
he recommends us to deliver, if possible, by the head or feet, but if
this cannot be got accomplished, he directs us to cut off the protruding
part. Upon the whole his rules of practice are much the same as our
author’s. (Cont. xxii.)
Haly Abbas gives ample directions for the management of these cases. When
the head presents (the child being dead and delivery found otherwise
impracticable), he directs us to fix hooks in the hollows of the eyes,
neck, or jaw-bone; or if the feet present, at the tops of the thighs. The
body of the child is then to be dragged along. When a hand presents, he
recommends us to pull down the arm and amputate at the shoulder; and in
like manner he directs us to amputate at the hip-joint when in footling
presentations the delivery cannot be otherwise accomplished. When the
head is preternaturally large, he directs us to open it and evacuate its
contents; and to do so in like manner with the chest when any obstruction
takes place at it. He makes no mention of any instrument resembling the
modern forceps. (Pract. ix, 57.)
SECT. LXXV.—ON RETENTION OF THE SECUNDINES.
Often, after the removal of the fœtus, the placenta (which is also called
the secundines) is retained in the uterus. When the mouth of the uterus
is dilated and the placenta separated, and rolled into a ball in some
part of the uterus, the extraction is most easy. The left hand warmed
and anointed is to be introduced into its cavity, and the secundines
extracted as they present. But if they adhere to the fundus uteri we
must introduce the hand in like manner, and grasp them and pull them
along, not straight down for fear of prolapsus, nor with great violence,
but they are to be moved gently, at first from this side to that, and
afterwards somewhat more strongly, for thus they will yield and be
freed from their adhesion. If the mouth of the uterus be found shut we
must have recourse to the same treatment. If the strength is not sunk,
sternutatories and fumigations with aromatics in a pot may be used; and
if the mouth of the womb dilate, the hand is to be introduced and an
attempt made to extract the placenta, as aforesaid. If even in this way
it cannot be extracted, one need not be alarmed, for after a few days
it will putrefy, dissolve into sanies and drop off. But since the fetid
smell affects the head and disorders the stomach, we must use suitable
fumigations, among which cardamom and dried figs are much approved.
* * * * *
COMMENTARY. We have mentioned in another place that Hippocrates’ practice
in retention of the placenta consisted in suspending weights from the end
of the umbilical cord.
Celsus directs us, when the placenta is not cast off soon after the
delivery of the child, to draw down the umbilical cord gently with the
left hand, taking care not to break it. The right hand is then to follow
it up to the secundines, and their veins and membranes being separated
from the womb, the whole are to be extracted along with whatever
coagulated blood may be in the uterus. (vii, 29.)
Our author merely abridges a fuller account of the subject given by
Aëtius from the works of Philumenus. (xvi, 24.)
Moschion reprobates the ancient practice of using sternutatories,
pessaries, and fumigations, and of suspending scales or weights from the
cord, because these means sometimes occasion hemorrhage. He recommends
the midwife, if the mouth of the womb be still open, to introduce her
left hand, and to take hold of whatever part of the placenta presents:
then, if it does not adhere to the fundus uteri it is to be extracted;
but if it is not separated it is to be moved gently hither and thither
without violence. When the mouth of the uterus is contracted, he advises
her to use those liquors and injections which are applicable for
inflammations of the womb. (Section liv.) His method of securing the
umbilical cord after delivery is nearly the same as that now adopted.
After the child has been allowed to lie on the ground for a few minutes,
two ligatures are to be applied round the cord, the nearest being four
fingers from the belly; it is then to be cut with a scalpel or any sharp
knife. He disapproves of using instruments of wood, glass, or reeds, and
hard crusts of bread, as practised by the ancients. (lxv.) He directs
lacerations of the perineum to be treated by applying ointments composed
of wax, oil of roses, litharge, ceruse, and alum, with suitable bandages.
(lvii.)
The practice of Soranus in these cases is most judicious, and such as
can scarcely be improved upon at the present day. He disapproves of all
violent attempts at extraction, but when the placenta cannot be got
otherwise removed from the womb, he approves of introducing the hand
well lubricated to extract the secundines gently. He directs us when the
mouth of the womb is shut to open it if possible with the fingers in a
gentle manner. This is the case now incorrectly called the hour-glass
contraction.
Avicenna repeats the directions given by Paulus and Aëtius, but seems
to have considered the introduction of the hand into the uterus as a
painful, and, in general, an unnecessary operation. (iii, 21, 2, 16.)
Albucasis follows our author’s practice. (Chirurg. ii, 78.)
Haly Abbas directs us to introduce the hand well lubricated with oil of
violets, or the like, into the uterus, and extract the placenta if it be
separated; but if it still adhere it is to be moved from side to side,
and not pulled straight downwards. He adds, that when not extracted, it
becomes putrid. (Pract. ix, 59.)
Rhases directs us when the secundines do not come away after delivery to
make the woman sneeze, and if they are still retained, to pare the nails,
and having introduced the hand into the uterus to pull cautiously so as
not to give pain. When they cannot be removed in this way, he recommends
us to throw injections into the womb so as to promote putrefaction of
the placenta. In another place he mentions, that when long retained, the
placenta putrefies and comes off in pieces. (Cont. xxii.)
SECT. LXXVI.—ON BURNING THE HIPS.
As in the case of the shoulder, so also the hip-joint getting dislocated
from a collection of humours requires burning. Wherefore Hippocrates
says: “When dislocation at the hip-joint takes place from long-continued
ischiatic disease, the leg wastes, and the patients are lame unless
burnt.” Burning, therefore, is to be performed more particularly at the
place where the joint is dislocated, for thus the redundant humour will
be dried up, and the part being condensed by the cicatrix will no longer
be able to receive the bone, wherefore the burning should be carried to a
considerable depth. The moderns form three eschars by burning; one behind
in the hollow of the buttocks, another a little above the knee on the
outside, and a third on the outside of the ankle in the fleshy part.
* * * * *
COMMENTARY. Hippocrates recommends us to burn the parts over the
hip-joint with crude flax. (De Affectionibus.) The author of another of
the Hippocratic treatises directs us to burn the bony parts with fungi
and the flesh with a red-hot iron. (De Affect. Int.)
Aëtius, upon the authority of Archigenes, recommends burning in this case
with irons, the roots of fuller’s herb and birthwort, or with goat’s
dung. (xii, 3.)
Cælius Aurelianus, in cases of ischiatic disease, speaks of forming
issues over the hip-joint by the actual and potential cauteries.
His potential cauteries, with which he mentions that eschars were
burnt, appear to have been the ashes of herbs, that is to say, impure
preparations of the caustic alkali, to which quicklime was sometimes
added. They must, therefore, have been nearly the same as the _calx cum
kali_ of modern use. He states, that some burned the part with the root
of fuller’s herb; others with pieces of iron shaped like the letter Γ;
that some raised the skin in a fold and transfixed it with heated irons;
that some burned it with fungi, and others with a piece of linen cloth
folded and laid on the part. (Pass. Tard. v, 1.)
But the fullest account which we have of the ancient modes of burning
the hips for diseases of the joint is that which is given in the book
‘Euporistôn,’ ascribed to Dioscorides. Mention is there made of the
methods of burning with goat’s dung, and with wool smeared with oil.
Some, it is said, form a ball of clay, and, having laid it on the place,
apply to it a burning staff as long as it can be borne. Others, having
stretched the skin over the affected joint, transfix it with a heated
style or writing pen. The Libyans performed the operation with shavings
of the lote tree, sulphur, and elaterium. The Marmaridæ are said to have
done it with green pieces of the wood of olive trees. The Parthians used
a leaden tube, the extremity of which they smeared with dough, in order
to prevent the oil in the inside from escaping; then hot cauteries, to
the number of forty or fifty, were introduced, and the burning continued
as long as it could be well endured. Care in the meantime was taken to
cool the face with cold water; and it was attended to, that the tube was
not over-filled with oil, lest it should run over. (Euporist. i, 242.)
Albucasis describes minutely the process of burning with red-hot irons.
(Chirurg. i, 43.) Haly Abbas in like manner directs us to burn an eschar
over the joint, and to keep it open for a considerable time. (Pract. ix,
81.)
Asclepiades (apud Nicetæ Collect.) mentions that he had seen two cases in
which dislocation had taken place at the hip-joint without any accident.
The editor of this work, Anthony Cocchi, states that he had met with
only one such case in the whole course of his practice. We need scarcely
remark that such cases, however, are by no means of rare occurrence.
SECT. LXXVII.—ON FISTULÆ AND FAVI.
The present occasion requiring us to treat of fistula in ano, it will not
be improper to give an account in the first place of fistulæ in general.
A fistula then is a callous sinus, attended with little or no pain, and
forming in most parts of the body. It generally originates in abscesses
not properly healed. The callus is compact and white, the flesh dry, and
therefore insensible, neither vein nor nerve passing to it. Sometimes
the sinus is dry and sometimes filled with a discharge. The discharge is
sometimes constant, and sometimes at intervals, the mouth of it being
at one time shut up, and at another time open. Sometimes the fistula
terminates on a bone, sometimes on a nerve, or some other important part;
and it is either straight or crooked; has either one orifice or many.
Those therefore that terminate upon large arteries, or nerves, or tendons
of considerable size, or the pleura, or any important part, are either
not to be meddled with at all, or with great and skilful caution; but the
others may be operated upon in this manner. We first examine them if they
be straight with a sound (specillum), or if crooked with a double-headed
specillum of a very flexible nature, such as those made of tin, and the
smallest of those made of copper. When there are two or more orifices,
we must not trust to the examination with a specillum, but injecting
the sinus by one of its openings we ascertain from the manner in which
the injection comes out whether it be one fistula with many orifices,
or if there be several fistulæ. After the examination, if the sinus be
superficial and narrow, it is to be distended by the introduction of
a specillum, and the callus is to be cut off with a properly-shaped
scalpel, or pared with the nails or the point of a scalpel. If it is
also broad the redundant parts are to be dissected away. If it is not
superficial, but deep and straight, we must cut off the callus all
around as far as we can make incisions, and if any part remain, destroy
it with a caustic medicine; or if the callus be large, and do not
yield to medicine, we must form a slough by burning it with hot irons.
If the fistula terminate with a bone, and if it is not diseased, we
need only scrape it, but if it is carious, or otherwise corrupted, the
whole diseased portion is to be cut out with counter perforators, and
if necessary we may bore a hole with a wimble (trephine?) whether the
bone be diseased only to the diploe or as far as the marrow. If a bone
project, as after a transverse fracture, we must saw it off. Taking,
therefore, two bandages, we apply the middle of the one to the projecting
bone itself, and get it kept stretched by an assistant; the other being
thicker, or formed of wool, we are to take in like manner, and apply the
middle of it to the flesh under the bone, and taking its ends below,
we give directions that the flesh below be retracted by this band lest
it be torn by the teeth of the saw, and in this manner we accomplish
the sawing. When any vital part is situated below, such as the pleura,
spinal marrow, or the like, in cutting or sawing the bone, we must use
the instrument called meningophylax for protecting them. If the bone is
not diseased, but is denuded of flesh all around, it is to be sawn in
the same manner, for bones which are disengaged from the other parts all
around cannot possibly incarnate. In like manner, the extremity of a bone
near a joint, if diseased, is to be sawn off; and often, if the whole
of a bone, such as the ulna, radius, tibia, or the like, be diseased,
it is to be taken out entire. But if the head of the thigh-bone, or
pelvis, or a vertebra of the spine be diseased, we must not attempt to
operate upon them for fear of the adjoining arteries. We must proceed
in this manner in every particular case, attention being paid to the
situation, proximity, and connexions of the affected parts, the extent
of the disease, the strength and powers of the patient. The favus being
a fistulous sinus with a milky discharge must be subjected to the same
operation and treatment as fistula.
* * * * *
COMMENTARY. For an account of the practice of Hippocrates we refer to our
notes on the 49th section of the Fourth Book.
Celsus states that if fistulæ spread deep, are crooked, or are numerous,
they are to be cured by an operation rather than by medicines. Wherefore,
if it spread transversely, he recommends us to introduce a specillum, or
sound, and cut down upon it. But if it is crooked, its bendings are to
be followed out and cut open in the same manner. When the operator has
reached the end of the fistula, all the callus is to be cut out, and the
lips of the wound secured by clasps and agglutinative applications. When
the fistula terminates with a rib he directs us to saw out a piece of it
lest it affect the adjoining parts. Fistulous sores about the abdomen he
pronounces to be highly dangerous. He recommends us, however, to attempt
a cure by making an incision, and uniting the edges of the wound by
sutures. (vii, 4.)
Aëtius lays down nearly the same rules for the treatment of fistulæ as
our author. When the sinus runs transversely along the skin, he directs
us to lay it open. When it penetrates downwards he advises us to cut
off the callus; and when the ulcer terminates with a bone to remove the
diseased lamina of it. (xiv, 55.)
Albucasis delivers the surgical treatment of fistulæ at great length. He
is very particular in inculcating the necessity of making free incisions,
and of removing any pieces of diseased bone which may happen to be found
at the bottom of the sore. He relates a case of fistulous ulcer in the
thigh, to cure which he removed large pieces of bone, sawing it down as
far as the marrow. Some of his saws are very ingeniously constructed,
and one of them is not unlike the saw introduced into the practice of
surgery by the late Mr. Hey, of Leeds. He enumerates nine causes which
prevent sores from healing; and as they appear to be of some practical
utility we shall briefly mention what they are: 1, a deficiency of blood
in the body; 2, cachexy, or bad condition thereof; 3, fungous flesh,
which prevents the union of the edges of the sore; 4, much sordes in the
ulcer; 5, putridity, or any other bad quality of the fluids; 6, improper
applications; 7 and 8, the pestilential state of the atmosphere and
the insalubrity of the place where the patient resides; 9, a diseased
bone. When none of these causes are present, the restorative principle
of nature will of itself effect the cure of any solution of continuity.
(Chirurg. ii, 88.)
Rhases gives extracts from Antyllus, and many other authors, on this
subject, but as their principles of treatment are much the same as those
delivered by Paulus, we need not occupy much room with an abstract
of them. Antyllus forbids us to use the knife when the fistula is
situated in the groin or fundament. When it is not judged expedient to
have recourse to an operation, one of his Arabian authorities, Aaron,
recommends a powder composed of equal parts of quicklime, cantharides,
arsenic, sandarach, sal ammoniac, and ginger. (Cont. xxviii.)
SECT. LXXVIII.—ON FISTULÆ IN ANO.
Fistulæ in ano are discovered, if they are _blind_, from their being
attended with pain, although no orifice appears; from there being a
purulent moisture about the anus, and in most cases from their being
preceded by symptoms of abscess; or, if they are _open_, by the
introduction of a sound or swine’s bristle; for the instrument will
pass down into a cavity and meet the index-finger introduced into the
anus if the fistula has penetrated to the inside; but if it has not
penetrated, the instrument does not come in contact with the finger
but the intermediate substance between them remains imperforated. The
fistula is known to be crooked and winding from the instrument’s passing
down but a short way, while a great quantity of pus is discharged in
proportion. Those near the intestines are known by an abdominal worm
or fæces sometimes passing through the mouth of them. In almost all
cases some callus appears about the orifice of the fistula. A fistula
is incurable that perforates the neck of the bladder, or extends to the
joint of the thigh, or to the rectum. A fistula is difficult to cure when
it has no orifice, is _blind_, ends with a bone, and has many windings.
All the rest are, in general, easily cured. We proceed with them thus:
having placed the patient in a supine posture, with the legs elevated, so
that the thighs may be bent upon the belly, as when an injection of the
bowels is administered, if the fistula terminate superficially, having
introduced a sound or ear-specillum through the orifice of it, we cut the
skin which covers it at one incision. But if the fistula terminate deeply
in the anus, having introduced a specillum into the mouth of it, and if
we find that it has perforated the gut, by introducing the finger into
the anus opposite the affected buttock, we take hold of the head of the
specillum, and bending it, bring it to the outside, and with one simple
division cut asunder the parts which lie over the sound. If the fistula
is found not to have as yet perforated the gut, and to have terminated
only deeply in the fundament, and if upon examination we find that a
scaly or membranous substance intervenes between the index-finger and
the extremity of the sound, we must perforate it violently with the head
of the sound, and forcing the sound through the rectum, we must again,
as formerly described, cut asunder the intervening parts with a scalpel;
or, having perforated the bottom of the fistula in ano with the sharp
part of a falciform instrument for operating upon fistulæ, we bring the
instrument out at the anus, and so divide all the intermediate space with
the edge of the instrument; and after the incision, having taken hold
of the surrounding parts, which mostly consist of callus, with a common
forceps, or one called staphylagra, we cut them out all around, avoiding
the sphincter muscle; for some cutting deep in an unskilful manner, have
wounded it, from which the patient has had an involuntary discharge
of fæces. Those who from timidity, avoid a surgical operation may be
treated with the ligature, as recommended by Hippocrates. For Hippocrates
directs us to pass a raw thread, consisting of five pieces, through the
fistula by means of a probe having a perforation, or a double-headed
specillum, and to tie the ends of the thread and tighten it every day
until the whole intermediate substance between the orifice be divided and
the ligature fall out. If it remain long, the thread may be sprinkled
with the detergent powder called psarum, or some such powder, and drawn
in. Some insert a thread into the opening of the falciform instrument
for operations on fistulæ, and pass it through in the manner described,
which I think ought not to be done. For by avoiding an operation, in
addition they incur the inconvenience of a slow recovery. With regard to
blind fistulæ, Leonides says: “When the fistula is deep, and penetrates
the sphincter, whether beginning in the fundament, or arising from a
distance and terminating in the sphincter, after the examination which
has been described, we dilate the anus as we do the female vagina, with
the instrument for that purpose, or the small specillum. When the orifice
of the fistula is discovered, the end of an ear-specillum is to be passed
through it, and pushed deep into it, and cutting down upon it where it
presents, the whole fistula is to be divided with a semispathula or a
spathula for operating upon fistulæ.” We having met with this state of
the disease, have found it impossible to practise this mode of operating,
because we could not discover the cavity of the fistula. For it was
situated between the anus and sphincter towards the right side, and the
dilator rather obscured the operation. But having dilated the wrinkles
about the anus a certain fissure appeared among them, being as it were
the defluxion of the fistula, for the pus passed out by it we saw to
pass the head of the specillum into the fistula by it, which served as
a director; and having passed the index-finger of the right hand to the
sphincter, and having found a certain thin substance intervening between
the finger and the sound, by pressing the sound violently to the finger,
we perforated the bottom of the fistula, which was turned upwards; and
passing with the finger the head of the instrument outwards, the whole
of the substance between the mouths of the fistula, (I mean the one so
situated as to favour the defluxion, and that now made by us,) we divided
with a scalpel and cut out the sound.
* * * * *
COMMENTARY. Hippocrates describes minutely the apolinose, or the cure
with the ligature, in his work ‘De Fistulis.’ We must mention, however,
that Kühn and Sprengel do not admit this among the genuine treatises
of Hippocrates, although they allow that it is ancient. Littré also,
though with some hesitation, has rejected it from his list of the genuine
works of Hippocrates. And yet, considering that it was received as such
by Galen and Erotian, it seems bold in any modern critic to refuse its
claims.
Celsus likewise describes distinctly the method of applying the ligature.
The process, he says, is slow but free from pain. It may be expedited by
smearing the thread with some escharotic ointment. The same thing, he
adds, may be accomplished by means of a scalpel guided upon a specillum
(sound). When many sinuses open by one mouth, he directs us to cut open
a straight fistula with a scalpel, and then the others being thereby
exposed are to be tied with a thread. The diet is to be of a diluent
nature, with a liberal allowance of water for drink. (vii, 4.)
Aëtius gives, from Leonides, a full account of fistulæ in ano, as we have
explained in another place. He recommends us to introduce a specillum,
and having cut open the fistula upon it, to pare away the callous parts
of it. (xiv, 11.)
Actuarius approves of the same practice as the others. He cautions
against making large incisions lest the sphincter ani be wounded. (Meth.
Med. iv, 6.)
Albucasis delivers nearly the same rules of treatment as our author.
According to circumstances he approves of the knife, the cautery, or the
apolinose. (Chir. ii, 80.)
Haly Abbas describes only the operation by the incision. He also states
that if the sphincter ani be wounded, it will occasion irretention of the
fæces. (Pr. ix, 60.) See also Rhases (Ad Mansor. ix, 80; Cont. xxviii);
and Avicenna (iii, 18, 1, 18.) Avicenna prefers twisted hairs or bristles
of a hog, as they will not putrefy.
Upon the whole no other of the ancient authorities has treated so
efficiently of fistulæ in ano as Paulus.
See an excellent account of the operation in Sprengel’s ‘History of
Medicine.’ John de Vigo trusted to septics, such as arsenic and the
ægyptiacum. Ambrose Paré approved of the apolinose and incision.
Severinus was an advocate for the cautery. Foubert and Camper likewise
practised the apolinose—the one with a leaden thread, the other with a
silk one. Guido de Cauliaco and Rogerius approve of the ligature. Brunus
and Theodoricus prefer the actual cautery, but describe the others. The
surgeons of this country have now generally rejected the methods with the
ligature and the cautery.
The following account of the ancient specillum by the learned Harduin
will serve to illustrate our author’s description of the operation. We
overlooked it in the commentary on the fifteenth section. “Quid sit
specillum Varro explicat (Lib. 5 de Lingua Lat.) _Quo oculos inunguimus
quibus specimus_ (hoc est, aspicimus), _specillum est_. Græcis μηλὴ
dicitur. Aëtius Serm. 8, 14, _cum specillo instrumento, quod melam Græci
appellant_. Instrumentum parvum ac teres, quo utuntur ad vulnerum aut
fistularum viam aut profunditatem pernoscendam. Une sonde de chirurgien.”
(Ad Plin. H. N. vii, 54.) If the κοπάριον, however, was the same as the
μηλὴ or the specillum, it was evidently used for cutting with as well as
for cutting upon.
SECT. LXXIX.—ON HEMORRHOIDS OR PILES.
The existence of hemorrhoids is rendered manifest to us by the discharge
from them. Before proceeding to the operation we must use frequent
clysters with the view of evacuating at the same time the contents of the
intestine, and, by irritating the anus, of rendering it more disposed to
eversion and protrusion of the gut. Having, therefore, laid the patient
on his back in a clear light, if we are to use the ligature we pass a
very thick thread round the lips and secure each of the hemorrhoids with
this ligature, leaving one as an outlet to the superfluous blood (for
so Hippocrates directs.) After the application of the ligature, using
a compress that has been dipped in oil and the bandage adapted for the
anus, we order the patient to remain quiet, and treat the bowels with
tepid oil and honied water, and afterwards we use a cataplasm made of
crumbs of bread and saffron; and after the falling off of the hemorrhoids
the cicatrization is to be promoted by wine. Leonides has not recourse to
the ligature, but having seized the hemorrhoids and held them for some
time with the forceps used for operations on the uvula he cuts them off
with a scalpel. After the operation we must use manna and starch with
chalcitis, or the plaster of burnt sponge with pitch, and the trochisk
called faustinum, in order to burn it completely. Others by filling the
cavity of the instrument called staphylocaustes, with caustic medicines,
have burnt hemorrhoids like a scirrhous uvula.
* * * * *