Of Medicine, in Eight Books

by Aulus Cornelius Celsus

The patient then is to be laid on his back, in the same manner as is described in the operation for the stone, either on a couch or bed. The physician standing on the right side, ought with his left hand to take hold of the penis if it be a man, and with his right to introduce the pipe into the urinary passage; and when it comes to the neck of the bladder, by an inclination of the pipe and the penis at once, to force it into the bladder, and when the urine is evacuated, to take it out again. In a woman, the urethra is both shorter, and straighter, and resembles a caruncle, being situated between the labia pudenda above the vagina; and they as frequently require assistance, but it is not attended with so much difficulty.

Sometimes a stone sliding into the urethra, sticks, where that grows narrower[(26)], not far from the end; if possible it ought to be drawn out either by a specillum oricularium, or the instrument, with which the stone is extracted in cutting for that distemper. If that has proved impracticable, the prepuce must be drawn out as much as possible, and the glans being covered, must be tied by a thread; then on one side a longitudinal incision must be made into the penis, and the stone extracted; after this the prepuce is let go; for by this means the sound part of the skin covers the incision in the penis, and the urine will be discharged in the natural way.

Since I have made mention of the bladder and stone, the place itself seems to require me to subjoin the chirurgical cure for calculous patients, when they can be relieved no other way. But since that is a very dangerous method, it is by no means proper to undertake it precipitately. Nor is it to be attempted in every season, nor at all times of life, nor in every degree of the disease; but only in the spring, and upon a patient, whose age exceeds nine years, and not fourteen; also if the disease has arisen to such a height that it can neither be overcome by medicines, nor protracted, but that in some time it must kill. Not but that now and then even a rash attempt succeeds; however it more frequently fails in this case, because there are more kinds and seasons of danger, all which I shall mention together with the operation itself.

Therefore when it is resolved to try the last remedy, for some days before, the body must be prepared by diet, that is, by taking moderately wholesome food, no way glutinous, and drinking water. In the mean time the patient must exercise by walking, to cause the stone to descend towards the neck of the bladder. Whether this has happened may be known by introducing the fingers, as I shall shew in the operation. When that is certain, the boy must first fast for a day; and then the operation must be performed in a warm place; which is conducted in this manner.

A strong and skilful man sits down upon a high seat, and laying the boy, whose back is towards him, in a supine posture, setting his hips upon his knees, takes hold of him, and drawing up his legs, orders the boy to put down his hands to his hams, and pull them toward his body with all his might, and at the same time he holds them in that posture. But if the patient be pretty strong, two able men must sit behind him on two contiguous seats, and both their seats, and their legs next each other must be tied together, to prevent their giving way. Then he is placed upon both their knees in the same manner, and the one according as he sits, lays hold of his left leg, and the other of his right; and at the same time he himself draws up his hams. Whether he be held by one or two, they lie forward with their breasts upon his shoulders. Whence it happens, that the sinus above the pubes, between the ilia, is extended without any wrinkles, and the bladder being compressed into a small compass, the stone may be the more easily laid hold of. Besides, two strong men are placed one at each side, who stand by, and do not suffer either the one or two, that hold the boy, to give way.

Then the physician, having carefully pared his nails, introduces his fore and middle fingers of the left hand together, being first slightly anointed with oil[(27)], into the anus of the patient, and lays the fingers of his right hand lightly upon the lowest part of his abdomen; lest if his fingers on both sides at once should press strongly upon the calculus, it might hurt the bladder. And this must not be done hastily, as in most cases; but so as may be safest: for hurting the bladder brings on convulsions, with a danger of death. And first of all the stone is sought for about the neck: where if it be found, it is expelled with less trouble; and therefore I said the operation was not to be attempted, unless this were known by its proper signs. If either it was not there, or has gone backward, the fingers are applied to the end of the bladder; and the right hand being removed also beyond it, it is brought gradually down.

And when the stone is found (as it must necessarily fall between the surgeon’s hands) it is drawn down with the greater caution by how much it is smaller and smoother, lest it escape, that is, lest there be a necessity to harass the bladder again and again. Therefore the right hand is always kept before the stone; and the fingers of the left force it downwards, till it come to the neck. Into which part, if it be oblong, it must be forced so as to come out prone[(28)]; if flat, so as to be transverse; if square, that it may rest upon two angles; if it be larger at one end, so that the smallest may pass first. In a round one, from the figure itself it is plain, there is no difference, save that if it be smoother in one part than another, that should come out first.

When it is brought to rest upon the neck of the bladder, a lunated incision must be made in the skin, near the anus, as far as the neck of the bladder, with the horns pointing a little towards the ischia; then in that part where the bottom of the wound is straiter, again under the skin[(29)], another transverse wound must be made, by which the neck may be cut; till the urinary passage be open in such a manner, that the wound is something larger than the stone. For those, who through fear of a fistula (which in that part the Greeks call ouroruas[ HU ]) make but a small opening, are reduced to the same inconvenience with greater danger; because the stone, when it is brought away by force, makes a passage, if it does not find one. And this is even more pernicious, if the shape or asperity of the stone contribute any thing to it: whence both an hemorrhage and convulsion may ensue. But though a person escape these, the fistula will be much larger, when the neck is lacerated, than it would have been if cut.

When the opening is made, the stone comes into view; the size of which makes a material difference with respect to its management. Therefore if it be small, it may be pushed forward on one side, and drawn out on the other by the fingers. If larger, a crotchet[(30)] made for the purpose must be put over the upper part of it. This at its extremity is thin, beat out into the form of a semicircle, broad and blunt; on the external part smooth[(31)], where it comes in contact with the wound; on the inside rough, where it touches the stone. And it ought to be pretty long; for one too short has not force enough to extract it. When it is fixed, it ought to be inclined to each side, that the stone may appear, and be held fast, because if it be laid hold of, it also gives way to it. And the necessity for this is, lest when the crotchet begins to be drawn, the stone may fly inward, and the crotchet fall upon the edge of the wound, and lacerate it, the danger of which I have already shewn.