19 When these lesions have been recognized their treatment must be discussed; in this some methods are common to all, some peculiar to particular kinds. I shall discuss first what is common to all. But I shall now speak of those cases demanding the knife: for those which are incurable, or should be cared for otherwise, will be mentioned as I come to the separate kinds. Now sometimes the inguinal region has to be cut into, sometimes the scrotum. In either case the man for three days
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before should drink water, and for the day before abstain also from food: on the day itself he must lie on his back; next if the groin has to be cut into, and if the pubes is already covered by hair, this is to be shaved off beforehand: and then after stretching the scrotum, so that the skin of the groin is rendered tense, the cut is made below the abdominal cavity, where the membranes below are continuous with the abdominal wall. Now the laying open is to be done boldly, until the outer tunic, that of the scrotum itself, is cut through, and the middle tunic reached. When an incision has been made, an opening presents leading deeper. Into this the index finger of the right hand is introduced, in order that by the separation of the intervening little membranes the hernial sac may be freed. Next the assistant grasping the scrotum with his left hand should stretch it upwards, and draw it away as far as possible from the groins, at first including the testicle itself until the surgeon cuts away with the scalpel all the fine membranes which are above the middle tunic if he is unable to separate it with his finger; then the testicle is let go in order that it may slip downwards, and show in the wound and then be pushed out by the surgeon's finger, and laid along with its two tunics upon the abdominal wall. There whatever is diseased is cut round and away, in the course of which many blood vessels are met with; the smaller ones can be summarily divided; but larger ones, to avoid dangerous bleeding, must be first tied with rather long flax thread. If the middle tunic be affected, or the disease has grown beneath it, it will have to be cut away even as high as the actual groin. Lower
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down, however, not all is to be removed: for at the base of the testicle there is an intimate connexion with the inner tunic, where excision is not possible without extreme danger; and so there it is to be left. The same is to be done if the inner tunic is the seat of the disease. But the cutting away cannot be done quite completely at the inguinal end of the wound, but only somewhat lower down, lest the abdominal membrane be injured and set up inflammation. On the other hand too much of its upper part should not be left behind, lest subsequently there forms a pouch which continues to be the seat of the same malady. The testicle having been thus cleared is to be gently returned through the incision, along with the veins and arteries and its cord; and it must be seen that blood does not drop down into the scrotum, or a clot remain anywhere. This will be accomplished if the surgeon takes the precaution of tying the blood vessels; the threads with which the ends of these are tied should hang out of the wound; following upon suppuration they will fall off painlessly. Through the margins of the wound itself two pins are then passed, and over this an agglutinating dressing. But it becomes necessary sometimes to cut away a little from one or other of the edges of the skin-incisions in order to make a broader and thicker scar. When this occurs the lint dressing must not be pressed on but must be applied lightly, and over it such things as repel inflammation, unscoured wool or sponge soaked in vinegar; all the other treatment is the same as when suppuratives have to be applied.
But when an incision is required lower down, then with the man on his back, the left hand is to
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be passed under the scrotum; next this must be grasped firmly and the incision made. If the disease is small in extent, the incision is limited, so as to leave intact the lower third of the scrotum in order to support the testicle; if more extensive, the incision is prolonged so that just a little is left at the bottom to support the testicle. But the scalpel at first should be held in a very light hand, with its edge vertical to the skin, until the wall of the scrotum has been divided; then the edge is sloped sideways so as to cut across the membranes between the scrotal wall and the middle tunic. And if the disease is in the wall of the scrotum there is no need to touch the middle tunic; if it also lies under the middle tunic, this too has to be cut through, and the inner tunic as well if that covers the lesion. Now wherever the disease is found to be, the assistant should press the scrotum gently upwards; the surgeon either with his finger, or with the handle of the scalpel, separates the middle tunic from its connexion with the scrotal wall, and brings it forwards; then with a knife, called from its shape 'the raven,' he lays it open so that his index and middle finger can enter. With these fingers so introduced the remainder of the tunic should be brought forwards, and the knife inserted in between the two fingers, and any diseased matter taken away or let out. If one of the tunics has been injured it also should be cut away; the middle one, as stated above, as far up as the groin; the inner one to a little below the groin. But before they are cut away, the blood vessels above too should be ligatured with flax thread, the ends of which are to be left hanging out of the wound, as in the case of other
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blood vessels that have had to be tied. This done, the testicle is to be replaced inside, and the scrotal margins united by stitches, not too few lest the edges fail to unite and the treatment is prolonged, and not too many lest they augment the inflammation. Here also it must be seen to that no blood remains in the scrotum. Then agglutinants are put on. But if at any time blood trickles down into the scrotum, or any clot collects in it, an incision should be made below, and after clearing out the blood, a sponge soaked in strong vinegar is put on. Further, all such wounds made for the above reasons, after having been bandaged up, when there is no pain, should not be dressed until the fifth day, but the wool or sponge is to be saturated sufficiently with vinegar twice a day; if there is pain, and when pins have been inserted they are then to be taken out; when lint has been used it must be changed and the fresh lint wetted with rose oil and wine. Should inflammation increase, to the previously mentioned applications add a plaster of lentils and honey or of pomegranate rind boiled in dry wine, or of the two combined. If the inflammation does not subside under these applications, after the fifth day the wound is to be fomented freely with hot water, until the scrotum itself both shrinks and becomes wrinkled; then apply a wheat flour plaster with pine resin added; which, for a robust patient has been boiled in vinegar, and for a delicate one in honey. Whatever the application used, there is no doubt that if there is much inflammation, suppuratives must be applied. But if pus collects in the scrotum itself, it must be let out through a small
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incision; and enough lint must be put on to cover the opening. When the inflammation is at an end, for the sake of the cords first the plaster and then a cerate is to be used. Such is the proper treatment of wounds of this sort. For the rest as regards both treatment and diet, these should conform to what has been prescribed for other sorts of wounds.
20 After this introduction, we come to particular conditions. And if in a young child intestine prolapses, bandaging should be tried before the knife. For this a strip of linen is taken, to one end of which is stitched a ball of rags which is placed on the prolapse itself so as to push back the intestines: then the rest of the strip of bandage is firmly tied all round; under this the intestines are often forced inside and the tunics become agglutinated together. Again, if the patient is older, and the large size of the swelling shows that much of the intestines has come down, and if in addition there is pain and vomiting, which generally happens because faeces from undigested food have slipped down, then it is clearly impossible to employ the knife except harmfully; the trouble can only be mitigated, and must be drawn out by other measures. Blood should be let from the arm, then if the patient's strength permits, fasting for three days should be prescribed, or else at least for as long as the strength allows. Meanwhile a plaster of linseed first boiled in honey wine is to be kept on over the hernia. Later one of barley meal with resin is to be applied, and the patient immersed in a bath of hot water to which olive oil also has been added; after which some light warm food is to be given. Some also employ a clyster; but that can only bring down something
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into the scrotum, and cannot evacuate anything from it. When by the measures just described, the disease has been mitigated, if at any time pain recurs, the same measures will have to be repeated which we have just found to be beneficial. If without causing any pain, a large amount of intestine has prolapsed, it is useless to operate; not that it is impossible to push back the intestines out of the scrotum, unless inflammation prevents it, but because as they are forced back they may become impacted in the groins and give rise to a swelling, so that the trouble is not ended but only changed in position. But in a case which is suitable for treatment by the knife, as soon as the incision made in the groin reaches the middle tunic, this must be seized near the margins by a couple of hooks, when, after drawing down all the fine membranes the surgeon sets it free. Nor is there any danger in wounding what has to be cut out, since the intestine must lie underneath it. When the middle tunic has been thus drawn down, it is slit open from the groin to the testicle, but so as not to injure the latter; then it is cut away. Generally, however, this treatment is only admissible in boyhood and when the trouble is limited. For a robust man with a more extensive disorder the testicle should not be turned out, but kept in position. The procedure is as follows. The groin is laid open as before down to the middle tunic, and this tunic is seized as described above with two hooks, whilst the assistant keeps the testicle in its place, so that it does not come out of the wound; then the middle tunic is cut into with a scalpel towards its lower part, and through the opening the index finger of the left hand is passed beneath the testicle which
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is forced up into the wound; then the thumb and forefinger of the right hand separate the vein, the artery and the cord, and their tunic from the one above them. Any little membranes in the way are divided with a scalpel until now the entire tunic comes into view. After cutting away what has to be excised, and replacing the testicle, a rather broad strip is to be pared off from the edges of the wound in the groin, so that by making the wound broader it may form more flesh.
21 But if omentum comes down, the groin is to be cut into as described above, and the tunics drawn down. Then it must be considered whether the mass is rather large or only small. For when quite small the omentum may be pushed back beyond the groin into the abdominal cavity, either with the finger, or with the opposite end of a probe; if the mass is larger what has prolapsed from the belly should be left hanging out of the wound, and smeared with caustic medicaments until it mortifies and falls off. In this condition too some transfix the tumour with a doubly threaded needle, and tie the two ends of each thread on opposite sides, under which treatment it mortifies, but more slowly. This may, however, be hastened by smearing the omentum beyond the ligature with medicaments which eat it away but do not erode; the Greeks call them septa. Some have cut away the omentum with shears. If it is quite small, this is unnecessary; if larger, bleeding may follow, because the omentum itself is connected with blood vessels, some rather large. And although in the case of an abdominal wound, prolapsed omentum is cut away
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with shears after it has mortified and there is no other safe way of removing it, no precedent can be drawn from that for this case. As to the treatment of the wound when the omentum has been replaced, it should be stitched; if the quantity was large, and has been left outside to mortify, the margins should be pared as described above.
But if a hydrocele occurs, in boys an incision is to be made in the groin, unless in their case too the large quantity of liquid prevents it; in men, and when there is a large amount of fluid, a scrotal incision is made. So then if the incision is in the groin, when the tunics have been drawn forwards the humour must then be evacuated there; if in the scrotum, and if the trouble is immediately beneath, there is nothing to do but to let out the fluid and cut away any membranes which are keeping it in; then the incision is washed with water to which salt or nitre has been added. If the fluid is under the middle tunic, or under the inner one, these tunics have to be brought out of the scrotal wound, and cut away.
22 Now a varix, when in the scrotal skin, must be burnt with finely pointed cauteries, which penetrate into the veins themselves, but so that nothing deeper than the veins is burnt; the cautery is to be applied especially where the veins form a twisted mass. Then flour which has been steeped in cold water is put on and over this the bandage I have described as suitable after anal operations. On the third day lentil meal with honey is applied: after the crusts have separated the ulcers are to be cleaned with honey, filled with rose oil, and cicatrized with dry lint. But when the veins overlying the middle tunic swell, the groin is to be
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incised and the tunic pressed out into the wound; from it the veins are separated by a finger or the handle of the scalpel. But at the part where they are still attached, the veins are to be tied with linen thread both above and below that part; then cut away just beyond the ligatures and the testicle replaced. But when the varix is situated upon the inner tunic, it is necessary to cut through the middle tunic; then, if but two or three veins are swollen and some part only is involved, so that most of it is still free of the disease, the same is to be done as described above, so that the veins after being ligatured on the side of the groin and testicle respectively are cut away, after which the testicle is replaced. But if the varix involves the whole of one testis, the index finger is to be passed into the wound and under the veins, so as to draw them gradually forward, and they must be brought up until the testicle of that side is level with the opposite one. Then pins are passed through the edges so that at the same time they take up the veins as well. It is done in this way: the pin perforates from without through one edge of the wound, then it is passed not through an actual vein but through its membrane, and is pushed out through this to the opposite margin of the incision. There is always a membrane between these veins, and no danger is involved, and when the pin has been fixed by a thread it holds the veins fast enough. Then whatever veins have been drawn forwards should be pushed back within the inguinal wound by the reverse end of the probe. The time to take out the pins is when the inflammation
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has ceased and the wound has cleaned, so that one and the same scar may bind together simultaneously both the margins of the incision and the veins. But if a varix has developed between the inner tunic and the testicle itself and its cord, there is but one method of treatment, to excise the testicle entirely. For it is now useless for generation, and always hangs down in an ugly way, while it is sometimes painful as well. But in this case also the groin is to be cut into, the middle tunic pressed out and cut away, and the inner tunic likewise. Then the cord by which the testicle is suspended is to be cut through. After this the veins and arteries towards the groin are to be ligatured with linen thread, and cut away below the ligature.
23 Flesh also, if it ever grows between the tunics, must certainly be cut out; but it is better to make an incision through the scrotum itself. But if the cord has become indurated, the condition cannot be cured either by surgery, or by medicaments. For burning fevers and green or black vomit oppress the patients, and besides these great thirst and roughness of the tongue; and generally from the third day frothy bile is passed in a smarting motion. But the patient cannot readily either take food, or retain it; not long after the extremities grow cold, tremor arises, the hands are outstretched involuntarily; then a cold sweating on the forehead is followed by death.
24 But when there is a varix actually situated in the inguinal region, if it forms a moderate swelling, a linear incision is made, if larger two incisions, and the included skin excised. Then without drawing out the testicle, as I directed to be done for cases
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of prolapse of the intestines, the veins are to be taken up, and ligatured where they are attached to the tunics, then cut away below the ligature knots. The treatment of the wound presents nothing novel.
25 From the above we pass to operations on the penis itself. And, if the glans is bare and the man wishes for the look of the thing to have it covered, that can be done; but more easily in a boy than in a man; in one in whom the defect is natural, than in one who after the custom of certain races has been circumcised; and in one who has the glans small and the adjacent skin rather ample, while the penis itself is shorter, rather than in one in whom the conditions are contrary.
Now the treatment for those in whom the defect is natural is as follows. The prepuce around the glans is seized, stretched out until it actually covers the glans, and there tied. Next the skin covering the penis just in front of the pubes is cut through in a circle until the penis is bared, but great care is taken not to cut into the urethra, nor into the blood vessels there. This done the prepuce slides forwards towards the tie, and a sort of small ring is laid bare in front of the pubes, to which lint is applied in order that flesh may grow and fill it up. It is seen that a large enough part of the penis has been bared, if the skin is distended little or not at all, and if the breadth of the wound above supplies sufficient covering. But until the scar has formed it must remain tied, only a small passage being left in the middle for the urine. But in one who has been circumcised the prepuce is to be raised from the underlying penis around the circumference of the glans by means of a scalpel. This is not so
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very painful, for once the margin has been freed, it can be stripped up by hand as far back as the pubes, nor in so doing is there any bleeding. The prepuce thus freed is again stretched forwards beyond the glans; next cold water affusions are freely used, and a plaster is applied round to repress severe inflammation. And for the following days the patient is to fast until nearly overcome by hunger lest satiety excite that part. When the inflammation has ceased, the penis should be bandaged from the pubes to the corona; over the glans the plaster is applied with the other end of the probe. This is done in order that the lower part may agglutinate, whilst the upper part heals without adhering.
On the other hand, if the glans has become so covered that it cannot be bared, a lesion which the Greeks call phimosis, it must be opened out, which is done as follows: underneath the foreskin is to be divided from its free margin in a straight line back as far as the frenum, and thus the skin above is relaxed and can be retracted. But if this is not successful, either on account of constriction or of hardness of the skin, a triangular piece of the foreskin is cut out from underneath, having its apex at the frenum, and its base at the edge of the prepuce. Then lint dressing and other medicaments to induce healing are put on. But it is necessary that the patient should lie up until the wound heals, for walking rubs the wound and makes it foul.
Some have been accustomed to pin up the prepuce in adolescents either for the sake of the voice, or for health's sake. This is the method: the foreskin covering the glans is stretched forwards and
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the point for perforation marked on each side with ink. Then the foreskin is let go. If the marks are drawn back over the glans too much has been included, and the marks should be placed further forward. If the glans is clear of them, their position is suitable for the pinning. Then the foreskin is transfixed at the marks by a threaded needle, and the ends so this thread are knotted together. Each day the thread is moved until the edges of the perforations have cicatrized. When this is assured the thread is withdrawn and a fibula inserted, and the lighter this is the better. But this operation is more often superfluous than necessary.
26 Sometimes we are compelled to draw off the urine by hand when it is not passed naturally; either because in an old man the passage has collapsed, or because a stone, or a blood-clot of some sort has formed an obstruction within it; but even a slight inflammation often prevents natural evacuation; and this treatment is needed not only for men but sometimes also for women. For this purpose bronze tubes are made, and the surgeon must have three ready for males and two for females, in order that they may be suitable for every body, large and small: those for males should be the longest, fifteen finger-breadths in length, the medium twelve, the shortest nine; females, the longer nine, the shorter six. They ought to be a little curved, but more so for men, and they should be very smooth and neither too large nor too small. Then the man must be placed on his back, in the way described for anal treatment, on a low seat or couch; while the practitioner stands on his right side, and taking the
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penis of the male patient in his left hand, with his right hand passes the pipe into the urethra; and when it has reached the neck of the bladder, the pipe together with the penis is inclined and pushed on right into the bladder; and when the urine has been evacuated, it is taken out again. The woman's urethra is both shorter and straighter, like a nipple placed between the inner labia over the vagina, and this requires assistance no less often though it is attended by somewhat less difficulty. Sometimes too a stone slips into the urethra itself, and lodges not far from its orifice, because this becomes narrower further down. The stone should if possible be extracted either by an earscoop or by the instrument with which a stone is drawn out in the course of lithotomy. If this cannot be done, the foreskin is drawn as far forwards as possible over the glans and tied there by a thread. Then to one side of the penis a longitudinal incision is to be made and the stone taken out, after which the prepuce is released. This is done in this way so that an intact portion of skin covers the incision into the penis, and urine flows out naturally.
Now that mention has been made of the bladder and of stone, this seems the proper place to describe what treatment is to be adopted in cases of calculus, when it is impossible otherwise to afford relief; but it is most inadvisable to undertake it hastily, since it is very dangerous. This operation is not suitable for every season or at any age or for every lesion, but it must be used in the spring alone, in a boy who is not less than nine years of age and not more than fourteen, and if the disease is so bad that it cannot be relieved by medicaments, or
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endured by the patient without shortly bringing his life to a close. Sometimes even a rash line of treatment is successful, but it generally disappoints, especially in this sort of case, where the types and seasons of danger are very numerous, and these I will describe along with the treatment itself. Therefore when it has been decided to make trial of this last resource, for some days beforehand the patient's body is to be prepared by dieting, so that he takes a moderate amount of food which is wholesome, and not glutinous, and drinks water. Meanwhile he should also take walking-exercise to encourage the stone to descend to the neck of the bladder. Whether this has happened is recognized by the insertion of the finger, as I shall point out in the course of the treatment. When that is assured and the boy has been kept fasting from the previous day, then the operation is carried out in a warm room, and in the following manner. A strong and well-trained man, seated on a high stool, seizes the boy from behind and draws him backwards until his buttocks rest on the man's knees. When the boys' legs have been drawn up, the man orders him to put his hands behind his knees, and to pull upon them as much as he can, and at the same time the man keeps them in this position. But if a stronger person is to be treated, two strong men are seated on stools, side by side, and both the stools and the adjacent legs of the men are lashed together, so that they cannot be separated. Then the patient is seated in the same way as above upon the knees of the two men; and according to their position, one man takes hold of the patient's left leg, the other of the right, whilst at the same
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time the patient pulls upon his own hams. Whether one or two men hold the patient, they press downwards with their chests upon the patient's shoulders. Hence it results that the hollow between the iliac regions above the pubes is outstretched without any folds, and as the bladder is crammed into a narrow space the calculus can easily be seized hold of. In addition, moreover, two strong men should be put to stand at the sides, and they by standing there prevent the man or men who holding the boy from slipping. Then the surgeon having carefully pared his nails and anointed his left hand, gently introduces two fingers, the index and the middle, first one and then the other, into the anus; next he places the fingers of his right hand upon the hypogastrium, but lightly, lest if the two sets of fingers should press around the calculus with any force, the bladder may be injured. And in this procedure we must not act with haste, as in most cases, but so that safety is the first consideration; for an injury to the bladder causes spasm with danger of death. And the stone is first sought for about the neck of the bladder; when found there it is expelled with less trouble. And this is why I said there should be no operation except when the stone has been recognized by its special signs. But if the stone is not found at the neck of the bladder, or if it has slipped backwards, the fingers are placed against the base of the bladder, while the surgeon's right hand too is placed above the stone and gradually follows it downwards. When the stone has been found, and it must fall between his hands, it is guided downwards with special care the smaller and the smoother it is, lest it escape. This is that the bladder may not
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be too often disturbed. Therefore the right hand of the surgeon is always kept above the stone whilst the fingers of the left press it downwards until it arrives at the neck of the bladder: and it must be pressed towards this so that if oblong, it comes out end on; if flat it lies crossways; if cubical, it rests on two of its angles; if any part is larger, the smaller part comes out first. In the case of a spherical stone, it is clear that the shape makes no difference, except that if any part is the smoother this should be in front. When the stone has now got there, then the skin over the neck of the bladder next the anus should be incised by a semilunar cut, the horns of which point towards the hips; then a little lower down in that part of the incision which is concave, a second cut is to be made under the skin, at a right angle to the first, to open up the neck of the bladder until the urinary passage is opened so that the wound is a little larger than the stone. For those who make a small opening for fear of a fistula, which in this situation the Greeks call rhyas, incur this same danger to a greater degree, because the stone, when it is pressed down with force, makes a way out for itself unless it is given one. And this is even more harmful if the shape of the stone or its roughness has caused any additional trouble. As a consequence bleeding and spasm may be set up. And even if the patient survives he will have, nevertheless, a much wider fistula if the neck of the bladder has been torn, than he would have had if it had been cut. Now when the urethra has been laid open, the stone comes into view; its colour is of no importance. If it is small, it can be pushed outwards with the fingers
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on one side, and extracted by those on the other. If large, we must put over the upper part of it the scoop made for the purpose. This is thin at the end, beaten out into a semicircular shape, smooth on the outer side, where it comes into contact with the body, rough on the inner where it touches the stone. The scoop must be rather long, for a short one has not the strength to extract. When the scoop has been put in, it should be moved to each side to see whether the stone is held, because if it has been well grasped, it is moved with the scoop. This is required lest when the scoop begins to be drawn forward, the stone should slip inwards and the scoop cut into and lacerate the wound opening, and I have noted above how dangerous this is. When it is certain that the stone is sufficiently held, almost simultaneously a triple movement is to be made; first towards each side, then outwards, this in such a way that the movement is gentle and the stone is at first drawn outwards but little; this done the one end is to be raised so that the scoop may stay further in, and more easily draw out the stone. But if at any time the stone cannot be properly caught from above, it will have to be taken hold of from one side. This is the simplest method of operation. But various contingencies call for some further observations. There are some stones which are not merely rough but also spinous, which if they have come down to the neck of the bladder of their own accord may be extracted without any danger. But it is not safe to search for these within the bladder and draw them out, for when they have wounded the bladder they cause a speedy death from spasm, and much more
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so if a spinous stone sticks to the bladder, and when being drawn down has folded it over. Now it may be inferred that the stone is at the neck of the bladder, when the patient has difficulty in passing water: or that the stone is spinous, when he passes bloody urine in drops. And it is most important that the calculus should be felt under the fingers, and that the operation should not be proceeded with unless this is assured. And then too the fingers must be applied gently, lest they wound by pressing forcibly: the incision is then made. Many use a scalpel here also. Since this is rather weak, and may meet some projecting part of the stone, and while cutting the flesh over the projection fail to divide what is in the hollow beneath, but leave something which necessitates a second operation. Meges made a straight blade, with a wide border on its upper part, semicircular and sharp below. This knife, with its handle grasped between the two fingers, index and middle, and the thumb put into the back of the blade, was so pressed down that any projection upon the stone might be cut through along with the flesh. By this means it followed that he made one opening of a sufficient size. But in whatever way the neck of the bladder is laid open, any rough stone should be extracted gently, and no force used to hasten matters.
A sandy stone is made evident before the operation by the sandy urine which is passed, and in the course of it, since it does not present a uniform resistance to the fingers in the rectum, and in addition it breaks up. Again soft stones and those composed of numerous small ones which only lightly adhere together, are indicated when the urine
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shows scalelike particles. All these should be brought out gently by changing as before the position of the fingers in turn, without injury to the bladder, yet so as not to leave behind in it any scattered remnants which will render the after-treatment difficult. When anything of this kind comes into view it is to be extracted by the fingers or scoop. And if there are several stones they are to be extracted one by one, but if a very small stone remains over it had better be left. For it is difficult to find it in the bladder, or when found it easily escapes again. In such a prolonged search the bladder is injured and fatal inflammations set up; so that some who have not been operated on have died after the bladder has been for a long while and in vain pushed about by the fingers. There is the additional reason that a small stone is later moved forward with the urine into the wound and so removed. If, however, at any time the stone appears too large to extract without tearing the neck of the bladder, it is to be split up; hence Ammonius the inventor of this process was surnamed lithotomus. This is done as follows: the scoop is passed over the stone, so that it easily keeps hold of the stone, even when it is struck; next an instrument is used of moderate thickness, its front end tapering yet blunt, and when this is put against the calculus, and its other end struck, it splits up the stone, great care being taken that the instrument does not come into contact with the bladder itself, and that no fragment from the broken calculus cuts into it.
Now these operations are similar in females too, yet there are some particulars to be mentioned
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about them. Since in women when the stone is small, the use of the knife is unnecessary because the stone is forced by the urine into the neck of the bladder which is shorter and more yielding in females than in males. Therefore the stone often escapes of itself, and if it sticks in the first part, which is narrower, yet it may be extracted by the scoop described above without any harm. But for larger stones the treatment is the same. Except that in the case of a virgin the fingers are passed as in males, in the case of a woman into the vagina. Then the incision is to be made in a virgin just under the left labium, in a woman between the urethra and pubic bone, and in both instances by a transverse wound. There is no need to be frightened if there is freer bleeding from a woman.
When the stone has been extracted, if the patient is strong and has not suffered excessively, it is well to let the bleeding go on, so that less inflammation may follow. Besides it is not unfitting for him to move about a little, in order that any blood clot still inside may drop out. But if again the bleeding does not cease of its own accord, it must be stopped lest all his strength be used up; and in weaker patients this is to be done immediately after the operation; since just as there is the risk of spasm from pushing about the bladder, so there is a second danger that in the absence of medicaments so much blood may be lost as to prove fatal. To prevent this the patient should be seated in a bath of strong vinegar to which a little salt has been added; under this treatment the bleeding generally stops, and it also has an astringent effect on the bladder so that the inflammation there is lessened. But if this
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is not successful, cups are to be applied on groins and hips and above the pubes. As soon as sufficient blood has been drawn away or the bleeding checked, the patient should be so placed on his back that his head is low, his hips a little raised; and two or three layers of linen soaked in vinegar are to be applied over the wound. Then after two hours he should be put into a hip bath and lean back in the hot water, so that the water covers him from his knees to his navel, while the rest of his body is wrapped up, except that his hands and feet are exposed, in order that he may be less exhausted and remain in the bath longer: the usual result is free sweating. And his mouth and face must be wiped with a sponge from time to time, and an end put to this hot bath whenever it becomes harmful by weakening the patient. Afterwards the patient is freely rubbed with oil, and a dressing of soft wool applied, soaked in warm oil, covering the pubes and hips and groins as well as the wound itself, which had previously been covered with a similar dressing, but of lint. From time to time this dressing is to be saturated with the warm oil in order that cold may not reach the bladder, and that the sinews may be gently softened. Some make use of heating plasters; these do more harm by their weight pressing upon the bladder, and by irritating the wound, than they do good by their heating. For the same reason not even a bandage is required. On the next day if there is difficulty in breathing, if urine is not passed, if the region about the pubes swells prematurely it may be recognized that a blood clot has collected in the bladder; for this the fingers are introduced into the rectum as before and the bladder stroked gently so as to break up
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clots; thus they subsequently escape by the wound. It is not inappropriate to inject vinegar mixed with soda into the bladder through the wound by means of an ear syringe, for in this way also clotted blood is broken up; and it is proper to do this even on the first day if we are afraid that there is a clot inside, especially when weakness prevents the patient from moving about to eliminate it. The treatment afterwards is the same, sitting in a hot bath, a pad and wool prepared as before as dressings. But a boy should not be put so often into the hot water nor kept in so long as an adolescent; a weak patient as a robust one; one with a slight inflammation as one severely inflamed; a patient with a relaxed body as one in good tone. Meanwhile, if the patient sleeps and breathes regularly and his tongue is moist and there is only moderate thirst and the hypogastrium is flat, if there is not much pain and but moderate fever, we may assume that the treatment is doing well. In such cases the inflammation generally ends on the fifth or seventh day; when it has passed off, the hip bath becomes unnecessary; whilst the patient is on his back the wound is just to be fomented enough with hot water to wash away any urine that irritates. Now the medicaments to be applied should be suppuratives, and if the wound seems to need cleaning, it is to be smeared with honey, or if that irritates it can be tempered with rose oil. The nine-drug plaster seems the most suitable at this stage of the treatment for it contains both suet as a suppurative, and honey to clean the wound, also marrow, best from a calf; its contents are particularly efficient in preventing the establishment of a fistula. But lint at this period is not to be
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applied directly to the wound, but it may be properly put on over medicaments to keep them in place. When, however, the wound is clean, it is to be healed by applying plain lint. During this period, however, when the course of the treatment has not gone well, various dangers arise. These may be expected: if there is persistent insomnia, laboured breathing, a dry tongue, great thirst, a distended hypogastrium; if the wound gapes; if the urine as it escapes does not irritate the wound; if there is some livid discharge by night and day alike before the third day; if the patient does not answer or replies slowly; if there are severe pains; if after the fifth day high fever oppresses the patient and a distaste for food persists; if he finds more ease by lying on his stomach. But the worst complication is spasm of the sinews and bilious vomiting before the ninth day. But when there is danger of inflammation the best treatment is by abstinence, food in small quantities and at stated intervals, and at the same time fomentations and the other things described above.
27 The nearest danger is canker. This is recognized if the discharge, whether from the wound, or through the penis, is a malodorous sanies, also something of the nature of blood-clot, and thin bits of flesh like flocks of wool; and in addition to this if the margins of the wound become dry; if there is pain in the groins; if the fever does not subside and it increases at night, if there are irregular shivering-fits as well. We must examine in what direction the canker is spreading. If to the penis, that part becomes hard and red and is painful to the touch, and the testicles swell; if into the bladder itself, anal pain follows, the hips harden, the legs
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cannot be easily stretched. But if to either side, this fact is clear to the eyes, and the gangrene shows the same marks on both sides, but smaller on that less affected.— But first it is important that the patient shall lie properly, that is, that the same part should always be uppermost and that that should be the part where the disease is spreading. Thus if the direction is into the penis, the patient is laid on his back; if into the bladder, on his belly; if into one side, then he lies on the more sound one. Coming to the treatment, the man should be placed in a bath containing a decoction of horehound or of cyprus or of myrtle; and the same fluid boiled is injected into the wound with a syringe; then is put on a plaster of lentils with pomegranate rind, both of which have been boiled in wine, or a similar decoction of blackberry, or of olive leaves, or of other material which I have set out as suitable for arresting and cleaning wounds affected by canker. Dry medicaments of this sort may be blown in through a quill. When the gangrene begins to come to a standstill, the wound is washed with honey wine, but at this stage a cerate should be avoided, for by softening the tissues it predisposes to that very malady: we must rather smear on washed lead with wine, over that the same spread on linen. By such measures it is possible to effect a cure, but we must not ignore the fact that when canker has once started, the stomach is often affected, since the bladder is closely associated with it; hence, it happens that food is not kept down, or when it is retained, not digested, nor is the body nourished; and thus the wound cannot clean, nor gain flesh: and these facts necessarily hasten death. But while it is in no way
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possible to save such cases as these, yet a method of treatment should be observed from the very first for a long while, in which of course due regard must be had to food and drink. For at first only fluid food should be given; when the wound has cleaned food of the middle class; greens and salted fish are always unsuitable. The amount of drink should be moderate, for if too little is drunk, the wound becomes inflamed, the patient suffers from insomnia and gets weaker; if too much is drunk, the bladder fills frequently and so is irritated. It is too obvious to need repetition that nothing except water is to be drunk. Now it generally happens under such a diet that the bowels do not act. They are to be moved by a clyster containing either fenugreek or mallow. The same decoction mixed with rose oil is to be injected into the wound itself through an ear syringe whenever the urine causes irritation and stops the wound from cleaning. General all the urine escapes at first through the wound; then in the course of healing it divides, and part begins to pass through the penis until the wound has completely closed; and this occurs at times in the third month, at times not before the sixth month, and occasionally not for a year. And we need not despair of the firm healing of the wound, unless the neck of the bladder has been roughly ruptured, or when owing to gangrene many large portions of the flesh have sloughed away and some fibrous tissue too. But the greatest care must be taken that no fistula, or only a very small one, is left there. With this object as the wound tends to form a scar, the patient should lie with his thighs
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and legs stretched out, except only when the stones have been soft and sandy: for then the bladder is slower in cleaning itself: and so it is necessary to keep the wound open longer, and only when there is nothing more to come out of the bladder is the wound allowed to heal. If the margins of the wound stick together, before the bladder has been cleaned, and pain and inflammation recur, the wound should be reopened, either by the finger, or by the reversed end of a probe, in order that what is causing the pain may be let out; and after such evacuation, when for some time clear urine has passed, then at length cicatrizing applications are put on; and as prescribed above, the legs are kept extended with the feet close together as much as possible. But if there seems to be danger of a fistula, from the causes mentioned above, a leaden tube should be put into the anus to make the closing of the fistula easier, or at any rate to narrow it, whilst the legs are kept extended and the thighs and ankles tied together until the scar has assumed its final form.
28 And whilst the foregoing can occur both in males and females, there are also some troubles which are peculiar to females, especially that occasionally their genitals do not allow of coitus, the orifices having coalesced. And this sometimes happens even in the mother's womb; sometimes when ulceration has occurred in those parts, and through bad treatment there the margins have become united during healing. If the condition is congenital a membrane obstructs the vulvar orifice; if due to ulceration flesh has filled the same. The membrane should be incised along two lines crossing
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one another like the letter X, great care being taken that the urethra is not injured; then the membrane is to be cut away all round. But if flesh has grown there, it must be laid open with a single straight cut; next when the margin has been seized either with a forceps or hook, a fine strip must be cut away from it, after which there is inserted wool rolled lengthwise (the Greeks call it lemniscus), dipped in vinegar, and over this is bandaged on greasy wool wetted with vinegar: this is changed on the third day and the wound treated like other wounds; and as soon as it begins to heal, a lead tube smeared with a cicatrizing ointment is passed in, and over this the same application applied until the cut surface has cicatrized.
29 Again when a woman has conceived, if the foetus, already nearly at term, dies inside and cannot get out of itself, an operation must be done, which may be counted among the most difficult; for it requires both extreme caution and neatness, and entails very great risk. But this shows, and not this only, how marvellous beyond all else is the womb. To begin with then the woman should be placed on her back across the bed, so that the iliac regions are compressed by her own thighs; by this means both her hypogastrium is in full view of the surgeon and the foetus is forced towards the mouth
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of the womb. This, after the death of the foetus contracts, but later on usually dilates a little. The surgeon making use of this opportunity should first insert the index finger of his greased hand, and keep it there until the mouth is opened again, and then he should insert a second finger, and the other fingers on the like opportunity, until the whole hand can be put in. To allow of this, much depends both on the size of the vagina, and the resistance of its sinewy tissues, and the patient's constitution, and also her strength of mind, especially since on occasion even both hands have to be passed in. It is also important that the hypogastrium and extremities should be kept very warm, that inflammation should not have begun, but that the treatment should be adopted without delay. For if the abdomen is already distended, the hand cannot be inserted nor can the foetus be extracted without the greatest suffering, and fatal spasm of the sinews often follows, accompanied by vomiting and tremor. But when the hand has reached the dead foetus its position is immediately felt. For it lies head on or feet foremost, or crosswise; generally, however, so that there is either a hand or foot within reach. It is the object now of the surgeon to direct it with his hand either into a head or even into a foot presentation, if it happens to be presenting otherwise: and if there is no other course, when a hand or foot is grasped, the trunk is straightened: for grasping a hand converts the presentation into a head one, grasping a foot into a foot presentation. Then if the head is nearest, a hook must be inserted which is completely smooth, with a short point, and this it is right to fix into an eye or ear or the mouth, even at times into the forehead, then this is pulled upon and extracts the foetus. But not every moment is proper for the extraction; for should this be attempted when the mouth of the womb is contracted, as there is no way out, the foetus is torn
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away from the hook, and its point then slips into the mouth of the womb itself; and there follows spasm of the sinews and great risk of death. Therefore whilst the mouth is contracted we should wait, and draw gently on the hook when it dilates, and so at these opportunities gradually extract the foetus. Now the right hand should pull the hook whilst the left is inserted within and pulls the foetus, and at the same time guides it. It also often happens that such a foetus is distended by fluid, and from it a foul sanies discharges. If so, the abdomen of the foetus is bored into by the index finger, when by escape of the fluid, the foetus is made smaller; then it is gently to be delivered by the hands alone. For if a hook is inserted it readily slips out of the soft little body, when the danger noted above is incurred. If the foetus has been turned to present by the feet it is also not difficult to extract; for the feet are grasped by the doctor's hands, and it is readily drawn out. But if the foetus is lying crosswise and cannot be turned straight, the hook is to be inserted into an armpit and traction slowly made; during this the neck is usually bent back, and the head turned backwards to the rest of the foetus. The remedy then is to cut through the neck, in order that the two parts may be extracted separately. This is done with a hook which resembles the one mentioned above, but has all its inner edge sharp. Then we must proceed to extract the head first, then the rest, for if the larger portion be extracted first, the head slips back into the cavity of the womb, and cannot be extracted without the greatest risk. Should this, however, happen, a folded pad is placed upon the woman's hypogastrium, and then
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a man strong, but not untrained, must stand on her left side, and place his two hands over the hypogastrium and press one over the other so that the head is forced to the mouth of the womb, when it must be extracted by the hook as described above. But if one foot presents whilst the other remains behind with the trunk, anything which has been drawn out must be cut away piecemeal; and if the buttocks begin to engage in the mouth of the womb they are to be pushed back and the foot of the foetus found and then drawn forwards. There are also other difficulties, which make it necessary to cut up and extract a foetus which does not come out whole. Now as soon as the foetus has been extracted it should be handed to the assistant to hold on his upturned hands, and the surgeon with his left hand must draw gently upon the navel cord, so as not to rupture it, whilst he passes his right hand along it up to what they called the secundines, which was the envelope of the foetus within the womb. When his hand has grasped the secundines including the whole of the blood vessels and membranes he brings them down from the womb in the same manner, and extracts the whole together with any retained blood clot. Then when the thighs have been tied together the woman is put to bed in a moderately warm room, which is free from draughts. Over the hypogastrium is placed greasy wool dipped in vinegar and rose oil. The rest of the treatment followed is the same as for inflammation and for wounds which are in the sinews.
30 Lesions of the anus also, when they do not yield to medicaments, require the aid of surgery.
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If, therefore, any fissure has persisted so long that it has become hard and callous, it is best to move the bowels by a clyster, then apply a hot sponge to soften the fissures and cause them to protrude. When brought into view each is excised and made into a fresh wound; then soft lint is put on and over this a pad smeared with honey, and all is covered with soft wool, fixed by a bandage; on the next and following days all the other emollient medicaments are to be used, which I said above, were required by such lesions when recent, and for the first few days at any rate the patient must live on fluids; then some food is gradually added, but of the class prescribed in the same passage. If however any pus arises in these fissures as the result of inflammation, as soon as it becomes evident, it is to be cut into, lest the anus itself suppurate. But this must not be done hastily, for if cut before it matures the inflammation is very much increased, and pus is somewhat more freely formed. Here too a light diet and emollient dressings are necessary.
The tumours, which are called condylomata, when hardened are treated by the following method. First of all the bowel is clystered; then the tumour is seized with a forceps close to its roots and cut away. After this, the same course of treatment is followed as that described above; only if there is any excrescence it is repressed by copper scales.
The mouths of veins which discharge blood are removed as follows. When any patient is losing
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blood, fasting is indicated, and a rather severe clystering of the bowel, to make the openings more prominent, and thus what may be called the little heads of the veins all come into view. Then if a head is very small and has a thin base it must be tied by a flax thread, a little above where it joins the anus. A sponge squeezed out of hot water is next to be applied until it becomes livid, then with a finger-nail or scalpel it is to be scratched off above the knot. Unless this is done great pain follows, and sometimes even difficulty in urinating. If the head is larger and the base broader, it is seized by one or two hooks, and an incision made a little above the base; in doing this nothing of the head should be left nor anything taken away from the anus. This is accomplished by not drawing upon the hooks either too much or too little. When the incision has been made, a pin should be passed through, and under the pin the head is tied round with a linen thread. If there are two or three, the lowest must be dealt with first; if more, they are not all treated at once, to avoid having tender scars in several places at once. If there is bleeding, it is taken up in a sponge; then lint is put on, the thighs and groins anointed, as well as the parts near the wound; over it is applied a cerate and a poultice of barley meal, and this part must be filled up with soft wool and then bandaged. The next day, the patient should sit in hot water and after that have the same poultice applied. Twice a day, before and after the operation, the necks and thighs are to be anointed with a liquid cerate; and the patient must be kept in a warm room. After five or six days, the bits of linen are removed
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by the aid of an earscoop. If the little heads do not come away at the same time, they are to be removed by the finger; then by the same soothing medicaments which I have described above, the wounds are healed up. After the trouble has been ended I have already noted elsewhere what must be done.
31 We next pass from the foregoing subjects to the legs, and if varicose veins occur there, they are removed by a procedure which is not difficult. To this place I have put off also the treatment of the small veins which cause trouble in the head, also of varicose veins on the abdomen, because it is all the same. Any vein therefore which is troublesome may be shrivelled up by cauterizing or cut out by surgery. If a vein is straight, or though crooked is yet not twisted, and if of moderate size, it is better cauterized. This is the method of cauterization: the overlying skin is incised, then the exposed vein is pressed upon moderately with a fine, blunt, hot cautery iron, avoiding a burn of the margins of the incision, which can easily be done by retracting them with hooks. This step is repeated throughout
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the length of the vein, generally at intervals of four fingers' breadth, after which a dressing is put on to heal up the burns. But excision is done in the following way: the skin is similarly incised over the vein, and the margins held apart by hooks; with a scalpel the vein is separated from surrounding tissue, avoiding a cut into the vein itself; underneath the vein is passed a blunt hook; the same procedure is repeated at the intervals noted above throughout the course of the vein which is easily traced by pulling on the hook. When the same thing has been done wherever there are swellings, at one place the vein is drawn forward by the hook and cut away; then, where the next hook is, the vein is drawn forwards and again cut away. After the leg has thus been freed throughout from the swellings the margins of the incisions are brought together and an agglutinating plaster put on over them.
32 But if the fingers, either before birth or later on account of ulceration of their adjacent surfaces, adhere together, they are separated by the knife; after that each finger is separately enclosed in a plaster without grease, and so each heals separately. If after ulceration of a finger, a badly formed scar has made it crooked, in the first place a poultice is tried, and if this is of no avail, which is generally the case with old scars and tendon injuries, we must see whether the trouble is in the tendon, or in the skin only. If it is in the tendon, it should not be touched, for the condition is incurable; if in the skin, the whole scar should be cut out, which had generally become hard and so did not allow the finger to be extended. When it had been thus straightened a new scar must be allowed to form there.
33 When gangrene has developed between the nails and in the armpits or groins, and if medicaments have failed to cure it, the limb, as I have stated elsewhere, must be amputated. But even that involves very great risk; for patients often die under the operation, either from loss of blood or syncope. It does not matter, however, whether the remedy is safe enough, since it is the only
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one. Therefore, between the sound and the diseased part, the flesh is to be cut through with a scalpel down to the bone, but this must not be done actually over a joint, and it is better that some of the sound part should be cut away than that any of the diseased part should be left behind. When the bone is reached, the sound flesh is drawn back from the bone and undercut from around it, so that in that part also some bone is bared; the bone is next to be cut through with a small saw as near as possible to the sound flesh which still adheres to it; next the face of the bone, which the saw has roughened, is smoothed down, and the skin drawn over it; this must be sufficiently loosened in an operation of this sort to cover the bone all over as completely as possible. The part where the skin has not been brought over is to be covered with lint; and over that a sponge soaked in vinegar is to be bandaged on. The remaining treatment is that prescribed for wounds in which suppuration is to be brought about.
1 The remaining part of my work relates to the bones; and to make this more easily understood, I will begin by pointing out their positions and shapes.
First then comes the skull, concave internally, convex externally, on both aspects smooth, where it covers the cerebral membrane as well as where it is covered by the skin bearing hair; and it is in one layer from the back of the head to the temples, in two layers from the forehead to the vertex. Its bones are hard externally, but the inner parts which connect them together are softer, and between these run large blood-vessels which probably supply their nutrition. It is rare for the skull to be solid without sutures; in hot countries, however, this is more easily found; and that kind of head is the firmest and safest from headaches. As for the rest, the fewer the sutures, the better for the heads; and there is no certainty as to the number, or even as to the position of the sutures. Generally, however, there are two above the ears separating the temples from the upper part of the head: a third stretches to the ears across the vertex and separates the occiput from the top of the head. A fourth runs likewise from the vertex over the middle of the head
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to the forehead, sometimes ending at the hairy margin, sometimes dividing the forehead itself and ending between the eyebrows. Most of these are dovetailed, but those which cross over above the ears are bevelled off a little all along their margin so that the lower bones smoothly overlap the upper. Now the thickest bone in the head is behind the ear, where hair does not grow, probably on that very account. Under the muscles covering the temples is situated the middle bone which slopes outwards. But the face has the largest suture; it begins at one temple, passes across the middle of the orbits and nose to the other temple. From this suture two short sutures are directed downwards from the inner corners of the eyes; and the cheeks at their upper parts also have transverse sutures. From the middle of the nostrils or of the gums of the upper teeth, one suture runs back through the middle of the palate, another cuts the same palate transversely. These are the sutures found in most skulls.
Now the largest passages leading into the head are those of the eyes, next the nostrils, then those of the ears. Those of the eyes lead direct and without branching into the brain. The two nasal passages are separated by an intermediate bone. These begin at the eyebrows and eye-corners, and their structure is for almost a third part bony, then changes into cartilage, and the nearer they get to the mouth the more soft and fleshy their structure becomes. Now these passages are single between the highest and lowest part of the nostrils, but there they each break up into two branches, one set from the nostrils to the throat for expiration and inspiration,
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the other leading to the brain and split up in its last part into numerous small channels through which we get our sense of smell. In the ear the passage is also at first straight and single, but as it goes further becomes tortuous. And close to the brain this too is divided into numerous fine passages which give the faculty of hearing. Adjacent to the passages there are two little pits, as it were, above which ends the bones which stretches across from the cheek, supported by deeper-seated bones: it may be called the yoke, from the same resemblance which led the Greeks to call it zygodes. But the lower jaw is a soft bone and a single one, of which the chin forms the middle and lowest portion, whence it is continued on the two sides to the temples; and it alone is movable, for the cheek-bones with all that bone which produces the upper teeth are immobile. Now the ends of the lower jaw itself form, as it were, two horns. One process broader below tapers to its tip, and as it passes higher, goes under the zygoma, and is fastened to the temporal muscles above it. The other is shorter and more rounded off, and in that pit which is adjacent to the auditory passages, it is set in a sort of hinge, and as it bends there forwards backwards supplies the power of movement to the lower jaw.
The teeth are harder than bone, some are fixed in the lower jaw, some in the cheek-bones. Of the teeth, the four in front are named by the Greeks tomis because they cut. These are flanked at each side by four canine teeth. Behind these on either side is generally a set of four molars, except in those who
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have five one tooth on each side coming through later. There are some in whom the four last, which generally come through late, do not make their appearance. Of these teeth the front ones are fixed by single roots, the molars at least by two, sometimes even by three or four; and generally the longer root produces the shorter teeth; the straight tooth has a straight root; a crooked tooth a crooked root. From the same root in children a new tooth grows which general pushes out the former one, but sometimes shows itself behind or in front of it.
Now the spine is the support of the head. It is composed of twenty-four vertebrae, seven in the neck, twelve belonging to the ribs; the remaining five are below the ribs. The vertebrae are bones rounded off and short; from each side they thrust out a transverse process; they are perforated in the middle where the spinal marrow which is connected with the brain passes downwards, and at the sides also through the two transverse processes they are traversed by fine channels, through which little membranes pass down resembling the cerebral membrane; with the exception of the three highest all the vertebrae have slight depressions in their articular processes on the upper side, on the lower side other articular processes grow downwards. The highest vertebra is therefore the immediate support of the head, receiving its small processes into two depressions, and this enables the head to move up and down. The second vertebra is made irregular by a protuberance and is attached to the lower side of the one above. To secure the rotation of the head the top of it ends in a narrower round process, so that the first vertebra
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encircling the top of this allows the head to turn sideways as well. After the same fashion the third vertebra supports the second, hence there is easy movement in the neck. And the neck could not even hold up the head were it not supported on each side by straight and powerful sinews which the Greeks call te/nontej; since whenever the head bends one of the sinews is always tense, and does not allow what is above to slip too far over. From the third vertebra in turn grow little protuberances which are inserted into the vertebra below; the remaining vertebrae are fastened into the ones below them by processes directed downwards and support the ones above them in the depression which they have on either side, and they are held together by many ligaments and cartilages. Thus by bending once in the required direction and avoiding moving in other directions man stands upright, or bends somewhat, to do anything that is required.
Below the neck the highest rib is placed on a level with the shoulders; after that there are six lower ribs, reaching as far as the bottom of the thorax; the ribs, which in their first part are rounded and end in small heads, as it were, are lightly fixed to the transverse processes of the vertebrae, which themselves have slight depressions; then the ribs flatten out and after curving outwards gradually degenerate into cartilage, and here, after again bending slightly inwards, they become united to the breast-bone. This, a strong and hard bone, begins below the throat, is lunated on each side, and, when it becomes itself softened into cartilage, is bounded by the praecordia. Below the upper ribs, there are five called by the Greeks nothae; they are short, thinner, and after changing gradually into
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cartilage, they are embedded in the highest part of the abdomen. The lowest of these consists for the most part only of cartilage. Again, from the neck two wide bones extend to the shoulders on each side; we call them scutula operta, the Greeks omoplatae. These bones are curved at their highest point, and below these they are triangular, and become gradually wider as they approach the spine. As they become wider, they become blunter. And they too at the lowest part soften into cartilage at the back and float, as it were, since they are unconnected with any other bone except at the top, but there they held in place by very strong muscles and sinews. Now at the level of the first rib, and a little behind its middle, a bone grows out which at first is slight but as it comes nearer the broad bone of the shoulder-blades becomes thicker and broader, and curves slightly outwards; and this at its other upper end is enlarged somewhat to support the root of the neck. But this bone itself is curved, and must not be reckoned among the hardest or most solid, and it lies with one head fixed as just stated, the other in a small depression of the breast-bone; it moves a little with the movement of the arm, and is connected with the flat bone of the shoulder-blades by sinews and cartilage.
From this point begins the humerus, which at both ends is swollen out, and is there soft, without marrow and cartilaginous; in the middle cylindrical, hard, contain in marrow; and slightly curved both forwards and outwards. Now its front part is that on the side of the chest, its back, that on the side of the shoulder-blades; its inner part that which faces the
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side, its outer away from the side. It will be clear in later chapters that this applies to all joints. Now the upper head of the humerus is more rounded than any other bone hitherto described and is inserted by a small excrescence into the top of the wide bone of the shoulder-blades, and the greater part of it is held fast by sinews outside its socket.
The humerus at its lower end has two processes, between which the bone is hollowed out even more than at its extremities. This furnishes a seat for the forearm, which consists of two bones. The radius, which the Greeks call cercis, is the uppermost and shorter; at its beginning it is thinner, with a round and slightly hollowed head which receives a small protuberance of the humerus; and it is kept in place there by sinews and cartilage. The ulna is further back and longer and at first larger, and at its upper extremity is inserted by two outstanding prominences into the hollow of the humerus, which, as I said above, is between the two processes. At their upper ends the two bones of the forearm are bound together, then they gradually separate, to come together again at the wrist, but with an alteration in size; since there the radius is the larger whilst the ulna is quite small. Further, the radius as it enlarges into its cartilaginous extremity is hollowed out at its tip. The ulna is rounded at the extremity, and projects a little at one part. And, to avoid repetition, it should not be overlooked that most bones turn into cartilage at their ends, and that all joints are bounded by it, for movement would be impossible unless apposition were smooth, nor could they be united with flesh and sinews unless some such intermediary material formed the connection.
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Turning to the hand, the first part of the palm consists of many minute bones of which the number is uncertain, but all are oblong and triangular, and are connected together on some plan since the upper angle of one alternates with the base of another; therefore they appear like one bone which is slightly concave. Now two small bones project from the hand and are fitted into the hollow of the radius; and at the other end five straight bones directed towards the fingers complete the palm; from these spring the fingers themselves, each composed of three bones; and all are similarly formed. A lower bone is hollowed out at its top to admit a small protuberance from an upper bone, and sinews keep them in place; from them grow nails which become hard, and thus these adhere by their roots to flesh rather than to bone.
And such are the arrangements for the upper limbs. Now the bottom of the spine is fixed between the bone of the hips, which lies crosswise and is very strong and so protects the womb, bladder and rectum; and the bone bulges out externally, is bent up towards the spin, and on the sides that is, the hips proper, it has rounded hollows; and from these start the bone they call the comb, situated crosswise above the intestines below the pubes, and this supports the belly; in men the bone is straight, in women more curved outwards so as not to hinder parturition.
Next in order are the thigh-bones, the heads of which are even more globular than those of the arm-bones, although those are the most globular of the other bones; below there are two processes, one directed forward, the other backward; after this the bones are hard and marrowy and convex on the outer
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side, and they are again enlarged at their lower ends also. The upper ends are inserted into hollows of the hip-bones, as the arm-bones into the shoulder-bones; then these tend gently downwards and inwards in order that they may support the upper parts of the body more evenly. But the heads at the lower end have a hollow in between, that the leg-bones may be more easily fixed into them. Their juncture is covered by a small, soft, cartilaginous bone, called the knee-cap. This bone, which floats freely and is not attached to any other bone, but held in place by flesh and sinews, is turned slightly towards the thigh-bone and protects the joint in all movements of the legs.
The leg itself is made up of two bones; for as the thigh-bone is throughout similar to the humerus, so is the leg like the forearm, hence the form and appearance of the one can be learnt from the other: and what holds good for the bones holds also for the soft parts. One bone lies outside, and this too itself is called the calf. It is the shorter, and is smaller in its upper part, but swells out just at the ankles. The other is placed more in front and is named tibia; it is the longer, and is larger at the upper end, and it alone joins with the lower head of the thigh-bone, as the ulna does with the humerus. These two bones, moreover, are joined together at the lower and upper ends, but in the middle as in the forearm they are separated. The leg below is received by the transverse bone of the ankles, which itself is set upon the heel-bone; the heel-bone is hollowed out in one part, and has excrescences at another part, so that it receives the excrescences of the ankle and is received itself into the hollow of the ankle. The
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heel-bone is without marrow, is hard, and projects somewhat backwards where it presents a rounded outline. The other bones of feet are constructed in a similar way to the bones of the hand; the sole corresponds to the palm, digits to digits, nails to nails.
2 Now when any bone has been injured, it either becomes diseased or splits or is broken or perforated or crushed or displaced.
A diseased bone generally first becomes fatty, next either blackened or rotten; and this occurs in cases of severe ulceration or fistula, when these have become chronic or even gangrenous. And it is necessary in the first place to expose the diseased bone by cutting out the ulcer, and if the bone disease extends beyond the margins of the ulcer to cut away the flesh until sound bone is exposed all round. Then if the diseased bone appears merely fatty, it is enough to apply a cautery once or twice until a scale of Boeotian comes away; or to scrape it away until there is bleeding, which is a sign of sound bone; for diseased bone is necessarily dry. The same is also to be done for diseased cartilage; it too must be scraped away with a scalpel until what remains is sound. Then, whether bone or cartilage has been scraped, finely powdered soda must be dusted on; and nothing different is to be done when the surface of the bone is black or carious, except that the treatment by cautery or scraping must be continued for a longer time. In these cases if the surgeon scrapes he should press boldly upon the instrument that he may effect more and finish sooner. The end is when white or hard bone is reached. White bone instead of black, or hard
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bone instead of carious clearly indicates the end of the diseased part. I have already stated that sound bone also bleeds to some extent.
But if in either case it is doubtful how deep the disease has reached, in the case of carious bone, this is readily ascertained. A fine probe is introduced into the hole, and according as it enters to a less or greater extent, it shows either that the caries is superficial or that it has penetrated more deeply, With black bone it is possible to form some opinion also from the pain and fever; when these are moderate in degree, the disease cannot have penetrated deeply. This becomes more obvious, however, when a trepan is used; for the limit of disease is reached when the bone dust ceases to be black.
Therefore, if caries has penetrated deeply, by means of the trepan holes are bored in the bone at frequent intervals, equal in depth to the extent of the disease; next cautery points are passed into these holes, until the bone becomes entirely dry. For after such applications, simultaneously the diseased part separates off from the bone underneath, and the cavity will make flesh, and no humour or very little will be subsequently discharged.
If on the other hand the disease, whether blackness or caries, has extended to the other side of the bone as well, excision is required; and the same can be done when caries has penetrated right through a bone. But whatever is wholly diseased is to be wholly removed; if the lower part is sound, only that which is corrupt should be excised. Further, if there is caries of the skull or breast-bone or rib, the cautery is useless, and excision is necessary. Nor are we to listen to those who await the third
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day after the bone has been laid bare before excising; for all cases are treated more safely before the inflammatory reaction. Therefore, whenever possible at the same sitting, the skin is to be incised, and the bone exposed, and freed from a that is diseased. And much the most dangerous case is in the breast-bone, for even if the operation has been successful, complete healing scarcely ever results.
3 Now bone is excised in two ways; if the damaged part is very small, with the modiolus, which the Greeks call xoineiki/j; if more extensive by means of trepans. I will describe the use of both. The modiolus is a hollow cylindrical iron instrument with its lower edges serrated; in the middle of which is fixed a pin which is itself surrounded by an inner disc. The trepans are of two kinds; one like that used by smiths, the other longer in the blade, which begins in a sharp point, suddenly becomes larger, and again towards the other end becomes even smaller than just above the point. When the disease is so limited that the modiolus can include it, this is more serviceable; and if the bone is carious, the central pin is inserted into the hole; if there is black bone, a small pit is made with the angle of a chisel for the reception of the pin, so that, the pin being fixed, the modiolus when rotated cannot slip; it is then rotated like a trepan by means of a strap. The pressure must be such that it both bores and rotates; for if pressed lightly it makes little advance, if heavily it does not rotate. It is a good plan to drop in a little rose oil or milk, so that it may rotate more smoothly; but if too much is used the keenness of
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the instrument is blunted. When a way has been cut by the modiolus, the central pin is taken out, and the modiolus worked by itself; then, when the bone dust shows that underlying bone is sound, the modiolus is laid aside. But if disease is too extensive for the modiolus to cover, the operation must be carried out by the trepan. With this a hole is made exactly at the margin of the diseased and sound bone, then not very far off a second, and a third, until the whole area to be excised is ringed round by these holes; and here also the bone dust shows how deep the trepan is to go. Next the excising chisel is driven through from one hole to the other by striking it with a mallet, and cuts out the intervening bone, and so a ring is made like the smaller one cut by the modiolus. And in whichever way the circle has been made, the same excising chisel should cut away from the corrupted bone every scale-like layer until sound bone is left. Black bone hardly ever penetrates the whole thickness of the bone, but caries sometimes does so, and especially when the cranium is diseased. A test of this is also made by means of the probe, which when inserted into a cavity which has solid bone underneath finds some resistance because of this and is wet when it comes up. If it finds a clear way, as it goes deeper between bone and membrane, it encounters no resistance and comes up dry; not because there is no harmful sanies within, but because this is spread over a wider area. If bone is diseased right through, whether it be black bone exposed by the trepan, or caries discovered by a probe, the use of the modiolus is generally out of place, because what goes down so deep must be more widely opened up.
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Then the trepan which I described second is to be used; and in order that it may not get too hot, it should be dipped repeatedly in cold water. But particular care must be taken when we have bored half through a bone consisting of a single layer, or through the upper layer of a bone of two layers; in the former the actual distance bored, in the latter the appearance of blood is the indication. Therefore the strap is then worked more gently and the left hand held up and moved away more often, and the depth of the borehole is to be examined in order that we may perceive just when the bone is being broken through anywhere, and not run the risk of injuring the cerebral membrane by the point; which causes severe inflammation with danger of death. When boreholes have been made, the intervening partitions are to be excised in the same way but much more carefully, lest the corner of the chisel injure the aforesaid membrane; until a sufficient opening has been made to insert a guard of the membrane which the Greeks call meningophylax. This consists of a plate of bronze, its end slightly concave, smooth on the outer side; this is so inserted that the smooth side is next the brain, and is gradually pushed in under the part where the bone is being cut through by the chisel; and if it is knocked by the corner of the chisel it stops the chisel going further in; and so the surgeon goes on striking the chisel with the mallet more boldly and more safely, until the bone, having been divided all round, is lifted by the same plate, and can be removed without any injury to the brain. When all this bone has been removed, the margins of the opening must be filed down
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smooth, and if any bone dust is sticking to the membrane it is to be removed. When the outer table has been removed, and the inner table left, it is not only the margins but also all the bone which is to be smoothed down, in order that skin may grow over it subsequently without harm; for when it grows over rough bone there is never sound healing, but it causes new pains. What is to be done when the bain is exposed, I will describe when I come to fractures. If some of the inner table has been preserved, medicaments which are not greasy, such as are fitted for recent wounds, are to be applied, and over that, unscoured wool soaked in oil and vinegar. In course of time flesh grows up from the bone and fills up the hollow made by the surgery. Also if any bone has been cauterized it separates from the healthy part, and between the sound and dead bone granulations form to throw off what has separated; and this is usually a thin and small splinter, which the Greeks call a scale.
It may possibly even happen as the result of an injury, that bone, although neither fissured nor fractured, yet has its surface indented and roughened; when this happens scraping and smoothing suffice. These conditions, although mostly occurring in the head, are found also in the other bones, so that whenever the same thing happens the same procedure is to be followed. But for bones which are fractured, fissured, perforated or crushed, some special treatment is required, suited for particular cases, and some general measures which apply to the majority; of these I will proceed to treat, beginning with the said cranium.
4 Therefore after a blow on the head first we
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must enquire whether the patient has had bilious vomiting, whether there has been obscurity of vision, whether he has become speechless, whether he has had bleeding from the nose or ears, whether he fell to the ground, whether he has lain senseless as if asleep; for such signs do not occur unless with fractured bone; and when they are present, we must recognize that treatment is necessary but difficult. If in addition there is also stupor, if the mind wanders, if either paralysis or spasm has followed, it is probable that the cerebral membrane has also been lacerated; and then there is little hope. But if none of these signs follows the injury, it is not even certain whether the bone is broken: and the first thing then to consider is whether he was struck by a stone or club or sword or other such weapon, and whether such a weapon was blunt or pointed, medium or heavy, used with much or little force; for the lighter the blow, the more easily we may conclude that the bone has resisted it. But the best plan is to make certain by exploration. Accordingly a probe should be introduced into the wound; it should be neither very fine nor pointed, lest it enter one of the natural sutures and give rise to a false belief in a fracture of bone; neither should it be too thick lest small fissures be missed. When the probe comes into contact with the bone, if nothing but what is smooth and slippery is met with, it can be seen that the bone is intact; if any roughness is met with, at least where there are no sutures, it is a sign that the bone is fractured. Hippocrates, with great men's love of truth in great matters, has described how he had
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been deceived by sutures. For shallow minds, because they have nothing, never belittle themselves; such a sincere confession of the truth befits a great mind which will still have many titles to greatness, and especially in performing the task of handing down knowledge for the advantage of posterity, that no one else may be deceived again by what has deceived him. But my regard for the memory of a great teacher has somehow led me into this digression. Now a suture may possibly deceive just because it is rough too; so that although there is really a fissure, yet we may take it to be a suture, where it is likely that there is one. Therefore we must not be deceived just by this; the safest way is to lay bare the bone. For as I have stated above, sutures are not always in the same position, and a natural union of bone and a fissure from injury may coincide, or the fissure may be close by. Therefore sometimes when the blow was severe, although nothing is detected by the probe, it is still best to open the place up. And if even then no fissure is visible, ink is to be applied over the bone, then it is to be scraped with a chisel; for a fissure will retain the blackness. It may even happen that the blow may have been upon one part of the head, and fracture at another. Thus if anyone has been heavily struck and bad signs have followed, and no fissure has been found in the part where the scalp has been wounded, it is worth while to examine whether some other part is softer and swollen, and to lay it open; then perhaps fissured bone may be found there. Even if it be uselessly incised, the scalp heals without much trouble. A fractured bone unless it is treated causes severe inflammations,
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and is treated afterwards with greater difficulty. Rarely, but now and then, it happens, however, that whilst the bone remains whole and sound, yet within the skull a blood-vessel in the cerebral membrane has been ruptured by the blow and some blood has escaped, and this having formed a clot, causes great pains, or sometimes obscures vision. But generally the pain is directly over the clot, and when the scalp at that point is incised, the bone is found to be pallid; if so, that bone also is to be cut out.
But for whatever cause this treatment is necessary, if the scalp has not been laid open sufficiently, it must be incised more widely until the injury is well in view. In doing so we must see that none of the fine inner membrane covering the skull, under the scalp, remains over the bone; for whenever this is lacerated by the chisel or trepan it causes severe fevers with inflammations, and so it is better to raise it wholly off the bone. If there is a cut as part of the wound we must take it as it is; if we have to make it, the best incision is generally that which is formed by two lines in the shape of the letter X; next the scalp is raised by cutting under each of the little tongues. When doing this if bleeding takes place it must be checked by the application of a sponge saturated with vinegar from time to time, also it must be absorbed by swabs of dry lint and the head must be raised higher. There need be no anxiety unless it comes from among the muscles covering the temples; but there also this is the safest method of dealing with it.
In every case of a fissured or fractured bone, the older practitioners resorted at once to the instruments for cutting out the fragments. But it is much
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better first to try the plasters which are prepared for the cranium. One of these dissolved in vinegar is to be put upon the fissured or fractured bone by itself; next over this, a little overlapping the wound, lint steeped in the same, and over this unscoured wool sprinkled with vinegar; then the wound is bandaged and the dressing changed daily, and so treated up to the fifth day; on the sixth day also the wound is steamed by means of a sponge, then dressed as before. And if granulation begins, and the feverishness either subsides or lessens, and appetite returns, and there is sufficient sleep, we should persevere with the same applications. Next as time goes on, the plaster is to be softened by the addition of the cerate made with rose oil that it may cause the flesh to grow more readily; for by itself it has a repressant action. Under this treatment fissures are often filled up by some callus which forms a sort of scab in the bone; and if the fragments are more widely separated, any that are not in contact also become fastened together by the same callus, and this is a better covering for the brain than the flesh which grows up after the bone has been excised. But if under this first treatment fever becomes intensified and sleep short and disturbed by dreams, while the wound discharges and does not heal, and the glands in the neck on each side swell, and there is great pain, and in addition a growing aversion to food, then at length we must resort to surgery with the chisel.
A blow on the cranium involves two dangers; either a split bone or a depressed fracture. If the bone is split, the edges may remain in close contact, either because one margin overrides the other, or
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because they have become closely interlocked again. Hence it follows that humour collects on to the cerebral membrane but has no means of exit, and so irritates it, exciting severe inflammation. But when there is a depressed fracture, the bone presses on the cerebral membrane and sometimes also sharp points like needles from the fractured bone cause irritation. Cases like this require assistance, with as little loss of bone as possible. Therefore if one edge overlies the other, it is sufficient to cut away the overlying edge with a flat chisel; when this is removed a gap is left wide enough for treatment. But when the fractured edges have become interlocked, a hole should be made with a trepan at a finger's breadth to one side; and from this two cuts should be made with the chisel to the fissure, in the form of the letter V, with the apex at the hole and the base at the fissure; but if the fissure is a lone one, similar curs should be made from a second hole. And thus there is no concealed cavity in that bone, and a way out is given freely to all harmful material within. Even when the fractured bone is depressed, it need not all be excised. But whether completely broken off and separated from the rest, or still attached by a small portion to the skull around, the fragment should be separated by the chisel from the sound bone. Next, in the depressed fragment, close to the groove which we have just made, holes are to be bored as well; two when the damage is of small extent, three when larger, and the intervening partitions must be cut through. Next the chisel is to be so used on each side of the said groove, that a crescent-shaped gap is made with its convexity on the side of the fragment, and its horns directed
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towards the intact bone. Then if there are any detached fragments which can be easily removed, they are to be seized with forceps made for the purpose and particularly the pointed fragments which are irritating the membrane. If this cannot be done easily, the plate which I have suggested as a guard of this membrane is to be passed underneath in order that all pointed fragments which project inwards may be cut away over the plate, and any depressed bone is to be raised by means of the same plate. This method of treatment ensures that fragments still attached become consolidated; and detached fragments come away in course of time under the dressing without any pain; and by that treatment there is left a gap in the skull large enough for the extraction of matter; and the brain is better protected by leaving the bone than if it had been excised. After this, that membrane should be sprinkled with strong vinegar, in order that any bleeding from it may be checked, or any collection of clot which remains inside may be broken up. Then the same plaster, softened as described above, should be put on the membrane itself; and the rest of the dressing as before, ointment on the lint, and unscoured wool; the patient should be kept in a warm room; the wound dressed daily, even twice a day in summer.
But if the membrane swells up through inflammation, it is to be bathed with tepid rose oil; if it swells so as to project even above the level of the skull, well-ground lentils or crushed vine leaves, mixed either with fresh butter or goose-grease, will control it; and the neck should be anointed with liquid cerate containing iris oil. But if it shall ap-
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pear that the membrane is not clean, equal parts of its special medicament and of honey are to be mixed together and poured on, and to keep this in place one or two pads of lint must be put on, and over all linen upon which some of the medicament has been smeared. When the membrane is clean, a cerate to form flesh is to be added to the medicament and similarly applied.
As regards abstinence and the food and drink at first and later, the same course is to be adopted as I prescribed for wounds, and all the more because the danger is greater when this part is affected. And even when the time has come not only to sustain but also to build up the patient, still anything requiring mastication should be avoided; and also smoke and anything which provokes sneezing. But there is good hope when the membrane is movable and of normal colour, when the flesh growing up is a brit red, and when the jaw and neck move with ease. Bad signs are: the membrane immobile, black or livid or any other unwholesome colour; delirium, acrid vomiting, paralysis or spasm livid flesh, rigor of jaw and neck. As for other signs — sleep, appetite, fever, colour of the pus — the indications as to recovery or death are the same as in the case of other wounds. When things are going well, flesh grows up from the ma itself and from the bone as well if it is in two layers, so that the space between the bones becomes filled up; sometimes it even grows out above the skull. If this occurs copper scales are to be dusted on in order to repress and control it. Also applications to induce a scar must be laid on the flesh. And this is readily brought about everywhere except on the forehead a little above the eye-
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brows; for there it is almost impossible to avoid a lifelong wound which has to be kept covered by medicated lint. It should be the rule for all cases in which the skull has been fractured, that until the scar is firm, the patient should avoid sun, wind, frequent baths, and the free use of wine.