De Medicina

22 Now, some mixtures of medicaments are used dry, without being combined, so that they are dusted or smeared on after some liquid has been mixed with them. Such is the present to eat away fungous flesh, which contains copper scales and frankincense soot, 4 grams each, verdigris 8 grams. But when combined with honey this compound cleans ulcers, when with wax it fills them up. Also antimony

sulphide and oak-galls, if they are mixed in equal proportions, corrode flesh. We may either sprinkle this mixture on dry or take it up in cadmian ointment and smear it on.

Honey mixed with lentils or with horehound or with olive leaves previously boiled in wine holds in check putrid flesh, prevents its further spread, and is a mild corrosive. The same is the action of melilot, boiled in honey wine, then pounded up; or lime with cerate; or bitter almonds with garlic in the proportion of three to one, with the addition of a little saffron. Or the composition containing litharge 24 grams, burnt ox-horn 48 grams, myrtle-oil and wine, 125 cc. of each. Or that mixture which consists of pomegranate flowers, blacking and lign-aloes, 8 grams each, split alum and frankincense 16 grams, oak-galls 32 grams, aristolochia 40 grams. Stronger as a corrosive is that compounded by calcining orpiment with copper ore, and with either soda or lime or burnt papyrus; salt with vinegar is similar. Or that composition which contains copper ore, pomegranate heads, lign-aloes, 8 grams each, split alum and frankincense, 16 grams each, oak-galls 32 grams, aristolochia 40 grams, with sufficient honey to combine them. An alternative is the composition containing cantharides 4 grams, sulphur 4 grams, darnel 12 grams, to which is added enough liquid pitch to combine them. Or also that composed of copper ore mixed with resin and rue; or slag similarly with resin; or black bryony berries with liquid pitch. The same property too belongs both to burnt wine-lees and lime and soda, equal parts, or to split alum, 1·33 grams, frankincense, sandarach and soda, 4 grams each, oak-galls 32 grams, aristolochia 40 grams, and as much honey as is required.

There is also the compound of Heras which contains myrrh and copper ore, 8 grams each, lign-aloes, frankincense, split alum, 16 grams, aristolochia and immature oak-galls, 32 grams each, pomegranate rind pounded 40 grams.

The compound of Iudaeus contains lime two parts; the reddest soda one part, mixed with the urine of a young boy to the consistency of strigil scrapings. But the place on which it is smeared should from time to time be moistened.

Then the compound of Iollas consists of burnt papyrus and of sandarach, 4 grams each, lime 8 grams, mixed with the same quantity of orpiment.

But if there is haemorrhage from the membrane covering the brain, a yolk of egg which has been charred and then pounded should be scattered on; for haemorrhage elsewhere orpiment and copper scales, 4 grams each, sandarach 8 grams, calcined marble 16 grams, should be dusted on. The same also checks canker. To induce scarifying, copper scales and frankincense soot, 8 grams each, lime 16 grams. The same also counters fungous flesh.

Also Timaeus used the following for ignis sacer and for canker: myrrh 8 grams, frankincense and blacking, 12 grams each, sandarach, orpiment, copper scales, 16 grams each, oak-galls 24 grams, burnt white-lead 32 grams. This is either scattered on dry or has the same effect when taken up in honey.

Sneezing too is excited by putting up the nose either white veratrum or soapwort; or the following mixture: pepper and white veratrum, 0·66 gram each, castoreum 1 gram, soda-scum 4 grams, soapwort 16 grams.

Now gargles are used as emollients or as repres-

sives or to draw out humour. As emollients, milk, pearl-barley or bran gruel; as repressants, a decoction of lentils or rose-leaves or blackberries or quinces or of dates. Mustard and pepper draw out humour.

23 Antidotes are seldom needed, but are at times important because they bring aid to the gravest cases. They are appropriately administered for bodily contusions, either from blows or in cases of a fall from a height, or for pain in the viscera, sides, fauces, or internal parts. But they are chiefly necessary against poisons introduced into our bodies through bites or food or drink.

One consists of poppy-tears 0·66 gram, sweet flag and malabathrum, 20 grams each, Illyrian iris and gum, 8 grams each, anise 12 grams, Gallic nard, dried rose-leaves and cardamons, 16 grams each, parsley 16·66 grams (or trifolium 20 grams), black casia, seseli, bdellium, balsam seed, white pepper, 20·66 grams each, storax 20·66 grams, myrrh, opopanax, Syrian nard, male frankincense and hypocistis juice, 24 grams each, castoreum 24 grams, costmary, white pepper, galbanum, turpentine resin, crocus, flowers of round rush 25 grams, liquorice root 33 grams, which are taken up in honey or in raisin wine.

Alternatively there is that which Zopyrus is said to have compose for a King Ptolemy, and to have called it ambrosia, consisting of the following: costmary and male frankincense, 1·33 grams each, white pepper 1 gram, flowers of round rush 8 grams,

cinnamon 12 grams, black casia 16 grams, Cilician saffron 17 grams, myrrh called stacte 20 grams, Indian nard 21 grams. Each ingredient is ground up separately, and they are taken up in boiled honey; then at the time of using, a quantity the size of an Egyptian bean is dissolved in a draught of wine.

But the most famous antidote is that of Mithridates, which that king is said to have taken daily and by it to have rendered his body safe against danger from poison. It contains costmary 1·66 grams, sweet flag 20 grams, hypericum, gum, sagapenum, acacia juice, Illyrian iris, cardamon, 8 grams each, anise 12 grams, Gallic nard, gentian root and dried rose-leaves, 16 grams each, poppy-tears and parsley, 17 grams each, casia, saxifrage, darnel, long pepper, 20·66 grams each, storax 21 grams, castoreum, frankincense, hypocistis juice, myrrh and opopanax, 24 grams each, malabathrum leaves 24 grams, flower of round rush, turpentine-resin, galbanum, Cretan carrot seeds, 24·66 grams each, nard and opobalsam, 25 grams each, shepherd's purse 25 grams, rhubarb root 28 grams, saffron, ginger, cinnamon, 29 grams each. These are pounded and taken up in honey. Against poisoning, a piece the size of an almond is given in wine. In other affections an amount corresponding in size to an Egyptian bean is sufficient.

24 Acopa again are useful for neuralgia. Of these there is one which consists of the flower of the round rush, 9·33 grams each, costmary, square rush, laurel berries, ammoniacum, cardamons, 17 grams each, myrrh and calcined copper 28 grams, Illyrian iris and wax 56 grams, Alexandrian flag,

round rush, aspalathus and balsam wood, 112 grams each, suet 4 grams, iris ointment 42 cc.

Another called euodes is prepared as follows: wax 84 grams, oil this quantity, and turpentine-resin, the size of a walnut, are boiled together, then pounded in a mortar, and into this is gradually dropped 63 cc. of the best honey, and then iris ointment and rose-oil, 125 cc. of each.

Now enchrista is the Greek name for liquid applications. Of these one is used for cleaning and filling up ulcers, especially about sinews. It is composed of a mixture of each parts of butter, calf's marrow, calf's suet, goose-fat, wax, honey, turpentine-resin, rose-oil and castor-oil. This are all liquefied separately, then the liquids are mixed and stirred up together. And the above is more for cleaning up wounds; it is more of an emollient if instead of the rose-oil, cyprus-oil is poured in.

And for ignis sacer litharge 24 grams, burnt ox-horn 48 grams, are rubbed together, adding by turns wine, especially that which is called sil, and myrtle-oil until 125 cc. of each is mixed in.

25 Pills are also numerous, and are made for various purposes. Those which relieve pain through sleep are called anodynes; unless there is overwhelming necessity, it is improper to use them; for they are composed of medicaments which are very active and alien to the stomach. There is one, however, which actually promotes digestion; it is composed of poppy-tears and galbanum, 4 grams each, myrrh, castory, and pepper, 8 grams each. Of this it is enough to swallow an amount the size of a vetch.

Another, worse for the stomach, but more soporific, consists of mandragora 1 gram, celery-seed and hyoscyamus seed, 16 grams each, which are rubbed up after soaking in wine. One of the same size mentioned above is quite enough to take.

But whether there is headache or ulceration or ophthalmia or toothache or difficulty in breathing or intestinal gripings or inflammation of the womb or pain in the hips of liver or spleen or ribs, or, whether owing to genital trouble, a woman collapses speechless, a pillar of the following kind counteracts pain by producing sleep: saxifrage, sweet flag, wild rue seed, 4 grams each, castory and cinnamon 8 grams, poppy-tears, panax root, dried mandrake apples, flowers of the round rush, 9 grams each, and 56 peppercorns. These are first pounded separately, then rubbed up all together, whilst gradually adding raisin wine until the mixture is either swallowed or dissolved in water and taken as a draught.

Or take a good handful of wild poppy-heads when just ripe for collecting the juice and put into a vessel and boil with water sufficient to cover it. When this handful has been well boiled there, after being squeezed out it is thrown away; and with its juice is mixed an equal quantity of raisin wine, and heated until to consistency of sordes. When the mixture has cooled, pills are formed, the size of our beans; they are used in many ways. For they procure sleep

whether taken as they are or in water; they relieve earache when a little rue-juice and raisin wine are added; when dissolved in wine they relieve gripings, and when mixed with cerate of rose-oil with the addition of a little saffron they relieve inflammation of the womb; also when smeared upon the forehead mixed with water they check the flow of phlegm into the eyes.

Again if inflammation of the womb prevents sleep take saffron 1·33 grams, anise and myrrh, 4 grams each, poppy-tears 12 grams, hemlock seed 32 grams. These are mixed together, and taken up in old wine, and a pill the size of a lupin is dissolved in 125 cc. of water. It is dangerous, however, to give it when there is fever.

For the relief of pain in the liver soda 1 gram, saffron, myrrh, Gallic nard, 4 grams each, are taken up in honey, and a pill the size of an Egyptian bean administered.

A pill to stop pain in the side is made of pepper, aristolochia, nard, and myrrh in equal parts.

A pill for pain in the chest is made from nard 4 grams, frankincense and casia, 12 grams each, myrrh and cinnamon, 24 grams each, saffron 32 grams, turpentine-resin 1 gram, honey three-quarters of a litre.

The pill of Athenion for cough contains myrrh and pepper, 0·66 gram each, castory and poppy-tears, 4 grams each; these are rubbed down separately, then together, and two pills, the size of our bean, are given in the morning and two at bed-time.

If cough prevents sleep the pill of Heracleides of Tarentum relieves both; it contains saffron 0·66 gram, myrrh, long pepper, costmary, galbanum, 1 gram each, cinnamon, castor and poppy-tears, 4 grams each.

But if ulcers of the throat causing cough are to be cleaned, panax, myrrh and turpentine-resin, 28 grams each, galbanum 0·66 gram, hyssop 1 gram are rubbed together, and 250 cc. of honey added to them and as much swallowed as can be taken up on the finger.

The pill of Cassius for colic contains saffron, anise, castory, 12 grams each, parsley 16 grams, pepper both long and round, 20 grams each, poppy-tears, round rush, myrrh, nard, 24 grams each; these are taken up in honey. It may be either swallowed as it is or dissolved in hot water.

A draught for the expulsion of a dead foetus or placenta consists of ammoniac salt 4 grams, or of Cretan dittany 4 grams in water.

In difficult labour hedge mustard in tepid wine should be administered on an empty stomach.

The voice is strengthened by frankincense 4 grams in two cups of wine.

For difficult micturition long pepper, castory, myrrh, galbanum, poppy-tears, saffron, costmary, 28 grams each; storax and turpentine-resin, 56 grams each, honey with absinth 42 cc. Of this an amount the size of an Egyptian bean should be taken in the morning and after dinner.

A medicine for the windpipe is prepared as follows: casia, iris, cinnamon, nard, myrrh, frankincense, 4 grams each; saffron 1 gram; and 30 peppercorns boiled in a litre and a half of raisin

wine until of the consistency of honey. Or, saffron, myrrh, frankincense, 4 grams each, similarly boiled in raisin wine to the same consistency. Or 750 cc. of raisin wine are boiled until a drop, if taken out, solidifies; thereupon pounded casia 4 grams is added.

26 Now that I have set out the properties of the medicaments, I will explain the classes of lesions harmful to the body: there are five; when something from without causes the lesion, as in the case of wounds; when some internal part has become corrupted, as in the case of canker; when some new formation has occurred, such as a stone in the bladder; when something has grown bigger, as when a vein swells up and is converted into a varix; when there is some defect, as when some part has been mutilated.

In some of these medicaments are more effectual, in others surgery. Postponing those conditions which demand in particular the scalpel and surgical treatment, I will speak now of those which chiefly require medicaments. As I have done before, I shall divide this part of treatment, and speak first of those lesions which may occur in any part of the body, then of those which attack particular parts. I shall begin with wounds.

In this connexion, however, a practitioner should know above all which wounds are incurable, which may be cured with difficulty, and which more readily. For it is the part of a prudent man first not to touch a case he cannot save, and to the risk the appearance of having killed one whose lot is but to die; next, when there is grave fear without, however, absolute

despair, to point out to the patient's relatives that hope is surrounded by difficulty, for then if the art is overcome by the malady, he may not seem to have been ignorant or mistaken. But while such steps become a prudent practitioner, it is like a mountebank to exaggerate a small matter in order to enhance his own achievement. It is right to commit himself to a statement that a case is simple in order that he may examine it with even more care for fear a case slight in itself may become worse by negligence on the doctor's part.

It is impossible to save a patient when the base of the brain, the heart, the gullet, the porta of the liver, or the spinal marrow has been pierced; when the middle of the lung, or the jejunum, or the small intestine, or the stomach, or kidneys have been wounded; or when the large blood-vessels and arteries in the region of the throat have been cut.

Again, there is hardly ever recovery when either the lung or the thick part of the liver or the membrane enclosing the brain, or the spleen, womb, bladder, any of the intestines or diaphragm has been wounded in any part. There is also grave danger when the point of a weapon has gone down to the large blood-vessels deeply seated in the armpits or hams. Also wounds are dangerous wherever the blood-vessels are larger, because they may exhaust the patient by profuse bleeding. This occurs not only in the armpits and hams, but also in those blood-vessels which go to the anus and testicles. Moreover, a wound is a bad one whenever it is in the armpits or in the thighs or in hollow places or in joints or between the fingers; also whenever a muscle

or sinew or artery or membrane or bone or cartilage is injured. The safest of all is a wound in the flesh.

The above wounds are severer or slighter according to their situations. Still, whenever it is large, a wound makes for danger.

The class of wound and its shape are also important. For a contused would is worse than one simply incised, hence it is better to be wounded by a sharp weapon than by a blunt one. A wound is worse also if a piece is cut out, or if the flesh is cut away in one part and hanging free in another. A curved wound is worst, a straight linear one safest; hence a wound is more or less serious, according as it approximates to the former or to the latter shape.

Again, both age and constitution and mode of life and the season have also some influence; for a boy or young adult heals more readily than does an old man; one who is strong than a weak man; a man who is not too thin or too fat than one who is either of these; one of sound habit than of unsound; one who takes exercise than a sluggard; one who is sober and temperate than one addicted to wine and venery. And the most opportune time for healing is the spring, or at any rate when the weather is neither cold nor hot, for wounds are harmed by excessive heat and excessive cold, but most of all by variations of these; hence autumn is the most pernicious season.

Now most wounds are open to view; some are inferred from their situation, which we have pointed out elsewhere when indicating the positions of the internal parts. Since, however, some of these wounds are near at hand, and it is of importance whether the wound is superficial or has penetrated inwards,

it is necessary to state the signs by which it is possible to recognize what has happened inside, and from which follow either hope or despair.

Now when the heart is penetrated, much blood issues, the pulse fades away, the colour is extremely pallid, cold and malodorous sweats burst out as if the body had been wetted by dew, the extremities become cold and death quickly follows.

But when the lung is pierced there is difficulty in breathing; frothy blood escapes from the mouth, red blood from the wound; and at the same time breath is drawn with a noise; to lie upon the wound affords relief; some stand up without any reason. Many speak if they have been laid upon the wound; if upon the opposite side they become speechless.

Symptoms that the liver should have been wounded are that considerable haemorrhage occurs from under the right part of the hypochondria; the hypochondria are retracted towards the spine; the patient is eased by lying on his belly; stabbing pains spread upwards as high as the clavicle and its junction with the scapula; to which, not infrequently, also bilious vomiting is added.

When the kidneys have been penetrated, pain spreads down to the groin and testicles; urine is passed with difficulty, and it is either bloodstained or actual blood clot is passed.

But when the spleen has been pierced, black blood flows out from the left side; the hypochondria on that side together with the stomach become hard; great thirst comes on; pain extends to the clavicle as when the liver has been wounded.

But when the womb has been penetrated, there is

pain in the groins and hips and thighs; blood passes downwards in part through the wound, in part by the vagina; bilious vomiting follows. Some become speechless, some are mentally disturbed, others whilst composed in mind complain of pain in their sinews and eyeballs, and when dying they suffer like those wounded in the heart.

When the brain or its membrane has been wounded, blood escape through the nostrils, in some also through the ears; and generally bilious vomiting follows. Some lose their senses and take no notice when spoken to; some have a wild look; in some the eyes move from side to side as if they were out of control; generally on the third or fifth day delirium supervenes; many have also spasm of sinews. Again, before death many tear off the bandages with which their head has been bound up, and expose the bared wound to cold.

But when the gullet has been penetrated, hiccough and bilious vomiting follow; if any food or drink is swallowed, it is returned at once; pulsation of the blood-vessels fades away; thin sweat breaks out, following which the extremities become cold.

The signs when the small intestine and the stomach have been wounded are the same; for food and drink come out through the wound; the hypochondria become hard, sometimes bile is regurgitated through the mouth. Only in the case of the intestine the situation of the wound is lower down. All other intestinal wounds cause the emission of faeces or a faecal odour.

When the marrow which is within the spine has been crushed, there is

either paralysis or spasm of sinews; sensation is interrupted; after some time there is involuntary evacuation from the parts below of either semen or urine of even faeces.

But if the diaphragm has been penetrated, the praecordia are contracted upwards; the spine is painful; breathing is laboured; frothy blood escapes.

When the bladder has been wounded, the groins are painful; the hypogastrium becomes tense; blood is passed, instead of urine, the urine being discharged from the actual wound. The gullet is affected, and so the patients either vomit bile or hiccough. Coldness and after that death follows.

Even when these facts are known, there are still some other things to be learnt about wounds and ulcerations in general, of which we will now speak. From wounds, then, there comes out blood, or sanies, or pus. Blood everybody knows; sanies is thinner than blood, varying both in thickness and stickiness and colour. Pus is the thickest and whitest, more sticky than either sanies or blood. Now blood comes out from a fresh wound or from one which is already healing, sanies between these two periods, pus from an ulceration already beginning to heal. Again, the Greeks distinguish by name different kinds of sanies and pus. For there is a kind of sanies which is named either hidros or melitera; there is pus which is called alaeodes. Hidros is thin, whitish, and comes from a bad ulceration, especially when inflammation has followed upon a wound of a sinew. Melitera is thicker, stickier and whitish, something like honey. It is likewise discharged from bad ulcerations, when sinews near to joints have been wounded, and among such places especially from the knees. Elaeodes is thin, whitish, fatty, in colour and fattiness not unlike olive-oil; it appears

in large ulcerations when they are healing. Blood is bad when it is too thin or too thick, livid or black in colour, or mixed with phlegm or variable; it is best when hot, red, moderately thick, and not sticky. Consequently from the first the treatment is more expeditious in the case of a wound from which good blood has flowed. Also later there is more hope in the case of wounds from which all the discharges are of the better kind. Thus sanies is bad when profuse, too thin, livid, or pallid or black or sticky or malodorous or when it erodes either the ulceration itself or the skin adjoining it; it is better when not profuse, moderately thick, reddish or whitish. But hidros is worse when it is profuse, thick, somewhat livid or pallid, stick, black, hot, malodorous; it is less serious when whitish, and when all the rest of its characteristics are the opposite of the foregoing. Melitera again is bad when profuse and very thick; better for being thinner and less copious. Amongst these discharges pus is the best; but it is likewise worse when profuse, thin, watery, and the more so if it is such from the beginning; and also if it is in colour like whey, if pallid, or livid, or like wine-lees; if, besides, it is malodorous, unless, however, it is the part which causes this odour. It is better, the smaller the quantity, the thicker and whiter; also if it is bland, odourless, uniform; none the less it should correspond in quantity with the size and age of the wound. For naturally there is more discharge, the larger the wound, si more when inflammation has not yet subsided. Elaeodes also is worse when large in quantity and but little fatty, the less in quantity and the more fatty the better.

After these matters have been investigated, when a man has been wounded who can be saved, there are in the first place two things to be kept in mind: that he should die from haemorrhage or inflammation. If we are afraid of haemorrhage which can be judged both from the position and size of the wound and from the force of the flowing blood, the wound is to be filled with dry lint, and over that a sponge applied, squeezed out of cold water, and pressed down by the hand. If the bleeding is not checked thus, the lint must be changed several times, and if it is not effective when dry, it is to be soaked in vinegar. Vinegar is powerful in suppressing a flow of blood; and some, therefore, pour it into wounds. But then there is an underlying fear of another kind, that if too much diseased matter is forcibly retained in the wound it will afterwards cause great inflammation. It is on this account that no use is made, either of corrosives or of caustics, owing to the crust they induce, although most of these medicaments suppress bleeding; but if for once recourse is had to them, choose those which have a milder action. But if even these are powerless against the profuse bleeding, the blood-vessels which are pouring out blood are to be seized, and round the wounded spot they are to be tied in two places and cut across between so that the two ends coalesce each on itself and yet have their orifices closed. When circumstances do not even admit of this, the blood-vessels can be burnt with a red-hot iron. But even when there has been a considerable bleeding from a place where there is neither sinew nor muscle, such as the forehead or top of the head, it is perhaps best to apply a cup to a distant part, in order to divert thither the course of the blood.

Against bleeding there is help in the foregoing measures, but against inflammation it lies simply in the bleeding itself. Inflammation is to be feared when a bone is injured or sinew or cartilage or muscle, or whenever there is little outflow of blood compared to the wound. Therefore, in such cases, it will not be desirable to suppress the bleeding early, but to let blood flow as long as it is safe; so that if there seems too little bleeding, blood should be let from the arm as well, at any rate when the patient is young and robust and used to exercise, and much more so when a drinking bout has preceded the wound. But if a muscle is seen to be wounded, it will be best to cut it right through; for when stabbed it causes death, when cut through it admits of cure.

Now, when bleeding has been suppressed if excessive, or encouraged when not enough has escaped of itself, then by far the best thing is for the wound to become agglutinated. But this is possible for a wound in the skin, or even in the flesh, if nothing else has occurred to do it harm. Agglutination is possible if the flesh is hanging free at one part, whilst attached at another, provided, however, that the flesh is still sound, and has a connexion with the body to feed it. But with wounds which are being agglutinated, there are two treatments. For if the wound is in a soft part, it will be stitched up, and particularly when the cut is in the tip of the ear or the point of the nose or forehead or cheek or eyelid or lip or the skin over the throat or abdomen. But if the wound is in the flesh, and gapes, and its margins are not easily drawn together, then stitching in unsuitable; fibulae (the Greeks call them ancteres) are then to be

inserted, which draw together the margins to some extent and so render the subsequent scar less broad. Now from the above it can be gathered also whether flesh which is hanging free at one part and attached at another, if it is still capable of juncture, demands suture or fibula. But neither of these should be inserted until the interior of the wound has been cleansed, lest some blood-clot be left in it. For blood clot turns into pus, and excites inflammation, and prevents agglutination of the wound. Not even lint which has been inserted to arrest bleeding should be left in, for this also inflames the wound. The suture or fibula should take up, not only skin but also some of the underlying flesh, where there is any, that it may hold more firmly, and not tear through the skin. And both are best used with a strand of a soft wool not too closely twisted that it may cause less irritation to the body, and both should be inserted at intervals not too distant or too close. For if the intervals are too distant, the wound is not held together; if too close, it is very hurtful, for the more often the needle this fixes the tissues, and the more places are wounded by the inserted stitches, the worse is the inflammation set up, especially in summer. Neither procedure needs any force, but is useful just so far as the skin follows that which draws it as if of its own accord. Generally, however, fibulae leave the wound wider open, a suture joins the margins together, but these should not be brought actually into contact throughout the whole length of the wound, in order that there may be an outlet for any humour collecting within. If any wound admits of neither of these, it should none the less be cleaned. Hence, upon every wound there is to be applied, first a sponge squeezed out of vinegar; or out of wine if the patient cannot bear the strength of vinegar. A slight wound is even benefited if a sponge is applied wrung out of cold water. But in whatever way it is put on, it is only of service while moist; and so it must not be allowed to become dry. And a wound can be treated without foreign and far-fetched and complicated medicaments. But if any one has not confidence in this treatment, a medicament should be put on, which has no suet in its composition, chosen from those which I have stated to be suitable for bleeding wounds: and especially, if it is a flesh wound, the composition called barbarum; if a wound of sinews or of cartilage or of some projecting part, such as the ears or lips, the seal of Polyides: the green composition called Alexandrian is also suitable for sinews; and that which the Greeks call rhaptousa for parts which project. When the body is bruised it is usual also for the skin to be broken to a small extent. When this occurs, it is not improper to lay it open more widely with a scalpel, unless there are muscles and sinews near, as it is inexpedient to cut into these. When it has been sufficiently opened, a medicament is seem to be put on. But if the skin over the contusion, although broken too little, yet must not be laid open more widely on account of sinews or muscles, then such applications should be made as gently extract humour, especially that which I have said is called rhypodes. It is also not inappropriate, when the wound is severe, after putting on what is beneficial, to lay on over this, wool saturated with vinegar and oil; or a poultice, gently repressant if to a soft part; or emollient to a part where there are sinews or muscles.

The bandage too for binding up a wound is best made of linen, and it should be so wide as to cover it in a single turn, not the wound alone but somewhat of its edges on either side. If the flesh has receded more from one edge, the traction is better made from that side. If equally from both, the bandage, put crosswise, should press the margins together; or if the character of the wound does not admit of that, the middle of the bandage is to be applied first, so that it may then be drawn to either side. Moreover, the wound is to be bandaged so that it is held together, yet not constricted. When it is not so held, it gapes; if it is constricted too much, there is a risk of canker. In winter there should be more turns of the bandage, in summer just those necessary; finally, the end of the bandage is to be stitched by means of a needle to the deeper turns; for a knot hurts the wound, unless, indeed, it is at a distance from it.

On the following point no practitioner should be ignorant so that he has to enquire as to the special treatment required for the internal organs, which I have spoken of above. For whilst an external wound is to be treated either by suture, or by some sort of medicine; in the case of the internal organs, nothing is to be moved, unless it be to cut away some bit of liver or spleen or lung which hangs outside. Otherwise internal wounds will be cured by the regulation of diet, and by those medicaments which I have stated in the preceding book to suit each individual organ.

So then, after this has been done on the first day,

the patient is to be put to bed; if the wound is severe, before inflammation sets in, he should abstain from food, as far as his strength permits; he should drink warm water until his thirst is quenched; or, if it is summer and he has neither fever nor pain, even cold water. There is, however, in this no standing order, for always account has to be taken of the bodily strength, since weakness may render it necessary for him to take food even from the first, light of course and scanty, just enough to sustain him; and many who are actually fainting from loss of blood must, before any treatment, be resuscitated by wine, which in other cases is most inimical to a wound.

It is dangerous when a wound swells overmuch; no swelling at all is the worst danger: the former is an indication of severe inflammation; the latter that the part is dead. And from the first if the patient retains his senses, if no fever follows, we may recognize that the wound will soon heal. And even fever should not cause alarm in the case of a large wound, if it persists while there is inflammation. That fever is harmful which either supervenes upon a slight wound, or lasts beyond the inflammatory period, or excites delirium; or which does not put an end to the rigor or spasm of sinews which has originated from the wound. Also involuntary bilious vomiting either immediately after the injury, or during the inflammatory period, is a bad sign only when sinews or even the neighbourhood of sinews have been wounded. The induction of a vomit, however, is not inappropriate, especially in those habituated to it; provided that this is not done immediately after food, or just when the inflammation has arisen, or

when the wound is situated in the upper part of the body.

When the wound has been so treated for two days, on the third it should be uncovered, sanies washed away with cold water, and then the same dressing applied again. By the fifth day the extent of inflammation in prospect is apparent. And on that day, when the wound has been uncovered again, its colour must be considered. If it is livid or pallid or patchy or dusky, it can be recognized that the wound is a bad one, and whenever this is observed, it should alarm us. It is best for the wound to be white or rubicund; also if the skin is hardened, thickened, or painful, danger is indication. Good signs are for the skin to be thin and soft without pain. But if the wound is agglutinating or swollen slightly, the same dressings as at first are to be applied; if there is severe inflammation and no hope of agglutination, then such applications are to be made as promote suppuration. And now the use of hot water as well is a necessity, in order to disperse diseased matter and to soften hardening and bring out pus. The temperature of the water must be pleasant to the hand when put into it, and the affusion is to be continued until the swelling is seen to have diminished and a more natural colour to have returned to the wound. After this fomentation, if the wound is not gaping widely, a plaster should be put on at once, particularly that tetrapharmacum if it is a large wound; in the case of wounds of joints, fingers, cartilaginous places, the plaster rhypodes; if the wound gapes more widely, that same plaster should be liquefied by iris unguent, and lint smeared with this laid all over the wound; upon this put the plaster, and above that greasy wool.

The bandages are to be even less tight than at first.

As to joints, there are certain special points to be noticed as, if the controlling sinews have been divided, weakness of the part concerned follows. If this is in doubt, and the wound has been made by a sharp weapon, a transverse wound is the more favourable; if by a blunt and heavy weapon, the shape of the wound makes no difference. But it is to be observed whether pus is being formed above the joint or beneath. If it is produced underneath, and thick and white discharge continues for some time, it is probable that a sinew has been cut, and the more so the greater the pains and inflammation, and the earlier these occur. But even though no sinew is divided, yet, if a hard swelling persists for a long while round about, the wound will last a long time and even after healing a swelling will persists; and in future that limb will be bent or stretched out slowly. There is, however, more delay in extending a limb which has been kept bent while treated, than in bending a limb which has been kept straight. Also there should be a definite rule as to position for a limb which has been wounded. If the wound is seem to be agglutinated, the limb is kept raised; it must not be bent either way if there is still inflammation; if pus is already being discharged it should be hanging down. The best medicament too is rest; movement and walking before healing are adverse. The danger, however, from movement is less for wounds of the head and arms than for the lower limbs. Walking about is least of all suited to an injured thigh or leg or foot. The patient's room should be kept warm.

Bathing, too, while the wound is not yet clean, is one of the worst things to do; for this makes the wound both wet and dirty, and then there is a tendency for gangrene to occur. It is advantageous to apply light rubbing, but in those parts which are rather far away from the wound.

When the inflammation has ended, the wound must be cleaned. And that is best done by putting on lint soaked in honey, and over it the plaster called tetrapharmacum or that called enneapharmacum. Then at length the wound is really clean when it is red, and neither too dry nor too moist. But a wound is not clean when it lacks sensation, when there is sensation which is not natural, when it is either too dry or too wet, when it is either whitish or pallid or livid or blackish.

When the wound is clean, there follows the growth of new flesh; and now warm water is necessary in order to remove sanies. The use of unscoured wool is superfluous; scoured wool is the better wrapping. But for filling up a wound certain medicaments also are useful; therefore it is not inappropriate to make use of such things as butter with rose-oil and a little honey; or the tetrapharmacum with the said rose-oil, or lint soaked in rose-oil. More beneficial, however, is an occasional bath, a nourishing diet, while avoiding everything acrid, but now somewhat fuller, for both poultry and venison and boiled pork can be given. In all cases, while fever and inflammation are present, wine is inappropriate; also, until the scar is formed, if either sinews or muscles have been wounded; or even if there is a deep flesh wound. But when the wound is of the safer kind, only skin deep, wine if

not too old, given in moderation, can even aid the growth of flesh. If any part is to be softened, which is necessary in the region of sinews and muscles, cerate also is to be used upon the wound. But if flesh fungates, dry lint is a moderate repressant, copper scales a more active one. If more fungation needs to be removed the still more active corrosives are to be employed. After all such applications, lycium dissolved in raisin wine or in milk, or even only an application of dry lint, is useful in inducing a scar.

Such is the procedure of a successful treatment; dangerous complications, however, are wont to occur. Sometimes the wound becomes the seat of chronic ulceration, and it becomes hardened, and the thickened margins are a livid colour; after which whatever medicament is applied is of little service; and this commonly occurs when the wound has been carelessly treated. At times, whether owing to excess of inflammation, or to unusually hot weather, or to excessively cold weather, of because the wound has been bandaged too tightly, or on account of old age, or of a bad habit of body, canker sets in. The Greeks divided this genus into species for which there are no terms in our language.

Now canker, whatever its species, corrupts not only the part it attacks, but it also spreads; next it is distinguished by differing signs. For sometimes a redness, over and above the inflammation, surrounds the wound, and this spreads with pain (the Greeks term it erysipelas); at times the wound is black because its flesh has become corrupted, and this is still more intensified by putrefaction when the wound is moist, and from the black wound is discharged a

pallid humour, which has a foul odour, and the granulations break down: at times also sinews and membranes undergo dissolution, and when a probe is introduced it passes to the side or downwards, and this lesion not infrequently affects the bone too; sometimes there arises what the Greeks call gangrene. The former varieties occur in any part of the body; gangrene in the extremities, that is, in the nails, armpits or groins, and generally in aged people or in those of a bad habit of body. The flesh in the wound becomes either black or livid, but dry and shrivelled; the skin near it is for the most part occupied by dusky pustules; then the skin around these becomes either pallid or livid, and usually wrinkled, deficient in sensation: farther away from the wound the skin is inflamed. All these things spread simultaneously, the ulceration into the pustules, the pustules into the pallid or livid part, that into the inflamed part, and that again into the sound flesh. Now together with the above an acute fever arises and great thirst: in some also delirium: others, although in their right minds, nevertheless stammer so that they can scarcely explain their feelings; the stomach begins to be affected: even the breath gets a foul odour. This disorder at its commencement admits of treatment; but when thoroughly established it is incurable, and most patients die in a cold sweat.

And such are the dangers following upon wounds. Now a wound when of long standing should be cut with a scalpel, its margins excised, and incisions made at the same time into any livid area surrounding the margins. If there is a small varix inside the wound which hinders healing, it also is to be excised.

Then when the blood has been let out and the wound made like a new one, the same treatment is to be adopted as that described for recent wounds. If any one does not want to use the scalpel, healing may be secured by using the plaster made up with ladanum, and, when that has eaten away the ulcer, by the one which induces a scar.

But what I have said is called erysipelas, not only follows upon a would, but is wont also to arise without a wound, and sometimes brings with it some danger, especially when it sets in about the neck or head. If strength permits, blood should be let; then repressives and refrigerants applied together, particularly white-lead with nightshade juice, or Cimolian chalk with rain-water as an excipient; or flour made into a paste with the same, with cyprus shoots added, or lentil meal if the skin is more delicate. Whatever is put on is to be covered over with beet leaves, and over that with lint wetted with cold water. If refrigerants by themselves have little effect, they are to be combined with the following: sulphur 4 grams, white-lead and saffron, 50 grams each; and these are pounded up with wine and the place smeared with them: or when the skin is more hardened, nightshade leaves are pounded, mixed with lard, and applied spread on lint.

But if there is a blackening which is not yet spreading, the milder corrosives of putrid flesh are to be put on, and the wound having been thus cleaned out, is cared for like other wounds. If there is more corruption, and it is already spreading, stronger corrosives are needed. If even these are not effective,

the place should be burnt by a cautery until no more humour escapes from it; for sound flesh is dry when it is burnt. After the cauterizing of a putrid wound, such drugs are to be applied as will loosen from the living flesh the crusts which the Greeks call eschara. When these have fallen off, the wound is to be cleaned by honey and resin in particular; but it can also be cleaned by the other materials with which suppurating wounds are treated and in the same way brought to healing.

But gangrene, when not yet widespread, but only beginning, is not very difficult to cure, at any rate in a young subject; and even more so if muscles are intact, sinews uninjured or but slightly affected, and no large joint opened, or if there is little flesh in the part, and so not much to putrefy, and if the lesion is limited to one place; and this mostly happens in a finger. In such a case the first thing to be done, when strength permits, is to let blood; then whatever has become dry, and by stretching out, as it were, in injuring also what is next to it, is cut away up to this point the sound tissue. Whilst the gangrene is spreading, medicaments which tend to promote suppuration are not to be applied; and therefore not even hot water. Weighty dressings also, although repressant, are unsuitable; but the lightest are needed; and over the parts which are inflamed refrigerants are to be used. If the malady is still not checked, the part between what is sound and diseased ought to be cauterized; and in such a case especially assistance is to be sought, not only from medicaments, but also from a system of diet; for this malady only occurs in a corrupt and diseased body. Therefore at first, unless weakness prohibits

it, the patient should fast; after that he should be given light food and drink to tone up the bowels, and so also the body in general. Later if the lesion has been checked, the same things should be put on the wound which were prescribed for putrid ulceration. And it is now also permissible to make use of a fuller diet — foods of the middle class, but only such as dry up the bowels and the body generally; and cold rain-water to drink. The bath is harmful until it is quite certain that soundness has returned; for a wound, if softened in the bath, is quickly again affected by the same malady. But it still happens sometimes that none of these remedies is effectual, and in spite of everything this canker spreads. In such circumstances there is one sad by solitary remedy to secure the safety of the rest of the body, that is to cut away the limb which is gradually dying.

Such are the treatments of the gravest wounds. But there should be no neglect of those in which the skin is intact, but some inner part has been contused; or where something has been scraped or rubbed off: or what a splinter has become fixed in the body, or where the wound is small but deep.

In the first case the best thing is to cook the rind of a pomegranate in wine, and pound up its interior and mix with rose-oil cerate, and so apply it: next, when the skin has been actually abraded, to lay on a soothing medicament such as lipara.

When the skin has been scraped and rubbed off, the plaster tetrapharmacum is to be applied, the food reduced and wine withdrawn. Such wounds are not to be disregarded because deeper structures are uninjured; for often from injuries of this kind

canker develops. But if the hurt is trifling, and of small extent, we may be content with the same soothing application.

A splinter too, whenever possible, should be extracted either by the hand or even by the help of an instrument. But if the splinter has been broken off or has penetrated too deeply for this to be done, it must be drawn towards the surface by a medicament. The best thing to draw it out is an application of pole-reed root pound up straight away if soft, but if already rather hard, boiled first in honey wine; to which honey should always be added, or birthwort also with honey. Of splinters the pole-reed is the worst because it is rough; there is the same harmfulness in fern. But by experience it has been learnt that either, when pounded up and applied, serves as a medicament against the other. Any medicament which has an extractive property has the same effect on splinters of all kinds.

The same treatment is best for deep and narrow wounds. The plaster of Philocrates is especially good for the former, that of Hecataeus for the latter.

Whatever the kind of wound, when the time has come for inducing the scar, which must be after the wound has cleaned and filled with new flesh, first lint is applied, wetted by cold water while the flesh is being nourished; afterwards, when it has to be checked, dry lint must be applied until the scar is induced. Then plumbum album should be bandaged on in order to keep down the scar, and to give it a colour as much as possible like sound skin. Wild cucumber root has the same property, so has the present contain in: elaterium 4 grams, litharge

8 grams, unguent 16 grams. These are taken up in turpentine until the whole is of the consistency of a plaster. Further, equal parts of verdigris and washed lead mixed together with rose-oil gently clean black scars; either the scar may be anointed, as can be done on the face; or the above may be applied as a plaster, which is more convenient for other parts of the body. But if the scar is either elevated or depressed, it is foolish, just for the sake of appearance, to submit to pain and medicinal applications. Else both conditions can be remedied, since either scar can be made into a wound by the use of a scalpel. Or if a medicament is preferred, corrosive compositions have the same effect. After the skin has been wounded, to an elevated cicatrix corrosives are applied, to a depressed one medicaments which make flesh, until the wound, in each case, is on a level with the sound skin; and then the scar is induced.