Of Medicine, in Eight Books

by Aulus Cornelius Celsus

When it appears that the stone is securely held, a triple motion must be made, almost at the same instant, to both sides, and then externally; but this must be done gently, and the stone must be first drawn a little forward; after this, the end of the crotchet must be raised upward, that it may be farther within the bladder, and bring it out the more easily. But if the stone cannot be conveniently held at the superior part, its side must be taken hold of. This is the most simple method.

But a variety of circumstances requires some particular observations. For there are some stones not only rough, but also full of sharp points, which falling of themselves into the neck of the bladder, are extracted without any danger. But if they are within the bladder, it is neither safe to seek them, nor draw them forward; because when they wound it, they bring on convulsions and death; and more especially if any point is fixed in the bladder, and causes it to fall into folds, as it is brought down towards the neck. Now a stone is discovered to be in the neck, when the urine is made with greater difficulty than ordinary; and to be pointed, when it comes away bloody; and this is particularly to be tried by the fingers, and the operation is not to be attempted unless we are sure it is there. And even then the fingers must be introduced, and opposed to it behind tenderly, lest they wound by pushing it with violence; then the incision must be made. And in this case also many have made use of the knife. Meges (because the knife being weak might fall on some prominence of the stone, and after having cut the flesh above it, would not divide where there is a hollow, but leave what will require a second incision) made an iron straight instrument, with a broad back on its upper part, and its lower part semicircular and sharp. This being taken between his fore and middle fingers, and his thumb laid upon it, he prest it so, that together with the flesh, he might cut any part of the stone that was prominent: by which he gained this advantage, that he made a sufficient opening at once. Now in whatever method the incision in the neck is made, a rough stone ought to be extracted gently; no violence being used for the sake of expedition.

But a sandy stone is easily discovered both before the operation, from the discharge of sandy urine, and in the operation; because it makes but a faint resistance to the fingers, and that not equally, and besides is apt to slide away. Also urine, that brings off with it something like scales, discovers the stones to be soft, and that they are composed of several small ones not firmly united together. All these it is proper to bring away gently, changing alternately the fingers in such a manner, that they may not hurt the bladder, and no broken relics stay behind, which may afterwards render the cure difficult. Any of these, that come into view, must be extracted either by the fingers or crotchet.

But if there are several stones, they must every one be taken out; but if any very small one remain, it may rather be left: for it is difficult to find it in the bladder; and when found, it quickly escapes. Thus by long search the bladder is hurt, and mortal inflammations are brought on; in so much that some, though they were not cut, when the bladder has been long, and to no purpose, roughly handled, by the fingers, have died. Besides all which, a small stone being brought to the wound afterwards by the urine, drops out.

In case the stone appears so large, that it cannot be extracted without lacerating the neck, it must be split. The author of this contrivance was Ammonius, who upon that account was called Lithotomus[ HV ] (the stone-cutter.) It is done in this manner. A crotchet is fixed upon the stone with so sure a hold as to prevent it from recoiling inward: then an iron instrument of moderate thickness, with a thin edge, but not sharp, is made use of. This is applied to the stone, and being struck on the other side, cleaves it; great care being taken, that neither the instrument come to the bladder, nor any thing fall in by the breaking of the stone.

These operations are performed upon females much in the same manner, concerning whom a very few peculiarities must be mentioned. For in them, where the stone is very small, cutting is unnecessary; because it is forced by the urine into the neck, which is both shorter, and laxer than in men: therefore it often drops out of itself, and if it sticks in the urinary passage, which is narrower, it is however extracted without any harm by the abovementioned crotchet. But in larger stones the same method is necessary. However, in a virgin, the fingers should be introduced into the rectum as in a man, in a married woman by the vagina. Again, in a virgin, the incision must be made below the left lip of the pudendum; but in a married woman, between the urinary passage, and the bone of the pubes; the wound also must be transverse in both places, and we need not be alarmed if the hæmorrhage be considerable from a female body.

When a stone is extracted, if the patient be strong, and not greatly spent, we may let the blood flow to lessen the inflammation. And it is not amiss for the patient to walk a little, that if any grumous blood remain within, it may drop out. But if it does not cease of itself, it must be stopped, lest the strength be entirely exhausted; and this is to be done immediately after the operation in weak patients. For as a person is in danger of a convulsion, whilst the bladder is fatigued, so there is another fear, when the applications are removed, lest there be such an hæmorrhage as to prove mortal: to prevent which, the patient ought to sit down in sharp vinegar with the addition of a little salt; by which means both the blood commonly stops, and the bladder is contracted, and therefore is less inflamed. But if that does little service, a cupping vessel must be applied, both in the knees[(32)] and hips, and above the pubes too.

When either a sufficient quantity of blood has been evacuated, or the hæmorrhage stopped, the patient must be laid upon his back, with his head low, and his hips a little raised; and over the wound must be applied a double or triple linen cloth wet with vinegar. Then after an interval of two hours, he must be let down in a supine posture into a bath of hot water, so that he may be under water from the knees to the navel, the other parts being covered with clothes, only with his hands and feet bare, that he may be both less exhausted, and be able to continue there the longer. This commonly produces a plentiful sweat; which in the face is to be now and then wiped off by a spunge. And the rule for the continuance of this bathing is, till it hurts by weakening. After that the patient must be anointed plentifully with oil, and a handful of soft wool saturated with warm oil, must be laid on, so as to cover the pubes and hips, and groin, and the wound itself, which must still remain covered with the linen beforementioned; and this is to be moistened now and then with warm oil; that it may both prevent the admission of cold to the bladder, and gently mollify the nerves. Some make use of healing cataplasms. These do more hurt by their weight, which by pressing upon the bladder[(33)] irritates the wound, than service by their heat: and for that reason, not so much as any kind of bandage is necessary.

On the day following, if there be a difficulty in breathing, if the urine is not evacuated, or if the part above the pubes has immediately swelled, we may be assured, that grumous blood has staid within the bladder. Therefore the fingers being introduced in the same manner as above, the bladder must be handled gently, and whatever has happened to be coagulated there dispersed; by which means it is afterwards discharged from the bladder through the wound. Neither is it improper to inject through the wound into the bladder by a syringe, a mixture of vinegar and nitre; for if there be any bloody concretions, they are discussed in that way. And these may be done even the first day, if we are afraid of any thing being within; especially when weakness has prevented the evacuation of it by walking. The other methods laid down for the preceding day, the putting him into the bath, applying the cloth, and wool in the manner above described, are to be continued.

But a boy is neither to be put so often into the warm water, nor kept there so long at a time, as a youth; the weak, as the strong; one affected with a slight inflammation, as another, in whom it is more violent; one whose body is disposed to evacuations, as he that is bound. But in the mean time, if the patient sleep, and his breathing be equal, his tongue moist, his thirst tolerable, his lower belly not at all swelled, and the pain and fever moderate, we may take it for granted that the cure goes on well.