Chapter XXI: Book VI: Sect. I.—preface to the Surgical Part (7)

COMMENTARY. Aristotle makes mention of imperforate vagina. (De Generat. Animal. iv, 4.) Aëtius treats of these diseases at considerably greater length than our author, but his practice is nearly the same. Upon the whole the amount of his directions respecting the treatment is, that when the obstruction is occasioned by a membrane, it is to be divided and the lips of the incision prevented from adhering by the introduction of suitable tents; or, if it is a fleshy body, it is to be dissected out, and the parts separated by a piece of sponge or tents. (xvi, 96.) The same operation is described by Soranus. (219.)

The same method of treatment, however, had been previously recommended by Celsus. Thus, when the obstruction is occasioned by a simple membrane, he recommends us to divide it by two transverse incisions like the letter Χ, taking great care not to wound the urinary passage, and then the membrane is to be cut out. When the obstruction is produced by a fleshy tumour, he directs us to expose it by making a straight incision; then, having seized it with a forceps or hook, to dissect it out, and introduce an oblong tent (λημνίσκος) soaked in vinegar, and apply externally wool moistened with vinegar. The dressings are to be removed on the third day, and the sore treated upon general principles. When the wound is healing, he advises us to introduce a leaden tube smeared with some suitable ointment to prevent adhesion. (vii, 28.)

Albucasis makes mention of a singular substitute for the leaden tube recommended by Celsus: “Coeat mulier omni die ut non consolidetur locus vice alia!!” The same advice is gravely given by Rhases (Cont. xxii), and by Alsaharavius, who, as we have formerly stated, was probably the same person as Albucasis. (Pract. xxv, 2, 19.) But when the obstruction arises from a fleshy tumour, Albucasis recommends us to make use of the leaden tube. (Chirurg. ii, 72.) Alsaharavius directs us to remove the obstruction by corrosive medicines or with the knife.

Rhases briefly describes the phimus, and directs us to perforate it with an instrument of iron, and then to introduce a tent moistened in some styptic wine.

Haly Abbas states that obstruction of the uterus may arise either from a natural, that is to say, a congenital impediment, or from the effects of ulceration. He recommends us to make the midwife clear away the obstruction with a scalpel or any other convenient instrument. The Arabians were very delicate in allowing male practitioners to perform surgical operations about the genital organs of women. (Pract. ix, 66.)

SECT. LXXIII.—ON ABSCESS OF THE WOMB.

When the abscess is situated at the mouth of the womb, so as that it can be operated upon, we must not be in haste in having recourse to incision, nor until the disease be ripened, and the inflammation has increased to its utmost, and the vascular bodies which surround it have become attenuated, owing to the importance of the uterus in the system. In operating, the woman should be placed on a seat in a supine posture, having her legs drawn up to the belly, and her thighs separated from one another. Let her arms likewise be brought down to her legs and secured by proper ligatures about the neck. The operator, sitting on her right side, is to make an examination with a speculum proportionate to her age. The person using the speculum should measure with a probe the depth of the woman’s vagina, lest the stalk (fistula) of the speculum being too long it should happen that the uterus should be pressed upon. If it be ascertained that the stalk is larger than the vagina, folded compresses are to be laid upon the alæ pudendi, in order that the speculum may be placed upon them. The stalk (fistula) is to be introduced, having a screw at the upper part, and the speculum is to be held by the operator, but the screw is to be turned by the assistant, so that the laminæ of the stalk being separated the vagina may be distended. When the abscess is exposed, if it be soft and thin (which may be ascertained by touching it with the finger), it is to be divided at the top by a scalpel or needle, and after the discharge of the pus, a soft oblong tent well smeared with rose-oil is to be introduced into the incision, or rather external to the opening into the woman’s vagina, so as not to produce compression. And externally to the alæ pudendi and the region of the pubes and loins unwashed wool, or clean wool dipped in oil, is to be applied. On the third day she is to be placed in a hip-bath of warm oil or water, or of a decoction of mallows; and having wiped the parts, we introduce the tent gently into the opening, spread with the ointment tetrapharmacon, either alone or with clarified honey; its strength, however, ought to be reduced with butter or oil of roses. The external parts are to be covered with cataplasms until the inflammation subside and the sore become clean. If it is got cleansed with difficulty, an injection of the decoction of iris, of birthwort, or of honey, may be thrown up with an ear-syringe. The healing process may be promoted by the calamine ointment diluted with wine and applied upon a pledget. But if the abscess be within the mouth of the uterus, we must decline operating.

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COMMENTARY. A similar description of the method of opening abscesses in the vagina is given by Aëtius. (xvi, 85.) The only difficulty in comprehending his description or our author’s arises from our unacquaintance with the construction of the ancient dioptræ or specula. Drawings of several sorts of them are given in the surgery of Albucasis and by Scultet. (Arsenal de Chirurg. tab. 18.) One of the simplest of them consists of two laminæ or plates so united that by turning a vice or screw they separated to the proper distance. Albucasis evidently copies our author’s description. (Chirurg. ii, 71.) The account given by Haly Abbas is quite similar. (Pract. ix, 57.)

SECT. LXXIV.—ON EMBRYULCIA AND EMBRYOTOMY.

We have described the treatment of difficult labours in the Third Book. If the process of parturition be not rectified by the means there laid down, we must proceed to the surgical operation, after having formed a probable conjecture whether the woman will survive or not; and if she may be saved, then we are to operate; but if not, we must decline attempting the operation. Those in a dying state are affected with coma, lethargy, and loss of muscular motion; they are difficult to rouse, or if roused by loud cries, they return a feeble answer, and again sink into a comatose state. Some have convulsive contractions, or subsultus tendinum, or insensibility to food. The pulse is found to be greatly inflated, but obscure and feeble. Those who are to recover have none of these symptoms. Having placed the woman in a supine posture, with her head rather depressed, her thighs are to be kept elevated by women on each side, or by certain assistants; or if they are not at hand, her chest is to be first fastened to the bed by ligatures, so that when the fœtus is pulled the woman’s body may not follow, and diminish the force of the pulling. Then the alæ pudendi being separated by an assistant, we must introduce the left hand lubricated with some unctuous substance, the fingers being contracted, to the mouth of the uterus, and dilate it, and having got it relaxed by lubricating it with oil, we seek for the most convenient place for fastening the hook (embryulcus). The most convenient places in presentations of the head are—the eyes, the occiput, the roof of the mouth, the chin, the clavicles, and the parts about the sides and hypochondrium; and in feet presentations, the bones of the pubes, the middle of the ribs, or, again, the clavicles. The hook is to be held in the right hand, and its curvature grasped with the fingers, and it is to be gently introduced with the left hand, and fixed on some of the afore-mentioned places, being pushed to the cavity of the uterus. And another is to be applied opposite to it in order that the pulling may be straight down and not to one side. Then we are to pull gently, not only straight-forward but also from side to side, as in the extraction of teeth; and there ought to be no relaxation of the pulling in the intervals. Then introducing the index-finger or more fingers besmeared with fat between the mouth of the womb and the impacted body, we must lubricate it all around. When the hook comes down properly it must be changed to a part above, and so on until the fœtus is completely extracted. When a hand presents, and is so impacted that it cannot be returned, we must wrap a cloth round it so that it may not slip, and pull it so far, and when it is properly fallen down it should be cut off at the shoulder. The same thing is to be done when two hands fall down into the vagina; and in like manner, when the feet come down, and the rest of the body does not come along, we must amputate at the groins, and then endeavour to turn the rest of the body. If the impaction take place owing to the head being larger than natural, if it be a hydrocephalous fœtus, we must open its skull with a polypus-scalpel, or a needle, or a sharp-pointed knife concealed between the fingers, in order that it may collapse when evacuated; but if it be a naturally large head, we must open the skull in like manner, and break down its bones with a tooth-forceps or a bone-forceps, and if the bones project they ought to be extracted. If, after the head has been delivered, an impediment should take place at the chest, the parts about the clavicles should be divided down to the cavity of the thorax with the same instrument, so that the thorax may collapse when its fluid contents are discharged; but if it do not collapse we may divide the clavicles and extract them, when the thorax will collapse. If the belly be inflated, owing to the death of the child, or its being dropsical, we must evacuate its contents with the intestines in the same way. In presentations by the feet the wrong direction may be easily rectified at the mouth of the womb. But if the fœtus stick at the chest or belly, we must wrap a cloth about it and draw it down, and making a division in the same manner, evacuate its contents. If, after the other parts are cut off, the head retreat backwards and is retained, we must introduce the left hand, and if the mouth of the womb be open, push up the hand to the cavity of the womb, and having found the head, bring it down with the fingers fixed in the mouth, and extract by one or two hooks fixed in it; but when there is inflammation at the mouth of the womb we must use no violence, but lubricate the parts with unctuous and fatty applications, and have recourse to hip-baths, embrocations, and cataplasms, in order that when the mouth is dilated extraction may be accomplished in the manner described above. Cross presentations, if they can be rectified, may be treated according to the afore-mentioned methods; but if not, the whole fœtus must be cut asunder within, and extracted in pieces, taking care that none of the parts of it be left behind. After the operation we must have recourse to the treatment for inflammations of the uterus. If hemorrhage come on, you have already had the management of it described.

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COMMENTARY. There is a curious treatise commonly published along with the works of Hippocrates on the extraction of the fœtus; but, as it is not mentioned by Erotian and Galen, it is now generally admitted not to be genuine. The author of it directs us, when the arm presents, to pull it down and amputate at the shoulder-joint; after which the head is to be brought to the proper position and delivery accomplished accordingly. This is not now the general rule of practice, and yet we were once compelled by necessity to deliver in this way, after we and an intelligent assistant had been foiled in all our attempts to turn the child. We have known of similar cases happening in the practice of other surgeons; and, in fact, this method of procedure was advocated lately by a sensible writer in the ‘Edinburgh Medical and Surgical Journal.’ The author of the ancient treatise in question recommends us to bring down the head in its natural state, if possible, but if this be found impracticable, to break it down. He directs us to give for drink a white, sweet, undiluted wine.

Celsus gives an interesting account of this subject, and his practice is deserving of much consideration. He recommends us, when the position is unnatural, to turn the child either to the head or the feet; adding, afterwards, that delivery may generally be accomplished easily enough by the feet. In arm presentations, he approves of turning to the head, that is to say, in cases when it is ascertained that the fœtus is dead. If the head is at hand, a smooth hook with a small point is to be fastened at the eye, the ear, the mouth, or the forehead, and its body is to be thus dragged down. This, however, must not be attempted when the mouth of the womb is not properly dilated. The right hand is to be employed in dragging down the fœtus, and the left in directing the instrument and the fœtus. When the body of the fœtus is distended with a fluid, it is to be let out, and the body brought down with a hook. If the child lie across and the position cannot be got rectified, the hook is to be inserted at the armpit, and extraction gradually performed. In extreme cases he recommends us to cut the neck asunder, and extract the parts separately, beginning with the head, for fear of its being left in the uterus. Should such an accident occur, however, he directs us to get the belly compressed so as to force the head down to the os uteri; after which it may be extracted with a hook in the manner described above. (Smellie relates histories of such cases.) When one foot presents, and the breech sticks at the os uteri, he recommends us, when the other foot cannot be found, to separate the one which protrudes; after which the body of the child may be pushed up, and the other leg found and brought down. It is to be recollected that this practice is only recommended when the child is dead. He adds, that other difficulties may give rise to the necessity of performing embryotomy. (vii, 29.)

Aëtius has an interesting chapter on the Extraction of the Dead Fœtus, copied from the works of Philumenus. His description of embryotomy is similar to our author’s. He directs us to apply two hooks to certain parts of the head, such as the eye, mouth, and chin, and thus to drag down the body. If the head is large or hydrocephalic, he advises us to open it and evacuate its contents; and if even then it is found to be too large for the passage, he recommends us to break down the bones of the skull and remove them with a forceps, after which the instrument is to be fixed and the fœtus dragged down. If obstruction to the delivery take place at the chest or the belly, he directs us to evacuate their contents in like manner. When an arm or both present, he recommends us to amputate at the shoulder-joint. If the child come down doubled, and the position cannot be got rectified, he advises us, if the head can be reached, to break down its bones, and then extract the other parts accordingly; but if the legs are got at most easily and cannot be brought down, they are to be amputated at the hip-joint, and then the head will be got delivered. When the body is so impacted in a doubled state that it cannot be moved, he directs us to separate the vertebra at the neck, and then to drag down the lower part of the body; after which the head is to be sought for by the hand introduced into the uterus, and brought along with two hooks. (xvi, 23.)

No ancient author has described the operation of embryotomy so accurately as Soranus; but as his account of the process is lengthy and does not differ essentially from that of Aëtius, (indeed the latter evidently copies from Soranus,) we need not seek to give any outline of it. (Op. 51, 52, 53.)

Avicenna takes his chapter on the extraction of the dead fœtus from our author. (iii, 21, 2, 24.) We have mentioned in the Third Book that he was acquainted with the forceps.

Albucasis, in like manner, takes his account of embryotomy from Paulus. He relates a singular case that came under his own knowledge of an extra-uterine conception; the most remarkable circumstance about which was, that the bones of the fœtus after a time were discharged at the umbilicus. The work of Albucasis contains drawings of the instruments used in his time for obstetrical operations. There are several forcipes among them, but as they all have teeth, it is to be presumed that they were used only for delivering the fœtus when dead. It is to be regretted that he has entirely omitted the forceps mentioned by Avicenna. (See Chirurg. ii, 76 and 77.)

Rhases directs us when the child’s head is large and cannot be brought down with fillets, to open it and deliver with hooks. When it is ascertained that the child is dead, he recommends us to break down the bones of the head and evacuate the brain. In preternatural presentations he recommends us to deliver, if possible, by the head or feet, but if this cannot be got accomplished, he directs us to cut off the protruding part. Upon the whole his rules of practice are much the same as our author’s. (Cont. xxii.)

Haly Abbas gives ample directions for the management of these cases. When the head presents (the child being dead and delivery found otherwise impracticable), he directs us to fix hooks in the hollows of the eyes, neck, or jaw-bone; or if the feet present, at the tops of the thighs. The body of the child is then to be dragged along. When a hand presents, he recommends us to pull down the arm and amputate at the shoulder; and in like manner he directs us to amputate at the hip-joint when in footling presentations the delivery cannot be otherwise accomplished. When the head is preternaturally large, he directs us to open it and evacuate its contents; and to do so in like manner with the chest when any obstruction takes place at it. He makes no mention of any instrument resembling the modern forceps. (Pract. ix, 57.)

SECT. LXXV.—ON RETENTION OF THE SECUNDINES.

Often, after the removal of the fœtus, the placenta (which is also called the secundines) is retained in the uterus. When the mouth of the uterus is dilated and the placenta separated, and rolled into a ball in some part of the uterus, the extraction is most easy. The left hand warmed and anointed is to be introduced into its cavity, and the secundines extracted as they present. But if they adhere to the fundus uteri we must introduce the hand in like manner, and grasp them and pull them along, not straight down for fear of prolapsus, nor with great violence, but they are to be moved gently, at first from this side to that, and afterwards somewhat more strongly, for thus they will yield and be freed from their adhesion. If the mouth of the uterus be found shut we must have recourse to the same treatment. If the strength is not sunk, sternutatories and fumigations with aromatics in a pot may be used; and if the mouth of the womb dilate, the hand is to be introduced and an attempt made to extract the placenta, as aforesaid. If even in this way it cannot be extracted, one need not be alarmed, for after a few days it will putrefy, dissolve into sanies and drop off. But since the fetid smell affects the head and disorders the stomach, we must use suitable fumigations, among which cardamom and dried figs are much approved.

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COMMENTARY. We have mentioned in another place that Hippocrates’ practice in retention of the placenta consisted in suspending weights from the end of the umbilical cord.

Celsus directs us, when the placenta is not cast off soon after the delivery of the child, to draw down the umbilical cord gently with the left hand, taking care not to break it. The right hand is then to follow it up to the secundines, and their veins and membranes being separated from the womb, the whole are to be extracted along with whatever coagulated blood may be in the uterus. (vii, 29.)

Our author merely abridges a fuller account of the subject given by Aëtius from the works of Philumenus. (xvi, 24.)

Moschion reprobates the ancient practice of using sternutatories, pessaries, and fumigations, and of suspending scales or weights from the cord, because these means sometimes occasion hemorrhage. He recommends the midwife, if the mouth of the womb be still open, to introduce her left hand, and to take hold of whatever part of the placenta presents: then, if it does not adhere to the fundus uteri it is to be extracted; but if it is not separated it is to be moved gently hither and thither without violence. When the mouth of the uterus is contracted, he advises her to use those liquors and injections which are applicable for inflammations of the womb. (Section liv.) His method of securing the umbilical cord after delivery is nearly the same as that now adopted. After the child has been allowed to lie on the ground for a few minutes, two ligatures are to be applied round the cord, the nearest being four fingers from the belly; it is then to be cut with a scalpel or any sharp knife. He disapproves of using instruments of wood, glass, or reeds, and hard crusts of bread, as practised by the ancients. (lxv.) He directs lacerations of the perineum to be treated by applying ointments composed of wax, oil of roses, litharge, ceruse, and alum, with suitable bandages. (lvii.)

The practice of Soranus in these cases is most judicious, and such as can scarcely be improved upon at the present day. He disapproves of all violent attempts at extraction, but when the placenta cannot be got otherwise removed from the womb, he approves of introducing the hand well lubricated to extract the secundines gently. He directs us when the mouth of the womb is shut to open it if possible with the fingers in a gentle manner. This is the case now incorrectly called the hour-glass contraction.

Avicenna repeats the directions given by Paulus and Aëtius, but seems to have considered the introduction of the hand into the uterus as a painful, and, in general, an unnecessary operation. (iii, 21, 2, 16.)

Albucasis follows our author’s practice. (Chirurg. ii, 78.)

Haly Abbas directs us to introduce the hand well lubricated with oil of violets, or the like, into the uterus, and extract the placenta if it be separated; but if it still adhere it is to be moved from side to side, and not pulled straight downwards. He adds, that when not extracted, it becomes putrid. (Pract. ix, 59.)

Rhases directs us when the secundines do not come away after delivery to make the woman sneeze, and if they are still retained, to pare the nails, and having introduced the hand into the uterus to pull cautiously so as not to give pain. When they cannot be removed in this way, he recommends us to throw injections into the womb so as to promote putrefaction of the placenta. In another place he mentions, that when long retained, the placenta putrefies and comes off in pieces. (Cont. xxii.)

SECT. LXXVI.—ON BURNING THE HIPS.

As in the case of the shoulder, so also the hip-joint getting dislocated from a collection of humours requires burning. Wherefore Hippocrates says: “When dislocation at the hip-joint takes place from long-continued ischiatic disease, the leg wastes, and the patients are lame unless burnt.” Burning, therefore, is to be performed more particularly at the place where the joint is dislocated, for thus the redundant humour will be dried up, and the part being condensed by the cicatrix will no longer be able to receive the bone, wherefore the burning should be carried to a considerable depth. The moderns form three eschars by burning; one behind in the hollow of the buttocks, another a little above the knee on the outside, and a third on the outside of the ankle in the fleshy part.

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COMMENTARY. Hippocrates recommends us to burn the parts over the hip-joint with crude flax. (De Affectionibus.) The author of another of the Hippocratic treatises directs us to burn the bony parts with fungi and the flesh with a red-hot iron. (De Affect. Int.)

Aëtius, upon the authority of Archigenes, recommends burning in this case with irons, the roots of fuller’s herb and birthwort, or with goat’s dung. (xii, 3.)

Cælius Aurelianus, in cases of ischiatic disease, speaks of forming issues over the hip-joint by the actual and potential cauteries. His potential cauteries, with which he mentions that eschars were burnt, appear to have been the ashes of herbs, that is to say, impure preparations of the caustic alkali, to which quicklime was sometimes added. They must, therefore, have been nearly the same as the _calx cum kali_ of modern use. He states, that some burned the part with the root of fuller’s herb; others with pieces of iron shaped like the letter Γ; that some raised the skin in a fold and transfixed it with heated irons; that some burned it with fungi, and others with a piece of linen cloth folded and laid on the part. (Pass. Tard. v, 1.)

But the fullest account which we have of the ancient modes of burning the hips for diseases of the joint is that which is given in the book ‘Euporistôn,’ ascribed to Dioscorides. Mention is there made of the methods of burning with goat’s dung, and with wool smeared with oil. Some, it is said, form a ball of clay, and, having laid it on the place, apply to it a burning staff as long as it can be borne. Others, having stretched the skin over the affected joint, transfix it with a heated style or writing pen. The Libyans performed the operation with shavings of the lote tree, sulphur, and elaterium. The Marmaridæ are said to have done it with green pieces of the wood of olive trees. The Parthians used a leaden tube, the extremity of which they smeared with dough, in order to prevent the oil in the inside from escaping; then hot cauteries, to the number of forty or fifty, were introduced, and the burning continued as long as it could be well endured. Care in the meantime was taken to cool the face with cold water; and it was attended to, that the tube was not over-filled with oil, lest it should run over. (Euporist. i, 242.)

Albucasis describes minutely the process of burning with red-hot irons. (Chirurg. i, 43.) Haly Abbas in like manner directs us to burn an eschar over the joint, and to keep it open for a considerable time. (Pract. ix, 81.)

Asclepiades (apud Nicetæ Collect.) mentions that he had seen two cases in which dislocation had taken place at the hip-joint without any accident. The editor of this work, Anthony Cocchi, states that he had met with only one such case in the whole course of his practice. We need scarcely remark that such cases, however, are by no means of rare occurrence.

SECT. LXXVII.—ON FISTULÆ AND FAVI.

The present occasion requiring us to treat of fistula in ano, it will not be improper to give an account in the first place of fistulæ in general. A fistula then is a callous sinus, attended with little or no pain, and forming in most parts of the body. It generally originates in abscesses not properly healed. The callus is compact and white, the flesh dry, and therefore insensible, neither vein nor nerve passing to it. Sometimes the sinus is dry and sometimes filled with a discharge. The discharge is sometimes constant, and sometimes at intervals, the mouth of it being at one time shut up, and at another time open. Sometimes the fistula terminates on a bone, sometimes on a nerve, or some other important part; and it is either straight or crooked; has either one orifice or many. Those therefore that terminate upon large arteries, or nerves, or tendons of considerable size, or the pleura, or any important part, are either not to be meddled with at all, or with great and skilful caution; but the others may be operated upon in this manner. We first examine them if they be straight with a sound (specillum), or if crooked with a double-headed specillum of a very flexible nature, such as those made of tin, and the smallest of those made of copper. When there are two or more orifices, we must not trust to the examination with a specillum, but injecting the sinus by one of its openings we ascertain from the manner in which the injection comes out whether it be one fistula with many orifices, or if there be several fistulæ. After the examination, if the sinus be superficial and narrow, it is to be distended by the introduction of a specillum, and the callus is to be cut off with a properly-shaped scalpel, or pared with the nails or the point of a scalpel. If it is also broad the redundant parts are to be dissected away. If it is not superficial, but deep and straight, we must cut off the callus all around as far as we can make incisions, and if any part remain, destroy it with a caustic medicine; or if the callus be large, and do not yield to medicine, we must form a slough by burning it with hot irons. If the fistula terminate with a bone, and if it is not diseased, we need only scrape it, but if it is carious, or otherwise corrupted, the whole diseased portion is to be cut out with counter perforators, and if necessary we may bore a hole with a wimble (trephine?) whether the bone be diseased only to the diploe or as far as the marrow. If a bone project, as after a transverse fracture, we must saw it off. Taking, therefore, two bandages, we apply the middle of the one to the projecting bone itself, and get it kept stretched by an assistant; the other being thicker, or formed of wool, we are to take in like manner, and apply the middle of it to the flesh under the bone, and taking its ends below, we give directions that the flesh below be retracted by this band lest it be torn by the teeth of the saw, and in this manner we accomplish the sawing. When any vital part is situated below, such as the pleura, spinal marrow, or the like, in cutting or sawing the bone, we must use the instrument called meningophylax for protecting them. If the bone is not diseased, but is denuded of flesh all around, it is to be sawn in the same manner, for bones which are disengaged from the other parts all around cannot possibly incarnate. In like manner, the extremity of a bone near a joint, if diseased, is to be sawn off; and often, if the whole of a bone, such as the ulna, radius, tibia, or the like, be diseased, it is to be taken out entire. But if the head of the thigh-bone, or pelvis, or a vertebra of the spine be diseased, we must not attempt to operate upon them for fear of the adjoining arteries. We must proceed in this manner in every particular case, attention being paid to the situation, proximity, and connexions of the affected parts, the extent of the disease, the strength and powers of the patient. The favus being a fistulous sinus with a milky discharge must be subjected to the same operation and treatment as fistula.

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COMMENTARY. For an account of the practice of Hippocrates we refer to our notes on the 49th section of the Fourth Book.

Celsus states that if fistulæ spread deep, are crooked, or are numerous, they are to be cured by an operation rather than by medicines. Wherefore, if it spread transversely, he recommends us to introduce a specillum, or sound, and cut down upon it. But if it is crooked, its bendings are to be followed out and cut open in the same manner. When the operator has reached the end of the fistula, all the callus is to be cut out, and the lips of the wound secured by clasps and agglutinative applications. When the fistula terminates with a rib he directs us to saw out a piece of it lest it affect the adjoining parts. Fistulous sores about the abdomen he pronounces to be highly dangerous. He recommends us, however, to attempt a cure by making an incision, and uniting the edges of the wound by sutures. (vii, 4.)

Aëtius lays down nearly the same rules for the treatment of fistulæ as our author. When the sinus runs transversely along the skin, he directs us to lay it open. When it penetrates downwards he advises us to cut off the callus; and when the ulcer terminates with a bone to remove the diseased lamina of it. (xiv, 55.)

Albucasis delivers the surgical treatment of fistulæ at great length. He is very particular in inculcating the necessity of making free incisions, and of removing any pieces of diseased bone which may happen to be found at the bottom of the sore. He relates a case of fistulous ulcer in the thigh, to cure which he removed large pieces of bone, sawing it down as far as the marrow. Some of his saws are very ingeniously constructed, and one of them is not unlike the saw introduced into the practice of surgery by the late Mr. Hey, of Leeds. He enumerates nine causes which prevent sores from healing; and as they appear to be of some practical utility we shall briefly mention what they are: 1, a deficiency of blood in the body; 2, cachexy, or bad condition thereof; 3, fungous flesh, which prevents the union of the edges of the sore; 4, much sordes in the ulcer; 5, putridity, or any other bad quality of the fluids; 6, improper applications; 7 and 8, the pestilential state of the atmosphere and the insalubrity of the place where the patient resides; 9, a diseased bone. When none of these causes are present, the restorative principle of nature will of itself effect the cure of any solution of continuity. (Chirurg. ii, 88.)

Rhases gives extracts from Antyllus, and many other authors, on this subject, but as their principles of treatment are much the same as those delivered by Paulus, we need not occupy much room with an abstract of them. Antyllus forbids us to use the knife when the fistula is situated in the groin or fundament. When it is not judged expedient to have recourse to an operation, one of his Arabian authorities, Aaron, recommends a powder composed of equal parts of quicklime, cantharides, arsenic, sandarach, sal ammoniac, and ginger. (Cont. xxviii.)

SECT. LXXVIII.—ON FISTULÆ IN ANO.

Fistulæ in ano are discovered, if they are _blind_, from their being attended with pain, although no orifice appears; from there being a purulent moisture about the anus, and in most cases from their being preceded by symptoms of abscess; or, if they are _open_, by the introduction of a sound or swine’s bristle; for the instrument will pass down into a cavity and meet the index-finger introduced into the anus if the fistula has penetrated to the inside; but if it has not penetrated, the instrument does not come in contact with the finger but the intermediate substance between them remains imperforated. The fistula is known to be crooked and winding from the instrument’s passing down but a short way, while a great quantity of pus is discharged in proportion. Those near the intestines are known by an abdominal worm or fæces sometimes passing through the mouth of them. In almost all cases some callus appears about the orifice of the fistula. A fistula is incurable that perforates the neck of the bladder, or extends to the joint of the thigh, or to the rectum. A fistula is difficult to cure when it has no orifice, is _blind_, ends with a bone, and has many windings. All the rest are, in general, easily cured. We proceed with them thus: having placed the patient in a supine posture, with the legs elevated, so that the thighs may be bent upon the belly, as when an injection of the bowels is administered, if the fistula terminate superficially, having introduced a sound or ear-specillum through the orifice of it, we cut the skin which covers it at one incision. But if the fistula terminate deeply in the anus, having introduced a specillum into the mouth of it, and if we find that it has perforated the gut, by introducing the finger into the anus opposite the affected buttock, we take hold of the head of the specillum, and bending it, bring it to the outside, and with one simple division cut asunder the parts which lie over the sound. If the fistula is found not to have as yet perforated the gut, and to have terminated only deeply in the fundament, and if upon examination we find that a scaly or membranous substance intervenes between the index-finger and the extremity of the sound, we must perforate it violently with the head of the sound, and forcing the sound through the rectum, we must again, as formerly described, cut asunder the intervening parts with a scalpel; or, having perforated the bottom of the fistula in ano with the sharp part of a falciform instrument for operating upon fistulæ, we bring the instrument out at the anus, and so divide all the intermediate space with the edge of the instrument; and after the incision, having taken hold of the surrounding parts, which mostly consist of callus, with a common forceps, or one called staphylagra, we cut them out all around, avoiding the sphincter muscle; for some cutting deep in an unskilful manner, have wounded it, from which the patient has had an involuntary discharge of fæces. Those who from timidity, avoid a surgical operation may be treated with the ligature, as recommended by Hippocrates. For Hippocrates directs us to pass a raw thread, consisting of five pieces, through the fistula by means of a probe having a perforation, or a double-headed specillum, and to tie the ends of the thread and tighten it every day until the whole intermediate substance between the orifice be divided and the ligature fall out. If it remain long, the thread may be sprinkled with the detergent powder called psarum, or some such powder, and drawn in. Some insert a thread into the opening of the falciform instrument for operations on fistulæ, and pass it through in the manner described, which I think ought not to be done. For by avoiding an operation, in addition they incur the inconvenience of a slow recovery. With regard to blind fistulæ, Leonides says: “When the fistula is deep, and penetrates the sphincter, whether beginning in the fundament, or arising from a distance and terminating in the sphincter, after the examination which has been described, we dilate the anus as we do the female vagina, with the instrument for that purpose, or the small specillum. When the orifice of the fistula is discovered, the end of an ear-specillum is to be passed through it, and pushed deep into it, and cutting down upon it where it presents, the whole fistula is to be divided with a semispathula or a spathula for operating upon fistulæ.” We having met with this state of the disease, have found it impossible to practise this mode of operating, because we could not discover the cavity of the fistula. For it was situated between the anus and sphincter towards the right side, and the dilator rather obscured the operation. But having dilated the wrinkles about the anus a certain fissure appeared among them, being as it were the defluxion of the fistula, for the pus passed out by it we saw to pass the head of the specillum into the fistula by it, which served as a director; and having passed the index-finger of the right hand to the sphincter, and having found a certain thin substance intervening between the finger and the sound, by pressing the sound violently to the finger, we perforated the bottom of the fistula, which was turned upwards; and passing with the finger the head of the instrument outwards, the whole of the substance between the mouths of the fistula, (I mean the one so situated as to favour the defluxion, and that now made by us,) we divided with a scalpel and cut out the sound.

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COMMENTARY. Hippocrates describes minutely the apolinose, or the cure with the ligature, in his work ‘De Fistulis.’ We must mention, however, that Kühn and Sprengel do not admit this among the genuine treatises of Hippocrates, although they allow that it is ancient. Littré also, though with some hesitation, has rejected it from his list of the genuine works of Hippocrates. And yet, considering that it was received as such by Galen and Erotian, it seems bold in any modern critic to refuse its claims.

Celsus likewise describes distinctly the method of applying the ligature. The process, he says, is slow but free from pain. It may be expedited by smearing the thread with some escharotic ointment. The same thing, he adds, may be accomplished by means of a scalpel guided upon a specillum (sound). When many sinuses open by one mouth, he directs us to cut open a straight fistula with a scalpel, and then the others being thereby exposed are to be tied with a thread. The diet is to be of a diluent nature, with a liberal allowance of water for drink. (vii, 4.)

Aëtius gives, from Leonides, a full account of fistulæ in ano, as we have explained in another place. He recommends us to introduce a specillum, and having cut open the fistula upon it, to pare away the callous parts of it. (xiv, 11.)

Actuarius approves of the same practice as the others. He cautions against making large incisions lest the sphincter ani be wounded. (Meth. Med. iv, 6.)

Albucasis delivers nearly the same rules of treatment as our author. According to circumstances he approves of the knife, the cautery, or the apolinose. (Chir. ii, 80.)

Haly Abbas describes only the operation by the incision. He also states that if the sphincter ani be wounded, it will occasion irretention of the fæces. (Pr. ix, 60.) See also Rhases (Ad Mansor. ix, 80; Cont. xxviii); and Avicenna (iii, 18, 1, 18.) Avicenna prefers twisted hairs or bristles of a hog, as they will not putrefy.

Upon the whole no other of the ancient authorities has treated so efficiently of fistulæ in ano as Paulus.

See an excellent account of the operation in Sprengel’s ‘History of Medicine.’ John de Vigo trusted to septics, such as arsenic and the ægyptiacum. Ambrose Paré approved of the apolinose and incision. Severinus was an advocate for the cautery. Foubert and Camper likewise practised the apolinose—the one with a leaden thread, the other with a silk one. Guido de Cauliaco and Rogerius approve of the ligature. Brunus and Theodoricus prefer the actual cautery, but describe the others. The surgeons of this country have now generally rejected the methods with the ligature and the cautery.

The following account of the ancient specillum by the learned Harduin will serve to illustrate our author’s description of the operation. We overlooked it in the commentary on the fifteenth section. “Quid sit specillum Varro explicat (Lib. 5 de Lingua Lat.) _Quo oculos inunguimus quibus specimus_ (hoc est, aspicimus), _specillum est_. Græcis μηλὴ dicitur. Aëtius Serm. 8, 14, _cum specillo instrumento, quod melam Græci appellant_. Instrumentum parvum ac teres, quo utuntur ad vulnerum aut fistularum viam aut profunditatem pernoscendam. Une sonde de chirurgien.” (Ad Plin. H. N. vii, 54.) If the κοπάριον, however, was the same as the μηλὴ or the specillum, it was evidently used for cutting with as well as for cutting upon.

SECT. LXXIX.—ON HEMORRHOIDS OR PILES.

The existence of hemorrhoids is rendered manifest to us by the discharge from them. Before proceeding to the operation we must use frequent clysters with the view of evacuating at the same time the contents of the intestine, and, by irritating the anus, of rendering it more disposed to eversion and protrusion of the gut. Having, therefore, laid the patient on his back in a clear light, if we are to use the ligature we pass a very thick thread round the lips and secure each of the hemorrhoids with this ligature, leaving one as an outlet to the superfluous blood (for so Hippocrates directs.) After the application of the ligature, using a compress that has been dipped in oil and the bandage adapted for the anus, we order the patient to remain quiet, and treat the bowels with tepid oil and honied water, and afterwards we use a cataplasm made of crumbs of bread and saffron; and after the falling off of the hemorrhoids the cicatrization is to be promoted by wine. Leonides has not recourse to the ligature, but having seized the hemorrhoids and held them for some time with the forceps used for operations on the uvula he cuts them off with a scalpel. After the operation we must use manna and starch with chalcitis, or the plaster of burnt sponge with pitch, and the trochisk called faustinum, in order to burn it completely. Others by filling the cavity of the instrument called staphylocaustes, with caustic medicines, have burnt hemorrhoids like a scirrhous uvula.

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COMMENTARY. Hippocrates directs us to pass a needle armed with a very thick thread through the hemorrhoids, and tie them with it. Septic applications are afterwards to be made to them. (De Victu Acut. 67.) The author of another of the Hippocratic treatises recommends us to cure them by burning with red-hot irons. (De Hæmorr.)

Celsus directs us when the base of a hemorrhoid is narrow to tie it with a thread where it joins the anus, and to apply over it a sponge squeezed out of hot water until it become livid, when it is to be scraped off with the nail or a scalpel. Sometimes, however, he says, the ligature occasions great pain and retention of urine. If the hemorrhoid be large and its base broad, he directs us to seize it with a hook, and dissect it out a little above its base: the part is to be secured with a thread. When there are many hemorrhoids he advises us not to operate upon them all at one time. When there is a discharge of blood it is to be stopped by the application of a sponge. The day after the operation he recommends us to use the tepid bath and catalapsms. (vii, 30.)

Aëtius approves of cutting off hemorrhoids, and describes the operation minutely. He directs us to seize the pile with a hook, grasp it firmly, and bind it with a thread, after which it is to be raised and cut off. To stop the bleeding a piece of sponge bound round with a thread is to be introduced into the anus. Suitable dressings and bandages are then to be applied, (xiv, 6.)

In the ‘Isagoge’ ascribed to Galen, the method of treating hemorrhoids by the ligature is particularly commended.

Albucasis prefers excision and burning, but if the patient will not submit to these methods of cure he approves of having recourse to the ligature. Excision is performed by seizing the hemorrhoid with a hook and cutting it at its base, after which some styptic application is to be made. The ligature is applied by transfixing the base of the hemorrhoid with a needle armed with a thread. (Chirurg. ii, 81.) He gives particular directions about the process of burning. (p. i, 37.)

When the hemorrhoid is internal Rhases directs us to evert the anus, and having laid hold of the tumour to cut it out. He also describes the process of tying them in the same terms as the other authorities. (Contin. xxiv.) The directions given by Avicenna are quite similar.

Haly Abbas recommends excision or the ligature. (Pract. ix, 61.)

Fabricius makes mention of all these methods of treatment, but speaks of the application of the cautery as being dangerous. Upon the whole he appears to have entertained great apprehensions from stopping the discharge of piles. (Œuv. Ch. ii, 94.)

Theodoricus and Brunus recommend excision, the cautery, and the ligature, according to circumstances. Theodoricus also makes mention of applications for consuming and drying them up.

SECT. LXXX.—ON CONDYLOMATA OR EXCRESCENCES, AND FISSURES.

Condyloma on the fundament differs in situation alone from that on the female parts of generation, being a wrinkled excrescence of the anus, either from a preceding inflammation or fissure. At first, then, it is called an excrescence, but when it becomes callous, condyloma. These also, like the former, are to be taken hold of with a forceps and cut out, and the cure completed with escharotics. Fissures are occasioned principally by hard fæces, and being slow of granulating owing to their callosity, must be converted into recent ulcers by paring them with the nails or a scalpel, when they may be made to granulate by proper applications.

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COMMENTARY. Celsus briefly directs us to seize the condyloma with a forceps and cut it out by the roots. Should any fungous flesh arise it is to be kept down with the squama æris. (vii, 30.)

Aëtius gives a fuller account of these affections than our author. The condyloma, he says, is a tubercle which forms in the soft wrinkled skin about the anus. When it becomes hard and callous he recommends us to take hold of it with a forceps and cut it out by the roots. Old fissures he directs us to treat by paring their edges and applying suitable dressings. (xiv, 3.)

The same treatment is recommended by the Arabians. See Haly Abbas (Chirurg. ix, 62); Albucasis (Chirurg. ii, 81, 82); Rhases (Contin. xxiv.)

SECT. LXXXI.—ON IMPERFORATE ANUS.

In new-born children the anus is sometimes found imperforate, being blocked up by a membrane. If possible, then, the membrane is to be ruptured with the fingers, but if not, we must cut it with the point of a scalpel, and accomplish the cure with wine. And since often in adults, owing to an ulcer not properly cured, a stricture takes place at the anus, we must break it with a convenient instrument, and treat it properly with a pipe of lead, or some wedge-shaped tent introduced into the anus until the cure be completed, lest contraction should again take place. The wedge-shaped tent is to be anointed with some healing ointment.

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COMMENTARY. Soranus describes this operation in very distinct terms. (p. 164.)

Albucasis evidently copies our author’s account, recommending us to break or divide the membrane, and introduce a canula of lead into the opening to prevent adhesion. (Chirurg. ii, 79.)

Haly Abbas, in like manner, directs us to make an opening and introduce a leaden tube or a piece of sponge. (Pract. ix, 63.)

SECT. LXXXII.—ON THE EXCISION OF VARICES.