Chapter XX: Book VI: Sect. I.—preface to the Surgical Part (6)

Rhases gives from preceding authors several descriptions of lithotomy, but as they closely resemble our author’s, we shall treat of them only in a cursory manner. In his first description he directs the surgeon to place the patient with his hands fastened to his ankles so as to press down the bladder. When the stone does not descend properly, so as to be felt externally, he recommends him to introduce one or more fingers into the rectum and push it outwards; and then while an assistant draws up the testicles the operator is to make a transverse (oblique?) incision, larger externally, but internally only of such a size as to allow the stone to pass out. If the stone does not come out readily it is to be extracted with an instrument, and the hemorrhage checked with a composition of aloes, frankincense, and vitriol. When the patient is a child he recommends the operator to place him upon the knees of an assistant, and to make pressure on the abdomen so as to force down the bladder. He forbids the operation when the stone cannot be brought down to the neck of the bladder. When the stone is large he directs it to be broken into pieces before extraction. His next description is taken from the celebrated Antyllus, but as it scarcely differs at all from the preceding one, we shall merely select a few remarks. When the stone is smooth, round, and small, he directs the surgeon to push it down to the neck of the bladder by means of a finger introduced into the rectum, and to make an incision down upon it; after which the stone is to be forced out. When pain supervenes after the operation, he recommends him to place the patient in a bath medicated with camomile, linseed, mallows, &c.; or if it be summer, and there be any disposition to hemorrhage, to place him in a vessel filled with strong vinegar. When it is ascertained that there are clots of blood in the bladder obstructing the urine, he directs the surgeon to introduce a finger by the incision, and extract them gradually. His next description is from an author named Sarad, whom he frequently quotes in other parts of his works. He directs the operator to introduce a finger into the rectum and push the stone outwards to the left side of the perineum, removed about the size of a grain of barley from the raphe (_daram_), and then to make an incision into the neck of the bladder. He afterwards gives a very circumstantial account of the operation from another author called Athuriscus. He particularly directs the operator to make an incision in the left side of the perineum and to open the neck of the bladder, as a wound of the body of the bladder seldom unites. When the stone is large he recommends him to seize it with strong pincers and break it into pieces. When a stone sticks in the urethra he directs him to tie one ligature behind it and to secure the prepuce before the glans with another, and then to cut down upon the stone. He gives very minute directions about the after treatment, recommending especially the removal of any clots which obstruct the passage. (Cont. xxiii.)

The practice of lithotomy appears to have been reckoned a disreputable occupation among the Arabians, for Avenzoar mentions it as an operation which an upright and respectable man would not witness, far less perform. (ii, 2, 7.)

As there are some doubts regarding the form of the incisions in the ancient methods of performing lithotomy, we will now give the words of some of the Arabian translators. Stephanus Antiochensis, the translator of Haly Abbas, has the following words: “Inter testes anumque finde et non in mediâ viâ sed in sinistri lateris parte ab intestinis, sitque _perallela_ fissura, et ab exterioribus larga, ab interioribus non.” The translator of Albucasis expresses himself thus: “Finde in eo quod est inter anum et testiculos et non in medio, ad latus natis sinistræ: fiat sectio _transversa_.” The following are the words of Avicenna’s translator: “Cave ne scindas super commissuram quum sit malum, commissura enim secundum veritatem est locus mortalis. Amplius fac super ipsum (lapidem?) scissuram tendentem ad _transversum_, studendo ut cadat scissura in collo vesicæ.” The translator of Rhases expresses himself in the following terms: “Scinde super lapidem cum instrumento _camadan_; et scissura debet fieri _transversa_, et sit exterior caro larga et in interiori vesicæ stricta.”

Yet notwithstanding all this we are inclined to think that the incision was _oblique_ and not _transverse_; for our author, whom they all follow, directs us to make the incision oblique (λοξὸς), and it is further clear that a transverse one would not answer the purpose so well. No dependence can be put in the accuracy of these barbarous translations. The language of Stephanus Antiochensis is particularly obscure. Casiri justly characterizes the translations of the Arabian authors as being “_perversiones_ potius quam _versiones_.” (Bibl. Hisp. Arab, i, 266.)

The ancient operation, with scarcely any alterations, is described by the earlier modern writers on surgery. See Brunus (Chirurg. Magna. ii, 17); and Guido de Cauliaco (Chir. vi, 2.) They direct us to introduce a finger into the rectum and push the stone outwards; then to make an incision down upon it on the left side of the raphe. Brunus recommends a longitudinal incision.

It appears that the ancient operation of lithotomy is still practised with great success by the native doctors of Hindostan. See ‘Transactions of the Medical and Physical Society of Calcutta,’ vol. iv. An interesting case in point, related in the ‘Medical Gazette’ for Feb. 7, 1845, forms a valuable commentary on the Celsian description of lithotomy. In the year 1827 Mr. Madden the traveller saw it performed in Tyre by an old pilot on a boy of thirteen years of age. The case did well.

SECT. LXI.—ON THE PARTS ABOUT THE TESTICLES.

As contributing to the understanding of the operations on herniæ, we shall premise a description of the parts about the testicles. The testicle itself is a glandular and friable substance, formed for the production of semen. The substances called parastatæ and cremasteres, are processes from the membrane of the spinal marrow, descending along with the arterial vessels in the testicles, by which the semen is injected into the pudendum; the spermatic vessels are veins from the vena cava passing to the testicles in a convoluted manner, and by them the testicles are nourished. The tunica vaginalis (erythroides or elytroides?) is of a nervous nature; at the convex and anterior part not adhering, but at the concave and posterior parts united to the testicle, deriving its origin from the peritoneal coat. This part, where it is united to the testicle, they call the posterior adhesion. The darti are membranes connecting the external skin to the tunica vaginalis, being united to it at the part where it is united behind to the testicle. But that wrinkled skin which forms an external covering to the testicles is called the scrotum.

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COMMENTARY. Celsus gives a similar description of the parts connected with the testicles. The testicles themselves, he says, consist of medullary matter and possess no sensibility of their own, but experience violent pains and inflammations from the membrane which surrounds them. They hang from the groins by nerves called cremasters by the Greeks, with each of which descend two veins and arteries. These are covered by a thin nervous white coat, without blood, called elytroides by the Greeks. (This must be the tunica vaginalis of modern anatomists.) Above it is a stronger tunic which adheres strongly to the inner at its lower part, and is called dartos by the Greeks. (This appears to be the cremaster muscle of modern anatomists.) The veins, arteries, and nerves are surrounded by many small membranes. (By these he seems to have meant the fasciæ from the aponeurosis of the external oblique muscle.) All these parts are covered by an external investment called the scrotum. (vii, 18.)

Ruffus Ephesius says that the scrotum is a loose substance in which the testicles are placed, being in particular fleshy externally; that it consists of two tunics, the external being corrugated and called dartos, and the internal being called erythroides (elytroides?). The dartos and scrotum connect the testicles to the parts above, but the erythroides (vaginalis?) is united to and surrounds the testicle itself. (De Corporis Humani partium appellationibus, ii.)

Oribasius describes the cremasters as being two muscles which descend from the groins and surround the tunica vaginalis. (Anatomica ex Galeno.) (This is very similar to Cloquet’s description of them.)

Theophilus’s description unfortunately has come down to us very incomplete. (De Fabricâ Hominis, v, ad finem.)

SECT. LXII.—ON HYDROCELE.

An inert fluid, collected about the parts which are enveloped by the scrotum, and occasioning a marked swelling there, has obtained this appellation. The fluid is, for the most part, collected in the tunica vaginalis around the testicle, at its anterior part; but the affection is sometimes, though rarely, formed externally to the tunica vaginalis. Often, however, it is collected in the proper tunic of the testicles, and surgeons call this affection hydrocele of the tunica adnata. If the complaint is formed from some preceding cause, such as weakness of the parts, the blood brought there for the purpose of nourishment is converted into an inert watery or serous substance. But if it is occasioned by a blow, a sanguineous or feculent substance constitutes its contents. The common symptom is a permanent swelling without pain about the scrotum, not disappearing under any circumstances, yet somewhat compressible when the collection is small, but not at all compressible when it is large. When the fluid is collected in the tunica vaginalis the swelling is globular, but somewhat oblong like an egg; and in these cases the testicle is not to be felt as being everywhere surrounded with the fluid. But that which is collected externally to the tunica vaginalis, is felt as through a small intervening substance. When it is formed in the adnata, being everywhere circumscribed and globular, the swelling has the appearance of another testicle. If the fluid be watery, the swelling is of one colour and transparent; but if it be feculent and bloody, it appears red or livid; and if these symptoms appear in both parts of the scrotum, you may be sure that there is a double hernia. We operate upon it in this manner. Having shaven the pubes and scrotum, unless the patient be a boy, we lay him in a supine posture upon a bench, and apply to his buttocks a cloth several times folded, and to the scrotum a sponge of considerable magnitude, and sitting at the left side of the patient, we give directions to an assistant sitting at his right side to draw the genital organs to the other side, and to draw up the skin of the scrotum to the abdomen. Then taking a scalpel we divide the scrotum longitudinally from its middle to near the pubes, making the incision straight and parallel to the raphe which divides the scrotum into two parts, and extending the incision down to the vaginalis. When the fluid is in the adnata, we make the incision where the apex of the tunica adnata makes its appearance, and separating the lips of the incision with a hook, and having dissected the darti with a knife for hydrocele and a scalpel, and laid bare the tunica vaginalis, we divide it through the middle with a lancet for bleeding, more especially in that part where it is separated from the testicle; and having discharged into some vessel the whole or most of the fluid, we cut away the vaginalis, especially its thinnest parts, with hooks. Afterwards, Antyllus uses sutures and the treatment for recent wounds; but the moderns have recourse to what is called the incarnative mode of treatment. If the testicle is found in a state of putrefaction, or otherwise diseased, the vessels which pass along with the cremaster are to be separately inclosed in a ligature, the cremaster cut, and the testicle removed. And when there are two hernias we may operate in the same manner twice, directing the incisions on both sides at the parts of the scrotum about the loins. After these things, having introduced the head of a probe through the incision below at the extremity of the scrotum, and elevating the scrotum upon it, we make an incision with a sharp-pointed scalpel in a convenient situation for the discharge of the coagulated blood and pus. By means then of the head of the probe we introduce an oblong pledget into the upper incision, and having sponged away the clotted blood, we introduce wool dipped in oil through the incision down to the testicle; and externally we may apply other pieces of wool dipped in wine and oil to the scrotum, hypogastrium, groins, perineum, and loins; and applying a compress three times folded upon them, and binding them with a six-legged bandage, and other proper bandages, we place the man in a reclining posture, putting wool under the scrotum for the sake of ease, and spreading the soft skin under him to receive the embrocations. We bathe with warm oil until the third day, after which having loosed the bandages we must use the ointment tetrapharmacon on a pledget, having changed the oblong one. Afterwards we may again apply the embrocations proper for inflammation until the seventh day, after which we have recourse to the medicine called motophylacion. After the ulcer has been cleaned and moderately incarnated, and the parts have been bathed, we must remove the oblong pledget, and have recourse to the subsequent treatment as formerly described. But if inflammation, hemorrhage, or any such disagreeable consequence come on, we must, in a word, treat each of these in a suitable manner, that I may not have occasion to make repetitions. But if we would rather have recourse to the cautery in cases of hydrocele (as is the practice of the moderns), we must follow all the directions given as to what is to be done before and after the operation, and also those given with regard to the operation itself, omitting only the incision with a scalpel, and the division for allowing the discharge of its contents. Wherefore having heated ten or twelve cauteries, shaped like the Greek letter Γ, and two sword-shaped ones, we must first burn the scrotum through the middle with the gamma-shaped, and having dissected away the membranes with a scalpel or blunt hook, we must burn with the sword-shaped as if cutting. Having laid bare the tunica vaginalis (which is easily recognized by its whiteness and density) with the extremity of a gamma-shaped cautery, we evacuate the fluid. Afterwards, when the whole is laid bare, we stretch it with hooks and remove it with a sword-shaped cautery.

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COMMENTARY. Celsus directs the surgeon, when water is contained in a hernial tumour, to make an incision in the groin, if the patient be a child, unless the largeness of the collection prevent; but in adults, and when the swelling is great, he recommends him to make it in the scrotum. Then if the incision be in the groin, the coats are to be drawn up there and the water discharged; but if in the scrotum, and if the disease be seated there, nothing more is to be done but to evacuate the fluid, and remove any membranes which may happen to contain it; after which the parts are to be washed with a solution of salt or soda. When the fluid is situated under the middle or inner coat (the tunica vaginalis and tunica albuginea?), all these tunics are to be removed without the scrotum and cut out. (vii, 21.) Celsus, as well as our author, describes the hæmatocele or bloody tumour, the existence of which is affirmed by Heister. (ii, 5, 123.)

Galen alludes incidentally to the evacuation of the fluid in hydrocele. (Meth. Med. xiv.) Sprengel and Guy de Cauliac affirm that he makes mention of the seton as a mode of cure; but if this assertion be correct we have not been able to find out the passage in which he does so.

Aëtius gives a very distinct account of the nature of hydrocele, but his description of the operation is by no means so accurate as our author’s. He trusts mostly to astringent and desiccative applications. (xiv, 22.)

Albucasis describes the operation in nearly the same terms as Paulus. His operation consisted of making an incision in the swelling and dissecting out the coats of the testicles. The dressings which he recommends are similar to those mentioned by our author. He also describes the operation by the cautery in nearly the same terms as Paulus. He adds, that if the patient be timid and do not choose to submit to these operations, the surgeon may let out the water either with a scalpel or the instrument used for tapping in dropsy. He states, however, that after this operation the water will collect again. (Chirurg. ii, 62.)

Avicenna briefly describes the operation of opening the tumour, and applying cauteries or strong medicines to the membranes. (iii, xxii, i, 6.)

Haly Abbas directs us to open the tumour, and cut out its tunics, and then to apply incarnative dressings. This treatment, he adds, the moderns prefer to the escharotic applications used by the ancients. (Pract. ix, 47.) He also describes the process of burning. (Pract. ix, 79.)

Rhases describes the operation of puncturing the scrotum for hydrocele. He also speaks of burning the part with a slender rod of iron, and of cutting out its tunics. (Cont. xxiv.)

The membrane called tunica adnata in our translation is the “ima tunica” of Celsus, and the “panniculus proprius” of the Arabian translation of Albucasis, and seems to be the same as the tunica albuginea of modern anatomists.

Sprengel gives an excellent history of the operation of hydrocele. (Hist. de la Méd. 18, 8.)

SECT. LXIII.—ON SARCOCELE AND TOPHI OF THE TESTICLES.

When flesh is formed in any part of the bodies which are connected by the scrotum, it gives rise to the disease called sarcocele. This arises either from some obscure cause, the testicle being attacked with a defluxion and becoming indurated, or from a blow, or from unskilful treatment after the operation for hernia. Its consequences are, a swelling of the same colour, with hardness; when the swelling is of a scirrhous nature, it is devoid of colour and sensibility; and when it is malignant there are sharp pains. When going to operate we place the patient as in the former case, and make the incisions in like manner; and if the complaint is occasioned by the growth of a fleshy tumour to the testicle, we divide the dartos and tunica vaginalis in like manner; then stretching the testicle and bringing it to the outside of the vaginalis, we separate the cremaster from the vessels, tie a ligature round the vessels, and cut the cremaster; then we remove the testicle affected with the fleshy tumour as a foreign body. But if the fleshy tumour be formed about any of the coats of the testicle or its vessels, having divided the scrotum and the membranes lying under the flesh, we must dissect out the whole fleshy tumour. But if the posterior process (“epididymis”?) be affected with sarcocele, having dissected all the surrounding parts, we remove the testicle along with it; for it is impossible for the testicle to continue without it. If tophi be formed about the testicle and the tunica vaginalis, they may be distinguished from sarcocele and hydrocele by their resistance, hardness, and inequality, and are to be operated upon as sarcocele.

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COMMENTARY. Celsus describes and recommends the same operations. He directs us to divide the nerve by which the testicle is suspended (the cremaster?), then to tie the veins and arteries at the groin with a thread, and cut them below the ligature. When a fleshy tumour is formed between the coats he recommends us to cut it out. (vii, 22, 23.) When the parts are indurated he forbids us to meddle with them.

Albucasis directs us to separate the cremaster from the vessels, to tie the vessels, and then remove the testicle from the surrounding parts. When the disease consists of a fleshy tumour which adheres to the testicle he directs us to cut it out. After the operation the wound is to be filled with rose-oil and wine. (Chirurg. ii, 63.) The other Arabians treat of the operation less minutely, with the exception of Haly Abbas, who describes it exactly as Albucasis. (Pract. ix, 48.)

SECT. LXIV.—ON CIRSOCELE AND PNEUMATOCELE.

When the vessels about the scrotum or darti are in a varicose condition, they are called simply varices, but if the nutrient vessels of the testicles be in a varicose state, the affection is named cirsocele. The symptoms of it are obvious. There is a collection attended with swelling, and somewhat curved, of a botryoidal shape, and accompanied with relaxation of the testicle. It also occasions certain inconveniences, especially in running, exercising, and walking. We may operate upon it thus. After putting the patient in a convenient posture, we must lay hold of the scrotum and push the cremaster to the under part; it is easily distinguished from the vessels, being more slender, firmer, and elastic, as being strong and firm; the patient also feels pain upon pressure, and moreover it is connected with the penis. Having secured the vessels in the scrotum by our own fingers and those of our assistant, and stretching them strongly, we press obliquely the point of a scalpel direct upon the vessels; then having transfixed the parts with hooks and dissected what lie under the skin, and having exposed the vessels, as mentioned in the operation of angiology and that for aneurism, and pushing through them a needle having a double thread, and cutting the loop of the thread, we tie the ligatures round the vessels where the varices arise and where they terminate, and make a straight incision in the intermediate space. Having evacuated the blood collected in the tumour, we apply the treatment for suppurations until the ligatures with the vessels themselves fall out of their own accord. Leonides says, that when a few of the vessels which nourish the testicles are in a varicose state this operation should be performed, but that when all are affected, the testicle should be cut out along with them, lest being deprived of its nutrient vessels it should decay. Pneumatocele being a species of aneurism, Leonides forbids us to operate upon it for fear of a hemorrhage, which cannot be restrained from taking place at the time; but, there being two kinds of it, the one occasioned by the four vessels which nourish the testicle, and the other by the arteries of the darti and scrotum being affected, the moderns refrain from meddling with the latter, but operate upon the former. We distinguish them from one another, inasmuch as that which arises from the arteries is easily made to disappear upon pressure with the fingers, whereas that from the nutrient vessels of the testicles, not at all or with much trouble. We operate upon it as for cirsocele, taking up each of the veins and securing it with a thread.

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COMMENTARY. Celsus thus describes the cirsocele: “Venæ intumescunt; eæque intortæ conglomeratæque a superiore parte, vel ipsum scrotum implent, vel mediam tunicam vel imam: interdum etiam sub imâ tunicâ, circa testiculum nervumque ejus, increscunt.” (vii, 18.) He describes the operation at great length afterwards. If the varicose tumour is upon the scrotum he directs us to burn it with slender and sharp irons, which are to be applied to the veins themselves, but in such a manner as to burn them alone. Then suitable dressings are to be applied for producing cicatrization. When the varicose veins are situated above the middle tunic, an incision is to be made in the groin, the tunic drawn out, and the veins separated from it with a finger or the handle of a scalpel. The veins are afterwards to be tied with a thread above and below; then they are to be cut below, and the testicle restored to its place. When the disease is situated above the third tunic (tunica albuginea?) the middle one must be cut out. Then if only two or three veins are in a varicose state they may be tied, as above directed, at the groin and where they join the testicle and cut out. When the disease is situated between the internal coat and the testicle, he says, there is no other remedy but the removal of the testicle. For this purpose he directs us to secure the arteries and veins with a thread, divide them, and then to cut the nerve by which the testicle is suspended (the cremaster?). (vii, 19 and 22.) He does not treat of pneumatocele. It must be obvious that the pneumatocele of our author was an aneurismal varix or erectile tissue. We see no good reason, therefore, for the animadversions which Heister makes upon his account of it. (See Surgery.)

This operation is briefly noticed in the ‘Isagoge’ of Galen, and ‘Meth. Med.’ (xiv.)

Albucasis considers it a dangerous operation, but says he will describe it as it was performed by the ancients. He accordingly gives our author’s account of it, directing us to dissect the congeries of vessels from the surrounding parts, to pass a needle, armed with a double thread, under them, and to tie them above and below; then to make a longitudinal incision in them, and to evacuate the feculent fluids which they contain. The wound is afterwards to be dressed with incarnants. If all the vessels are involved in the disease, he directs us to remove the testicle altogether. (Chirurg. ii, 64.) He says he never saw the operation performed for pneumatocele; but that the ancients operated for it in the same manner as for cirsocele. (66.)

Avicenna and Rhases treat of the pneumatocele, and recommend carminative applications to it; but they do not describe the surgical operation.

Haly Abbas borrows the description of Paulus. (Pract. ix, 49.)

SECT. LXV.—ON ENTEROCELE, OR INTESTINAL HERNIA.

Enterocele is a descent of the intestine into the scrotum, and is occasioned either from rupture of the peritoneum which takes place in the groin, or from stretching of the peritoneum. Both these, I mean rupture and stretching, are occasioned by previous violence, such as a blow, a leap, or loud crying, but that from stretching in particular is connected with relaxation and other weaknesses of the body. The common symptoms of both are a marked swelling in the scrotum, which is increased by exercise, heat, retention of the breath, and other exertions; and its symptoms are, that it goes up slowly upon pressure, and quickly falls down again, and that while the person affected with it lies in a recumbent posture it remains in its proper place until he stands again erect. The retention of fæces in the region of the scrotum often brings on dangerous symptoms; for it is attended with pain, and sometimes with rumbling of wind upon pressure. The peculiar symptoms of hernia from distension are, that it does not occur suddenly, but gradually; that it falls down occasionally from any ordinary causes; that the swelling appears equable and deep-seated, the protruded intestine being surrounded by the peritoneum. In those from rupture the descent at first is sudden, and happens only from violence; the swelling is very large, and appears seated superficially immediately under the skin, owing to the intestines having burst through the peritoneum. If the omentum alone falls down to the scrotum in rupture of the peritoneum the affection is called epiplocele, but if intestine descend along with it, it is named epiploenterocele; and if water be contained in the tunica vaginalis it receives an appellation compounded from all the three. But neither these nor the intestinal hernia from rupture of the peritoneum are proper subjects for surgery, but we operate upon enterocele alone from distension, in the following manner: after placing the patient in a recumbent posture, and getting the skin in the groin stretched by an assistant, we make a transverse incision, cutting as in the operation of angiology (but some make the incision not transverse but longitudinal), then having transfixed it with hooks we stretch out the incision to such a degree as to afford room for the testicle to pass through; then passing through the inner skin a number of hooks proportionate to the size of the wound, and dissecting the membranes and fat with a blind hook or scalpel we cut them across. When the peritoneum is everywhere laid bare, introducing the index-finger at the back part of the scrotum between the darti and peritoneum, we free the posterior process (epididymis?); and then with the right hand doubling its extremity to the inside of the scrotum, and at the same time stretching the peritoneum in the left hand, we bring the testicle with the vaginalis tunica to the incision, and give directions to one assistant to stretch the testicle, whilst we, having completely cleared the posterior process, ascertain by the fingers whether a fold of intestine be comprehended in the tunica vaginalis, and if so we must press it down to the belly; then we take a large-sized needle containing a doubled thread of ten pieces, and we pass it through the middle at the extremity of the peritoneum close to the incision; and cutting the double we make four pieces of them, and laying them over one another in the form of the Greek letter Χ, we bind the peritoneum securely, and again twisting round the pieces we secure it so that none of the nutrient vessels may have a free passage to it lest any inflammation be occasioned, and we apply another ligature farther out, less than two fingers’ breadth distant from the former. After making these ligatures we leave about the size of a finger of the peritoneum, and cut off the whole all round, removing at the same time the testicle, then making an incision at the lower part of the scrotum to favour the discharge, we introduce an oblong pledget, and apply embrocations of oil and bandages as for hydrocele. We must also make the other applications as there laid down. I have known some not unskilful surgeons who after the incision into the tunica vaginalis burnt the extremity of it with heated cauteries for fear of hemorrhage, as would appear. These after the operation straightway bathed their patients in a long wooden trough containing hot water, until the seventh day, repeating this as often as five times during the period of a day and a night, more especially with children; and it succeeded wonderfully, for they remained free from inflammation, and the ligatures fell out speedily along with the parts. In the intervals between the bathings the afore-mentioned embrocations were applied. Another surgeon, in addition to the means already mentioned, rubbed into their back at the time pepper triturated with oil.

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COMMENTARY. Celsus recommends us, if the patient be a child, to make an attempt, in the first place, to effect a cure with bandages. In more advanced ages, if a large portion of intestine has fallen down, and if attended with pain and vomiting, which symptoms generally arise from retention of the fæces, it is clear, he says, that the knife is not applicable, and that the case is to be remedied by other means. He recommends venesection in the arm, the tepid bath, warm cataplasms, and spare diet; but he disapproves of purgatives. This is his treatment of strangulated hernia. When an operation with the scalpel is resolved upon, an incision having been made in the groin down to the middle tunic (tunica vaginalis?), the lips of it are to be separated with the assistance of hooks, while the surgeon frees the tunic from all the small membranes (external fascia?). When this tunic is removed, an incision is to be made from the groin down to the testicle, which is to be carefully cut out. This process, however, is only applicable when the patient is of a tender age, and the mischief is moderate. When the patient is a strong man and the disease greater, the testicle is not to be removed, but is to be allowed to remain in its place. It is accomplished in this manner: the groin being opened with a scalpel, in the same manner, down to the middle tunic, it is to be seized with two hooks, so that an assistant may prevent the testicle from falling out at the wound; then that tunic is to be cut downwards with a scalpel, and under it the index-finger of the left hand is to be pushed down to the bottom of the testicle so as to force it up to the wound: then the thumb and index-finger of the right hand separate the vein, artery, nerve, and their tunic, from the upper tunic. But if any small membranes (fasciæ?) come in the way, they are to be cut out with a scalpel, until the whole tunic be exposed. Having cut out what is proper, and replaced the testicle, a somewhat broader thong of skin is to be removed from the lips of the wound in the groin, in order to enlarge the wound, and thereby occasion a greater formation of new flesh. The object of this operation, it will be remarked, is to produce a firm cicatrix at the external abdominal ring. In cases of epiplocele, he recommends us either to replace the omentum, or to cause the death of it by septic medicines, cauteries, or the ligature; or to cut it out with a pair of scissors, but of this proceeding he does not much approve, as it may occasion dangerous hemorrhage. (vii, 20, 21.)

Galen briefly states that intestinal and omental herniæ are to be cured by pressing up the intestine or omentum, removing as much as possible of the spermatic vessels; or otherwise drawing out the peritoneum, fomenting it, and then cutting it off. (Isagoge.) He mentions that it was customary to bleed the patient before the operation when he was plethoric. (De Opt. sec.)

Aëtius speaks of the operation as being highly dangerous. He forbids attempts at reduction while the prolapsed parts are affected with inflammation, tormina, and flatus. (xiv, 23.)

Albucasis’s account of the treatment is quite similar to our author’s. He states that the disease is occasioned by the descent of a portion of intestine to the testicle, owing to rupture or distension of the peritoneum. Sometimes, he says, fæces get into the prolapsed bowels, and being retained give rise to violent and sometimes fatal symptoms. When going to operate he directs us, in the first place, to make the patient reduce the intestine if reducible. Then an incision is to be made along the whole skin of the testicle, and hooks are to be fixed in the lips of the wound so as to enlarge it, and allow a passage for the testicle. The membranes, then, below the skin, are to be dissected, so as to expose completely the tunica vaginalis (_sifac album._) The index-finger is then to be introduced between the tunica vaginalis and the second coat (tunica albuginea?) so as to free the adhesions at the back part of the testicle. The operator is afterwards to separate the testicle from all its adhesions and raise it up to the external wound. He must now examine whether any portion of intestine remain protruded, and if so, it must be replaced. The operator is then to take a large needle armed with a cord of ten threads, and having introduced it behind the tunic under the skin of the testicle (tunica vaginalis?) its extremities are to be cut, and the threads arranged into four pieces. With them the peritoneum is to be tightly bound in a crucial form, so as that the nutrient vessels may not be able to reach it, which will obviate inflammation. Another ligature is to be applied afterwards at the distance of less than two fingers’ breadth from the former. After applying these two ligatures, about a finger’s breadth of the peritoneum is to be left, and the rest is then to be cut all around, and the testicle removed along with it. An incision is then to be made at the lower part so as to allow an outlet for the blood and matter. Wool dipped in oil is to be applied afterwards, and bound as formerly described. Sometimes, he adds, the cautery is applied to the tunica vaginalis after the incision for fear of hemorrhage. (Chirurg. ii, 65.) He describes minutely the treatment by burning in another place. (i, 47.)

Avicenna recommends the cautery, but does not describe the other operation. Haly’s description is evidently taken from our author. (Pract. ix, 50.)

Rhases states correctly that hernia generally arises from dilatation of the passage which leads from the cavity of the abdomen to the testicle. In ordinary cases, he says, there is no rupture of the peritoneum. He states that the contents of the hernial tumour are either intestines or omentum. The omentum, he adds, is the intestine most commonly found in ruptures. He says the peritoneum (_sifac_) lines the whole intestines and surrounds the testicles. Antyllus, from whom he gives a subsequent extract, states in like manner that the peritoneum descends to the testicles and forms the tunica elytroides, i. e. vaginalis. Antyllus also affirms that hernia arises from relaxation of the passage between the cavity of the abdomen and the testicles. This opinion regarding ruptures is maintained by several of the authorities quoted by Rhases. (Contin. xxiv.)

Sprengel says of Rhases: “Sa théorie des hernies proprement dites est infiniment préférable à celle des Grecs.” (Hist. de la Méd.) The account which Rhases gives of ruptures is, no doubt, very correct; but there is every reason to suppose that it was entirely taken from the works of the Greek surgeons.

The operations practised by the ancients for the radical cure of hernia cannot but appear to us extremely cruel and hazardous; and yet the danger attending them must have been less than is generally supposed, otherwise they could not have been so frequently performed as they were about two centuries ago. Fabricius ab Aquapendente mentions that a celebrated rupture doctor of his time informed him that he used to operate upon 200 patients at an average every year. Fabricius, however, prudently recommends us not to perform the operation except in extreme cases, and to be content in general with supporting the parts by means of a truss.

The ancients never operated to relieve strangulated hernia.

SECT. LXVI.—ON BUBONOCELE, OR INGUINAL HERNIA.

Enterocele arising from distension commences as bubonocele; for at first the peritoneum being stretched the relaxed intestine is protruded as far as the groin, and forms this disease, which the ancients operated upon in this manner. After making the incision to the extent of three fingers’ breadth transversely across the tumour in the groin, and removing the membranes and fat, and the peritoneum being exposed in the middle where it is raised up to a point, let the knob of a probe be applied, by which the intestines will be pressed deep down. The prominences, then, of the peritoneum formed on each side of the knob of the probe are to be united to one another by sutures, and then we extract the probe, neither cutting the peritoneum nor removing the testicle, nor anything else, but curing it with the applications for fresh wounds. But since burning in cases of bubonocele is preferred by most of the moderns it will be right for us to give an account of this operation. After the man has undergone moderate exercise, let him cough violently and strain to keep in his breath; and when the swelling appears at the groin we mark with black ink or collyrium the place that is to be burned in a triangular figure, making its transverse line above in the situation of the groin, and we also make a mark in the middle of the triangle. Having laid the patient in a recumbent posture we first apply to the mark in the middle nail-shaped cauteries heated in the fire, afterwards burn the sides of the triangle with gamma-shaped (Γ) cauteries, and afterward level the triangle with cauteries shaped like tiles or lentils, an assistant during the whole process of burning wiping away the ichorous discharges with a rag; and in those who are of a moderate habit of body the burning should be carried to such a depth as to touch the fat. But in those who are lean we must not attend to this mark lest by mistake we should burn the peritoneum; nor again in those who are grosser and fatter, for in them the fat appears before a sufficient burning has taken place. We must, therefore, be rather guided as to its extent by a skilful conjecture. After the burning, having triturated salts with leeks we apply them to the eschar, and use the inguinal bandage shaped like the Greek letter Χ. On the following days we complete the cure with the dressings fitting for eschars, such as lentils with honey, and the like.

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COMMENTARY. Celsus directs us, when the inguinal tumour is moderate in size, to make one incision; but if larger, he recommends two lines to be made, so that the middle may be cut out; then, without extracting the testicle, as advised in certain cases of prolapsed intestines, the veins are to be bound together and tied where they adhere to the tunics, and afterwards cut below the knots. (vii, 24.)

Avicenna speaks of astringent applications and the actual cautery, but disapproves of the incision and suture. (iii, 22, 1.)

The operations of the suture and burning are described by Albucasis (Chirurg. ii, 67, and i, 47); by Rhases (Cont. xxiv); and by Haly Abbas (Pract. ix, 52, and ix, 80.) They all evidently copy from our author.

Garengoit affirms that Paulus has made mention of crural hernia, but we agree with Heister that this is a mistake.

SECT. LXVII.—ON RHACOSIS, OR RELAXATION OF THE SCROTUM.

When the skin about the scrotum is relaxed without the bodies within being affected, rhacosis is formed, being a most unseemly complaint. Wherefore Leonides, having placed the man in a recumbent posture, cut off the redundant skin with a scalpel direct upon some board or some hard skin, and united the lips of the wound with sutures. But Antyllus, having first transfixed the redundant skin with three or four ligatures, cut off what was external to them with a sharp-pointed pair of scissors or scalpel, and having secured the parts with sutures, effected the cure by the treatment for recent wounds.

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COMMENTARY. Our author’s description of the two modes of performing the operation is copied by Albucasis. (Chirurg. ii, 68); and by Haly Abbas (Pract. ix, 53.)

SECT. LXVIII.—ON CASTRATION.

The object of our art being to restore those parts which are in a preternatural state to their natural, the operation of castration professes just the reverse. But since we are sometimes compelled against our will by persons of high rank to perform the operation, we shall briefly describe the mode of doing it. There are two ways of performing it, the one by compression, and the other by excision. That by compression is thus performed: children, still of a tender age, are placed in a vessel of hot water, and then when the parts are softened in the bath, the testicles are to be squeezed with the fingers until they disappear, and, being dissolved, can no longer be felt. The method by excision is as follows: let the person to be castrated be placed upon a bench, and the scrotum with the testicles grasped by the fingers of the left hand, and stretched; two straight incisions are then to be made with a scalpel, one in each testicle; and when the testicles start up they are to be dissected around and cut out, having merely left the very thin bond of connexion between the vessels in their natural state. This method is preferred to that by compression; for those who have had them squeezed sometimes have venereal desires, a certain part, as it would appear, of the testicles having escaped the compression.

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COMMENTARY. We have given Celsus’s description of the operation in the 64th section of this Book. Albucasis describes the operations by compression and by excision. In the former the testicle is squeezed by the operator while the patient is seated in hot water. In the other the spermatic cord is to be first secured with a ligature and then the testicle cut out. (Chirurg. ii, 69.)

They are likewise described in nearly the same terms by Haly Abbas. (Pract. ix, 54.) The castration of the inferior animals is mentioned by Aristotle (Hist. Animal. ix, 50); by Varro (De Re Rustica, iii, 9); by Columella (De R. R. vi, 26); and by Palladius (De R. R. vi, 7.) Varro informs us that it was customary to make capons by burning the testicles of cocks with a red-hot iron. It appears from Juvenal that the surgeons in his time were often called upon to perform castration. (Sat. vi, l. 370.) Abulpharagius likewise mentions that the performance of this operation constituted at one time an important part of the surgical practice in Bagdad. (Dynast. ix.) But the Emperor Justinian condemned the operation as being dangerous and often fatal.

Sprengel gives an interesting history of castration. One of the most important points in this operation is the mode of tying the cord. Some modern authorities affirm that no bad effects result from putting a ligature round the whole cord, but others condemn this practice as bringing on convulsions and tetanus. All admit the difficulty of securing the artery separately.

SECT. LXIX.—ON HERMAPHRODITES.

This affection derives its name from a combination of the names Hermes and Aphrodite (Mercury and Venus,) and occasions great deformity to both sexes. There being four varieties of it, according to Leonides; three of them occur in men and one in women. In men, sometimes about the perineum and sometimes about the middle of the scrotum, there is the appearance of a female pudendum with hair; and in addition to these there is a third variety, in which the discharge of urine takes place at the scrotum as from a female pudendum. In women there is often found above the pudendum and in the situation of the pubes the appearance of a man’s privy parts, there being three bodies projecting there, one like a penis, and two like testicles. The third of the male varieties in which the urine is voided through the scrotum is incurable; but the other three may be cured by removing the supernumerary bodies and treating the part like sores.

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COMMENTARY. This section of our author is copied by Albucasis (Chirurg. ii, 70); and by Haly Abbas (Pract. ix, 55.) Avicenna briefly mentions this monstrosity. (iii, 20, 2, 43.)

Guy of Cauliac and Brunus describe it in the same terms as the Arabians.

SECT. LXX.—ON EXTIRPATION OF THE NYMPHA AND CAUDA PUDENDI.

In certain women the nympha (clitoris?) is excessively large and presents a shameful deformity, insomuch that, as has been related, some women have had erections of this part like men, and also venereal desires of a like kind. Wherefore, having placed the woman in a supine posture, and seizing the redundant portion of the nympha in a forceps we cut it out with a scalpel, taking care not to cut too deep lest we occasion the complaint called rhœas. The cauda is a fleshy excrescence arising from the mouth of the womb, and filling the female pudendum, sometimes even projecting externally like a tail; and it may be removed in the same manner as the nympha.

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COMMENTARY. That the nympha and clitoris were used anciently as synonymous terms is evident from Ruffus Ephesius (De Partibus Hominis); Soranus (c. 6); and Pollux (Onomasticon, ii.) Martial, in more than one place, makes allusion to unnatural practices connected with an enlarged clitoris. Aëtius says that it is a small muscular substance situated at the commissure of the alæ pudendi above the meatus urinarius. He adds, that when preternaturally enlarged it is to be amputated. Like our author, he directs us to take hold of the tumour with a forceps and cut off the protuberance, taking care not to carry the excision too far. He recommends us to apply a sponge squeezed out of an astringent wine or cold water, with suitable dressings. He gives the same account of the cauda as our author. (xvi, 103 and 104.) It was a tumour arising from the uterus itself. Albucasis merely transcribes our author’s account of these operations. (Chirurg. ii, 71.) Avicenna briefly recommends us to remove the enlarged nympha by medicines or the knife. (iii, 22; i, 24.) It would appear that this operation, like circumcision, is still often practised in the East.

The chapters of Soranus, in which these operations were treated of, are unfortunately wanting.

On extirpation of the enlarged clitoris see Heister’s Surgery (ii, 5, 147). The _cauda pudendi_ was probably the cauliflower excrescence of the os uteri described by late authorities on midwifery.

SECT. LXXI.—ON THYMI, CONDYLOMATA, AND HEMORRHOIDS ABOUT THE FEMALE PARTS OF GENERATION.

The thymus is an excrescence sometimes red, but sometimes white, for the most part without pain, and resembling the clusters of thyme. The condylomata are rugose protuberances; and the hemorrhoids resemble those about the anus, and, like them, sometimes pour forth blood. Such excrescences in women, when brought into view and exposed, are to be seized with a forceps and cut out with the point of a half-spatula. And we are then to use pounded galls, or fissile alum. For the more distinguished surgeons do not approve of ligatures in these cases.

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COMMENTARY. Aëtius gives a fuller account of these tubercles. He recommends us to seize them with a forceps and cut them out by the roots. He directs us not to interfere with such hemorrhoids of the womb as are varicose and malignant. Those which are hard and do not bleed are to be cut out at once, but such as are disposed to bleed are to be seized with a forceps and a ligature put round them before they are cut. Moschion, however, condemns this practice as being highly dangerous.

Albucasis evidently copies from our author. (Chirurg. ii, 73.)

Haly Abbas briefly directs us to seize these tubercles with a forceps and cut them out with a pair of scissors. (Pract. ix, 65.)

Rhases, treating of diseases of the uterus, says, “if there be a red piece of flesh in the mouth of the womb, if situated at its anterior part, and if it be round, or long, and not attended with pain, some surgeons cut it off, but I prefer tying it.” (Cont. xxii.) This description seems to apply to polypus of the womb.

See a full account of the condylomata and hemorrhoids of the womb, by Lodovicus Mercatus (in the Gynæcia, p. 962.) He remarks that Celsus and Aëtius call any tubercle arising from inflammation by the name of condyloma, whereas Paulus applies the term only to callous tubercles of the uterus. He approves of seizing them with a forceps and cutting them out.

SECT. LXXII.—ON IMPERFORATE PUDENDUM AND PHIMUS.

Some women have the genital parts imperforate, sometimes naturally, and sometimes owing to some previous disease. And sometimes it is deep-seated, sometimes in the alæ pudendi, or in the intermediate places, and is sometimes occasioned by an adhesion of the parts, and sometimes by obstruction. The obstructing substance is either flesh or membrane. The disease occasions great impediment sometimes in coition, sometimes in conception, or in parturition, and occasionally during the menstrual purgation, provided the membrane or flesh occasion a complete obstruction; for in certain cases there is a perforation in the middle. Having ascertained the cause, either from its being obvious to the sight, or by introducing the speculum, if it be a simple adhesion only, it may be separated by a straight incision, made with a scalpel, for operating upon fistulæ. But if it is an obstruction, having transfixed the connecting body, whether it be membrane or flesh, with hooks, we stretch it and divide with a scalpel for fistulæ; and having stopped the hemorrhage with such applications as are desiccative without being stimulant, we have then recourse to such medicines as promote cicatrization, applying a priapus-shaped tent covered with some epulotic medicine, in those cases especially in which the operation is performed upon a part not very deep-seated, in order that the parts may not unite again. And the phimus which is formed at the mouth of the uterus is operated upon in the same manner.

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