14 There are also around the navel many lesions about which, owing to their rarity, there is little agreement among authorities. But it is probable that each has passed over what was unknown to himself; while no one has depicted what he had not seen. Common to all cases is an ugly prominence of the umbilicus, and the causes are sought for. Meges gave three; rupture into it of the intestine, of the omentum, or of humour. Sostratus said nothing about the omentum; in addition to the other two he said that at times there was increase of flesh in that part, sometimes sound, sometimes cancerous. Gorgias himself also omitted mention of the
p.379
omentum; but he gave the same number of causes, three, and said that occasionally wind also ruptured into it. Heron having given all these four causes, made mention of both the omentum and of that form which was caused simultaneously by the omentum and intestine. But which of these causes it is, may be recognized by the following indications. When intestine has prolapsed the swelling is neither hard nor soft; it is reduced by anything cold; and it increases not only under heat of all kinds but also when the breath is held. At intervals it rumbles, and if the patient lies down on his back the swelling subsides, as the intestine has slipped back. But when it is the omentum, whilst other signs are similar, the swelling is softer, broad at its base, thinned out towards its apex; if any one grasps it, it slips away. When both intestine and omentum have prolapsed, the signs are mingled, and the softness is intermediate between the two; but the flesh is harder, and even when the patient lies on his back there is always swelling, and it does not yield to pressure, to which the preceding forms yield readily. If it is malignant the signs are the same as I have stated for cancer. Humour fluctuates when pressed upon; wind, on the other hand yields under pressure, but returns at once, also the swelling retains the same shape when the patient lies down on his back. Of these varieties, the disorder due to wind does not admit of treatment; also cancerous flesh is dangerous to treat, so should be left alone. Sound flesh ought to be cut away and the wound dressed with lint. Some let out humour, either by perforating with a needle, or by cutting into the apex of the tumour, and then similarly dressing the wound with lint. As to the
p.381
rest of the treatment opinions vary. Of course the patient must be laid on his back, in order that the swelling, whether it be intestine or omentum, may slip back into the abdomen. But when the navel sac was then empty, some caught it between two little rods, and fastened the ends of the rods tightly together, so that it mortified there; some passed a needle doubly threaded through the base of the sac, then knotted the two ends of each thread on opposite sides, as is done also in staphyloma of the eye; from in this way that part beyond the ligatures mortifies. Some, in addition, before tying the ends also cut into the protrusion along a marked line and excised it: in order that they might more easily insert a finger and push back whatever had ruptured into the sac; then at length they tied the ligatures. But it is quite enough to order the patient to hold his breath so that the tumour shows itself at its largest; then to mark its base with ink; next with the patient on his back, to compress the tumour with the fingers, so that whatever has not slipped back of itself is forced back by the hand. After this the umbilicus is drawn forwards, and tightly constricted with flaxen thread along the marks of the ink; next the part beyond the ligature is either burnt with caustics or with the cautery, until it mortifies, after which the wound is dressed like other burns. This method answers best, not only when it is intestine or omentum or both, but even when it is humour. But first precautions must be taken against any danger from the ligature. For neither an infant nor a robust adult nor an old man is suited to this treatment, but a child between seven and fourteen years of
p.383
age. Secondly a suitable body for it is one that is sound, but where there is general ill-health, or pustules or eruptions, and such like, it is not suitable. The smaller tumours also are readily curable, but there is danger in the treatment of those which are excessively large. Moreover the autumn and winter seasons should be avoided, the spring is the best season, early summer is not unfavourable. The patient should also fast on the day before the operation, and that is not enough, but the bowels also are to be moved by a clyster, in order that all that has extruded may more readily return into the abdomen.
15 I have said elsewhere that in those who are dropsical the water ought to be let out: here I must describe how this should be done. Now some make the perforation about four fingers breadth below the navel, and to the left; some make it by perforating the navel itself; some first burn through the skin and then cut into the abdominal cavity, because flesh which has been divided by cautery heals less quickly. Now when entering the knife great care should be taken that no blood vessel is cut into. The knife must be such that its point should be about the third of a finger's breadth, and it should be so entered as to penetrate the membrane separating the flesh from the interior; then a lead or bronze tube should be inserted, either with lips curved back at its outer end, or with a collar round the middle so that the whole of it cannot slip inside. The part of the tube within the abdominal cavity should be a little longer than the part outside, in order that it may project inwards beyond the deeper membrane. Through this tube
p.385
the humour is let out; and when the greater part has escaped, the tube is to be closed by a lint plug, and left in the wound if it was not burnt with a cautery; then on each of the following days about one hemina is let out, until there appears no trace of fluid. Some, however, even when the skin has not been cauterized, take out the tube forthwith, and then bandage on the wound a squeezed-out sponge; then on the next day they pass in a tube again (which the recent wound admits if it is slightly stretched) in order that any remaining fluid may be let out. They are satisfied when this has been done twice in this manner.