Aëtius and most of the medical authors subsequent to Galen, mention the operation of paracentesis, and approve of it.
Vegetius, the veterinary surgeon, recommends paracentesis for the dropsy of cattle, when the swelling is not removed by purging. (Mulom. iii, 25.)
Avicenna expresses himself rather unfavorably of paracentesis. He says, it ought never to be attempted until every other remedy has proved ineffectual, and unless the strength of the patient be good, and he can endure exercise, abstinence from drink, and restricted diet. His description of the operation is taken from Paulus. (iii, 14; iv, 13.)
Serapion mentions the operation in very brief terms. (iv, 7.)
Albucasis’s description is very minute; but, upon the whole, little different from our author’s as to the place of the incision or the instruments with which it is to be performed. After the perforation has been made in the manner directed by our author, he recommends the introduction of a canula made of silver, copper, or brass, and having a small hole at the bottom and three in its sides; he advises us to evacuate only half the water at first. He adds, that when the canula is removed the skin will cover the opening in the abdominal muscles, and thereby stop the discharge. The remaining part of the water is to be removed afterwards, according to the strength of the patient. (Chirurg. ii, 54.)
Haly Abbas does not in general approve of the operation. He mentions, that he never saw it performed but once, and then it did not save the patient. He adds, that Galen relates that he only knew of one case in which it had proved successful. He directs the incision to be made three fingers’ breadth, straight below the navel, that is to say, in the linea alba; but if the liver is diseased he recommends it to be made in the left side, or if the spleen, in the right. (Pract. ix, 41).
Rhases gives Antyllus’s description of the operation, which, however, is scarcely at all different from that of our author. He directs us to make the assistants stand behind and compress the sides of the abdomen, and, if possible, recommends to make the patient sit on a bench. He directs us to make the incision with a large needle below the navel, when the collection is connected with disease of the intestines; but if from the liver, on the left side; or if from the spleen, on the right. Like the other authorities noticed above, he directs us to make the opening of the peritoneum higher up than that of the skin. A canula, made of copper, is then to be introduced into the opening. If the pulse sink during the operation he advises us to stop the discharge of the water. (Cont. xix.)
We have mentioned in our notes on Book Third, section 48, that Hippocrates and Aëtius approved of scarifications at the ankles. It appears that Archigenes also was an advocate for this practice in dropsical cases.
Dropsy of the womb and hydatids thereof are correctly described by Soranus. It seems to be now agreed that the dropsy in this case is a species of large hydatid. (120.)
Protrusion of the navel takes place when the peritoneum there is ruptured and prolapsed; or from the omentum, intestine, and sometimes an inert fluid falling down upon the navel, sometimes from hypertrophy of the flesh, and sometimes from a collection of blood there, proceeding from the rupture of a vein or artery, as in aneurisms; and sometimes the collection consists not of blood, but of spirits only. If, then, the omentum be protruded, there appears a swelling at the navel, which is free from discoloration, soft to the touch, without pain, and uneven; but if it is intestine in addition to the afore-mentioned symptoms, there is greater inequality,—the tumour, when pressed by the fingers, disappears, sometimes with borborygmi; and it is increased by baths and straining. If its contents be a fluid, the tumour is equally soft, not yielding to pressure, and is neither diminished nor increased by it. If it consist of blood, in addition to the afore-mentioned symptoms, the swelling is more livid; but if it arise from hypertrophy of flesh, the tumour will be harder, elastic, and will continue of the same size. Those occasioned by flatulence are attended with softness, a certain sound when tapped, and disappearance upon pressure. We must operate then in this manner. Having placed the man in an erect posture, we order him to press down at the same time that he retains his breath; then, having marked the whole prominence of the navel with black ink, we are to lay him on his back, and dissect around the tumour with a scalpel, agreeably to the marking; then, stretching the middle with a hook, we must apply a thread or string around the part which is dissected, for thus it will be prevented from falling down, when secured with a knot. Then, at the top, having opened the constricted tumour, we must introduce the index-finger, and search carefully lest any fold of the intestine, or part of the omentum, be included in the ligature; and if intestine be included, we must loosen the fold of the thread, and push it inwards, but if it is omentum we may draw it out, and cut off what is redundant of it, securing, as is proper, with a thread, any vessel that may come in the way; and then taking two needles, containing a plain thread, we pass them through the scarified part in the form of the Greek letter Χ, and cutting the doubles of the threads, as we mentioned for aneurism, we make constriction with the four heads. After the bodies secured by the ligatures have become putrid and dropped off, we complete the cure by dressing the part with pledgets, and strive to make the cicatrix particularly hollow. Such is the operation when the part concerned is the intestine or omentum. But if flesh, or fluid, or blood occasions the complaint, having divided the middle of the tumour circularly, and then removed whatever lies external to the peritoneum at the navel, we perform the cure by incarnative applications. But exomphalos arising from aneurism, or the presence of flatus, we must abandon as hopeless, like other cases of aneurism.
Commentary. Celsus gives an interesting abstract of the ancient opinions upon this subject, but as it differs but little from our author’s description, we shall not dwell very particularly upon it. He directs us to cure the disease either by passing through the tumour a needle armed with two threads, in the manner described for staphyloma, or to produce mortification of the part by pressure between two rules. Some, he says, first make an incision in the tumour, so as to be enabled to remove with the greater facility whatever is protruded, but this he thinks unnecessary, as it will be sufficient merely to return the prolapsed substance, and apply a ligature round its base; after which the outer part is to be destroyed by medicines or the cautery. This operation, he adds, will be sufficient, whether the contents of the hernial tumour be intestine, omentum, or water. He intimates, however, that the operation is attended with some danger, and that it is only to be performed between the ages of seven and fourteen, and when the body is in a healthy state. He forbids to interfere with scirrhous tumours. (vii, 14.)
The description of the operation given by Albucasis is very minute, but is to the same effect as our author’s. (Chirurg. ii, 52.) Rhases, in like manner, recommends us to pass a needle, armed with two threads, through the tumour, and to secure it by a crucial knot. He, Avicenna, and Haly Abbas evidently copy our author’s description.
The operation with the ligature, as first described by Celsus, was revived, with very slight modifications, by the celebrated Desault, of Paris, but is now seldom practised.
How wounds of the peritoneum are to be treated is next to be considered. If then the wound be small, so that the prolapsed intestine being distended with air, cannot be restored to its place, it will be necessary either to evacuate the flatus or enlarge the wound. The former measure is the better, provided one can accomplish it. But how may this be most probably done? By removing the cause which occasions the inflation of the intestine. But what is this? Congelation of the surrounding air; so that the cure is to be performed by heating. Wherefore, having soaked a soft sponge in hot water, and then squeezed it out, foment the intestine therewith. In the meantime let hot austere wine be prepared, for it is more heating than water, and communicates strength to the intestine. If, after having had recourse to all these things, the intestine remain inflated, we must divide as much of the peritoneum as the prolapsed intestine requires. The straight instruments called syringotoma, used for operating upon fistulæ, are very proper for this incision. A recumbent position of the patient is the best when the wound is in the lower part; and when in the right side, he may lie on the left, and when in the left, on the right; and this is common both to great and small wounds. But the replacement of the intestine into its proper place when the wound is large, requires a skilful assistant. For he must take hold of the wound externally with his hands, and contract and compress it a little, so as to expose always a small portion to the sewer, and also must compress moderately what is sewed until the whole is sewed. What is the most proper mode of performing the operation called gastroraphé, we must next explain. Since the abdomen must be united with the peritoneum, we have to begin by passing a needle through the skin from without inwards; but when it has transfixed the skin and the whole rectus muscle, passing by the adjacent peritoneum, we must push the needle from within through the other part of the peritoneum, and so hence from within outwards, through the rest of the abdomen; and when it has passed out we must push the needle again from without inwards through this part of the abdomen, and, passing by the adjacent portion of the peritoneum, and beginning again from the opposite side of this membrane, perforate it from within outwards, and at the same time all the other parts of the abdomen; then beginning again from this, sew it with the opposite membrane, and afterwards transmit it from the neighbouring skin outwards; and do this repeatedly until the whole wound be sewed up. The space between the sutures required to keep the under parts together must be very small, but the interval between those required to keep the skin from falling asunder need not be so small. Excess in either respects must be avoided, and a medium chosen between the two extremes. And a medium is likewise to be observed as to the consistence of the thread, for that which is too hard breaks the soft skin, and what is too soft is itself first broken. In the same manner, passing the needle too near the lips of the wound, occasions often a rupture of the remainder which is too narrow. But if too much is taken in, much of the skin remains ununited. These observations apply to the treatment of all ulcers, but are more especially to be observed in gastroraphé; and, as aforesaid, we must act, forming a conjecture as to the adhesion of the peritoneum with the abdomen, from the circumstance that the latter being membraneous seldom adheres; or, as some do, by bringing together the parts of the same kind; that is to say, peritoneum to peritoneum, and abdomen to abdomen. Or, it may be done thus: in the same manner as above, we must pass a needle from the side of the abdomen nearest us, from without inwards, and through it above; then passing both lips of the peritoneum, we must again turn the needle from without inwards through both lips of the peritoneum, and again turning it from within outwards, pass it through the opposite part of the abdomen. This mode differs from the common and vulgar one, inasmuch as the needle is passed through the four lips at one perforation, and exactly conceals the peritoneum within the abdomen. The proper applications are those formed of the same materials as the applications for recent wounds; but in order that no vital part may be affected sympathetically, some tender wool is to be dipped in moderately hot oil, and the whole space between the groins and armpits wrapped in it. It will be better, also, to evacuate the bowels by a clyster of warm oil. But if any of the intestines be wounded, dark austere wine, in a tepid state, should be injected, more especially if it be perforated quite through. The large intestines are easily cured, but the small ones with difficulty, and the jejunum is utterly incurable, from the multitude of its convolutions and the magnitude of its vessels, and owing to its coats being thin and nervous; besides, it receives all the bile in an undiluted state, and is nearest to the liver. The under and fleshy parts of the stomach we may attempt to cure, for we may succeed, not only because these parts are thicker, but because curative medicines are more readily applied to them, owing to their situation. The parts, however, about the mouth of the stomach and œsophagus are affected by the medicines only in passing down; and the exquisite sensibility of the mouth of the stomach is an obstacle to the cure of wounds of it. When, from a rupture of the peritoneum, the omentum is prolapsed, and either becomes livid or black, the part anterior to the black portion may be included in a ligature, for fear of hemorrhage, and then the part behind the ligature is to be cut off, and the extremities of the ligature allowed to hang from the under part of the sewed wound of the abdomen, in order that they may readily escape when cast off by the suppuration of the wound.
Commentary. The description of gastroraphé here given will be sufficiently intelligible upon an attentive perusal. It is taken from Galen. (Meth. Med. vi, 4.) By abdomen, in this place, is to be understood the abdominal parietes, namely, the skin and muscles. Galen explains that ἐπιγάστριον is used in this sense.
Celsus gives a long description of a somewhat different method of performing gastroraphé. He uses two needles. (vii, 16.)
Several modes of performing the operation are minutely described by Albucasis. He relates the history of a case in which he practised gastroraphé. (ii, 87.)
Haly Abbas recommends the warm bath, to facilitate reduction. The method of performing gastroraphé which he directs, is similar to the suture now practised upon dead bodies after dissections. (Pract. ix, 43.)
Rhases describes various modes of gastroraphé. He speaks of performing the operation with the string of a harp. (Cont. xxviii.) That the strings of the ancient harp were made of the guts of a sheep is clearly proved from the following passage in the Odyssey of Homer:
The modes of gastroraphé described by Galen and Celsus are explained and commented upon by Van Swieten (Comment. cccxi), and by Fabricius ab Aquapendente. (Œuv. Chir. ii, 53.) A complete history of the operation is given by Sprengel. (Hist. de la Méd. xviii, 21.) Ambrose Paré performed the operation exactly like Galen.
When there is a small deficiency in the skin of the penis, some, in order to repair the deformity, have attempted a double surgical operation; sometimes cutting the skin all round above at the commencement of the penis, in order that by this solution of continuity the skin may be drawn downwards until the glans (as it is called) be covered; and sometimes with a scalpel dissecting its inner surface from the root of the glans, and then drawing it downwards, and surrounding the glans with a soft ligature; but a piece of cloth must be interposed at the incision, in order to prevent an adhesion of the prepuce to the glans. Antyllus approves most of this method, of which he gives a full description, but we have been content with a brief outline, because it is rare that this surgical operation is required, as the complaint neither occasions any defect of the functional office, nor such deformity that one would choose to submit to the hazard of an operation on account of it.
Commentary. Celsus describes the operation as follows: “Cutis circa glandem prehenditur et extenditur, donec illam ipsam condat; ibique deligatur: deinde, juxta pubem, in orbem tergus inciditur, donec coles nudatur; magnâque curâ cavetur, ne vel urinæ iter, vel venæ quæ ibi sunt, incidantur. Eo facto, cutis ad vinculum inclinatur, nudaturque circa pubem velut circulus; eoque linamenta dantur, ut caro increscat, et id impleat: satisque velamenti supra latitudo plagæ præstat. Sed, donec cicatrix sit, cinctum esse id debet: in medio tantum relicto exiguo urinæ itinere.” (vii, 25.)
Rhases directs us to put a proper piece of lead upon the glans, then to draw the prepuce over it, and secure it with a ligature, having previously dissected it from the parts below, if necessary. (Cont. xiv.) This is much the same as our author’s operation for phimosis. See section lv.
The reader will find the ancient operation described by Fabricius ab Aquapendente. (Œuv. Chirurg. ii, 61.)
In many children the glans is not perforated at birth, but the meatus is situated under the part called canis, at the termination of the glans. Hence they can neither make water forwards unless they draw up the member to the pubes, nor procreate, as the semen cannot be injected direct into the uterus. In addition to these defects, the complaint occasions no ordinary deformity. Wherefore, the simplest and least dangerous mode of operation is that by amputation. Having then placed the patient in a supine posture, we have to stretch the glans forcibly with the fingers of the left hand, and then with the point of a scalpel we are to amputate the glans at the corona, not making the amputation obliquely, but carving it, as it were, all round, so that an eminence may appear in the middle resembling the glans. And since a hemorrhage frequently takes place, we may stop it by styptics if possible, but if not, we must have recourse to burning with slender cauteries.
Commentary. Galen makes mention of this deformity. (De usu Partium.) See also Theophilus. (De Fab. Hom. v, 22.)
Albucasis evidently transcribes our author’s description. The part named canis (κυὼν) by our author is called finis capitis virgæ in the translation of Albucasis, and finis coronæ in the translation of Haly Abbas. (Pract. ix. 44.) We do not remember to have seen the term κυὼν applied by any other medical author to a part of membrum virile. Perhaps the proper word is ἳς gent. ἱνὸς which is applied by Galen to a part of the genital member. (Meth. Med. xiv. 16.)
Guido de Cauliaco directs us to make an opening with a suitable instrument and introduce a canula of lead or wood. (iv, 2.)
There are two causes of phimosis; for sometimes the prepuce so covers the glans that it cannot be retracted; and sometimes when drawn behind, it cannot be brought forward, which last species is properly called paraphimosis. The first variety is occasioned either from a cicatrix formed in the prepuce, or from an adhesion by flesh. But the second variety takes place in inflammations of the genital organs when the skin being brought back, the glans swells, and it cannot longer allow of being drawn forward. If it is the first species of phimosis we may operate upon it in this manner. After having placed the patient properly, and drawn the prepuce forwards, and having fastened three or four hooks into its extremity and giving them to assistants to hold, we direct them to stretch and open it; and then if the external adhesion be from a cicatrix, we divide the prepuce from the internal parts with a lancet or sharp knife in three or four places, making the divisions at the inner parts direct and equally distant from one another. The prepuce at the glans is double, wherefore we divide the mouth of the inner part; for having thus opened the contraction formed by the cicatrix, we are enabled to retract the prepuce. But if a preternatural adhesion of the flesh of the internal parts occasion the phimosis we may make scarifications in all the flesh, drawing back the prepuce and scraping away the fleshy prominences between the incisions, and afterwards apply a tube of lead to the whole glans, having wrapped it in dried paper (papyrus), the tube having its opening the same everywhere; for thus, by the application of the tube, the prepuce, when brought forwards again, is prevented from forming adhesions, being kept separate by the lead and the paper wrapped round it; for by getting swelled with the moisture it separates the skin still more. This we may do whether we operate upon a phimosis occasioned by a cicatrix, or one from a preternatural adhesion of flesh. But if the complaint called paraphimosis take place, and become chronic, adhesions take place, and the complaint is incurable, unless one choose to submit to the operation for deficiency of prepuce. But if it has not yet formed adhesions, we may make three, four, or more direct incisions circularly, and having bathed with much tepid oil, draw the prepuce outwards.
Commentary. Celsus describes the operation as follows: “Subter a summâ orâ, cutis inciditur recta linea usque ad frænum; atque ita superius tergus relaxatum, cedere retro potest. Quod si parum sic profectum est, aut propter angustias, aut propter duritiem tergoris, protinus triangula forma cutis ab inferiore parte excidenda est, sic ut vertex ejus ad frænum, basis in tergo extremo sit. Tum superdanda linamenta sunt alia que medicamenta quæ ad sanitatem perducant. Necessarium autem est, donec cicatrix sit, conquiescere: nam ambulatio, atterendo ulcus sordidum reddit.” (vii, 25.)
Our author’s description of the operation for keeping the prepuce separated from the glans, by means of a leaden tube, is mostly taken from Galen. (Meth. Med. xiv, 16.)
When there has been a previous ulceration about the glans, or prepuce, an adhesion of the one part to the other takes place. We must, therefore, dissect around, as far as may be, endeavouring to separate the adhesion with the point of a scalpel, or of a polypus knife, and more especially to free the glans completely from the prepuce, to which it adheres; but, if this be found difficult, we must rather add of the glans to the prepuce with which it is united, than contrariwise; for the prepuce, being thin, is readily perforated. After the disengagement of the adhesion, a thin cloth, dipped in cold water, is to be placed between the glans and the prepuce, that no adhesion may again take place, and the parts are to be healed with some astringent wine.
Commentary. Albucasis describes the operation in exactly the same terms. (Chirurg. ii, 56.)
We do not treat at present of those who are circumcised in conformity to a heathen rite, but of those in whom the prepuce has become black from some affection of the privy part. In such cases, it becomes necessary to cut off the blackened portion all around; and afterwards we must have recourse to the squama æris, with honey, or to pomegranate-rind and tare, in the form of those applications which are made upon a pledget. And if there be a hemorrhage, we must use lunated cauteries, which contribute to two good purposes: I mean the stoppage of the bleeding and of the spreading sore. But if the whole glans be consumed, having introduced a leaden tube into the urethra, we direct the patients to make water through it.
Commentary. See a similar description in Albucasis. (Chirurg. ii, 57.) Albucasis describes the mode of performing the operation on boys, as a rite of the Jewish religion. He directs the prepuce to be cut with a pair of scissors, and the part allowed to bleed freely. From the manner in which he expresses himself respecting the operation, there can be no doubt that he was a Jew, and it is equally clear that our author was a Pagan.
Fabricius ab Aquapendente describes a similar operation. (Œuv. Chirurg. 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.)
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.
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.)
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.
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.)
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.)
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.)