Chapter XXV: Preface (3)

If however blood has made its way into the scrotum, or any coagulated blood has fallen down into it, an incision should be made below it; and after cleansing it, a spunge moistened with sharp vinegar must be applied round it. A wound that has been made for these reasons, after it is tied up, if there be no pain, must not be opened for the first five days; but either the wool or spunge, that lies over it, must be sprinkled twice a day with vinegar alone; if there be pain, it must be opened on the third day; and where there are fibulæ, they must be cut; and where lint, that must be changed; and what is put on, must be wet with oil of roses and wine. If the inflammation increases, to the foregoing applications must be added a cataplasm of lentils and honey, of pomegranate bark boiled in a rough wine, or a mixture of these. If the inflammation does not give way to them, after the fifth day, the wound must be fomented with plenty of hot water, till the scrotum itself be both extenuated, and become more wrinkled; then a cataplasm must be applied of wheat meal, with an addition of pine resin; which, if the patient be a robust man, must be boiled up with vinegar; if more delicate, with honey. And whatever the disorder has been, if there be a great inflammation, without doubt medicines to promote a suppuration must be applied.

But if pus is generated within the scrotum, a small incision ought to be made to give a vent; and so much lint is to be applied as to cover the orifice. When the inflammation is removed, upon account of the nerves, the last-mentioned cataplasm, and then cerate must be used. This is the peculiar treatment of wounds of this kind. All other things both in regard to the manner of dressing, and the diet, should be conformable to the directions we have given about other wounds.

CHAP. XX.

OF THE CURE OF A RUPTURE OF THE INTESTINE INTO THE SCROTUM.

These things being premised, we must descend to the particular species. And if the intestine comes down in a young child, a bandage must be made trial of before the knife: for this purpose a roller is sewed, to which in one part a bolster is used made of cloths, which is applied under the intestine to repel it; and then the rest of the roller is bound tight about him: by means of which, the intestine is often forced in, and the coats are agglutinated together. Again if the patient be advanced in years, and from the largeness of the tumour it appears, that much of the intestine has fallen down, and the case is attended with pains and vomiting (which generally proceeds from the excrements getting down into that part by a crudity) it is plain that the knife cannot be used without fatal consequences; the complaint is therefore only to be alleviated; and the intestine evacuated by other methods.

The patient ought to be bled in the arm: and then if his strength will admit, abstinence must be enjoined for three days; if he cannot bear that, at least as long as his strength will allow. At the same time must be kept upon it a cataplasm of lintseed boiled in mulse. After these both barley meal with resin must be applied, and the patient put into a bath of warm water mixed with oil; and some light and hot food must be given. Some even administer clysters. These may carry something into the scrotum, but cannot evacuate any thing from thence. The disease being mitigated by the methods above prescribed, if the pain returns at any time, the same course must be pursued.

If a great portion of the intestine has fallen down without pain, it is also needless to make an incision; not but that it may be removed from the scrotum (unless an inflammation prevent) but because when repelled thence, it stops at the groin, and raises a tumour there; and thus there is not a termination, but a change of the malady.

But where the use of the knife is proper, as soon as the wound made in the groin shall reach to the second coat, that must be taken hold of near the lips with two small hooks, while the physician disengages it by taking out all the small membranes: for that, which is to be cut, cannot be injured without danger, as the intestine must lie below it. When it shall be separated, an incision must be made from the groin to the testicle, care being taken not to wound the last; then it must be cut out. For the most part however this operation is _only_ practicable in children, and in a moderate degree of the malady.

But if it be a robust man, and the disorder be more considerable, the testicle ought not to be taken out, but to remain in its place. The operation is performed in this manner. The groin is opened in the same way by a knife, as far as the middle coat; and this coat in like manner is taken hold of with two hooks, and the testicle is held by an assistant(24), so as to prevent its coming out at the wound; then an incision must be made downward in this coat with a knife; and below it the fore finger of the left hand is introduced to the bottom of the testicle, which it forces up to the wound: then the thumb and fore finger of the right hand separate the vein and artery, and their nerve, and coat from the external coat. And if any small membranes obstruct this, they are divided by the knife, till the coat be wholly exposed to view. When all is cut out, that requires excision, and the testicle is replaced, a pretty broad habenula is to be taken from the lip of the wound in the groin, that the wound may be the larger, and generate the more flesh.

CHAP. XXI.

OF THE CURE OF A RUPTURE OF THE OMENTUM INTO THE SCROTUM.

But if the omentum descends, the groin must be opened, and the coats separated in the same manner as directed before. And it must be considered whether it be a large or small part of it. For when it is very small, it must be forced back over the groin into the abdomen by a finger or the broad end of a probe: if it is large, whatever has fallen out of the abdomen must be allowed to remain there; and it must have escharotic medicines laid on it, till it mortify and fall off. Some in this case pass through it a needle with two threads, and tie the two ends of each contrary ways; by which it mortifies with equal certainty, but not so soon. The effect is accomplished sooner, if the part of the omentum above the ligature be rubbed with eating medicines, but not corrosive; they are called septica by the Greeks. There have been others, who have cut off the omentum with scissars: which is not necessary, where the quantity is small; and if large, it may occasion an hemorrhage; for the omentum is also connected by veins, and some of them large. Neither can this practice be justified by an example drawn from the cases of the belly opened by a wound, where the part of the omentum, which falls out, is cut away by the scissars: since in this case, it is both mortified, and cannot be taken off in any other way more safely. If the omentum be reduced, the wound ought to be stitched; or if it has been large and has mortified externally, the lips must be cut off, as proposed before.

[Sidenote: _Of a hydrocele._]

If there be a fluid within _the membranes_, an incision must be made, in boys upon the groin, unless too large a quantity of fluid forbid the operation in that place; but in men, and where-ever there is a large quantity, the scrotum must be opened. Then if the incision be made in the groin, the coats must be drawn out at that part, and the humour evacuated; if at the scrotum, and the disease be immediately below that coat, there is no more required but to evacuate the humour, and cut away any of the membranes, that happen to contain it; then it must be washed with water, and an addition either of salt, or nitre: if the disease lie within the middle or innermost coat, they must be taken entirely out of the scrotum and cut off.

CHAP. XXII.

OF A RAMEX IN THE SCROTUM.

A ramex situated upon the scrotum must be cauterized with small and sharp irons run into the veins themselves, provided they burn nothing else: it is peculiarly necessary to apply the cautery where they are twisted and rolled together; afterwards meal mixed up with cold water must be laid on; and the bandage must be applied, which I recommended for the anus; on the third day lentils with honey must be put to it: after the separation of the eschars, the ulcers must be deterged with honey, embrocated with rose oil, and brought to cicatrize by dry lint. Where the veins above the middle coat swell, the groin must be cut, and the coat brought without the orifice; after which the veins are to be separated from it by the finger, or the handle of the knife, and where they adhere, tied both above and below by a thread; then they must be cut through close to the ligatures, and the testicle replaced. But if the ramex be situated upon the innermost coat, it is necessary to cut out the middle one. And then if two or three veins swell, so that some part be affected, but the greater part be from the disease, the same method must be pursued as directed above; that is, the veins being tied both at the groin and testicle, may be cut off, and the testicle reduced to its place. But if the ramex have seized upon the whole of it, the fore finger must be introduced through the wound, and put under the veins, so as to draw them out gradually and uniformly, till the one testicle be equal to the other; then fibulæ are to be put in the lips in such a manner, as to lay hold of these veins likewise. It is done thus. A needle passes through the lip from the external part, and then is directed not through the vein itself, but its membrane, and from thence is forced into the other lip. The veins ought not to be wounded, lest they discharge blood. There is always a membrane between these veins, which occasions no danger, and holds them fast enough, when taken up by the thread: and therefore two fibulæ are sufficient. After this, whatever veins have been brought out, should be returned into the groin with the broad end of the probe. The time for loosing the fibulæ is, when the inflammation is gone, and the ulcer deterged; that the cicatrix may at once bind up both the lips and the veins.

When the ramex has grown between the innermost coat, and the testicle itself and its nerve, the only cure is to cut off the whole testicle: for it does not in the least contribute to generation, and hangs down in all indecently, in some even with pain. But in this case too, an incision is to be made in the groin, and the middle coat must be drawn out and cut away; the innermost one is to be treated in the same manner; and the nerve, by which the testicle depends, to be cut off. After this, the veins and arteries must be tied by a thread at the groin, and cut off below the ligature.

CHAP. XXIII.

OF A SARCOCELE.

If flesh happen to grow between the coats, it must certainly be taken out; and the most convenient way of doing it is by an incision in the scrotum.

But if the nerve be indurated, the disorder cannot be cured either by the hand or medicines. For the patients are oppressed with ardent fevers, and either green, or black vomitings, besides these a violent thirst, and roughness of the tongue; and generally about the third day, frothy bile is discharged by stool, which excoriates the parts; and food can neither be easily taken or retained; not long after, the extremities grow cold, a tumour comes on, the hands are expanded involuntarily; then comes on a cold sweat in the forehead, which is followed by death.

CHAP. XXIV.

OF A RAMEX IN THE GROIN.

When there is a ramex in the groin, if the swelling be small, a single incision ought to be made; if it be larger, it ought to be done in two lines, that what lies between may be cut out; and then without taking away the testicle, as I have above shewn to be sometimes practised in a rupture of the intestines, the veins must be taken up, and tied, where they adhere to the coats, and cut off below these knots. The cure of this wound is no way different from others.

CHAP. XXV.

THE OPERATIONS REQUISITE IN THE DISORDERS OF THE PENIS.

From those we are to proceed to the operations upon the penis. If the glans be bare, and a person chuses for the sake of decency to have it covered, that may be done; but more easily in a boy than a man; and more easily in one, to whom it is natural, than in another, who according to the custom of some nations has been circumcised; better where the glans is small, and the skin about it pretty large, and the penis itself short, than where there is quite the reverse of these circumstances. The cure of these, in whom it is natural, is performed in this manner. The skin about the glans is laid hold of, and extended till it cover it, and tied there; then near the pubes a circular incision is made on the skin of the penis, till it be laid bare; and great caution is used not to cut either the urinary pipe, or the veins in that part. When this is done, the skin is drawn towards the ligature, so that a part near the pubes is laid bare resembling a hoop; then over it is applied lint, that the flesh may grow and fill it up, and the breadth of the wound may afford a sufficient covering to the glans. But the ligature must be continued till a cicatrix be formed, leaving only in the middle a small passage for the urine. But in a person, that has been circumcised, under the circle of the glans, the skin ought to be separated by a knife from the inner part of the penis. This is not very painful, because the extremity being loosened, it may be drawn backwards by the hand, as far as the pubes; and no hemorrhage follows upon it. The skin being disengaged, is extended again over the glans; then it is bathed with plenty of cold water, and a plaister put round it of efficacy in repelling an inflammation. For the following days the patient is to fast, till he be almost overcome with hunger, lest a full diet should perhaps cause an erection of that part. When the inflammation is gone, it ought to be bound up from the pubercles to the circle of the glans; and a plaister being first laid on the glans, the skin ought to be brought over it; for thus it will happen, that the inferior part may be united, and the superior heal so as not to adhere.

On the contrary, if the glans be covered, so that it cannot be denuded (which malady the Greeks call phymosis) it must be opened: which is done in this manner. An incision is made in the prepuce below its extremity, in a right line to the frænum; and the upper part being thus relaxed, may be drawn back. But if this be not effectual, either upon account of the straitness or hardness of the prepuce, a piece of skin must be immediately cut out in the lower part in the form of a triangle, with its vertex at the frænum, and the base at the extremity of the prepuce. Then lint is to be applied over it, and other medicines to heal it. And it is necessary to continue at rest till it be cicatrized; for walking, by the attrition it causes, renders the ulcer foul.

[Sidenote: _Of infibulating boys._]

Some have made a practice of infibulating boys, sometimes upon account of their health(25): the method of doing it is this. The skin that covers the glans is extended, and marked on both sides with ink, where it may be perforated, and then is let go. If these marks return upon the glans, too much has been taken up, and it ought to be marked nearer the extremity: if the glans is not reached by them, that part is proper for the fibula. Then where the marks are, the skin is pierced by a needle followed by a thread, and the two ends of this thread are tied together, and moved every day, till small cicatrices be formed about the orifice. When these are confirmed, the thread is taken out, and a fibula put in, which, the lighter it is, is so much the better. But this operation however is more frequently needless than necessary.

CHAP. XXVI.

OF THE OPERATION NECESSARY IN A SUPPRESSION OF URINE, AND LITHOTOMY.

Sometimes when no urine is made, an operation is necessary to discharge it, either because the passage is collapsed from old age, or because a stone, or some other concretion from blood has obstructed it within; and a moderate inflammation also often prevents it from being evacuated in a natural way. And this is requisite not only in men, but in women too sometimes. For this purpose are made copper pipes; and that these may serve for all bodies larger and smaller, a physician must have by him three for men, and two for women. Of the male kind, the largest is fifteen fingers breadth long, the middle size twelve, the least nine; for the females, the greater is nine, and the lesser six. They ought to be curved, but more especially the male kind, and very smooth; and their diameter neither too large, nor too small.

The patient then is to be laid on his back, in the same manner as is described in the operation for the stone, either on a couch or bed. The physician standing on the right side, ought with his left hand to take hold of the penis if it be a man, and with his right to introduce the pipe into the urinary passage; and when it comes to the neck of the bladder, by an inclination of the pipe and the penis at once, to force it into the bladder, and when the urine is evacuated, to take it out again. In a woman, the urethra is both shorter, and straighter, and resembles a caruncle, being situated between the labia pudenda above the vagina; and they as frequently require assistance, but it is not attended with so much difficulty.

Sometimes a stone sliding into the urethra, sticks, where that grows narrower(26), not far from the end; if possible it ought to be drawn out either by a specillum oricularium, or the instrument, with which the stone is extracted in cutting for that distemper. If that has proved impracticable, the prepuce must be drawn out as much as possible, and the glans being covered, must be tied by a thread; then on one side a longitudinal incision must be made into the penis, and the stone extracted; after this the prepuce is let go; for by this means the sound part of the skin covers the incision in the penis, and the urine will be discharged in the natural way.

Since I have made mention of the bladder and stone, the place itself seems to require me to subjoin the _chirurgical_ cure for calculous patients, when they can be relieved no other way. But since that is a very dangerous method, it is by no means proper to undertake it precipitately. Nor is it to be attempted in every season, nor at all times of life, nor in every degree of the disease; but only in the spring, and upon a patient, whose age exceeds nine years, and not fourteen; also if the disease has arisen to such a height that it can neither be overcome by medicines, nor protracted, but that in some time it must kill. Not but that now and then even a rash attempt succeeds; however it more frequently fails in this case, because there are more kinds and seasons of danger, all which I shall mention together with the operation itself.

Therefore when it is resolved to try the last remedy, for some days before, the body must be prepared by diet, that is, by taking moderately wholesome food, no way glutinous, and drinking water. In the mean time the patient must exercise by walking, to cause the stone to descend towards the neck of the bladder. Whether this has happened may be known by introducing the fingers, as I shall shew in the operation. When that is certain, the boy must first fast for a day; and then the operation must be performed in a warm place; which is conducted in this manner.

A strong and skilful man sits down upon a high seat, and laying the boy, whose back is towards him, in a supine posture, setting his hips upon his knees, takes hold of him, and drawing up his legs, orders the boy to put down his hands to his hams, and pull them toward his body with all his might, and at the same time he holds them in that posture. But if the patient be pretty strong, two able men must sit behind him on two contiguous seats, and both their seats, and their legs next each other must be tied together, to prevent their giving way. Then he is placed upon both their knees in the same manner, and the one according as he sits, lays hold of his left leg, and the other of his right; and at the same time he himself draws up his hams. Whether he be held by one or two, they lie forward with their breasts upon his shoulders. Whence it happens, that the sinus above the pubes, between the ilia, is extended without any wrinkles, and the bladder being compressed into a small compass, the stone may be the more easily laid hold of. Besides, two strong men are placed one at each side, who stand by, and do not suffer either the one or two, that hold the boy, to give way.

Then the physician, having carefully pared his nails, introduces his fore and middle fingers of the left hand together, being first slightly anointed with oil(27), into the anus of the patient, and lays the fingers of his right hand lightly upon the lowest part of his abdomen; lest if his fingers on both sides at once should press strongly upon the calculus, it might hurt the bladder. And this must not be done hastily, as in most cases; but so as may be safest: for hurting the bladder brings on convulsions, with a danger of death. And first of all the stone is sought for about the neck: where if it be found, it is expelled with less trouble; and therefore I said the operation was not to be attempted, unless this were known by its proper signs. If either it was not there, or has gone backward, the fingers are applied to the end of the bladder; and the right hand being removed also beyond it, it is brought gradually down.

And when the stone is found (as it must necessarily fall between the surgeon’s hands) it is drawn down with the greater caution by how much it is smaller and smoother, lest it escape, that is, lest there be a necessity to harass the bladder again and again. Therefore the right hand is always kept before the stone; and the fingers of the left force it downwards, till it come to the neck. Into which part, if it be oblong, it must be forced so as to come out prone(28); if flat, so as to be transverse; if square, that it may rest upon two angles; if it be larger at one end, so that the smallest may pass first. In a round one, from the figure itself it is plain, there is no difference, save that if it be smoother in one part than another, that should come out first.

When it is brought to rest upon the neck of the bladder, a lunated incision must be made in the skin, near the anus, as far as the neck of the bladder, with the horns pointing a little towards the ischia; then in that part where the bottom of the wound is straiter, again under the skin(29), another transverse wound must be made, by which the neck may be cut; till the urinary passage be open in such a manner, that the wound is something larger than the stone. For those, who through fear of a fistula (which in that part the Greeks call ouroruas[HU]) make but a small opening, are reduced to the same inconvenience with greater danger; because the stone, when it is brought away by force, makes a passage, if it does not find one. And this is even more pernicious, if the shape or asperity of the stone contribute any thing to it: whence both an hemorrhage and convulsion may ensue. But though a person escape these, the fistula will be much larger, when the neck is lacerated, than it would have been if cut.

[HU] Οὐρορυὰς: this word, as far as I can find, occurs no where else.
It is variously written in the different editions. The sense seems to
determine it to what I have expressed in the translation, with which
the etymology of it agrees.

When the opening is made, the stone comes into view; the size of which makes a material difference _with respect to its management_. Therefore if it be small, it may be pushed forward on one side, and drawn out on the other by the fingers. If larger, a crotchet(30) made for the purpose must be put over the upper part of it. This at its extremity is thin, beat out into the form of a semicircle, broad and blunt; on the external part smooth(31), where it comes in contact with the wound; on the inside rough, where it touches the stone. And it ought to be pretty long; for one too short has not force enough to extract it. When it is fixed, it ought to be inclined to each side, that the stone may appear, and be held fast, because if it be laid hold of, it also gives way to it. And the necessity for this is, lest when the crotchet begins to be drawn, the stone may fly inward, and the crotchet fall upon the edge of the wound, and lacerate it, the danger of which I have already shewn.

When it appears that the stone is securely held, a triple motion must be made, almost at the same instant, to both sides, and then externally; but this must be done gently, and the stone must be first drawn a little forward; after this, the end of the crotchet must be raised upward, that it may be farther within the bladder, and bring it out the more easily. But if the stone cannot be conveniently held at the superior part, its side must be taken hold of. This is the most simple method.

But a variety of circumstances requires some particular observations. For there are some stones not only rough, but also full of sharp points, which falling of themselves into the neck of the bladder, are extracted without any danger. But if they are within the bladder, it is neither safe to seek them, nor draw them forward; because when they wound it, they bring on convulsions and death; and more especially if any point is fixed in the bladder, and causes it to fall into folds, as it is brought down _towards the neck_. Now a stone is discovered to be in the neck, when the urine is made with greater difficulty than ordinary; and to be pointed, when it comes away bloody; and this is particularly to be tried by the fingers, and the operation is not to be attempted unless we are sure it is there. And even then the fingers must be introduced, and opposed to it behind tenderly, lest they wound by pushing it with violence; then the incision must be made. And in this case also many have made use of the knife. Meges (because the knife being weak might fall on some prominence of the stone, and after having cut the flesh above it, would not divide where there is a hollow, but leave what will require a second incision) made an iron straight instrument, with a broad back on its upper part, and its lower part semicircular and sharp. This being taken between his fore and middle fingers, and his thumb laid upon it, he prest it so, that together with the flesh, he might cut any part of the stone that was prominent: by which he gained this advantage, that he made a sufficient opening at once. Now in whatever method the incision in the neck is made, a rough stone ought to be extracted gently; no violence being used for the sake of expedition.

But a sandy stone is easily discovered both before the operation, from the discharge of sandy urine, and in the operation; because it makes but a faint resistance to the fingers, and that not equally, and besides is apt to slide away. Also urine, that brings off with it something like scales, discovers the stones to be soft, and that they are composed of several small ones not firmly united together. All these it is proper to bring away gently, changing alternately the fingers in such a manner, that they may not hurt the bladder, and no broken relics stay behind, which may afterwards render the cure difficult. Any of these, that come into view, must be extracted either by the fingers or crotchet.

But if there are several stones, they must every one be taken out; but if any very small one remain, it may rather be left: for it is difficult to find it in the bladder; and when found, it quickly escapes. Thus by long search the bladder is hurt, and mortal inflammations are brought on; in so much that some, though they were not cut, when the bladder has been long, and to no purpose, roughly handled, by the fingers, have died. Besides all which, a small stone being brought to the wound afterwards by the urine, drops out.

In case the stone appears so large, that it cannot be extracted without lacerating the neck, it must be split. The author of this contrivance was Ammonius, who upon that account was called Lithotomus[HV] (_the stone-cutter_.) It is done in this manner. A crotchet is fixed upon the stone with so sure a hold as to prevent it from recoiling inward: then an iron instrument of moderate thickness, with a thin edge, but not sharp, is made use of. This is applied to the stone, and being struck on the other side, cleaves it; great care being taken, that neither the instrument come to the bladder, nor any thing fall in by the breaking of the stone.

[HV] λιθοτόμος.

These operations are performed upon females much in the same manner, concerning whom a very few peculiarities must be mentioned. For in them, where the stone is very small, cutting is unnecessary; because it is forced by the urine into the neck, which is both shorter, and laxer than in men: therefore it often drops out of itself, and if it sticks in the urinary passage, which is narrower, it is however extracted without any harm by the abovementioned crotchet. But in larger stones the same method is necessary. However, in a virgin, the fingers should be introduced _into the rectum_ as in a man, in a married woman by the vagina. Again, in a virgin, the incision must be made below the left lip of the pudendum; but in a married woman, between the urinary passage, and the bone of the pubes; the wound also must be transverse in both places, and we need not be alarmed if the hæmorrhage be considerable from a female body.

When a stone is extracted, if the patient be strong, and not greatly spent, we may let the blood flow to lessen the inflammation. And it is not amiss for the patient to walk a little, that if any grumous blood remain within, it may drop out. But if it does not cease of itself, it must be stopped, lest the strength be entirely exhausted; and this is to be done immediately after the operation in weak patients. For as a person is in danger of a convulsion, whilst the bladder is fatigued, so there is another fear, when the applications are removed, lest there be such an hæmorrhage as to prove mortal: to prevent which, the patient ought to sit down in sharp vinegar with the addition of a little salt; by which means both the blood commonly stops, and the bladder is contracted, and therefore is less inflamed. But if that does little service, a cupping vessel must be applied, both in the knees(32) and hips, and above the pubes too.

When either a sufficient quantity of blood has been evacuated, or the hæmorrhage stopped, the patient must be laid upon his back, with his head low, and his hips a little raised; and over the wound must be applied a double or triple linen cloth wet with vinegar. Then after an interval of two hours, he must be let down in a supine posture into a bath of hot water, so that he may be under water from the knees to the navel, the other parts being covered with clothes, only with his hands and feet bare, that he may be both less exhausted, and be able to continue there the longer. This commonly produces a plentiful sweat; which in the face is to be now and then wiped off by a spunge. And the rule for the continuance of this bathing is, till it hurts by weakening. After that the patient must be anointed plentifully with oil, and a handful of soft wool saturated with warm oil, must be laid on, so as to cover the pubes and hips, and groin, and the wound itself, which must still remain covered with the linen beforementioned; and this is to be moistened now and then with warm oil; that it may both prevent the admission of cold to the bladder, and gently mollify the nerves. Some make use of healing cataplasms. These do more hurt by their weight, which by pressing upon the bladder(33) irritates the wound, than service by their heat: and for that reason, not so much as any kind of bandage is necessary.

On the day following, if there be a difficulty in breathing, if the urine is not evacuated, or if the part above the pubes has immediately swelled, we may be assured, that grumous blood has staid within the bladder. Therefore the fingers being introduced in the same manner as above, the bladder must be handled gently, and whatever has happened to be coagulated there dispersed; by which means it is afterwards discharged from the bladder through the wound. Neither is it improper to inject through the wound into the bladder by a syringe, a mixture of vinegar and nitre; for if there be any bloody concretions, they are discussed in that way. And these may be done even the first day, if we are afraid of any thing being within; especially when weakness has prevented the evacuation of it by walking. The other methods laid down for the preceding day, the putting him into the bath, applying the cloth, and wool in the manner above described, are to be continued.

But a boy is neither to be put so often into the warm water, nor kept there so long _at a time_, as a youth; the weak, as the strong; one affected with a slight inflammation, as another, in whom it is more violent; one whose body is disposed to evacuations, as he that is bound. But in the mean time, if the patient sleep, and his breathing be equal, his tongue moist, his thirst tolerable, his lower belly not at all swelled, and the pain and fever moderate, we may take it for granted that the cure goes on well.

But in such patients the inflammation ceases commonly about the fifth or seventh day: when that is abated, the bath is needless. Only the wound, as the patient lies in a supine posture, must be fomented with hot water, that if the urine corrodes, it may be washed away. Digestive medicines must be laid on; and if the ulcer appears to want deterging, honey may be applied. If that corrodes, it must be tempered with rose oil. The enneapharmacum plaister seems fittest for this intention, for it both contains suet to promote digestion, and honey to deterge the ulcer, marrow also, and especially that of veal, which is particularly efficacious in preventing a fistula from remaining. And at that time lint is not necessary over the ulcer; but is properly laid above the medicine to keep that on. But when the ulcer is cleansed, it must be brought to cicatrize by lint alone.

At this time, however, if the cure has not proceeded happily, various dangers arise: which one may quickly prognosticate, if there be a continual watching, or a difficulty of breathing, if the tongue be dry, if there be a violent thirst, if the bottom of the belly swells, if the wound gapes, if the urine that makes its way through it, does not corrode it; in like manner, if before the third day some livid stuff drops out; if the patient makes no answers to questions, or very slowly; if there are vehement pains; if after the fifth day violent fevers come on, and a nausea continues; if lying upon the belly is the most agreeable posture. However nothing is worse than a convulsion, and a bilious vomiting before the ninth day. But there being reason to fear an inflammation, it must be obviated by abstinence, and moderate food seasonably administered; and by applying, at the same time, fomentations, and the other means above prescribed.

CHAP. XXVII.

OF A GANGRENE AFTER CUTTING FOR THE STONE.

The next danger is that of a gangrene. This is known by a discharge of fetid sanies both by the wound and the penis, and together with that, something not very different from grumous blood, and little films like small locks of wool; it is also known by the lips of the wound being dry, by a pain in the groin, by the continuance of the fever, and its increase at night, and by the accession of irregular shudderings. Now it must be considered to what part the gangrene spreads. If to the penis, that part grows hard and red, and is painful to the touch, and the testicles swell, if to the bladder, a pain of the anus follows, the hips swell, the legs cannot be easily extended; but if to one side, it is apparent to the sight, and has these same symptoms on either side, but not so violent.

The first circumstance of importance is, that the body lie in a proper posture, that the part into which the disease is propagated be always laid highest. Thus if it tends to the penis, the patient should lie supine; if to the bladder, upon his belly; if to one side, upon the other, which is sound. Then as to the means of cure, the patient must be put into a bath made of a decoction of horehound, or cypress, or myrtle, and the same liquor must be injected into the wound by a syringe; then a mixture of lentils and pomegranate bark both boiled in wine must be laid on; or bramble, or olive leaves boiled in the same manner, or other medicines, which we have prescribed for restraining and cleansing gangrenes. And if any of these shall be in a dry form, they must be blown in through a writing reed.

When the gangrene begins to stop, the ulcer should be washed with mulse. And at this time cerate must be avoided, which softens the flesh, and prepares it for receiving the infection. Rather let washed lead with wine be laid on; over which shall be applied the same spread upon a linen cloth: by which a cure may be accomplished. Nevertheless we should not be ignorant, that when a gangrene has begun, the stomach, which has a certain sympathy with the bladder, is often affected; whence it happens, that the food can neither be retained, nor if any is retained, can it be concocted, nor the body nourished; and therefore the wound can neither be deterged nor incarned: which must of necessity soon bring on death.

But as it is not possible, by any means, to save patients under these circumstances, from the first day however, the method of cure must be _regularly_ observed. In _the conduct of_ which some caution is also necessary with regard to the food and drink: for at the beginning, none but moist food ought to be given; when the ulcer is deterged, of the middle kind; greens and salt fish are always hurtful. A moderate quantity of drink is required: for if too little is drunk, the wound is inflamed, the patient labours under a want of sleep, and the strength of the body is diminished: if too much be taken, the bladder is frequently filled, and by that means irritated. It is too plain to require a frequent repetition, that the drink must be nothing but water.

It generally happens from a diet of this kind, that the belly is bound. A clyster must be given of a decoction of fenugreek or mallows in water. The same liquor mixed with rose oil, must be injected into the wound by a syringe, when the urine corrodes it, and prevents it from being cleansed. For the most part, at first, the urine is discharged by the wound; whilst it is healing, it is divided, and part begins to be discharged by the penis, till the wound be entirely closed: which happens sometimes in the third month, sometimes not before the sixth, at other times after a whole year.

And we should not despair of a solid agglutination of the wound, unless where the neck has been greatly lacerated, or many and large caruncles, and at the same time some nervous substances have come away by a gangrene. But the greatest precaution must be used, that no fistula, or at least a very small one, be left there. Therefore, where the wound tends to cicatrize, the patient should lie with his thighs and legs extended: unless the stones have been soft or sandy; for in that case the bladder is not so soon cleansed: and, therefore, it is necessary for the wound to be longer open; and never to be brought to cicatrize till nothing more of that nature be discharged.

But if the lips have united before the bladder was cleansed, and the pain and inflammation have returned, the wound must be separated by the fingers, or the broad end of a probe, to allow a passage to what causes the pain: which being evacuated, and the urine having come away pure for a pretty while, cicatrizing medicines must at length be laid on, and the feet extended, as I directed before, as close to one another as possible.

But if from those causes, which I mentioned, there appears to be danger of a fistula, to close it the more easily, or at least to contract it, a leaden pipe must be introduced into the anus(34); and the legs being extended, the thighs and ancles must be tied together, till there be a cicatrix as good as we can obtain.

CHAP. XXVIII.

OF THE OPERATIONS REQUIRED WHEN A MEMBRANE, OR FLESH OBSTRUCTS THE VAGINA IN WOMEN.

The foregoing diseases may happen both to men and women. But some are peculiar to women; as in the first place, where the vagina, by its lips being joined, does not admit of coition. And this happens sometimes in the womb of the mother; at other times, from an ulcer in those parts, and the lips, in healing, having by bad management been united. If it be from the birth, a membrane obstructs the vagina: if from an ulcer, it is filled up with flesh.

In the membrane an incision must be made in two lines crossing each other, in the form of the letter X, great care being taken not to wound the urinary passage; and then the membrane is to be cut out. But if flesh has grown there, it is necessary to open it in a straight line; then taking hold of it with a vulsella or hook, to cut off a small habenula, as it were, from the orifice of the vagina, after which must be introduced a piece of lint rolled in a long form (by the Greeks called lemniscus) dipped in vinegar; and over this sordid wool moistened with vinegar is to be bound on; the third day, these are to be removed, and the part dressed like other wounds. And when it begins to heal, it is proper to introduce into the part a leaden pipe armed with a cicatrizing medicine; and over that to apply the same medicine, till the wound be cicatrized.

CHAP. XXIX.

THE METHOD OF EXTRACTING A DEAD FOETUS OUT OF THE WOMB.

When a woman conceives, if the foetus dies in the womb, near the time of delivery, and cannot come away of itself, an operation is necessary. This may be reckoned amongst the most difficult: for it both requires the highest prudence and tenderness, and is attended with the greatest danger. But above all, the wonderful nature of the womb, as in other cases, so in this also, is easily discovered.

In the first place, it is proper to lay the woman on her back, across a bed, in such a posture, that her ilia may be compressed by her thighs: whence it happens, that both the bottom of her belly is presented to the view of the physician, and the child is forced to the mouth of the womb; which is close shut, when the foetus is dead, but at intervals opens a little. The physician, making use of this opportunity, having his hand anointed, ought to introduce, at first, the fore-finger, and keep it there till the mouth be opened again, and then he must introduce another finger, and the rest upon the like opportunities offering, till his whole hand be within it. Both the capacity of the womb, and the strength of its nerves, and the habit of the whole body, and even the fortitude of the mind conduce much to the facility of doing this: especially, as in some cases, it is necessary to have both hands within the womb.

It is of importance, that both the bottom of the belly, and the extremities of the body be as warm as possible; and that an inflammation be not begun, but that help be administered instantly, while the case is recent. For if the body be already swelled, the hand can neither be introduced, nor the fœtus brought away without the greatest difficulty; and together with a vomiting and tremor, there generally follow mortal convulsions. When the hand is introduced upon the dead fœtus, it immediately discovers its posture: for it is either turned upon the head, or the feet, or lies transverse but commonly in such a manner; that either its hand or foot is near.

The intention of the physician is, by his hand, to turn the child, either upon its head, or even upon its feet, if it happened to be in a different posture. And if there is no other hinderance, taking hold of the hand or foot puts the body in a better posture: for the hand _being laid hold of_, will turn it upon the head, and the foot upon its feet. Then if the head is nearest, a crotchet should be introduced, in every part smooth, with a short point, which is properly fixed, either in the eye, or the ear, or the mouth, sometimes even in the forehead; and then being drawn outwards, brings away the child. Yet it is not to be extracted at any moment of time indifferently: for should it be attempted, when the mouth of the womb is shut, there being no exit for the child, it breaks to pieces, and the point of the crotchet slips upon the mouth of the womb itself, and there ensue convulsions, and extreme danger of death. Therefore, it is necessary to forbear, when the womb is shut; and when it opens, to draw gently; and every such opportunity to extract it gradually. The right hand must draw the crotchet, the left being kept within, must pull the child, and at the same time direct it.

It sometimes happens, that the child is distended with water, and there is a fœtid sanies discharged from it. If this be the case, the body must be perforated with the fore-finger, that its bulk may be lessened by the discharge of the humour: then it must be taken out gently by the hands only: for the crotchet being fixed in a putrid body, easily loses its hold. The danger attending which, I have already pointed out.

But a child being turned upon its feet, is not difficult to extract: for these being taken hold of, it is easily brought away by the hands alone.

If it be transverse, and cannot be got into a proper direction, a crotchet must be fixed in the armpit, and gradually pulled: in this case, the neck is generally doubled, and the head turns back upon the body. The remedy is, to cut through the neck, that the two parts may be brought away separately. This is done by a crotchet, which resembles the former, save that it is sharp all along the internal part. Then we must endeavour to bring away the head first, after that, the rest of the body: because generally, when the largest part is extracted, the head slips back into the womb, and cannot be extracted without the greatest danger.

However, if this has happened, a double cloth must be laid upon the belly of the woman, and a strong and skilful man ought to stand at her left side, and put both his hands upon the lower part of her belly, and press with one upon another: by which means the head is forced into the mouth of the womb, and may then be extracted by the crotchet, in the manner above described.

But if one foot be found at the mouth of the womb, and the other is behind, with the body, whatever is protruded, must be gradually cut away. And if the buttocks begin to press upon the mouth of the womb, they must be thrust back again, and the other foot sought for and brought forward. There are also some other difficulties, which make it necessary to cut the child into pieces, when it cannot be brought away entire.

Whenever a fœtus is brought away, it must be delivered to an assistant; who must take it in his hands, and then the physician ought to draw the umbilical cord gently with his left hand, but not to break it, and with the right to follow it, as far as what they call the secundines, which were the covering of the fœtus within the womb; and taking hold of the extremities of these, to separate all the small veins and membranes in the same manner, by his hand, from the womb, and to extract the whole of it, and any concreted blood that remains within. Then the woman’s thighs must be laid close together, and she placed in a room moderately warm, without any thorough air. To the bottom of her belly must be applied sordid wool dipped in vinegar and rose-oil. The remaining part of the cure ought to be the same, as is used in inflammations, and such wounds as are in nervous parts.

CHAP. XXX.

THE OPERATIONS REQUIRED IN DISEASES OF THE ANUS.