De Medicina

29 Again when a woman has conceived, if the foetus, already nearly at term, dies inside and cannot get out of itself, an operation must be done, which may be counted among the most difficult; for it requires both extreme caution and neatness, and entails very great risk. But this shows, and not this only, how marvellous beyond all else is the womb. To begin with then the woman should be placed on her back across the bed, so that the iliac regions are compressed by her own thighs; by this means both her hypogastrium is in full view of the surgeon and the foetus is forced towards the mouth

of the womb. This, after the death of the foetus contracts, but later on usually dilates a little. The surgeon making use of this opportunity should first insert the index finger of his greased hand, and keep it there until the mouth is opened again, and then he should insert a second finger, and the other fingers on the like opportunity, until the whole hand can be put in. To allow of this, much depends both on the size of the vagina, and the resistance of its sinewy tissues, and the patient's constitution, and also her strength of mind, especially since on occasion even both hands have to be passed in. It is also important that the hypogastrium and extremities should be kept very warm, that inflammation should not have begun, but that the treatment should be adopted without delay. For if the abdomen is already distended, the hand cannot be inserted nor can the foetus be extracted without the greatest suffering, and fatal spasm of the sinews often follows, accompanied by vomiting and tremor. But when the hand has reached the dead foetus its position is immediately felt. For it lies head on or feet foremost, or crosswise; generally, however, so that there is either a hand or foot within reach. It is the object now of the surgeon to direct it with his hand either into a head or even into a foot presentation, if it happens to be presenting otherwise: and if there is no other course, when a hand or foot is grasped, the trunk is straightened: for grasping a hand converts the presentation into a head one, grasping a foot into a foot presentation. Then if the head is nearest, a hook must be inserted which is completely smooth, with a short point, and this it is right to fix into an eye or ear or the mouth, even at times into the forehead, then this is pulled upon and extracts the foetus. But not every moment is proper for the extraction; for should this be attempted when the mouth of the womb is contracted, as there is no way out, the foetus is torn away from the hook, and its point then slips into the mouth of the womb itself; and there follows spasm of the sinews and great risk of death. Therefore whilst the mouth is contracted we should wait, and draw gently on the hook when it dilates, and so at these opportunities gradually extract the foetus. Now the right hand should pull the hook whilst the left is inserted within and pulls the foetus, and at the same time guides it. It also often happens that such a foetus is distended by fluid, and from it a foul sanies discharges. If so, the abdomen of the foetus is bored into by the index finger, when by escape of the fluid, the foetus is made smaller; then it is gently to be delivered by the hands alone. For if a hook is inserted it readily slips out of the soft little body, when the danger noted above is incurred. If the foetus has been turned to present by the feet it is also not difficult to extract; for the feet are grasped by the doctor's hands, and it is readily drawn out. But if the foetus is lying crosswise and cannot be turned straight, the hook is to be inserted into an armpit and traction slowly made; during this the neck is usually bent back, and the head turned backwards to the rest of the foetus. The remedy then is to cut through the neck, in order that the two parts may be extracted separately. This is done with a hook which resembles the one mentioned above, but has all its inner edge sharp. Then we must proceed to extract the head first, then the rest, for if the larger portion be extracted first, the head slips back into the cavity of the womb, and cannot be extracted without the greatest risk. Should this, however, happen, a folded pad is placed upon the woman's hypogastrium, and then a man strong, but not untrained, must stand on her left side, and place his two hands over the hypogastrium and press one over the other so that the head is forced to the mouth of the womb, when it must be extracted by the hook as described above. But if one foot presents whilst the other remains behind with the trunk, anything which has been drawn out must be cut away piecemeal; and if the buttocks begin to engage in the mouth of the womb they are to be pushed back and the foot of the foetus found and then drawn forwards. There are also other difficulties, which make it necessary to cut up and extract a foetus which does not come out whole. Now as soon as the foetus has been extracted it should be handed to the assistant to hold on his upturned hands, and the surgeon with his left hand must draw gently upon the navel cord, so as not to rupture it, whilst he passes his right hand along it up to what they called the secundines, which was the envelope of the foetus within the womb. When his hand has grasped the secundines including the whole of the blood vessels and membranes he brings them down from the womb in the same manner, and extracts the whole together with any retained blood clot. Then when the thighs have been tied together the woman is put to bed in a moderately warm room, which is free from draughts. Over the hypogastrium is placed greasy wool dipped in vinegar and rose oil. The rest of the treatment followed is the same as for inflammation and for wounds which are in the sinews.

30 Lesions of the anus also, when they do not yield to medicaments, require the aid of surgery.

If, therefore, any fissure has persisted so long that it has become hard and callous, it is best to move the bowels by a clyster, then apply a hot sponge to soften the fissures and cause them to protrude. When brought into view each is excised and made into a fresh wound; then soft lint is put on and over this a pad smeared with honey, and all is covered with soft wool, fixed by a bandage; on the next and following days all the other emollient medicaments are to be used, which I said above, were required by such lesions when recent, and for the first few days at any rate the patient must live on fluids; then some food is gradually added, but of the class prescribed in the same passage. If however any pus arises in these fissures as the result of inflammation, as soon as it becomes evident, it is to be cut into, lest the anus itself suppurate. But this must not be done hastily, for if cut before it matures the inflammation is very much increased, and pus is somewhat more freely formed. Here too a light diet and emollient dressings are necessary.

The tumours, which are called condylomata, when hardened are treated by the following method. First of all the bowel is clystered; then the tumour is seized with a forceps close to its roots and cut away. After this, the same course of treatment is followed as that described above; only if there is any excrescence it is repressed by copper scales.

The mouths of veins which discharge blood are removed as follows. When any patient is losing

blood, fasting is indicated, and a rather severe clystering of the bowel, to make the openings more prominent, and thus what may be called the little heads of the veins all come into view. Then if a head is very small and has a thin base it must be tied by a flax thread, a little above where it joins the anus. A sponge squeezed out of hot water is next to be applied until it becomes livid, then with a finger-nail or scalpel it is to be scratched off above the knot. Unless this is done great pain follows, and sometimes even difficulty in urinating. If the head is larger and the base broader, it is seized by one or two hooks, and an incision made a little above the base; in doing this nothing of the head should be left nor anything taken away from the anus. This is accomplished by not drawing upon the hooks either too much or too little. When the incision has been made, a pin should be passed through, and under the pin the head is tied round with a linen thread. If there are two or three, the lowest must be dealt with first; if more, they are not all treated at once, to avoid having tender scars in several places at once. If there is bleeding, it is taken up in a sponge; then lint is put on, the thighs and groins anointed, as well as the parts near the wound; over it is applied a cerate and a poultice of barley meal, and this part must be filled up with soft wool and then bandaged. The next day, the patient should sit in hot water and after that have the same poultice applied. Twice a day, before and after the operation, the necks and thighs are to be anointed with a liquid cerate; and the patient must be kept in a warm room. After five or six days, the bits of linen are removed by the aid of an earscoop. If the little heads do not come away at the same time, they are to be removed by the finger; then by the same soothing medicaments which I have described above, the wounds are healed up. After the trouble has been ended I have already noted elsewhere what must be done.

31 We next pass from the foregoing subjects to the legs, and if varicose veins occur there, they are removed by a procedure which is not difficult. To this place I have put off also the treatment of the small veins which cause trouble in the head, also of varicose veins on the abdomen, because it is all the same. Any vein therefore which is troublesome may be shrivelled up by cauterizing or cut out by surgery. If a vein is straight, or though crooked is yet not twisted, and if of moderate size, it is better cauterized. This is the method of cauterization: the overlying skin is incised, then the exposed vein is pressed upon moderately with a fine, blunt, hot cautery iron, avoiding a burn of the margins of the incision, which can easily be done by retracting them with hooks. This step is repeated throughout

the length of the vein, generally at intervals of four fingers' breadth, after which a dressing is put on to heal up the burns. But excision is done in the following way: the skin is similarly incised over the vein, and the margins held apart by hooks; with a scalpel the vein is separated from surrounding tissue, avoiding a cut into the vein itself; underneath the vein is passed a blunt hook; the same procedure is repeated at the intervals noted above throughout the course of the vein which is easily traced by pulling on the hook. When the same thing has been done wherever there are swellings, at one place the vein is drawn forward by the hook and cut away; then, where the next hook is, the vein is drawn forwards and again cut away. After the leg has thus been freed throughout from the swellings the margins of the incisions are brought together and an agglutinating plaster put on over them.

33 When gangrene has developed between the nails and in the armpits or groins, and if medicaments have failed to cure it, the limb, as I have stated elsewhere, must be amputated. But even that involves very great risk; for patients often die under the operation, either from loss of blood or syncope. It does not matter, however, whether the remedy is safe enough, since it is the only

one. Therefore, between the sound and the diseased part, the flesh is to be cut through with a scalpel down to the bone, but this must not be done actually over a joint, and it is better that some of the sound part should be cut away than that any of the diseased part should be left behind. When the bone is reached, the sound flesh is drawn back from the bone and undercut from around it, so that in that part also some bone is bared; the bone is next to be cut through with a small saw as near as possible to the sound flesh which still adheres to it; next the face of the bone, which the saw has roughened, is smoothed down, and the skin drawn over it; this must be sufficiently loosened in an operation of this sort to cover the bone all over as completely as possible. The part where the skin has not been brought over is to be covered with lint; and over that a sponge soaked in vinegar is to be bandaged on. The remaining treatment is that prescribed for wounds in which suppuration is to be brought about.