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Danielle S. Walsh
Todd A. Ponsky
Nicholas E. Bruns Editors

The SAGES Manual

of Pediatric Minimally
Invasive Surgery

123
The SAGES Manual
of Pediatric Minimally
Invasive Surgery
Danielle S. Walsh • Todd A. Ponsky
Nicholas E. Bruns
Editors

The SAGES Manual

of Pediatric Minimally
Invasive Surgery
Editors
Danielle S. Walsh, MD, FACS, Todd A. Ponsky, MD, FACS
FAAP Associate Professor of Surgery
Associate Professor of Surgery and Pediatrics
Division of Pediatric Surgery Northeast Ohio Medical
East Carolina University College
Brody School of Medicine Division of Pediatric Surgery
Greenville, NC, USA Akron Children’s Hospital
Akron, OH, USA
Nicholas E. Bruns, MD
Research Fellow
Division of Pediatric Surgery
Akron Children’s Hospital
Akron, OH, USA
Resident in General Surgery
Cleveland Clinic,
Cleveland, OH, USA

ISBN 978-3-319-43640-1    ISBN 978-3-319-43642-5 (eBook)

DOI 10.1007/978-3-319-43642-5

Library of Congress Control Number: 2016959450

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of
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storage and retrieval, electronic adaptation, computer software, or by similar or
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The use of general descriptive names, registered names, trademarks, service
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statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of pub-
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or omissions that may have been made.

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Preface

…find though she be but little, she is fierce.—Shakespeare

More than once pediatric surgeons have heard general

surgeons comment on their “fear” of caring for pediatric sur-
gical patients. The diminutive size of the patient can intimi-
date, but those of us flourishing in the pediatric world
recognize a well-kept secret—infants and children are fierce
in their desire to live, handling the surgical insults that would
cause many adults to give out, with determination of some-
times Olympic proportions. While they tolerate large inci-
sions for invasive procedures with aplomb, showing their
scars as badges of courage on the playground, we believe our
kids deserve to reap the same benefits from minimally inva-
sive techniques that the adult population embraces. This
book was developed to help current and future surgeons in
advancing their comfort in approaching children with lapa-
roscopy, thoracoscopy, and endoscopy.
The mission of the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES) is to improve patient
care through education, research, innovation, and leadership,
principally in gastrointestinal endoscopic surgery. The pediat-
ric surgery community within SAGES has been grateful that
the leadership of SAGES has recognized the need to apply
this mission to not only the adult general surgical population
but to all patients, including our youngest and smallest. It is

v
vi Preface

with this in mind that these authors set out to educate ALL
surgeons, not just pediatric specialists, in the applications of
minimally invasive surgery to children through this
textbook.
The focus of this text is on the technical knowhow of these
minimally invasive techniques. There are larger resources for
detailed information on pathophysiology and others review-
ing each and every alternative technique for managing a
particular disorder. However, this publication is for providing
a safe way of technically approaching a particular problem
utilizing percutaneous or per-orifice methods in a concise
compendium. It is appropriate for the trained professional
looking for a refresher on a less commonly performed inter-
vention, an adult MIS surgeon with a pediatric emergency
unable to be transferred, or a surgical student or resident in
need of critical teaching points for understanding.
This coeditor team greatly appreciates the support we
have received from SAGES and Springer in making this
endeavor come to fruition. We applaud the authors, col-
leagues, staff, families, and patients who contributed to this
book through either time, effort, patience, or use of their
surgical journey to build the knowledge and content within
these pages. It is our hope that many a student of surgery will
benefit from the herein pearls of wisdom as they endeavor to
improve the care of a pediatric surgical patient.

Greenville, NC, USA Danielle S. Walsh

Akron, OH, USA Todd A. Ponsky
Akron, OH, USA Nicholas E. Bruns
Contents

1 Physiologic Considerations for Minimally

Invasive Surgery in Infants and Children.................. 1
Brian T. Craig and Gretchen Purcell Jackson
2 Pediatric Laparoscopic and Thoracoscopic
Instrumentation............................................................ 11
Sarah Gilmore and Colin A. Martin
3 Pediatric Endoscopic Instrumentation...................... 25
Timothy D. Kane, Folashade Adebisi Jose,
Danielle S. Walsh, and Nicholas E. Bruns
4 Minimally Invasive Approaches
to the Pediatric Thyroid and Parathyroid................. 41
Thom E. Lobe, Simon K. Wright, and Go Miyano
5 Bronchoscopy and Tracheobronchial Disorders...... 51
Ian C. Glenn, Domenic Craner, and Oliver Soldes
6 Thoracoscopic Thymectomy....................................... 71
Christine M. Leeper and Stefan Scholz
7 Thoracoscopic Ligation of the Patent
Ductus Arteriosus......................................................... 83
Laura Y. Martin and Jeffrey Lukish
8 Thoracoscopic Aortopexy........................................... 97
Azmath Mohammed and Nathan Novotny

vii
viii Contents

9 Thoracoscopic Sympathectomy.................................. 107

Wesley Barnes, Zachary Hothem,
and Nathan Novotny
10 Thoracoscopic Treatment of Pectus Excavatum:
The Nuss Procedure..................................................... 127
Barrett P. Cromeens and Michael J. Goretsky
11 Thoracoscopic Approach to Eventration
of the Diaphragm......................................................... 145
Jingliang Yan and Federico G. Seifarth
12 Minimally Invasive Approaches to Congenital
Diaphragmatic Hernias................................................ 153
Kelly Arps, Priya Rajdev, and Avraham Schlager
13 Thoracoscopic Repair of Esophageal Atresia
and Tracheoesophageal Fistula................................... 171
Ibrahim Abd el-shafy and José M. Prince
14 Thoracoscopic Approaches to Congenital
Lung Lesions................................................................. 179
Robert L. Ricca and John H.T. Waldhausen
15 Thoracoscopic Lung Biopsies and Resections
in Children..................................................................... 197
Oliver J. Muensterer
16 Thoracoscopic Treatment of Pediatric
Chylothorax................................................................... 211
J. Eli Robins and Kevin P. Mollen
17 Treatment of Empyema in Children.......................... 225
Ashwini S. Poola and Shawn D. St. Peter
18 Thoracoscopic Approach to Pediatric
Mediastinal Masses....................................................... 239
Angela M. Hanna and Brandon VanderWel
19 Minimally Invasive Approaches to Esophageal
Disorders: Strictures, Webs, and Duplications.......... 261
Timothy D. Kane and Nicholas E. Bruns
 Contents ix

20 Esophageal Replacement Surgery in Children......... 277

Ian C. Glenn, Mark O. McCollum,
and David C. van der Zee
21 Minimally Invasive Approaches to Achalasia........... 301
Timothy D. Kane and Nicholas E. Bruns
22 Minimally Invasive Approaches to GERD
and Hiatal Hernia in Children.................................... 315
Bethany J. Slater and Steven S. Rothenberg
23 Laparoscopic Pyloromyotomy.................................... 327
Lilly Ann Bayouth and Shannon W. Longshore
24 Minimally Invasive Gastrostomy................................ 339
Julietta Chang and Federico G. Seifarth
25 Laparoscopic Duodenoduodenostomy...................... 351
Jeh B. Yung and Federico G. Seifarth
26 Laparoscopic Approach to Intestinal Atresia........... 361
Cristina Mamolea, Jeh B. Yung,
and Federico G. Seifarth
27 Laparoscopic Resection of Abdominal Cysts
and Duplications........................................................... 373
Aaron P. Garrison and William Taylor Walsh
28 Anomalies of Intestinal Rotation:
Laparoscopic Ladd’s Procedure................................. 381
Eric J. Rellinger, Sarah T. Hua,
and Gretchen Purcell Jackson
29 Laparoscopic Exploration for Pediatric
Chronic Abdominal Pain............................................. 393
Ian C. Glenn and Aaron P. Garrison
30 Laparoscopic Lysis of Adhesions for Pediatric
Bowel Obstruction........................................................ 401
Melody R. Saeman and Diana L. Diesen
31 Laparoscopic Meckel’s Diverticulectomy................. 413
David Rodeberg and Sophia Abdulhai
x Contents

32 Laparoscopic Management of Pediatric

Inflammatory Bowel Disease...................................... 429
Kevin N. Johnson and James D. Geiger
33 Laparoscopic Management of Intussusception........ 443
Nicholas E. Bruns and Anthony L. DeRoss
34 Laparoscopic Appendectomy..................................... 451
Harveen K. Lamba, Nicholas E. Bruns,
and Todd A. Ponsky
35 Laparoscopic Approach to Enteral Access
for Chronic Constipation............................................. 465
Andrew T. Strong and Federico G. Seifarth
36 Laparoscopic-Assisted Pull-­Through
for Hirschsprung’s Disease.......................................... 481
Richard Cheek, Lauren Salesi, and Stefan Scholz
37 Laparoscopic-Assisted Anorectal Pull-Through
for Anorectal Malformations...................................... 499
Mohammad Ali Abbass and Federico G. Seifarth
38 Laparoscopic Pediatric Inguinal Hernia Repair...... 515
Nicholas E. Bruns and Todd A. Ponsky
39 Laparoscopic Epigastric Hernia Repair.................... 527
Anne-Sophie Holler and Oliver J. Muensterer
40 Minimally Invasive Approach to Pediatric
Pancreatic Disorders.................................................... 537
Meagan Elizabeth Evangelista
and Danielle S. Walsh
41 Laparoscopic Cholecystectomy for Biliary
Dyskinesia, Cholelithiasis, and Cholecystitis............ 551
Moriah M. Hagopian and Diana L. Diesen
42 Laparoscopic Treatment of Biliary Atresia............... 565
Dominic Papandria and Stefan Scholz
43 Laparoscopic Treatment of Choledochal Cysts........ 581
Bethany J. Slater and Steven S. Rothenberg
 Contents xi

44 Laparoscopic Splenectomy.......................................... 593

Alessandra Landmann, Juan L. Calisto,
and Stefan Scholz
45 Laparoscopic Adrenalectomy in Children................ 609
Craig A. Wengler, Heather R. Nolan,
and Joshua Glenn
46 Minimally Invasive Support for Placement
of Ventricular Shunts.................................................... 621
Celeste Hollands
47 Bariatric Surgery in Adolescents................................ 633
Robert Michael Dorman, J. Hunter Mehaffey,
and Carroll M. Harmon
48 Laparoscopic Management of Pediatric
Ovarian Disease............................................................ 649
Angela M. Hanna and Jose Alberto Lopez
49 Laparoscopic Management of Testicular
Disorders: Cryptorchidism and Varicocele............... 667
Armando Rosales, Gavin A. Falk,
and Cathy A. Burnweit
50 Laparoscopic Resection of Renal Masses................. 685
Neel Parekh and Curtis J. Clark
51 Minimally Invasive Management
of Urinary Reflux......................................................... 699
Charlotte Wu and Hans G. Pohl
52 Laparoscopic Approaches to Peritoneal
Dialysis Access.............................................................. 721
Ruchi Amin and Danielle S. Walsh

Index....................................................................................... 733
Contributors

Mohammad Ali Abbass Pediatric Surgery, Cleveland Clinic

Foundation, Cleveland, OH, USA
Sophia Abdulhai General Surgery, East Carolina University,
Greenville, NC, USA
Ruchi Amin General Surgery, East Carolina University,
Greenville, NC, USA
Kelly Arps Emory University School of Medicine, Atlanta,
GA, USA
Wesley Barnes General Surgery, Beaumont Health System,
Royal Oak, MI, USA
Lilly Ann Bayouth General Surgery, East Carolina
University, Greenville, NC, USA
Nicholas E. Bruns Pediatric Surgery, Akron Children’s
Hospital, Akron, OH, USA
General Surgery, Cleveland Clinic, Cleveland, OH, USA
Cathy A. Burnweit Nicklaus Children’s Hospital, Miami,
FL, USA
Juan L. Calisto Pediatric General and Thoracic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, PA,
USA

xiii
xiv Contributors

Julietta Chang Digestive Diseases Institute, Cleveland Clinic

Foundation, Cleveland, OH, USA
Richard Cheek General Surgery, Allegheny General
Hospital, Pittsburgh, PA, USA
Curtis J. Clark Urology, Akron Children’s Hospital/
Northeast Ohio Medical University, Akron, OH, USA
Brian T. Craig Monroe Carell Jr. Children’s Hospital at
Vanderbilt, Nashville, TN, USA
Domenic Craner Pediatric General Surgery, Akron
Children’s Hospital, Akron, OH, USA
Barrett P. Cromeens General Surgery, East Carolina
University, Greenville, NC, USA
Anthony L. DeRoss Pediatric Surgery, Cleveland Clinic
Children’s, Surgery, Cleveland Clinic Lerner College of
Medicine of Case Western Reserve University, Cleveland,
OH, USA
Diana L. Diesen Pediatric Surgery, Department of Surgery,
Southwestern Medical, Children’s Health Dallas, Dallas, TX,
USA
Robert Michael Dorman Pediatric Surgery, Women and
Children’s Hospital of Buffalo, Buffalo, NY, USA
Ibrahim Abd el-shafy Pediatric Surgery, Cohen Children’s
Medical Center, Queens, NY, USA
Meagan Elizabeth Evangelista Pediatric Surgery, East
Carolina University, Greenville, NC, USA
Gavin A. Falk Nicklaus Children’s Hospital, Miami, FL,
USA
Aaron P. Garrison Pediatric Surgery, Akron Children’s
Hospital, Akron, OH, USA
James D. Geiger Pediatric Surgery, Mott Children’s Hospital,
University of Michigan, Ann Arbor, MI, USA
 Contributors xv

Sarah Gilmore University of Alabama School of Medicine in

Birmingham, Birmingham, AL, USA
Ian C. Glenn Pediatric Surgery, Akron Children’s Hospital,
Akron, OH, USA
Joshua Glenn Pediatric Surgery, Mercer University School
of Medicine/The Medical Center – Navicent Health, Macon,
GA, USA
Michael J. Goretsky Pediatric Surgery, Carolinas HealthCare
System, Charlotte, NC, USA
Moriah M. Hagopian General Surgery, University of Texas
Southwestern Medical Center, Dallas, TX, USA
Angela M. Hanna Pediatric Surgery, Swedish Medical
Center, Seattle, WA, USA
Carroll M. Harmon Pediatric Surgery, Women and Children’s
Hospital of Buffalo, Buffalo, NY, USA
Celeste Hollands Surgery, University of South Alabama,
Mobile, AL, USA
Anne-Sophie Holler Pediatric Surgery, University Medicine,
Johannes Gutenberg University Mainz, Mainz, Germany
Zachary Hothem General Surgery, Beaumont Health
System, Royal Oak, MI, USA
Sarah T. Hua Pediatric Surgery, Monroe Carell Jr. Children’s
Hospital at Vanderbilt, Nashville, TN, USA
Gretchen Purcell Jackson Monroe Carell Jr. Children’s
Hospital at Vanderbilt, Nashville, TN, USA
Kevin N. Johnson Pediatric Innovation, Pediatric Surgery,
Mott Children’s Hospital, University of Michigan, Ann
Arbor, MI, USA
Folashade Adebisi Jose Pediatric Gastroenterology, East
Carolina University, Greenville, NC, USA
xvi Contributors

Timothy D. Kane Surgery and Pediatrics, Children’s National

Medical Center, George Washington University School of
Medicine, Washington, DC, USA
Harveen K. Lamba Pediatric Surgery, Akron Children’s
Hospital, Akron, OH, USA
Alessandra Landmann General Surgery, University of
Oklahoma Health Sciences Center, Oklahoma City, OK,
USA
Christine M. Leeper Surgery, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Thom E. Lobe Regeneveda, The Beverly Hills Institute of
Cellular Therapy, Chicago, IL, USA
Shannon W. Longshore Surgery, East Carolina University,
Greenville, NC, USA
Jose Alberto Lopez General Surgery, Swedish Medical
Center, Seattle, WA, USA
Jeffrey Lukish Johns Hopkins University, Baltimore, MD,
USA
Cristina Mamolea General Surgery, Cleveland Clinic
Foundation, Cleveland, OH, USA
Colin A. Martin University of Alabama at Birmingham,
Birmingham, AL, USA
Laura Y. Martin Surgery, Johns Hopkins Hospital, Baltimore,
MD, USA
Mark O. McCollum Pediatric Surgery, Akron Children’s
Hospital, Akron, OH, USA
J. Hunter Mehaffey General Surgery, University of Virginia
Medical Center, Charlottesville, VA, USA
Go Miyano Pediatric Surgery, Shizuoka Children’s Hospital,
Shizuoka, Japan
Azmath Mohammed General Surgery, Beaumont Health
System, Royal Oak, MI, USA
 Contributors xvii

Kevin P. Mollen Children’s Hospital of Pittsburgh of UPMC,

Pittsburgh, PA, USA
Oliver J. Muensterer Pediatric Surgery, University Medicine
Mainz, Mainz, Germany
Heather R. Nolan General Surgery, Mercer University
School of Medicine/The Medical Center – Navicent Health,
Macon, GA, USA
Nathan Novotny Pediatric Surgery, Beaumont Health
System, Oakland University William Beaumont School of
Medicine, Royal Oak, MI, USA
Dominic Papandria Pediatric General and Thoracic Surgery,
Children’s Hospital of Pittsburgh of UPMC, University of
Pittsburgh School of Medicine, Pittsburgh, PA, USA
Neel Parekh Urology, Akron Children’s Hospital/Northeast
Ohio Medical University, Akron, OH, USA
Shawn D. St. Peter Surgery, Children’s Mercy Hospital,
Kansas City, MO, USA
Hans G. Pohl Urology and Pediatrics, Children’s National
Medical Center, Washington, DC, USA
Todd A. Ponsky Surgery and Pediatrics, Pediatric Surgery,
Akron Children’s Hospital, Akron, OH, USA
Ashwini S. Poola Surgery, Children’s Mercy Hospital, Kansas
City, MO, USA
José M. Prince Pediatric Surgery, Cohen Children’s Medical
Center of Northwell Health/Hofstra Northwell School of
Medicine, New Hyde Park, NY, USA
Priya Rajdev General Surgery, Emory University, Atlanta,
GA, USA
Eric J. Rellinger Pediatric Surgery, Monroe Carell Jr.
Children’s Hospital at Vanderbilt, Nashville, TN, USA
Robert L. Ricca Surgery, Naval Medical Center Portsmouth/
Uniformed Services University, Portsmouth, VA, USA
xviii Contributors

J. Eli Robins Surgery, East Carolina University, Greenville,

NC, USA
David Rodeberg Pediatric Surgery, East Carolina University,
Greenville, NC, USA
Armando Rosales Nicklaus Children’s Hospital, Miami,
FL, USA
Steven S. Rothenberg Pediatric Surgery, Rocky Mountain
Hospital for Children, Denver, CO, USA
Melody R. Saeman Surgery, University of Texas Southwestern,
Dallas, TX, USA
Lauren Salesi School of Medicine, University of Pittsburgh,
Pittsburgh, PA, USA
Avraham Schlager Pediatric Surgery, Akron Children’s
Hospital, Akron, OH, USA
Stefan Scholz Pediatric General and Thoracic Surgery,
Children’s Hospital of Pittsburgh of UPMC, School of
Medicine, University of Pittsburgh, Pittsburgh, PA, USA
Federico G. Seifarth Pediatric Surgery, Kalispell Regional
Healthcare, Kalispell, MT, USA
Bethany J. Slater Rocky Mountain Hospital for Children,
Denver, CO, USA
Oliver Soldes Pediatric Surgery, Akron Children’s Hospital,
Akron, OH, USA
Andrew T. Strong General Surgery, Cleveland Clinic
Foundation, Cleveland, OH, USA
Brandon VanderWel General Surgery, Swedish Medical
Center, Seattle, WA, USA
John H.T. Waldhausen Division Chief Pediatric General and
Thoracic Surgery, Seattle Children’s Hospital, Seattle,
WA, USA
William Taylor Walsh General Surgery, South Pointe
Hospital, Warrensville Heights, OH, USA
 Contributors xix

Danielle S. Walsh Pediatric Surgery, East Carolina University,

Greenville, NC, USA
Craig A. Wengler Surgery, Mercer University School of
Medicine/The Medical Center – Navicent Health, Macon,
GA, USA
Simon K. Wright Minimally Invasive Head and Neck Surgery,
ENT Clinic of Iowa, West Des Moines, IA, USA
Charlotte Wu Urology, Yale–New Haven Hospital, Yale
University School of Medicine, New Haven, CT, USA
Jingliang Yan General Surgery, Cleveland Clinic Foundation,
Cleveland, CT, USA
Jeh B. Yung General Surgery, Cleveland Clinic Foundation,
Cleveland, OH, USA
Jeh B. Yung Pediatric Surgery, Kalispell Regional Healthcare,
Kalispell, MT, USA
David C. van der Zee Pediatric Surgery, University Medical
Center Utrecht, Wilhelmina Children’s Hospital, Utrecht,
The Netherlands
1.  Physiologic Considerations
for Minimally Invasive Surgery
in Infants and Children

Brian T. Craig and Gretchen Purcell Jackson

Introduction
Laparoscopy and thoracoscopy have gained widespread acceptance
in the surgical approach to infants and children. Minimally invasive
procedures are routinely performed and often considered the standard of
care for common pediatric operations, such as appendectomy, pyloro-
myotomy, and ­fundoplication. Many pediatric surgeons employ laparos-
copy or thoracoscopy for advanced procedures including operations for
duodenal atresia, malrotation, anorectal malformations, Hirschsprung’s
disease, congenital diaphragmatic hernia, and tracheoesophageal fistula
[1, 2]. Additionally, there are case reports of minimally invasive pancre-
atectomy, hepatectomy, and resections for neuroblastoma and Wilms
tumor in children. The general trend in pediatric surgical practice has
been increased adoption of minimally invasive approaches.
Safe application of minimally invasive surgery in pediatric patients
necessitates a thorough understanding of the physiologic effects of
­carbon dioxide (CO2) insufflation in this population. Regardless of the
operation being performed, two main effects produce the physiological
consequences of insufflation: (1) increased intra-abdominal or intratho-
racic pressure and (2) CO2 absorption through the visceral and parietal
peritoneum (Fig. 1.1). One series reported a 7 % rate of needing to stop
insufflation either transiently or permanently for children undergoing
laparoscopy [3, 4]. Patients who had insufflation-related incidents and
needed the procedure halted were younger with lower immediate preop-
erative body temperature, and the operations were longer and had higher

© Springer International Publishing Switzerland 2017 1

D.S. Walsh et al. (eds.), The SAGES Manual of Pediatric
Minimally Invasive Surgery, DOI 10.1007/978-3-319-43642-5_1
2 B.T. Craig and G.P. Jackson

Fig. 1.1. Two major stimuli produce the observed physiologic changes during
abdominal insufflation for laparoscopy: (1) increased intra-abdominal pressure
(blue arrows), which impedes full lung expansion and can decrease flow through
the aorta and vascular system, and (2) enhanced CO2 absorption (red arrows) by
the visceral and parietal peritoneum, which increases the necessary minute ventila-
tion to maintain acid-base balance. Figure courtesy of Sarah Hua.

insufflation pressures. Therefore, during minimally invasive operations,

pediatric surgeons and anesthesiologists frequently contend with acute
physiologic changes from abdominal or thoracic insufflation that may
significantly change the course of the procedure. They should anticipate
such changes and be prepared to manage them.
This chapter describes the effects of abdominal and thoracic insufflation
on the cardiovascular, pulmonary, metabolic, and immune/inflammatory
systems, with a special emphasis on neonates and infants, as these
patients differ significantly from adults and older children both anatomi-
cally and physiologically. General principles for preoperative preparation
and postoperative care are addressed. Physiologic sequelae of abdominal
insufflation are discussed in context of the organ systems affected.

Preoperative Evaluation
As with any pediatric or neonatal operation, general fitness for a
planned minimally invasive operation is of paramount importance.
Appropriate history related to nutritional status and growth should be
obtained for every patient, and any symptoms or signs that could suggest
 1. Physiologic Considerations for Minimally Invasive Surgery… 3

cardiac or pulmonary impairment must be elicited. Anesthetic management

plans need to be carefully formulated, especially in neonatal cases
with extended procedures, reverse Trendelenburg positioning, and higher
insufflation pressures [5]. General endotracheal anesthesia remains the
standard for pediatric laparoscopic and thoracoscopic operations to allow
the anesthesiologist to contend with the physiologic effects of ­hypercarbia
and increased intra-abdominal or intrathoracic pressures [2].
Several specific comorbidities warrant special consideration in preop-
erative planning. Minimally invasive procedures are increasingly being
performed in infants with congenital heart disease. These patients may
be more susceptible to changes in preload due to impaired venous return
or changes in systemic resistance associated with increased intra-abdominal
pressure [6]. Laparoscopic and thoracoscopic operations can be done
safely in these patients in experienced centers with dedicated pediatric
cardiac anesthesia teams [6–8].
Underlying pulmonary disease is another important comorbidity to
consider before undertaking a minimally invasive procedure in a child.
Excretion of excess CO2 that is absorbed through the visceral and parietal
peritoneum is a primary concern of the anesthesiologist managing the
infant undergoing laparoscopic or thoracoscopic surgery. Increasing min-
ute ventilation is the primary tool used to remove excess CO2. Any pulmo-
nary condition that may limit the ability to increase minute v­ entilation or
impair gas exchange could rapidly lead to a respiratory acidosis. If laparos-
copy is to be undertaken in a patient with baseline pulmonary dysfunction,
intensive postoperative monitoring should be utilized to limit risks of
hypoventilation from retained hypercarbia. A related problem is portal
hypertension, which has been shown to accelerate absorption of CO2 to a
level twice that of the already increased absorption displayed in children
[9]. Similar to the patient with pulmonary disease, patients with portal
hypertension should be managed with increased vigilance to limit the nega-
tive effects of hypercarbia in the postoperative period.

 hysiologic Effects of Pneumoperitoneum

P
by System
Cardiovascular System
Several studies have examined the cardiovascular effects of pneumo-
peritoneum in children. Direct measurement of flow in the thoracic aorta by
transesophageal echocardiography (TEE) in healthy 6- to 30-month-old
4 B.T. Craig and G.P. Jackson

infants and children undergoing laparoscopic assisted orchiopexy for

­undescended testicles with a maximum insufflation pressure of 10 mmHg
showed significantly decreased flow, decreased stroke volume, and incre­
ased systemic resistance. However, these changes resolved completely after
desufflation of the abdominal cavity. Significant changes in mean arterial
pressure (MAP) or end-tidal CO2 were not observed during these relatively
short procedures, nor were any clinically important sequelae [10]. In
another study of healthy 2- to 6-year-old children undergoing laparoscopic
inguinal herniorrhaphy, an initial insufflation to an abdominal pressure
of 12 mmHg decreased cardiac index (CI) as measured by TEE [11].
Interestingly, CI returned to baseline with a decrease in insufflation pressure
to 6 mmHg and did not decrease with a subsequent increase in abdominal
pressure to 12 mmHg, suggesting an adaptation to the change in afterload
induced by abdominal insufflation. A recent study exposed neonatal and
adolescent piglets to 180 min of abdominal insufflation, which caused a
decrease in CI and MAP that persisted well into the recovery period after
insufflation ended. This effect was more pronounced in the neonates [12].
The extended response to the pressure stimulus suggests a need for vigi-
lant monitoring in the postoperative period to ensure that hypotension
does not ensue. Prolonged exposure to higher insufflation pressures
(>8–10 mmHg) may also induce capillary microcirculatory changes and
impair venous return [1]. In contrast, a study using low-pressure insuffla-
tion no greater than 5 mmHg combined with reverse Trendelenburg
­positioning in children ages 6 to 36 months undergoing laparoscopic
fundoplication actually increased CI, heart rate, and MAP [13].
In summary, in the otherwise healthy infant or child, abdominal
insufflation pressures of 12 mmHg or less for short- to medium-length
procedures may cause changes in CI, MAP, or systemic resistance when
specifically measured but rarely (3.2 % of cases) produce clinically sig-
nificant effects requiring intervention [4]. The location of monitoring
may not affect the accuracy of blood pressure measurements. In a piglet
model, no difference was found between measured carotid and femoral
arterial blood pressures with up to 24 mmHg abdominal insufflation, a
level nearly twice that of the highest commonly used clinically [14].

Pulmonary System
The pulmonary effects of pneumoperitoneum in pediatric patients
are the result of anatomic and physiologic differences between adults
and children. The alveolar surface area to body surface area ratio in
 1. Physiologic Considerations for Minimally Invasive Surgery… 5

infants and children is smaller than that of adults. Therefore, children

have a significantly higher minute ventilation and oxygen consumption
(up to twice that of an adult) even at baseline to maintain PaCO2 in the
normal range [1]. In patients younger than 1 year of age, the space-
occupying effects of abdominal insufflation lead to increased peak inspi-
ratory pressure, reduced tidal volume, and decreased compliance [15].
These changes in turn produce decreased functional residual capacity
(FRC), increased pulmonary vascular resistance, and increased shunt
fraction, which in combination with the increased CO2 absorption can
lead to hypercarbia if the minute ventilation is not increased concomi-
tantly [15].
Hypercapnia is a significant concern in minimally invasive surgery,
especially in children with underlying pulmonary disease. In one series
of laparoscopic and thoracoscopic procedures performed in neonates
(i.e., <1 month of age), h­ ypercapnia >45 mmHg was reported in 2.3 %
of cases [4]. The degree of hypercapnia depends on insufflation pressure
and duration of pneumoperitoneum. In piglet models, PaCO2 has been
shown to increase 25 % with stepwise increases in insufflation pressure
with associated increases in mortality from CO2 embolism [16]. In a
study of low-pressure (i.e., maximum 5 mmHg) insufflation for fundo-
plication, CO2 rose 28 % on average when patients up to 3 years of age
were exposed for more than an hour [17]. Careful monitoring for hyper-
capnia is warranted for all pediatric minimally invasive procedures, and
laparoscopic insufflation pressures should be limited, with a maximum
recommended pressure of 12 mmHg for neonates [15].
An important consideration for respiratory monitoring is that a gradient
will develop between the PaCO2 and the end-­tidal CO2 after abdominal
insufflation because of an increased CO2 and diminished functional resid-
ual volume. This gradient has been documented to increase significantly in
adults during the first 60 min of insufflation for laparoscopic colorectal
surgery but to stabilize or decrease thereafter [18]. In young children with
cyanotic congenital heart disease undergoing laparoscopic fundoplication,
the gradient increased by a factor of nearly 2.5 soon after initial insufflation
of the abdomen [19]. This gradient was shown to be as high as 8 mmHg in
one study of laparoscopic fundoplication in children without underlying
cardiac or respiratory disease; as in other studies, the gradient decreased
with longer insufflation stimulus [20]. Measuring CO2 elimination has also
been used to monitor this process. End-tidal CO2 increases disproportion-
ately for younger patients ­ compared to older children with the same
­insufflation pressures and dura­tion, and it remains elevated even after
6 B.T. Craig and G.P. Jackson

the conclusion of the procedure [15]. For these reasons, postoperative

monitoring of respiratory rate is critical to safely performing laparoscopy
in infants and neonates.
Another potential problem in infants undergoing laparoscopy is
hypoxemia. In neonates and infants, there is a close relationship between
functional residual capacity (FRC) and airway closing pressure. When
FRC decreases in response to the increased intra-abdominal pressure,
airway closure will exacerbate right-to-left intrapulmonary shunt and
can lead to hypoxemia [5].

Inflammatory/Immune System
In children, data from a study of procedures for acute abdominal pain
suggested that laparoscopic compared to open operations did not result
in differences in major inflammatory mediators such as cortisol and
IL-6 [21]. However, several subsequent studies have demonstrated a
lesser degree of increase in inflammatory mediators including IL-6,
CRP, TNF-α, and cortisol with laparoscopy compared to open approach
for a variety of operations [22–25]. Cellular responses are also affected
by laparoscopy, in a manner similar to the cytokine responses. Both
­macrophages and neutrophils are recruited to the peritoneal cavity with
insufflation, though the numbers are lower with CO2 insufflation com-
pared to air [26].

Other
Compared with adults, children have a greater body surface area to
volume ratio [27] and thus are at increased risk for hypothermia. During
minimally invasive surgical procedures in infants and children, hypo-
thermia is reported to occur in 1.8 % of cases [4]. Temperature moni­
toring is especially important in newborns. Dry CO2 insufflation on
continuous flow of 5–8 L/min will lead to massive evaporative losses
relative to body size, and the accompanying heat loss can approach 40 %
of a neonate’s metabolic power capacity, despite their higher-per-kilogram
power capacity compared to adults [3]. Additionally, gas leaks around
port sites in a neonate can result in a much greater loss of insufflation
gas, thereby requiring higher flow rates and potentially exacerbating
hypothermia if non-humidified CO2 is used.
 1. Physiologic Considerations for Minimally Invasive Surgery… 7

Reversible anuria during laparoscopy is a consistent observation in

the literature, occurring in 88 % of neonates and 14 % in older children.
Up to one-third of older children will experience oliguria [28].
Interestingly, these decreases in urine output are not responsive to vol-
ume challenge and do not reflect decreases in renal blood flow. Thus,
intraoperative fluid resuscitation during laparoscopic procedures should
not be governed by urine output alone.
Finally, potential catastrophic events can occur during laparoscopy,
and some of these severe complications may be more likely in children.
Venous air embolism due to cannulation and insufflation of a patent
umbilical vein has been reported in several instances and has sometimes
led to cardiac arrest [1]. CO2 pneumothorax is another rare complication
that has been reported in children. In one case, it was discovered at the
end of the procedure when the infant did not resume spontaneous respi-
rations with reversal of anesthesia, although the child eventually recov-
ered with no reported long-term effects [29].

Thoracoscopic Surgery Considerations

Many of the major pediatric thoracic operations have been performed
thoracoscopically, including resection for congenital pulmonary airway
malformation, repair of congenital diaphragmatic hernia, and repair of
esophageal atresia with and without concomitant tracheoesophageal fis-
tula [1]. Thoracoscopy is routinely employed in pediatric surgical prac-
tice for other procedures such as decortication, sympathectomy, and lung
biopsies or resections. A knowledge of the physiology of minimally
invasive chest procedures is essential for their safe application.
Two potential effects of thoracoscopic surgery merit consideration.
First, single-lung ventilation produces ventilation/ perfusion (V/Q) mis-
match, which is most pronounced in neonates. Several factors make
neonates particularly susceptible to V/Q mismatch: a narrower window
between FRC and residual volume, a compliant chest wall, a lateral
decubitus positioning, and a neuromuscular blockade [5]. The end result
is hypoxia.
Second, there is a widely held belief that CO2 absorption is greater
during thoracoscopy compared to laparoscopy, which could lead to meta-
bolic acidosis, as reported during congenital diaphragmatic hernia repair [1].
In support of this hypothesis, end-tidal CO2 has been shown to increase
significantly after chest insufflation and persist after desufflation, and
8 B.T. Craig and G.P. Jackson

these changes are greater in younger patients and larger than those
observed during laparoscopy [30]. The data on these two responses are
far from conclusive, and more work is needed to identify specific situa-
tions that will produce clinically important changes in CO2 level and
acid-base status.

Postoperative Care
The most important consideration in the postoperative care of ­children
undergoing minimally invasive procedures is respiratory monitoring in
the first several hours after abdominal desufflation, when residual hyper-
carbia may be present and the potential for hypoventilation persists. This
risk is especially important in neonates, infants, and young children, and
we recommend these patients be monitored with continuous pulse oxim-
etry for at least the first several hours after laparoscopy. Further work will
be needed to accurately determine if a predefined, mandatory length of
stay in the anesthesia recovery area or in a monitored hospital unit is
necessary to prevent life-threatening hypoventilation.

Summary
• Laparoscopy is physiologically safe and effective approach in pediat-
ric patients of all ages and for many pediatric abdominal surgical
procedures.
• Increased intra-abdominal pressure leading to impaired pulmonary
mechanics and increased CO2 absorption are the two primary stimuli
that lead to the array of physiologic sequelae during and after
laparoscopy.
• Cardiac index, mean arterial pressure, and aortic blood flow decrease
during abdominal insufflation but rarely with important clinical
consequences.
• Increased minute ventilation must be achieved during minimally inva-
sive surgery, especially in neonates, to prevent hypercarbia and subse-
quent acidosis.
• Reversible anuria and oliguria occur with laparoscopy, and this effect
is more pronounced in younger patients.
• Increases in inflammatory mediators and cellular responses are decreased
during laparoscopic compared to open operations in children.
• Vigilant postoperative monitoring for neonates should be employed
as CO2 retention may persist after abdominal desufflation.
 1. Physiologic Considerations for Minimally Invasive Surgery… 9

References
1. Lacher M, Kuebler JF, Dingemann J, Ure BM. Minimal invasive surgery in the new-
born: current status and evidence. Semin Pediatr Surg. 2014;23(5):249–56.
2. Ponsky TA, Rothenberg SS. Minimally invasive surgery in infants less than 5 kg:
experience of 649 cases. Surg Endosc. 2008;22(10):2214–9.
3. Blinman T, Ponsky T. Pediatric minimally invasive surgery: laparoscopy and thoracos-
copy in infants and children. Pediatrics. 2012;130(3):539–49.
4. Kalfa N, Allal H, Raux O, et al. Multicentric assessment of the safety of neonatal
video surgery. Surg Endosc. 2007;21(2):303–8.
5. Means LJ, Green MC, Bilal R. Anesthesia for minimally invasive surgery. Semin
Pediatr Surg. 2004;13(3):181–7.
6. Watkins SC, Morrow SE, McNew BS, Donahue BS. Perioperative management of
infants undergoing fundoplication and gastrostomy after stage I palliation of hypo-
plastic left heart syndrome. Pediatr Cardiol. 2012;95:204–11.
7. Slater B, Rangel S, Ramamoorthy C, Abrajano C, Albanese CT. Outcomes after lapa-
roscopic surgery in neonates with hypoplastic heart left heart syndrome. J Pediatr
Surg. 2007;42(6):1118–21.
8. Cribbs RK, Heiss KF, Clabby ML, Wulkan ML. Gastric fundoplication is effective in
promoting weight gain in children with severe congenital heart defects. J Pediatr Surg.
2008;43(2):283–9.
9. Bozkurt P, Kaya G, Yeker Y, et al. Arterial carbon dioxide markedly increases during
diagnostic laparoscopy in portal hypertensive children. Anesth Analg. 2002;95(5):
1236–40.
10. Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic effects of pneumo-
peritoneum during laparoscopic surgery in healthy infants: assessment by continuous
esophageal aortic blood flow echo-Doppler. Anesth Analg. 1998;86(2):290–3.
11. Sakka SG, Huettemann E, Petrat G, et al. Transoesophageal echocardiographic assess-
ment of haemodynamic changes during laparoscopic herniorrhaphy in small children.
Br J Anaesth. 2000;84:330–4.
12. Metzelder ML, Kuebler JF, Huber D, et al. Cardiovascular responses to prolonged
carbon dioxide pneumoperitoneum in neonatal versus adolescent pigs. Surg Endosc.
2010;24(3):670–4.
13. De Waal EEC, Kalkman CJ. Haemodynamic changes during low-pressure carbon diox-
ide pneumoperitoneum in young children. Paediatr Anaesth. 2003;13(1):18–25.
14. Aksakal D, Hückstädt T, Richter S, et al. Comparison of femoral and carotid blood
pressure during laparoscopy in piglets. J Pediatr Surg. 2012;47(9):1688–93.
15. Bannister CF, Brosius KK, Wulkan M. The effect of insufflation pressure on pulmo-
nary mechanics in infants during laparoscopic surgical procedures. Paediatr Anaesth.
2003;13(9):785–9.
16. Beebe DS, Zhu S, Kumar MVS, et al. The effect of insufflation pressure on CO(2)
pneumoperitoneum and embolism in piglets. Anesth Analg. 2002;94(5):1182–7.
17. McHoney M, Corizia L, Eaton S, et al. Carbon dioxide elimination during laparoscopy
in children is age dependent. J Pediatr Surg. 2003;38(1):105–10.
10 B.T. Craig and G.P. Jackson

18. Tanaka T, Satoh K, Torii Y, Suzuki M, Furutani H, Harioka T. Arterial to end-tidal

carbon dioxide tension difference during laparoscopic colorectal surgery. Masui.
2006;55(8):988–91.
19. Wulkan ML, Vasudevan SA. Is end-tidal CO2 an accurate measure of arterial CO2
during laparoscopic procedures in children and neonates with cyanotic congenital
heart disease? J Pediatr Surg. 2001;36(8):1234–6.
20. Sanders JC, Gerstein N. Arterial to endtidal carbon dioxide gradient during pediatric
laparoscopic fundoplication. Paediatr Anaesth. 2008;18(11):1096–101.
21. Bozkurt P, Kaya G, Altintas F, et al. Systemic stress response during operations for acute
abdominal pain performed via laparoscopy or laparotomy in children. Anaesthesia.
2000;55(1):5–9.
22. Ure BM, Niewold TA, Bax NMA, et al. Peritoneal, systemic, and distant organ inflam-
matory responses are reduced by a laparoscopic approach and carbon dioxide vs air.
Surg Endosc. 2002;16(5):836–42.
23. Wang L, Qin W, Tian F, et al. Cytokine responses following laparoscopic or open
pyeloplasty in children. Surg Endosc. 2009;23(3):544–9.
24. Montalto AS, Bitto A, Irrera N, et al. CO2 pneumoperitoneum impact on early liver
and lung cytokine expression in a rat model of abdominal sepsis. Surg Endosc. 2012;
26(4):984–9.
25. Papparella A, Noviello C, Romano M, et al. Local and systemic impact of pneumo-
peritoneum on prepubertal rats. Pediatr Surg Int. 2007;23(5):453–7.
26. Moehrlen U, Ziegler U, Boneberg E, et al. Impact of carbon dioxide versus air pneu-
moperitoneum on peritoneal cell migration and cell fate. Surg Endosc. 2006;20(10):
1607–13.
27. Berdan EA, Segura BJ, Saltzman DA. Physiology of the newborn. In: Holcomb GW,
Murphy JP, Ostlie DJ, editors. Ashcraft’s pediatric surgery. 6th ed. Elsevier Saunders;
2014:3–18.
28. Gómez Dammeier BH, Karanik E, Glüer S, et al. Anuria during pneumoperitoneum
in infants and children: a prospective study. J Pediatr Surg. 2005;40(9):1454–8.
29. Lew YS, Thambi Dorai CR, Phyu PT. A case of supercarbia following pneumoperito-
neum in an infant. Paediatr Anaesth. 2005;15(4):346–9.
30. Bishay M, Giacomello L, Retrosi G, Thyoka M, Garriboli M, Brierley J, Harding L,
Scuplak S, Cross KM, Curry JI, Kiely EM, De Coppi P, Eaton S, Pierro A. Hypercapnia
and acidosis during open and thoracoscopic repair of congenital diaphragmatic hernia
and esophageal atresia: results of a pilot randomized controlled trial. Ann Surg.
2013;258(6):895–900.
2.  Pediatric Laparoscopic
and Thoracoscopic Instrumentation

Sarah Gilmore and Colin A. Martin

Early Experience
Pediatric minimally invasive surgery (MIS) has lagged behind its
adult counterpart. In 1973, a report in the Journal of Pediatric Surgery
by Gans and Berci described 16 early laparoscopic pediatric cases [1].
These early advances were ­possible in part by the Hopkins rod-lens opti-
cal system (Fig. 2.1). However, widespread adoption of pediatric lapa-
roscopy was initially met with criticism. The first adult laparoscopic
cholecystectomy was performed in 1985 [2] and was widely regarded as
experimental and dangerous. There has been no single procedure that has
propelled the advance of MIS in pediatric patients the way laparoscopic
cholecystectomies did with adult MIS. Training modules for teaching
laparoscopic cholecystectomy to adult surgeons were not well suited for
teaching the advanced skills required for pediatric surgery [3]. This pro-
cedure was not considered standard of care in pediatrics until many
years later. However, great strides have been made within the last 20
years. Today, it is common practice for neonates to undergo minimally
invasive surgery. A study conducted by Rothenberg et al. over a 51-month
period with 183 infants weighing 1.3–5.0 kg who underwent 195 proce-
dures using minimally invasive techniques “demonstrates that advanced
endosurgical techniques in infants is safe, effective, and associated with
the same benefit as that seen in older patients” [4].

© Springer International Publishing Switzerland 2017 11

D.S. Walsh et al. (eds.), The SAGES Manual of Pediatric
Minimally Invasive Surgery, DOI 10.1007/978-3-319-43642-5_2
Another random document with
no related content on Scribd:
country to avoid the infection, on returning to town, when all infection
had apparently ceased, were generally attacked, and died; a singular
instance of this kind happened at Mogodor, where, after the mortality
had subsided, a corps of troops arrived from the city of Terodant, in
the province of Suse, where the plague had been raging, and had
subsided; these troops, after remaining three days at Mogodor, were
attacked with the disease, and it raged exclusively among them for
about a month, during which it carried off two-thirds of their original
number, one hundred men; during this interval the other inhabitants
of the town were exempt from the disorder, though these troops were
not confined to any particular quarter, many of them having had
apartments in the houses of the inhabitants of the town.
The destruction of the human species in the province of Suse was
considerably greater than elsewhere; Terodant, formerly the
metropolis of a kingdom, but now that of Suse, lost, when the
infection was at its height, about eight hundred each day: the ruined,
but still extensive city of Marocco,[149] lost one thousand each day;
the populous cities of Old and New Fas diminished in population
twelve or fifteen hundred each day,[150] insomuch, that in these
extensive cities, the mortality was so great, that the living having not
time to bury the dead, the bodies were deposited or thrown
altogether into large holes, which, when nearly full, were covered
over with earth. All regulations in matters of sepulture before
observed were now no longer regarded; things sacred and things
prophane had now lost their distinction, and universal despair
pervaded mankind. Young, healthy, and robust persons of full
stamina, were, for the most part, attacked first, then women and
children, and lastly, thin, sickly, emaciated, and old people.
After this violent and deadly calamity had subsided, we beheld
general alteration in the fortunes and circumstances of men; we saw
persons who before the plague were common labourers, now in
possession of thousands, and keeping horses without knowing how
to ride them. Parties of this description were met wherever we went,
and the men of family called them in derision (el wurata) the
inheritors.[151] Provisions also became extremely cheap and
abundant; the flocks and herds had been left in the fields, and there
was now no one to own them; and the propensity to plunder, so
notoriously attached to the character of the Arab, as well as to the
Shelluh and Moor, was superseded by a conscientious regard to
justice, originating from a continual apprehension of dissolution, and
that the El khere,[152] as the plague was now called, was a judgment
of the Omnipotent on the disobedience of man, and that it behoved
every individual to amend his conduct, as a preparation to his
departure for paradise.
The expense of labour at the same time encreased enormously,
[153] and never was equality in the human species more conspicuous
than at this time; when corn was to be ground, or bread baked, both
were performed in the houses of the affluent, and prepared by
themselves, for the very few people whom the plague had spared,
were insufficient to administer to the wants of the rich and
independant, and they were accordingly compelled to work for
themselves, performing personally the menial offices of their
respective families.
The country being now depopulated, and much of the territory
without owners, vast tribes of Arabs emigrated from their abodes in
the interior of Sahara, and took possession of the country contiguous
to the river Draha, as well as many districts in Suse; and, in short,
settling themselves, and pitching their tents wherever they found a
fertile country with little or no population.
The symptoms of this plague varied in different patients, the
variety of age and constitution gave it a like variety of appearance
and character. Those who enjoyed perfect health were suddenly
seized with head-aches and inflammations; the tongue and throat
became of a vivid red, the breath was drawn with difficulty, and was
succeeded by sneezing and hoarseness; when once settled in the
stomach, it excited vomitings of black bile, attended with excessive
torture, weakness, hiccough, and convulsion. Some were seized with
sudden shivering, or delirium, and had a sensation of such intense
inward heat, that they threw off their clothes, and would have walked
about naked in quest of water wherein to plunge themselves. Cold
water was eagerly resorted to by the unwary and imprudent, and
proved fatal to those who indulged in its momentary relief. Some had
one, two, or more buboes, which formed themselves, and became
often as large as a walnut, in the course of a day; others had a
similar number of carbuncles; others had both buboes and
carbuncles, which generally appeared in the groin, under the arm, or
near the breast. Those who were affected[154] with a shivering,
having no buboe, carbuncle, spots, or any other exterior
disfiguration, were invariably carried off in less than twenty-four
hours, and the body of the deceased became quickly putrified, so
that it was indispensably necessary to bury it a few hours after
dissolution. It is remarkable, that the birds of the air fled away from
the abode of men, for none were to be seen during this calamitous
period; the hyænas, on the contrary, visited the cemeteries, and
sought the dead bodies to devour them. I recommended Mr.
Baldwin’s[155] invaluable remedy of olive oil, applied according to his
directions; several Jews, and some Mooselmin, were induced to try
it, and I was afterwards visited by many, to whom I had
recommended it, and had given them written directions in Arabic
how to apply it: and I do not know any instance of its failing when
persevered in, even after the infection had manifested itself.
I have no doubt but the epidemy which made its appearance at
Cadiz, and all along the southern shores of Spain, immediately as
the plague was subsiding in West Barbary, was the same disorder
with the one above described, suffering, after its passage to a
Christian country, some variation, originating from the different
modes of living, and other circumstances; for nothing can be more
opposite than the food, dress, customs, and manners of
Mohammedans and Christians, notwithstanding the approximation of
Spain to Marocco. We have been credibly informed, that it was
communicated originally to Spain, by two infected persons, who went
from Tangier to Estapona, a small village on the opposite shore;
who, after eluding the vigilance of the guards, reached Cadiz. We
have also been assured that it was communicated by some infected
persons who landed in Spain, from a vessel that had loaded produce
at L’araiche in West Barbary. Another account was, that a Spanish
privateer, which had occasion to land its crew for the purpose of
procuring water in some part of West Barbary, caught the infection
from communicating with the natives, and afterwards proceeding to
Cadiz, spread it in that town and the adjacent country.
It should be observed, for the information of those who may be
desirous of investigating the nature of this extraordinary distemper,
that, from its character and its symptoms, approximating to the
peculiar plague, which (according to the before mentioned Arabic
record) ravaged and depopulated West Barbary four centuries since,
the Arabs and Moors were of opinion it would subside after the first
year, and not appear again the next, as the Egyptian plague does;
and agreeably to this opinion, it did not re-appear the second year:
neither did St. John’s day, or that season, affect its virulence; but
about that period there prevails along the coast of West Barbary a
trade wind, which beginning to blow in the month of May, continues
throughout the months of June, July, and August, with little
intermission. It was apprehended that the influence of this trade
wind, added to the superstitious opinion of the plague ceasing on St.
John’s day, would stop, or at least sensibly diminish the mortality; but
no such thing happened, the wind did set in, as it invariably does,
about St. John’s day; the disorder, however, encreased at that
period, rather than diminished. Some persons were of opinion, that
the infection maintained its virulence till the last; that the decrease of
mortality did not originate from a decrease of the miasma, but from a
decrease of population, and a consequent want of subjects to prey
upon; and this indeed is a plausible idea; but admitting it to be just,
how are we to account for the almost invariable fatality of the
disorder, when at its height, and the comparative innocence of it
when on the decline? for then, the chance to those who had it, was,
that they would recover and survive the malady.
The old men seemed to indulge in a superstitious tradition, that
when this peculiar kind of epidemy attacks a country, it does not
return or continue for three or more years, but disappears altogether
(after the first year), and is followed the seventh year by contagious
rheums and expectoration, the violence of which lasts from three to
seven days, but is not fatal. Whether this opinion be in general
founded in truth I cannot determine; but in the spring of the year
1806, which was the seventh year from the appearance of the
plague at Fas in 1799, a species of influenza pervaded the whole
country; the patient going to bed well, and on rising in the morning, a
thick phlegm was expectorated, accompanied by a distressing
rheum, or cold in the head, with a cough, which quickly reduced
those affected to extreme weakness, but was seldom fatal,
continuing from three to seven days, with more or less violence, and
then gradually disappearing.
During the plague at Mogodor, the European merchants shut
themselves up in their respective houses, as is the practice in the
Levant; I did not take this precaution, but occasionally rode out to
take exercise on horseback. Riding one day out of the town, I met
the Governor’s brother, who asked me where I was going, when
every other European was shut up? “To the garden,” I answered.
“And are you not aware that the garden and the adjacent country is
full of (Genii) departed souls, who are busy in smiting with the plague
every one they meet?” I could not help smiling, but told him, that I
trusted to God only, who would not allow any of the Genii to smite
me unless it were his sovereign will, and that if it were, he could
effect it without the aid of Genii. On my return to town in the evening,
the sandy beach, from the town-gate to the sanctuary of Seedi
Mogodole,[156] was covered with biers. My daily observations
convinced me that the epidemy was not caught by approach, unless
that approach was accompanied by an inhaling of the breath, or by
touching the infected person; I therefore had a separation made
across the gallery, inside of my house, between the kitchen and
dining parlour, of the width of three feet, which is sufficiently wide to
prevent the inhaling the breath of a person. From this partition or
table of separation I took the dishes, and after dinner returned them
to the same place, suffering none of the servants to come near me;
and in the office and counting-house, I had a partition made to
prevent the too near approach of any person who might call on
business; and this precaution I firmly believe to be all that is
necessary, added to that of receiving money through vinegar, and
taking care not to touch or smell infectious substances.
 Fear had an extraordinary effect in disposing the body to receive
the infection; and those who were subject thereto, invariably caught
the malady, which was for the most part fatal. At the breaking out of
the plague at Mogodor, there were two medical men, an Italian and a
Frenchman, the latter, a man of science, a great botanist, and of an
acute discrimination; they, however, did not remain, but took the first
opportunity of leaving the place for Teneriffe, so that the few
Europeans had no expectation of any medical assistance except that
of the natives. Plaisters of gum ammoniacum, and the juice of the
leaves of the opuntia, or kermuse ensarrah, i.e. prickly pear, were
universally applied to the carbuncles, as well as the buboes, which
quickly brought them to maturity: many of the people of property took
copious draughts of coffee and Peruvian bark. The Vinaigre de
quatre voleurs was used by many, also camphor, smoking tobacco,
or fumigations of gum Sandrac; straw was also burned by some,
who were of opinion, that any thing which produced abundance of
smoke, was sufficient to purify the air of pestilential effluvia.
During the existence of the plague, I had been in the chambers of
men on their death-bed: I had had Europeans at my table, who were
infected, as well as Moors, who actually had buboes on them; I took
no other precaution than that of separation, carefully avoiding to
touch the hand, or inhale the breath; and, notwithstanding what may
have been said, I am decidedly of opinion that the plague, at least
this peculiar species of it, is not produced by any infectious principle
in the atmosphere, but caught solely by touching infected
substances, or inhaling the breath of those who are diseased; and
that it must not be confounded with the common plague of Egypt, or
Constantinople, being a malady of a much more desperate and
destructive kind. It has been said, by persons who have discussed
the nature and character of the plague, that the cultivation of a
country, the draining of the lands, and other agricultural
improvements, tend to eradicate or diminish it; but at the same time,
we have seen countries depopulated where there was no morass, or
stagnate water for many days journey, nor even a tree to impede the
current of air, or a town, nor any thing but encampments of Arabs,
who procured water from wells of a great depth, and inhabited plains
so extensive and uniform, that they resemble the sea, and are so
similar in appearance after, as well as before sun-rise, that if the eye
could abstract itself from the spot immediately surrounding the
spectator, it could not be ascertained whether it were sea or land.
I shall now subjoin a few cases for the further elucidation of this
distemper, hoping that the medical reader will pardon any inaccuracy
originating from my not being a professional man.
Case I.—One afternoon, I went into the kitchen, and saw the
cook making the bread; he appeared in good health and spirits; I
afterwards went into the adjoining parlour, and took up a book to
read; in half an hour the same man came to the door of the room,
with his eyes starting from his head, and his bed clothes, &c. in his
hands, saying, “open the gate for me, for I am (m’dorb) smitten.” I
was astonished at the sudden transition, and desired him to go out,
and I would follow and shut the gate. The next morning he sent his
wife out on an errand, and got out of bed, and came to the gate half
dressed, saying that he was quite recovered, and desired I would let
him in. I did not, however, think it safe to admit him, but told him to
go back to his house for a few days, until he should be able to
ascertain that he was quite well; he accordingly returned to his
apartments, but expired that evening, and before day-break his body
was in such a deplorable state, that his feet were putrefied. His wife,
by attending on him, caught the infection, having a carbuncle, and
also buboes, and was confined two months before she recovered.
Case II.—L’Hage Hamed O Bryhim, the old governor of Mogodor,
had twelve or more children, and four wives, who were all attacked,
and died (except only one young wife); he attended them
successively to the grave, and notwithstanding that he assisted in
performing the religious ceremony of washing the body, he never
himself caught the infection; he lived some years afterwards, and out
of the whole household, consisting of wives, concubines, children,
and slaves, he had but one person left, which was the before
mentioned young wife: this lady, however, had received the infection,
and was confined some time before she recovered.
Case III.—Hamed ben A—— was smitten with the plague, which
he compared to the sensation of two musket balls fired at him, one in
each thigh; a giddiness and delirium succeeded, and immediately
afterwards a green vomiting, and he fell senseless to the ground; a
short time afterwards, on the two places where he had felt as if shot,
biles or buboes formed, and on suppurating, discharged a fœtid
black pus: a (jimmera) carbuncle on the joint of the arm near the
elbow was full of thin ichor, contained in an elevated skin,
surrounded by a burning red colour; after three months confinement,
being reduced to a skeleton, the disorder appeared to have
exhausted itself, and he began to recover his strength, which in
another month was fully re-established. It was an observation
founded on daily experience, during the prevalence of this disorder,
that those who were attacked with a nausea at the stomach, and a
subsequent vomitting of green or yellow bile, recovered after
suffering in various degrees, and that those who were affected with
giddiness, or delirium, followed by a discharge or vomiting of black
bile, invariably died after lingering one, two, or three days, their
bodies being covered with small black spots similar to grains of gun-
powder: in this state, however, they possessed their intellects, and
spoke rationally till their dissolution.
When the constitution was not disposed, or had not vigour enough
to throw the miasma to the surface in the form of biles, buboes,
carbuncles, or blackish spots, the virulence is supposed to have
operated inwardly, or on the vital parts, and the patient died in less
than twenty-four hours, without any exterior disfiguration.
Case IV.—It was reported that the Sultan had the plague twice
during the season, as many others had; so that the idea of its
attacking like the small-pox, a person but once in his life, is refuted:
the Sultan was cured by large doses of Peruvian bark frequently
repeated, and it was said that he found such infinite benefit from it,
that he advised his brothers never to travel without having a good
supply. The Emperor, since the plague, always has by him a
sufficient quantity of quill bark to supply his emergency.
Case V.—H. L. was smitten with the plague, which affected him
by a pain similar to that of a long needle (as he expressed himself)
repeatedly plunged into his groin. In an hour or two afterwards, a
(jimmera) carbuncle appeared in the groin, which continued
enlarging three days, at the expiration of which period he could
neither support the pain, nor conceal his sensations; he laid himself
down on a couch; an Arabian doctor, applied to the carbuncles the
testicles of a ram cut in half, whilst the vital warmth was still in them;
the carbuncle on the third day was encreased to the size of a small
orange; the beforementioned remedy was daily applied during thirty
days, after which he resorted to cataplasms of the juice of the
(opuntia) prickly pear-tree, (feshook) gum ammoniac, and (zite el
aud) oil of olives, of each one-third: this was intended to promote
suppuration, which was soon effected; there remained after the
suppuration a large vacuity, which was daily filled with fine hemp
dipped in honey; by means of this application the wound filled up,
and the whole was well in thirty-nine days.
Case VI.—El H——t——e, a trading Jew of Mogodor, was sorely
afflicted; he called upon me, and requested some remedy; I advised
him to use oil of olives, and having Mr. Baldwin’s mode of
administering it,[157] I transcribed it in the Arabic language, and gave
it to him; he followed the prescription, and assured me, about six
weeks afterwards, (that with the blessing of God) he had preserved
his life by that remedy only; he said, that after having been anointed
with oil, his skin became harsh and dry like the scales of a fish, but
that in half an hour more, a profuse perspiration came on, and
continued for another half hour, after which he experienced relief:
this he repeated forty days, when he was quite recovered.
Case VII.—Moh——m’d ben A—— fell suddenly down in the
street; he was conveyed home; three carbuncles and five buboes
appeared soon after in his groin, under the joint of his knee, and
arm-pits, and inside the elbow; he died in three hours after the
attack.
Case VIII.—L. R. was suddenly smitten with this dreadful
calamity, whilst looking over some Marocco leather; he fell
instantaneously; afterwards, when he had recovered his senses, he
described the sensation as that of the pricking of needles, at every
part wherein the carbuncles afterwards appeared: he died the same
day in defiance of medicine.
 Case IX.—Mr. Pacifico, a merchant, was attacked, and felt a
pricking pain down the inside of the thick part of the thigh, near the
sinews; he was obliged to go to bed. I visited him the next day, and
was going to approach him, but he exclaimed, “Do not come near
me, for although I know I have not the prevailing distemper, yet your
friends, if you touch me, may persuade you otherwise, and that
might alarm you; I shall, I hope, be well in a few days.” I took the hint
of Don Pedro de Victoria, a Spanish gentleman, who was in the
room, who offering me a sagar, I smoked it, and then departed; the
next day the patient died. He was attended during his illness by the
philanthropic Monsieur Soubremont, who did not stir from his bed-
side till he expired; but after exposing himself in this manner,
escaped the infection, which proceeded undoubtedly from his
constantly having a pipe in his mouth.
Case X.—Two of the principal Jews of the town giving
themselves up, and having no hope, were willing to employ the
remainder of their lives in affording assistance to the dying and the
dead, by washing the bodies and interring them; this business they
performed during thirty or forty days, during all which time they were
not attacked: when the plague had nearly subsided, and they began
again to cherish hopes of surviving the calamity, they were both
smitten, but after a few days illness recovered, and are now living.
From this last case, as well as from many others similar, but too
numerous here to recapitulate, it appears that the human constitution
requires a certain miasma, to prepare it to receive the pestilential
infection.
General Observation.—When the carbuncles or buboes appeared
to have a blackish rim round their base, the case of that patient was
desperate, and invariably fatal. Sometimes the whole body was
covered with black spots like partridge-shot; such patients always fell
victims to the disorder, and those who felt the blow internally,
shewing no external disfiguration, did not survive more than a few
hours.
The plague, which appears necessary to carry off the overplus of
encreasing population, visits this country about once in every twenty
years: the last visitation was in 1799 and 1800, being more fatal than
any ever before known.
The Mohammedans never postpone burying their dead more than
twenty-four hours; in summer it would be offensive to keep them
longer, for which reason they often inter the body a few hours after
death; they first wash it, then lay it on a wooden tray, without any
coffin, but covered with a shroud of cotton cloth; it is thus borne to
the grave by four men, followed by the relations and friends of the
deceased, chaunting, (La Allah illa Allah wa Mohammed rassul
Allah.) There is no God but the true God, and Mohammed is his
prophet. The body is deposited in the grave with the head towards
Mecca, each of the two extremities of the sepulchre being marked by
an upright stone. It is unlawful to take fees at an interment, the bier
belongs to the (Jamâ) mosque, and is used, free of expense, by
those who apply for it. The cemetery is a piece of ground uninclosed,
attached to some sanctuary, outside of the town, for the
Mohammedans do not allow the dead to be buried among the
habitations of the living, or in towns; they highly venerate the
burying-places, and, whenever they pass them, pray for the
deceased.
Diseases.—The inhabitants of this country, besides the plague
already described, are subject to many loathsome and distressing
diseases.
Many of the cities and towns of Marocco are visited yearly by
malignant epidemies, which the natives call fruit-fevers; they
originate from their indulgence in fruit, which abounds throughout
this fertile garden of the world. The fruits deemed most febrile are
musk-melons, apricots, and all unripe stone fruits. Alpinus, de
Medicina Egyptiorum, says, “Autumno grassantur febres
pestilentiales multæ quæ subdole invadunt, et sæpe medicum et
ægrum decipiunt.”
Jedrie (Small-pox).—Inoculation for this disease appears to have
been known in this country long before we were acquainted with it in
Europe. The Arabs of the Desert make the incision for inoculation
with a sharp flint. Horses and cattle are very much subject to the
jedrie: this disease is much dreaded by the natives; the patient is
advised to breathe in the open air. The fatality of this disease may
proceed, in a great measure, from the thickness of the skin of the
Arabs, always exposed to the sun and air, which, preventing the
effort which nature makes to throw the morbid matter to the surface,
tends to throw it back into the circulation of the blood.
Mjinen and Baldness.—Children are frequently affected with
baldness; and the falling sickness is a common disease; the women
are particularly subject to it; they call it m’jinen, i.e. possessed with a
spirit.
Head-ache, Bowel Complaints, and Rheumatism.—The head-
ache is common, but it is only temporary, arising generally from a
suddenst oppage of perspiration, and goes off again on using
exercise, which, in this hot climate, immediately causes perspiration.
The stomach is often relaxed with the heat, and becomes extremely
painful, this they improperly call (Ujah el Kulleb) the heart ache. They
are frequently complaining of gripings, and universal weakness,
which are probably caused by the water they continually drink; they
complain also of (Ujah el Adem) the bone-ache, rheumatism, which
is often occasioned by their being accustomed to sit on the ground
without shoes.
(Bu Telleese) Nyctalopia.—This ophthalmic disease is little known
in the northern provinces; but in Suse and Sahara it prevails. A
defect of vision comes on at dusk, but without pain; the patient is
deprived of sight, so that he cannot see distinctly, even with the
assistance of candles. During my residence at Agadeer, in the quality
of agent for the ci-devant States General of the United Provinces, a
cousin of mine was dreadfully afflicted with this troublesome disease,
losing his sight at evening, and continuing in that state till the rising
sun. A Deleim Arab, a famous physician, communicated to me a
sovereign remedy, which being extremely simple, I had not sufficient
faith in his prescription to give it a trial, till reflecting that the simplicity
of the remedy was such as to preclude the possibility of its being
injurious: it was therefore applied inwardly; and twelve hours
afterwards, to my astonishment, the boy’s eyes were perfectly well,
and continued so during twenty-one days, when I again had
recourse to the same remedy, and it effected a cure, on one
administration, during thirty days, when it again attacked him; the
remedy was again applied with the same beneficial effect as before.
Ulcers and eruptions.—Schirrous ulcers, and other eruptions,
frequently break out on their limbs and bodies from the heated state
of the blood, which is increased by their constant and extravagant
use of stimulants; for whenever they sit down to meat, the first
enquiry is (Wosh Skune) Is it stimulating? if it be not, they will not
touch it, be it ever so good and palatable. These eruptions often turn
to leprous affections.
The Venereal Disease.—The most general disorder, however, is
the venereal disease, which is said to have been unknown among
them, till the period when Ferdinand King of Castille expelled the
Jews from Spain, who coming over to Marocco, and suffering the
Africans to cohabit with their wives and daughters, the whole empire
was, as it were, inoculated with the dreadful distemper; they call it
the great disease,[158] or the woman’s disorder; and it has now
spread itself into so many varieties, that, I am persuaded, there is
scarcely a Moor in Barbary who has not more or less of the virus in
his blood; they have no effectual remedy for it; they know nothing of
the specific mercury, but usually follow a course of vegetable diet for
forty days, drinking during that time decoctions of sarsaparilla, which
afford them a temporary relief. The heat of the climate keeping up a
constant perspiration, those who have this disorder, do not suffer so
much from it as persons do in Europe; and this, added to their
abstaining in general from wine, and all fermented liquors, may be
the cause of their being enabled to drag through life without
undergoing a radical cure, though they are occasionally afflicted with
aches and pains till their dissolution. From repeated infection, and
extreme negligence, we sometimes see noseless faces, no remedy
having been administered to exterminate the infection; ulcers,
particularly on the legs, are so common, that one scarcely sees a
Moor without them. I have heard many of them complain, that they
had never enjoyed health or tranquillity since they were first infected.
If any European surgeon happen to prescribe the specific remedy,
they generally, from some inaccuracy of interpretation, want of
confidence, or other cause, neglect to follow the necessary regimen;
this aggravates the symptoms, and they then discontinue the
medicine, from a presumption of its inefficacy; it has even been
asserted that mercury does not incorporate with the blood, but
passes off with the fæces, producing no salutary effect. In cases of
gonnorrhœa they apply, locally, (the Hendal) coloquinth, which
(assisted with tisanes and diuretics) is attended with most beneficial
effects.
The Bashaw Hayanie, an old man of 100 years of age, who
governed Suse and Agadeer part of the time when I was established
there (and who was a favourite of the Emperor Muley Ismael) has
assured me, that by compelling the Bukarie blacks to carry burdens
up the mountain to the town of Agadeer, in the heat of the day, they
have been cured of this disease. If this be true, it can be attributed
only to the profuse perspiration induced by violent exercise in a hot
country. The constant and general use of the warm bath may also
tend to assuage the virulence of this enemy to the human
constitution.
Leprosy.—Leprosy, called Jeddem, is very prevalent in Barbary;
people affected with it are common in the province of Haha, where
oil argannick is much used, which, when not properly prepared, is
said to heat the blood.[159] The lepers of Haha are seen in parties of
ten or twenty together, and approach travellers to beg charity. In the
city of Marocco there is a separate quarter, outside of the walls,
inhabited by lepers only. In passing through this place, I observed
that its inhabitants were not generally disfigured in personal
appearance; the women, when young, are extremely handsome;
some few have a livid, spotted, or cracked skin: they are sometimes
flushed in the face, and at others pale: when they appear abroad,
they assist their complexion with (el akker) rouge, and (el kahol) lead
ore, with which latter they blacken their eye-lashes and eye brows,
and puncture the chin from the tip to the middle of the lower lip; but
this practice, which they think increases their beauty, rather
disfigures them.
Leprosy being considered epidemical, those who are affected with
it are obliged to wear a badge of distinction whenever they leave
their habitations, so that a straw hat, with a very wide brim, tied on in
a particular manner, is the signal for persons not to approach the
wearer; the lepers are seen in various parts of Barbary, sitting on the
ground with a wooden bowl before them, begging; and in this way
they collect sometimes a considerable sum for such a country: they
intermarry with each other; and although the whole system is said to
be contaminated, yet they seldom discover any external marks of
disease, except those before-mentioned, and generally a paucity or
total want of eye-brows. On any change of weather, and particularly
if the sky be overcast, and the air damp, they will be seen sitting
round a fire, warming their bones, as they term it, for they ache all
over till the weather resumes its wonted salubrity.
Elephantiasis and Hydrocele.—Persons affected with the
elephantiasis, dropsy, and hydrocele, are frequently met with,
particularly about Tangier, the water of which is said to occasion the
latter; and those who are recently affected with it, affirm, that it
leaves them on removing from the place.[160] During my stay once at
Tangier, after travelling through the country, I observed one of my
servants labouring under the disorder; on speaking to him about it,
and regretting that there was no physician to afford him relief, he
laughed, and made light of it, saying he hoped I would not stay long
in Tangier, as it was occasioned by the water of the place, and would
leave him as soon as we departed; which was actually the case, for
two days after our departure it had almost entirely subsided. The
elephantiasis has been thought a species of leprosy, for it desiccates
the epidermis of the legs, which swell and appear rugous.
(El Murrar) Bile.—This is a very general disease, as well as all
those which proceed from a too copious secretion of bile. The Jews,
and the Mohammedans who are not scrupulous, use brandy made
from raisins or figs to remove the bilious sensation, which operates
as an anodyne. Senna, rhubarb, and succotrine aloes, mixed with
honey, are administered with temporary success.
(Bu Saffra) Jaundice.—Men, as well as horses, having the
jaundice, are punctured with a hot iron, through the skin, at the
joints. I have seen both cured in six or seven days by this operation.
 (Tunia) Tape-worm.—This is a disease to which the people are
particularly subject; they take large quantities of (El Assel ou
Assheh) honey and worm-seed, which produces beneficial effects.
The children are generally afflicted with this disease; the eyes
appear hollow, with a whiteness of the adjacent skin.
(Bu Wasir), Hæmorrhoides.—This disease is very general;
refrigerants are applied for its cure internally, and an unguent,
composed of oil of almonds, and the juice of the opuntia, or prickly-
pear tree.
Hydrophobia is entirely unknown in West Barbary, which is the
more extraordinary, as dogs abound every where, are frequently
destitute of water, and suffer intolerably from heat and exposure to
the sun.
Hernia.—Cases of hernia are sometimes met with, though not so
frequently as in Europe.
They have no effectual remedy for any of the before mentioned
diseases; their whole materia medica consists, with little exception,
of herbs and other vegetables, from their knowledge of the medical
virtues of which much might be learned by European physicians.
Bleeding is a general remedy for various complaints; the healthy let
blood once a year. Scarification on the forehead, at the back of the
head, below the root of the hair, on the loins, the breast, and the legs
is generally practised in cases of violent head-ache proceeding from
an obstructed perspiration.
The classification of remedies among the Arabs is remarkably
simple, the two grand divisions are refrigerants and heating
medicines: they quote some ancient Arabian, who says,
Shrub Dim Wine produces blood.
El Ham el Ham Meat produces flesh.
Khubs Adem Bread produces bone.
U el bakee makan But all other things produce no good.
FOOTNOTES:
 [147]See the Author’s observations, in a letter to Mr. Willis, in
Gentleman’s Magazine, February 1805.
[148]See page 105.
[149]I have been informed that there are still at Marocco,
apartments wherein the dead were placed; and that after the
whole family was swept away the doors were built up, and remain
so to this day.
[150]There died, during the whole of the above periods, in the
city of Marocco, 50,000; in Fas, 65,000; in Mogodor, 4,500; and in
Saffy, 5,000; in all 124,500 souls!
[151]Des gens parvenues, as the French express it; or
upstarts.
[152]The good, or benediction.
[153]At this time I received from Marocco a caravan of many
camel loads of beeswax, in serrons containing 200 lbs. each; I
sent for workmen to place them one upon another, and they
demanded one dollar per serron for so moving them.
[154]M’drob is an idiom in the Arabic language somewhat
difficult to render into English; it is well known that the
Mohammedans are predestinarians, and that they believe in the
existence of spirits, devils, &c. their idea of the plague is, that it is
a good or blessing sent from God to clear the world of a
superfluous population—that no medicine or precaution can cure
or prevent it; that every one who is to be a victim to it is (mktube)
recorded in the Book of Fate; that there are certain Genii who
preside over the fate of men, and who sometimes discover
themselves in various forms, having often legs similar to those of
fowls; that these Genii are armed with arrows: that when a person
is attacked by the plague, which is called in Arabic l’amer, or the
destiny or decree, he is shot by one of these Genii, and the
sensation of the invisible wound is similar to that from a musquet-
ball; hence the universal application of M’drob to a person
afflicted with the plague, i.e. he is shot; and if he die, ufah
ameruh, his destiny is completed or terminated (in this world). I
scarcely ever yet saw the Mooselmin who did not affirm that he
had at some time of his life seen these Genii, and they often
appear, they say, in rivers.
[155]Late British Consul in Egypt.
 [156]A sanctuary a mile south-east of the town of Mogodor,
from whence the town receives its name.
[157]Mr. Baldwin observed, that whilst the plague ravaged
Egypt, the dealers in oil were not affected with the epidemy, and
he accordingly recommended people to anoint themselves with oil
every day as a remedy.
[158]In Arabic, el murd el kabeer, or el murd En’sâh.
[159]See page 138.
[160]I mention this, from its being the popular, and generally
received opinion of the natives only; the case of my servant
would, indeed, seem to favour such an opinion, but his cure was
probably owing to other causes.
 CHAPTER IX.
Some Observations on the Mohammedan Religion.

I shall not attempt to give a philosophical dissertation on the tenets

of the religion of Mohammed, a subject that has been often ably
discussed by various authors; but a few desultory observations may,
perhaps, be not improper in this place.
Many writers have endeavoured to vilify the Mohammedan
religion, by exposing the dark side of it, and their representations
have been transmitted to posterity by enthusiasts who, probably,
have been anxious to acquire ecclesiastical fame; but we shall, on a
minute examination of the doctrines contained in the Koran, find that
it approaches nearer to the Christian religion, in its moral precepts,
than any other with which we are acquainted. Indeed, were there as
many absurdities in this religion as some persons have attributed to
it, it is probable that it would not have extended itself over so great a
portion of the habitable globe; for we find it embraced, with little
exception, from the shores of West Barbary, to the most eastern part
of Bengal, an extent of upwards of 8000 miles; and from the
Mediterranean to Zanguebar and Mosambique, with the exception of
some nations of Pagans; neither is there any language spoken and
understood by so great a proportion of the population of the world as
that in which it is promulgated.
Koran, chap. vii.—“Forgive easily: command nothing but what is
just: dispute not with the ignorant”
Koran, chap. xi.—“O earth, swallow up thy waters: O heaven,
withhold thy rain; immediately the waters subsided, the ark rested on
Mount Al Judi, and these words were heard: Wo to the wicked
nation!”
Chap. xiii.—“They who do good for evil shall obtain paradise for
their reward.”
 From these extracts we see that the Mohammedans have some
of the same moral precepts laid down for their guidance which are
inculcated by the Gospel of Christ. They believe in the flood; they
teach forgiveness of injuries, justice, and rendering good for evil. The
nations which followed paganism were taught by Mohammed the
unity of God. He exhorted them to believe with the heart, that there is
only one God, omnipotent, omniscient, omnipresent, eternal, and
that he is spiritual. That the angels are subtle, pure bodies, formed of
light; neither eating, drinking, or sleeping; not of different sexes;
having no carnal desires, nor degrees of relationship, and are of
various forms.
Mohammed maintained that Jesus Christ was a prophet, and that
those who believed it not were infidels. He says, the sacred books
are 104, of which the Almighty gave
To Adam 10
To Seth 50
To Idris, or Enoch 30
To Abraham 10
To Moses 1 ,which is the Law
To David 1
To Jesus 1 , which is the Gospel
To Mohammed 1 , the Koran;
and he asserts, that whoever rejects, or calls in question the divine
inspiration of any of the foregoing books, is an infidel. He says also,
that he who can lay his hand on his heart and say, “I fear not the
resurrection, nor am I in any concern about hell, and care not for
heaven,” is an incorrigible infidel.
Religion and the State are considered as twins, inseparable; if
one die, the other cannot survive.
The most refined and intelligent Mohammedans are not of
opinion, that God is the author of all good and evil; but maintain that
every man who follows the direct or good way, has the protecting
eye of God upon him, and that God is with him; but that, if he