SECT. L.—ON DROPSIES.
The formation of dropsical swellings, their varieties and causes, how they are to be distinguished from one another, and their treatment by medicine, having been explained in the [Third Book], and it having been there shown that ascites alone falls under the province of surgery, we are now going to give an account of it. Wherefore we must make the patient stand erect; or if that cannot be done, we must cause him to be seated; or if he be so weak that this cannot be done, we must abandon the operation entirely. If then the man be standing erect we give orders to the assistants standing behind to press with their hands and push downwards the swelling to the pubes. Then taking a sharp-pointed knife or lancet, if the dropsy is among the intestines, in the perpendicular line of the navel, and about three fingers’ breadth distance from it we divide the hypogastrium as far as the peritoneum. But if the liver be primarily affected we must make our incision on the left side of the navel; or if the spleen, on the right, for we must not make an incision in that part on which the patient is disposed to lie. And having dissected with the point of the instrument the skin that lies over it, we divide the peritoneum a little above the first incision until the instrument comes to an empty space. After this we introduce through the incision of the abdomen and peritoneum a copper tube, having an opening like those of writing-pens, and by this we must abstract the fluid in proportion to the strength; feeling the pulse, and then removing the tube, we stop the flow of the fluid, (for it will stop immediately from the alteration of the incision,) and, for the sake of security, we introduce a twisted tent into the incision of the abdominal parietes alone; and having placed the man in a recumbent posture and recruited him, we may next day again evacuate through the tube a small quantity of fluid proportionate to his strength; and thus, in like manner, until very little be left, avoiding, by all means, a sudden evacuation. For some ignorant persons having evacuated the vital spirit with the fluid have immediately killed the patient. Some for the sake of greater security having evacuated a small quantity of the fluid by the operation so as to relieve the powers of the system from its great load, procure the discharge of the remainder by hydragogue medicines, by burying the patient in heated sand, by insolation, abstinence from liquids, giving desiccative food; and they have recourse likewise to burning over the stomach, liver, spleen, and hypogastrium; and make five eschars about the navel, some by slender cauteries of iron, and others by those substances called iscæ, or some other such like material. And many have been rather cured by this method alone, sometimes without paracentesis having been had recourse to at all.
Commentary. Hippocrates declares in one of his Aphorisms, that the sudden evacuation of the matter in empyema, or of the water in dropsy, proves fatal. He speaks of evacuating the fluid with an instrument called τρυπαντρωγλητήριον, which Camper thinks must have been a kind of trochar.
Galen, in his Commentary on the Aphorisms of Hippocrates, (vi, 7) remarks, that in his time the operation of paracentesis was in general use, instead of burning. He states, however, that he had seldom seen recovery take place after the operation. (See in particular Meth. Med. xiv.)
Aristotle alludes to paracentesis near the conclusion of his work on the ‘Generation of Animals.’
Cælius Aurelianus mentions that Erasistratus, Evenor, and Thessalus were advocates for paracentesis, but that Asclepiades, Themison, and Soranus disapproved of it. He himself approves very much of the operation, and answers all the objections which had been made to it. He says, it relieves the fulness and difficulty of breathing, and prepares the parts for the action of the remedies. He agrees, however, with the other authorities, that a sudden evacuation of the water is attended with danger. (Pass. Tard. iii, 8.)
Celsus gives a good description of the operation. Some, he says, perform it at a spot four fingers’ breadth below the navel in the left side; some do it at the navel; and some burn the skin and then perforate the abdominal parietes. He directs the operator to be careful not to wound a vessel. The size of the point of the perforator, he says, should be the third part of a finger’s breadth. After the perforation has been made, a tube (canula) of lead or copper is to be introduced and the water drawn off gradually. The whole is not to be removed at one time, but a tent is to be introduced into the opening, unless it was made with fire, to prevent it from healing too soon. He speaks favorably of the operation, unless the patient be much debilitated. (vii, 15; also ii, 10.)
Aëtius and most of the medical authors subsequent to Galen, mention the operation of paracentesis, and approve of it.
Vegetius, the veterinary surgeon, recommends paracentesis for the dropsy of cattle, when the swelling is not removed by purging. (Mulom. iii, 25.)
Avicenna expresses himself rather unfavorably of paracentesis. He says, it ought never to be attempted until every other remedy has proved ineffectual, and unless the strength of the patient be good, and he can endure exercise, abstinence from drink, and restricted diet. His description of the operation is taken from Paulus. (iii, 14; iv, 13.)
Serapion mentions the operation in very brief terms. (iv, 7.)
Albucasis’s description is very minute; but, upon the whole, little different from our author’s as to the place of the incision or the instruments with which it is to be performed. After the perforation has been made in the manner directed by our author, he recommends the introduction of a canula made of silver, copper, or brass, and having a small hole at the bottom and three in its sides; he advises us to evacuate only half the water at first. He adds, that when the canula is removed the skin will cover the opening in the abdominal muscles, and thereby stop the discharge. The remaining part of the water is to be removed afterwards, according to the strength of the patient. (Chirurg. ii, 54.)
Haly Abbas does not in general approve of the operation. He mentions, that he never saw it performed but once, and then it did not save the patient. He adds, that Galen relates that he only knew of one case in which it had proved successful. He directs the incision to be made three fingers’ breadth, straight below the navel, that is to say, in the linea alba; but if the liver is diseased he recommends it to be made in the left side, or if the spleen, in the right. (Pract. ix, 41).
Rhases gives Antyllus’s description of the operation, which, however, is scarcely at all different from that of our author. He directs us to make the assistants stand behind and compress the sides of the abdomen, and, if possible, recommends to make the patient sit on a bench. He directs us to make the incision with a large needle below the navel, when the collection is connected with disease of the intestines; but if from the liver, on the left side; or if from the spleen, on the right. Like the other authorities noticed above, he directs us to make the opening of the peritoneum higher up than that of the skin. A canula, made of copper, is then to be introduced into the opening. If the pulse sink during the operation he advises us to stop the discharge of the water. (Cont. xix.)
We have mentioned in our notes on [Book Third, section 48], that Hippocrates and Aëtius approved of scarifications at the ankles. It appears that Archigenes also was an advocate for this practice in dropsical cases.
Dropsy of the womb and hydatids thereof are correctly described by Soranus. It seems to be now agreed that the dropsy in this case is a species of large hydatid. (120.)