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.
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.)