The third part of the Art of Medicine is that which cures by the hand, as I have already said, and indeed it is common knowledge. It does not omit medicaments and regulated diets, but does most by hand. The effects of this treatment are more obvious than any other kind; inasmuch as in diseases since luck helps much, and the same things are often salutary, often of no use at all, it may be doubted whether recovery has been due to medicine or a sound body or good luck. Besides, in cases where we depend chiefly upon medicaments, although an improvement is clear enough, yet it is often clear that recovery is sought in vain with them and gained without them: this can be seen for instance in treating the eyes, which after being worried by doctors for a long time sometimes get well without them. But in that part of medicine which cures by hand, it is obvious that all improvement comes chiefly from this, even if it be assisted somewhat in other ways. This branch, although very ancient, was more practised by Hippocrates, the father of all medical art, than by his forerunners. Later it was separated from the rest of medicine, and began to have its own professors; in Egypt it grew especially by the influence of Philoxenus, who wrote a careful and comprehensive work on it in
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several volumes. Gorgias also and Sostratus and Heron and the two Apollonii and Ammonius, the Alexandrians, and many other celebrated men, each found out something. In Rome also there have been professors of no mean standing, especially the late Tryphon the father and Euelpistus, and Meges, the most learned of them all, as can be understood from his writings; these have made certain changes for the better, and added considerably to this branch of learning.
Now a surgeon should be youthful or at any rate nearer youth than age; with a strong and steady hand which never trembles, and ready to use the left hand as well as the right; with vision sharp and clear, and spirit undaunted; filled with pity, so that he wishes to cure his patient, yet is not moved by his cries, to go too fast, or cut less than is necessary; but he does everything just as if the cries of pain cause him no emotion.
But it can be asked what is the proper province of this part of my work because surgeons claim for themselves the treatment of wounds as well, and of many of the ulcerations which I have described elsewhere. I for my part deem one and the same man able to undertake all of these; and when divisions are made, I praise him who has undertaken the most. I have myself kept for this part cases in which the practitioner does not find wounds but makes them, and in which I believe wounds and ulcerations to be benefited more by surgery than by medicine; as well as all that which concerns the bones. These cases I shall proceed to discuss in turn, and leaving to another volume the subject of bones I shall deal with the rest in this one; beginning
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with cases which occur anywhere in the body I shall pass on to those which occur in special situations.
1 First then the displacements, in whatever part of the body they are, ought to be immediately treated, so that the skin is several times incised with a sharp scalpel where the pain is, and the blood as it issues wiped off with the back of the knife. But if relief is rather slow in coming and there is now redness as well, and if, where the redness is, there is swelling in addition, wherever there is swelling this treatment is best. Repressants are then to be applied, in particular unscoured wool soaked in vinegar and oil. In a slighter case the same applications may afford relief even without the scalpel; and if there is nothing else at hand, wood-ash, preferably of vine twigs, or failing that any other kind, stirred to a paste in vinegar, or even in water.
2 There is prompt relief in such cases; but there is more trouble where a lesion has arisen internally of itself which causes swellings and tends to suppuration. I have described elsewhere the various classes of abscession, and I have pointed out the suitable medicaments; it now remains to speak of those which should be treated by surgery. Before the abscession becomes hardened, the overlying skin should be scarified and a cup put on, in order to draw outwards whatever bad and corrupted matter has collected; and it is right to repeat this every
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third day until every indication of inflammation has gone. It may be, however, that the cupping has no effect; for at times, although seldom, it happens that the abscess is enclosed in a covering of its own, which the ancients named a coat. Meges, because every such coat is sinew-like, said that no sinew could be produced under a lesion by which flesh is eaten away; but that when pus has been there for a long time, a callus forms round it. This has no bearing upon the mode of treatment, for the same thing ought to be done, whether it be a coat, or a callus. There is nothing to prevent a callus being called a coat, since it covers. Moreover at times the coat has formed after the pus has become more matured; so that what is under it cannot be drawn out by cupping. But this is readily recognized when the application of a cup causes no change. Therefore when that happens, or there is already hardening, there is no help from cupping, but as I have said elsewhere it is whilst matter is collecting that it has to be diverted or dispersed, or else matured. In the two former contingencies no further treatment is needed. When pus has matured, if in the armpits or groins it will not often have to be cut into. The same is true when the abscess is of moderate extent, so also when it is in the skin, or even in the flesh, unless the patient's weakness forces us to hurry; it is sufficient to poultice in order to make the pus come out of its own accord. For the place which has not felt the knife may generally escape without a scar. But if the abscess is more deeply seated, we must consider whether the part has sinews or not. For if it is free from sinews, it should be laid open with a red-hot cautery-knife;
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which has this advantage, that a small wound continues open longer for the withdrawal of the pus, and the resulting scar is small. But if there are sinews near by, the cautery is unsuitable, lest spasm of the sinews ensues or paralysis of the limb; then the scalpel becomes necessary. But although abscesses elsewhere can be opened even whilst immature, where there are sinews, we must wait for them to be fully matured, since the skin then becomes thin, and the pus joins it, and so is nearer to get at. Most abscesses require a linear incision; but in that termed panus, because it generally thins out the skin extremely, all the skin overlying the pus is to be cut away. But when the scalpel is used, care should always be taken that the incisions made are as few and as small as possible, but enough in number and extent to afford the necessary relief. For the larger cavities may at times have to be cut into rather widely even by two or three incisions, and cuts must be so made that the deepest part of the cavity gets a vent, lest any fluid should be left there to eat its way gradually into adjoining tissue, which was previously sound. Also it is natural that the skin should have to be cut away rather widely. For when the whole bodily habit has become vitiated in the course of a prolonged disease and the abscess cavity has extended widely and the skin over it has already become pallid, then we can recognize that the skin is already dead and of no further use; and therefore the excision of overlying skin is better, especially if the suppuration is round about the larger joints, and if the patient, confined to bed, has been exhausted by diarrhoea, and gained nothing from his food. But the skin should be so cut out as to
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leave a myrtle leaf shaped wound, in order that it may heal more readily: and this should be the constant rule, whenever, or for whatever reason, the practitioner cuts out skin. Where the pus has been let out, for the armpit or groin lint plugging is unsuitable, but a sponge squeezed out of wine must be put on. In other parts, if likewise a lint plug is unnecessary, a little honey will be infused into the cavity to clean it, then agglutinants put on: if lint plugs are needed, over them also should be placed sponges similarly squeezed out of wine. But it has been said elsewhere when plugging is, and is not requisite. In all other ways the same procedure is to be followed after an abscess has been opened by incision, which I have described for one which has ruptured under medicaments.
3 Now how the treatment is succeeding, how much is to be either hoped or feared, can be learnt straightaway from signs which on the whole are the same as have been mentioned already for wounds. Good signs are: ready sleep, easy breathing, no harassing thirst, no aversion to food; for any feverishness to pass off; and for the pus to be white and uniform, not foul. Bad signs are: wakefulness, laboured breathing, thirst, aversion to food, fever, the pus dark or like wine lees, and foul. Again, bad signs in the course of the treatment are: haemorrhage, or if the margins become fleshy before the sinus has been filled up by flesh, and this flesh is insensitive and not firm. But the worst sign of all is a faint, whether during the dressing, or after it. Again there is some reason for anxiety when the illness suddenly subsides, and then suppuration breaks out; or if the illness persists after the pus
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has been let out. And one cause for anxiety is if the wound is insensible to corrosives. But while it is chance that makes the signs point now one way, now another, it is the practitioner's part to strive to bring about healing. Therefore whenever it is dressed, the abscess cavity should be washed out, with wine mixed with rain water or with a decoction of lentils, when the discharge seems to need checking; with honey wine when cleaning is required; after which it is dressed as before. When the discharge appears to be checked, and the cavity clean, then is the time to help the growth of flesh, both by irrigating with equal parts of wine and honey, and by laying on a sponge soaked in wine and rose oil. Although the growth of flesh is helped by these medicaments, this is better attained, as I have said elsewhere, by a careful regimen; this consists, after the cessation of the fever and a return of appetite, in an occasional bath, gentle rocking daily, food and drink suitable for making flesh. These prescriptions all apply to abscesses which have burst under medicaments; but they have been held over to this place because it is scarcely possible to cure a large abscess without using the knife.
4 Again, for fistulae which penetrate so deeply that a medicated bougie cannot be passed down to the ends, or those which are tortuous or multiple, surgery has the advantage over medicine; and there is less trouble if the fistula runs horizontally under the skin, than when it tends directly inwards. Therefore if it lies horizontally under the skin, a probe should be introduced and cut down upon. When there are bends, these are followed up in
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the same way with the probe and knife; so also when they present multiple branchings. When the end of the fistula is reached, all the callus should be cut out, then pins are inserted through the skin margin, and agglutinating medicaments spread over all. But if it runs straight inwards, after its chief direction has been explored by means of the probe, that cavity ought to be excised, then a pin is to be inserted through the skin opening, and agglutinating medicaments applied as above; or if there is more corrupt ulceration, which is at time the case when there is disease of bone, after the bone has been treated, suppuratives are put on.
Now it is common for fistulae to have their exit between ribs; when this is the case the rib must be cut across on either side at that spot, and the segment removed lest anything diseased be left within. Fistulae which have passed between the ribs often involve the transverse septum separating the viscera above from the intestine. This can be recognized by the position of the fistula and the severity of the pain, and because at times, air with frothy humour escapes from the fistula, especially when the patient has held his breath. In that case there is no opportunity for the medical art. But in the case of other fistulae near the ribs which are curable, greasy medicaments are objectionable but anything else which suits wounds may be used; the best, however, is lint put on dry, or after soaking in honey if anything has to be cleaned.
There is no bone in the abdomen, but all the same fistulae there are so dangerous that Sostratus thought them incurable. Experience, however, shows that this is not always the case. Indeed — and this may
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seem very remarkable — a fistula which forms over the liver, spleen, or stomach, is safer than one right over the intestine, not because a fistula there is more harmful, but because it opens the way to another danger. Some writers who have had experience of this have shown little perception of the true facts. For often the abdomen is actually penetrated by a weapon, and sutures bring the margins of the wound together and how this is done I will presently point out. Therefore also when a fine fistula breaks through the abdominal wall, it is possible to cut it out, and to join its margins by suture. But if such a fistula widens out inside, this excision necessarily leaves a wide gap which cannot be sutured without applying great force especially in the deeper part where the abdomen is enclosed by a kind of membrane which the Greeks call peritoneum. Therefore, when the patient begins to get up and move about, the sutures break, and intestines prolapse; which causes his death. But these cases are not altogether desperate, and so for the finer fistulae, treatment is to be adopted.
Special consideration is required in the case of those in the anus. In these, where a probe has been passed up to its end, the skin should be cut through, next through this new orifice the probe is to be drawn out, followed by a linen thread which has been passed through the eye made for the purpose in the other end of the probe. Then the two ends of the linen thread are taken and knotted together so as to grip loosely the skin overlying the fistula. The linen thread should be made up of two or three strands of raw flax, twisted up so as to
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make one. Meanwhile the patient can do his business, walk, bathe, and take food as if in the best of health. Only this thread is to be moved twice a day, but without undoing the knot, the part of the thread outside being drawn within the fistula, and the thread must not be left until it becomes foul, but every third day the knot is to be undone, and to one end that of another fresh thread is tied, and the old thread being withdrawn the new one is to be left in the fistula after being similarly knotted. For thus the thread cuts through the skin overlying the fistula slowly, and whilst the skin released from the thread undergoes healing, that which is still gripped is being cut through. This method of treatment is lengthy but causes no pain. Those in a hurry should constrict the skin with the thread, so that they may continue through more quickly; and at night they should insert into the fistula some fine pledglets of wool, in order that its overlying skin, being put on the stretch, may be thinned out; but these measures cause pain. More speed may be added, but more pain as well, if both the thread and the pledglets are smeared with some one of the medicaments, which I have noted for the eating away of callus. Even here, however, the knife must be used, if the fistula extends inwards, of is multiple. In these kinds of fistulae, therefore, when the probe has been inserted, the skin is to be cut through along two lines so that between them a very fine strip of skin may be taken out, in order that the margins may not unite at once, and that there may be room for the smallest possible quantity of lint to be inserted; all the rest is done in the way described for abscesses. If, however, from one
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orifice several sinuses lead off, the straight part of the fistula is to be laid open with the scalpel, and the others branching from it, which are now exposed, are to be gripped by a thread. Should any fistula extend so far inwards that it cannot be safely laid open by the knife, a medicated bougie is to be put in. But in all such cases, whether treated surgically or by medicaments, the food should be moist, the drink abundant, and for a while water: when flesh begins to grow up, then at length the patient is to make use of the bath occasionally, and of flesh-making food.
5 Missiles too, which have entered the body and become fixed within, are often very troublesome to extract. And some of the difficulties arise from their shape, some owing to the positions to which they have penetrated. Whatever the missile may be, it is extracted, either by the wound of entry, or through the spot towards which it is pointing. In the former case, the missile has already made a way for its withdrawal; in the latter the way out is made with the scalpel; for the flesh is cut through upon its point. But if the missile is not deeply seated, and lies in superficial tissue, or if it is certain that it has not crossed the line of large blood vessels or sinews, there is nothing better than to pull it out by the way it entered. But if the distance it has to be withdrawn is greater than that which remains to be forced through, or if it has crossed the line of blood vessels and sinews, it is more convenient to lay open the rest of its course and so draw it out. For it will be more easily got at and more safely pulled out. And in the case of one of the larger limbs, if the point has passed beyond the middle, a through and through wound
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heals more easily because it can be dressed with a medicament at both ends. But if the missile is to be drawn back, the wound should be enlarged with a scalpel, for then the missile comes away more easily, also less inflammation is caused; for this becomes more severe if the missile itself lacerates the tissues while being withdrawn. So also when a counter opening is made, this ought to be too wide for the missile to fill as it is passing out. In either case, the greatest care should be taken that no vein, nor one of the larger sinews, nor an artery, is cut. When any one of these is observed, it is to be caught by a blunt hook and held away from the scalpel. Than the incision has been made large enough, the missile is to be drawn out, proceeding in the same way, and taking the same care, lest that which is being extracted should injure one of those structures which I have said are to be protected.
The foregoing are general rules; there are some rules which apply to special missiles, and these I will at once set out. Nothing penetrates so easy into the body as an arrow, and it also becomes very deeply fixed. And this happens both because it is propelled with great force and because it is sharply pointed. Hence it is more often to be extracted through a counter opening than through the wound of entry, and especially so because it is generally furnished with barbs which lacerate more when drawn backwards than if pushed through a counter opening. When a passage out has been laid open, the flesh ought to be stretched apart by an instrument like a Greek letter; next when the point has come into view, if the shaft is still attached, it is to be pushed on until the point can be seized from
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the counter opening and drawn out: if the shaft has already become detached, and only the arrowhead is within, the point should be seized by the fingers or by forceps, and so drawn out. Nor is the method of extraction different when it is preferred to withdraw the arrow by the wound of entry; the wound having been enlarged, either the shaft, if it is still attached, or, if not, the arrowhead itself, is pulled upon. When the barbs come into view, if they are short and fine, they should be nipped off on the spot by forceps, and the missile drawn out without them. If the barbs are too large and resistant for this, they must be covered by reed pens which have been split, and thus pulled out carefully so as not to tear the flesh. This is what is to be done in the case of arrows.
But if it is a broad weapon which has been embedded, it is not expedient to extract it through a counter opening, lest we add a second large wound to one already large. It is therefore to be pulled out by the aid of some such instrument as that which the Greeks call the Dioclean cyathiscus, because invented by Diocles, whom I have said already to have been among the greatest of the ancient medical men. The instrument consists of two iron or even copper blades, one blade has at each angle of its end a hook, turned downwards; the other blade has its sides turned up so that it forms a groove, also its end is turned up somewhat, and perforated by a hole. The latter blade is first passed up to the weapon, and then underneath it, until the point is reached, the blade is then rotated somewhat until the point becomes engaged in the perforation. After the point has entered the perforation, the
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hooks of the first mentioned blade are fitted by the aid of the fingers over the upturned end of the blade already passed, after which simultaneously the cyathiscus and the weapon are withdrawn.
There is a third kind of missile which at times has to be extracted such as a lead ball, or a pebble, or such like, which has penetrated the skin and become fixed within unbroken. In all such cases the wound should be laid open freely, and the retained object pulled out by forceps the way it entered. But some difficulty is added in the case of any injury in which a missile has become fixed in bone, or in a joint between the ends of two bones. When in a bone, the missile is swayed until the place which grips the point yields, after which it is extracted by the hand, or by forceps; this is the method also used in extracting teeth. In this way the missile nearly always comes out, but if it resists, it can be dislodged by striking it with some instrument. The last resort when it cannot be pulled out, is to bore into the bone with a trepan close by the missile, and from that hole to cut away the bone in the shape of the letter V, so that the lines of the letter which diverge to either side face the missile; after that it is necessarily loosened and easily removed. If the missile has forced its way actually into a joint between the ends of two bones, the limbs above and below are encircled by bandages or straps, by means of which they are pulled in opposite directions, so that the sinews are put on the stretch; the space between the ends of the bone is widened by these extensions, so that the missile is without difficulty withdrawn. In doing this care must be taken, as mentioned elsewhere, to avoid injury to a sinew, vein or artery
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while the weapon is being extracted by the same method which was described above.
But if the missile is also poisoned, after doing all the same things, even more promptly, if possible, in addition that treatment is to be applied which is given for one who has drunk poison, or has been bitten by a snake. The care of the wound itself after the extraction of the missile does not differ from that of a wound in which nothing has lodged and on which I have said enough elsewhere.
6 Such are lesions which can arise in any part of the body; the remainder occur in special situations, of these I am going to speak, beginning with the head. On the head many kinds of small tumours occur; besides those called ganglia, melicerides and atheromata, different authorities distinguish certain sorts by different names, and to these I myself will add one, steatoma. Although these tend to occur both in the neck and in the armpits and flanks, yet I have not dealt with them separately for there is little difference among them and none of them are dangerous and all are treated in the same way. Now all the above start from a very small beginning and grow slowly for a long time and have a coat of their own to enclose them. Some of them are hard and resistant, some soft and yielding; some become partially bald, others continue to be covered by their proper hair; generally they are painless. What they contain can be surmised, but cannot be fully known until the contents have been turned out. Generally, however, in those which are resistant, we find something like little stones, or balls of compressed hair; and in those which are yielding either some material similar to honey or thin
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porridge or something like grazed cartilage or bruised and bloody flesh, and the contents generally vary in colour. Ganglia are mostly resistant; atheromata have porridge-like contents; meliceris has a more fluid humour, and so it fluctuates when pressed upon; a steatoma contains a kind of fat. This last spreads most widely and loosens all the skin over it so that it is flaccid, although in the others the skin is more tense. All parts covered by hair should be shaved first and the incision made across the middle; but the coat of a steatoma is also to be cut into in order to let out whatever has collected within, because it is not easy to separate the coat from the skin and underlying flesh; in the other kinds the coating is to be preserved entire. Then as soon as the white and tight coat is seen, it is to be separated from the skin and flesh by the handle of the scalpel, and turned out together with its contents. But if muscle adheres to the deeper part of the tunic, lest it should be injured, only the superficial part of the tunic is to be cut away, and the deeper part left in position. When the whole has been removed the margins of the incision are to be brought together, a pin passed through them and, over this, an agglutinating medicament applied. When the whole, or any part of the coat has been left, suppuratives must be applied.
7 But whilst the preceding kinds of lesion do not differ much among themselves or in the mode of treatment, those in the eyes which demand surgical measures are different from each other and differently treated. For instance in the upper eyelid cysts are apt to be formed, fatty and weighty, which hardly allow the eyes to be raised, and they set up
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a slight but persistent discharge of rheum from the eyes; and these generally occur in children. When the eyeball has been pressed with two fingers so as to render the skin of the upper eyelid tense, a transverse linear incision is to be made with a scalpel, with so light a touch that the cyst itself is not cut into; when the way is opened it protrudes of itself. It should then be seized with the fingers and taken out, for it comes away easily. One of the ointments, with which running eyes are anointed, is then smeared on, and in a very few days a fine scar is induced. There is more trouble when the cyst has been cut into, for it lets out a humour, and afterwards, because it is very thin, it cannot be laid hold of. Should this chance to happen, something to promote suppuration should be applied.
A very small tumour forms in the same upper eyelid, above the line of the eyelashes, which from its resemblance to a barleycorn is termed by the Greeks crithê. Its contents are slow to come to a head and contained within a coat; it should be fomented with hot bread or with wax gently heated, but not so hot that it cannot easily be borne by that part; for under this treatment it is often dispersed, but at times it matures. When pus shows itself, it should be cut across with a scalpel and any humour inside squeezed out; then the eyelid is afterwards also to be fomented as above by steam, and ointment applied until it heals.
Other tumours also, not unlike these, form on the eyelids; but they are not quite the same shape and are mobile, so that they can be pushed about
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with the finger; and so the Greeks call them chalazia. They should be cut down upon, from the outside if under the skin, from the inside if under the cartilage, than separated from the sound tissue by the handle of the scalpel. If the cut is on the inner surface, first mild, then more acrid ointment is to be applied; if on the outer, an agglutinating plaster is put on.
An unguis too, called pterygium in Greek, is a little fibrous membrane, springing from the angle of the eye which sometimes even spreads so as to block the pupil. Most often it arises from the side of the nose, but sometimes from the temporal angle. When recent it is not difficult to disperse by the medicaments which thin away corneal opacities; if it is of long standing, and thick, it should be excised. After fasting for a day, the patient is either seated facing the surgeon, or turned away, so that he lies on his back, his head in the surgeon's lap. Some want him facing if the disease is in the left eye and lying down if in the right. Now one eyelid must be held open by the assistant, the other by the surgeon; but he holds the lower lid when seated opposite the patient, and the upper when the patient is on his back. Thereupon the surgeon passes a sharp hook, the point of which has been a little incurved, under the edge of the pterygium and fixes the hook in it; next, leaving that eyelid also to the assistant, he draws the hook towards himself thus lifting up the pterygium, and passes through it a needle carrying a thread; then having detached the needle, he takes hold of the two
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ends of the thread, and raises up the pterygium by means of the thread; he now separates any part of it which adheres to the eyeball by the handle of the scalpel until the angle is reached; next by alternately pulling and slackening the thread, he is able to discover the beginning of the pterygium and the end of the angle. For there is double danger, that either some of the pterygium is left behind and if this ulcerates, it is hardly ever amenable to treatment; or that with it part of the flesh is cut away from the angle; and if the pterygium is pulled too strongly, the flesh follows unnoticed, and when it is cut away a hole is left through which there is afterwards a persistent flow of rheum; the Greeks name it rhyas. Therefore the true edge of the angle must certainly be observed; and when this has been clearly determined, after the pterygium has been drawn forward just enough, the scalpel is to be used, then that little membrane is to be cut away as not to injure the angle in any way. After that, lint soaked in honey is to be put on, and over that a piece of linen, and either a sponge or unscoured wool. And for the next few days the eye must be opened daily to prevent the eyelids uniting by a scar for if that happens a third danger is added; and the lint is to be put on again, and last of all one of the salves applied which help wounds to heal. But this treatment ought to be in the spring, or certainly before winter; this warning applies to many cases, and it will be enough to give it here once for all. For there are two classes of treatment: one in which we cannot choose the time but must make the best of things, as in the case of wounds; the other in which there is no urgency and
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it is safest to wait, for example when the affection progresses slowly and the patient is not racked by pain. Then we should wait for spring, or if there is more urgency, autumn is better than either summer or winter, and especially mid-autumn when the hot weather has broken and the cold not yet begun. The more essential the part to be treated, the greater the danger; and often the larger the wound to be made, the more regard should thus be paid to the season.
In the course of treating pterygium, lesions arise, as I have just said, which are also apt to arise from other causes. Sometimes when the pterygium has not been quite cut away or from some other cause, a small tumour, called by the Greeks encanthis, forms at the angle and this does not allow the eyelids to be completely drawn down. It should be caught up with a hook and cut around, but with so delicate a touch that nothing is cut away from the angle itself. A bit of lint is then besprinkled with oxide of zinc or blacking, and inserted into that angle after separating the lids, and over this the dressing as above is bandaged on. Upon the following days, the eye is dressed in the same way, after having been fomented with tepid, or even with cold water.
At times the eyelids adhere together, and the eye cannot be opened. When this happens, the eyelids commonly adhere to the white of the eye, that is to say, when an ulceration upon either has been carelessly treated; for in the course of healing what could and should have been kept apart has been allowed to stick: the Greeks give the name of ancyloblepharus to one who suffers from both lesions. When the eyelids only stick together they
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are separated without difficulty, but sometimes this is useless for they stick together again. Separation should be tried, however, because it is generally a success. The reverse end of a probe is to be inserted and the eyelids separated by this, then small pledglets of wool are put in until ulceration of the part has ceased. But when an eyelid adheres to the white of the eye itself, Heraclides of Tarentum invented the method of cutting underneath the eyelid with the knife held, but very carefully, so that nothing is cut away, either from the eyeball, or from the eyelid, and if something must be, rather from the eyelid. The eyeball should afterwards be anointed with the medicaments with which trachoma is treated; and the eyelid turned up every day, not only that the medicament may be applied to the ulceration, but also lest the eyelid should adhere again; moreover the patient himself should be told to raise his eyelid frequently with two fingers. I for my part do not remember anyone to have been cured by this method. Meges also has recorded that he tried many times, but was never successful, for the eyelid has always again become adherent to the eyeball.
Again, at the angle next to the nostrils, there opens a sort of small fistula, due to some lesion, through which rheum persistently drips; the Greeks call it aigilops. This causes a persistent eye trouble; sometimes it even eats away the bone, and penetrates to the nostril. And at time it has the character of a carcinoma when the veins become distended and look jaundiced, the skin livid, hard and irritable to the slightest touch, and it gives rise to inflammation in the parts near to it. Of
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these affections it is dangerous to treat those which resemble carcinoma, for that even hastens death. Again, it is useless to treat those which penetrate to the nostrils for they never heal. But when limited to the angle, treatment is possible so long as we do not forget that it is difficult. The nearer the opening to the angle, the greater the deficiency, on account of the very narrow space for handling the lesion. When the trouble is fresh, however, cure is easier. Now the margin of the opening is to be caught up by a hook, then as I have described for fistula in general the whole channel down to the bone is to be excised; and the eye and adjacent parts having been well covered over, the bone is to be cauterized; and more thoroughly when there is already decay, in order that a thicker scale may separate. Some apply caustics, such as cobbler's blacking or bronze or copper filings, which act more slowly, and do not have the same effect. After cauterization of the bone, the same treatment is followed as in other burns.
The eyelashes also may irritate the eye from two causes: one is that the skin on the outer surface of the eyelid becomes relaxed and slips downwards, causing its eyelashes to be turned inwards against the eyeball because the cartilage does not simultaneously give way; in the other case, beyond the natural row of eyelashes another row sprouts out, which is directed straight inwards against the eyeball. The following are the modes of treatment. If eyelashes have grown where they ought not, a fine iron needle flattened like a spear point is put into the fire; then when the eyelid is turned up, so that the offending eyelashes can be seen by
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the operator, the red hot needle is passed along their roots, from the angle, for a third of the length of the eyelid, then for a second and for a third time, until the opposite angle is reached; this causes all the roots of the eyelashes so cauterized to die. A medicament is then applied to check inflammation, and when the crusts have become detached, cicatrization is to be induced. This kind of trouble is very easily cured. Some say that a needle carrying a doubled-up hair from a woman's head should be passed through the eyelid from within outwards close to the eyelashes, and where the needle has passed through, an eyelash is to be inserted into the loop of the said hair where doubled, and the eyelash drawn by the loop through to the outer surface of the eyelid; there it is to be glued down; and a medicament is then applied to agglutinate the puncture; thus it comes about that afterwards that eyelash is directed outwards. But in the first place this cannot be done unless the eyelash is rather long, and in this situation they are generally short; further, when numerous eyelashes are affected, the passing of a needle so many times is necessarily a prolonged torture, and it may set up severe inflammation. Lastly, when there is any rheum subsisting there, and the eye has been irritated previously by the eyelashes, and now by the perforation through the eyelid, it is scarcely possible that the glue binding down the eyelash should not be dissolved; and so it comes to pass that the eyelash returns to the position from which it was forcibly removed. But there is no doubt about the following treatment of too lax an eyelid, which is commonly practised by everybody. It is necessary to close the eye and
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from the middle, either of the upper or the lower eyelid, to seize a fold of skin between a finger and thumb, and so to raise it; then consider how much must be removed the lid to be in a natural position for the future. In this too there are two dangers; that if too much has been excised the eyeball cannot be covered, if too little nothing has been gained, and a patient has been cut to no purpose. Next where it is seen that incision is to be made, a mark must be made by two lines of ink, but in such a way that between the margin holding the eyelashes, and the marked line adjacent, there remains skin enough for a needle afterwards to take up. When everything is ready the scalpel is to be applied; and the incision nearer the eyelashes themselves is to be made first in the case of the upper lid, but second for the lower one; in the case of the left eye, the incision is made from the outer angle; of the right eye from the inner one; then the skin between the two incisions is to be excised. Next the edges of the wound are to be brought into opposition by one stitch, and the eye is to be closed and if the eyelid descends too little the suture is slackened, if too much, either the suture is tightened, or even an additional fine strip may be excised from the margin furthest from the eyelashes. Where the eyelid has been cut other sutures may be put in but not more than three. Further, in the case of the upper lid, a linear incision is to be made under the row of eyelashes itself, so that these having been drawn away from under are directed upwards, and when there is but a slight drooping of the upper lid, this alone may suffice; the lower lid does not need the additional incision. When these things
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have been done, a sponge squeezed out of cold water is bandaged on. The next day an agglutinating plaster is applied; on the fourth day the sutures are taken out, and a salve for repressing inflammation smeared on.
But in the course of the above treatment it sometimes happens that when too much skin has been excised, the eyeball is not covered; and occasionally this also occurs from some other cause: the Greeks call the condition lagophthalmus. If too much of the eyelid is lost, no treatment can restore it; if a small loss it may be remedied. Just below the eyebrow the skin is to be incised in the figure of a crescent with the horns pointing downwards. The incision should reach as far as the cartilage without injuring it; for should the cartilage be cut into, the eyelid will droop, and cannot afterwards be raised. Therefore if the skin is merely drawn apart, it follows that the bottom of the eyelid droops slightly because of the gap made by the cut above; into this gap lint is to be inserted, both to prevent the separated edges from reuniting, and to help the growth of the flesh between, so that the eyeball comes to be properly covered when the gap has filled up.
Whilst a defect in the upper eyelid is that it descends too little and so does not cover the eyeball, sometimes the lower lid is not raised enough but hangs down and gapes open, and cannot reach the upper lid. And this, too, happens sometimes from the defective treatment described above, sometimes from old age: the Greeks call it ectropion.
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If this is due to bad treatment, the same procedure as that noted above is employed, but the horns of the incision are to be directed now towards the jaws, not towards the eyeball: if from old age, all that extrudes is burnt away with a fine cautery, then honey smeared on; from the fourth day the eye is steamed, and anointed with medicaments to induce a scar.
Such as a rule are the lesions which are apt to occur around the eyeball in the angles or eyelids. But in the eyeball itself the outer tunic is sometimes raised, by the rupture or by the relaxation of certain membranes inside, and its shape becomes like a grape: the Greeks therefore call the lesion staphyloma. There are two modes of treatment. In one a needle carrying two threads is passed through the middle of its base, and first the two ends of the upper thread, and then those of the lower, are knotted, and these gradually cut through and so excise the staphyloma. In the other method, a piece about the size of a lentil is cut off from its tip, then oxide or carbonate of zinc is dusted on. After either method, wool soaked in white of egg is applied; subsequently the eye is steamed, and then anointed with soothing medicaments.
Again, small hard tumours in the white of the eyeball are called clavi, from a resemblance in shape to nailheads. These it is best to transfix with a needle at their base, and to cut away underneath the needle; then to anoint with soothing medicaments.
I have already made mention elsewhere of
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cataract, because when of recent origin it is also often dispersed by medicaments: when it is more chronic it requires treatment by surgery, and this is one of the most delicate operations. Before I speak of this, the nature of the eyeball itself has to be briefly explained. A knowledge of this is often useful, but especially here. The eyeball, then, has two external tunics, of which the outer is called by the Greeks ceratoides. In that part of the eye which is white it is fairly thick; over the region of the pupil it is thin. To this tunic the under one is joined; in the middle where the pupil is, it is pierced by a small hole: around this it is thin, further out it too is thicker and is called by the Greeks chorioides. These two tunics whilst enclosing the contents of the eyeball, coalesce again behind it, and after becoming thinned out and fused into one, go through the space between the bones, and adhere to the membrane of the brain. Under these two tunics, at the spot where the pupil is, there is an empty space; then underneath again is the thinnest tunic, which Herophilus named arachnoides. At its middle the arachnoides is cupped, and contained in that hollow is what, from its resemblance to glass, the Greeks call hyaloides; it is humour, neither fluid nor thick, but as it were curdled, and upon its colour is dependent the colour of the pupil, whether black or steel-blue, since the outer tunic is quite white: but this humour is enclosed by that thin
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membrane which comes over it from the interior. In front of these is a drop of humour like white of egg, from which comes the faculty of seeing; it is named by the Greeks crystalloides.
Now either from disease or from a blow, a humour forms underneath the two tunics in what I have stated to be an empty space; and this as it gradually hardens is an obstacle to the visual power within. And there are several species of this lesion; some curable, some which do not admit of treatment. For there is hope if the cataract is small, and immobile, if it has also the colour of sea water or of glistening steel, and if at the side there persists some sensation to a flash of light. If large, if the black part of the eye has lost its natural configuration and is changed to another form, if the colour of the suffusion is sky blue or golden, if it shakes and moves this way and that, then it is scarcely ever to be remedied. Generally too the case is worse when the cataract has arisen from a severe disease, from severe pains in the head or from a blow of a violent kind. Old age is not favourable for treatment, since apart from this lesion, sharpness of vision is naturally dulled; neither is childhood favourable, but rather intermediate ages. Neither a small nor a sunken eye is satisfactory for treatment. And in the cataract itself, there is a certain development. Therefore we must wait until it is no longer fluid, but appears to have coalesced to some sort of hardness. Before
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treatment the patient should eat in moderation and for three days beforehand drink water, for the day before abstain from everything. Then he is to be seated opposite the surgeon in a light room, facing the light, while the surgeon sits on a slightly higher seat; the assistant from behind holds the head so that the patient does not move: for vision can be destroyed permanently by a slight movement. In order also that the eye to be treated may be held more still, wool is put over the opposite eye and bandaged on: further the left eye should be operated on with the right hand, and the right eye with the left hand. Thereupon a needle is to be taken pointed enough to penetrate, yet not too fine; and this is to be inserted straight through the two outer tunics at a point intermediate between the pupil of the eye and the angle adjacent to the temple, away from the middle of the cataract, in such a way that no vein is wounded. The needle should not be, however, entered timidly, for it passes into the empty space; and when this is reached even a man of moderate experience cannot be mistaken, for there is then no resistance to pressure. When the spot is reached, the needle is to be sloped against the suffusion itself and should gently rotate there and little by little guide it below the region of the pupil; when the cataract has passed below the pupil it is pressed upon most firmly in order that it may settle below. If it sticks there the cure is accomplished; if it returns to some extent, it is to be cut up with the same needle and separated into several pieces, which can be the more easily stowed away singly, and form smaller obstacles to vision. After this the
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needle is drawn straight out; and soft wool soaked in white of egg is to be put on, and above this something to check inflammation; and then bandages. Subsequently the patient must have rest, abstinence, and inunction with soothing medicaments; the day following will be soon enough for food, which at first should be liquid to avoid the use of the jaws; then, when the inflammation is over, such as has been prescribed for wounds, and in addition to these directions it is necessary that water should for some time be the only drink.
Also with regard to the discharge of a thin rheum which troubles the eyes, I have already explained what is to be done by means of medicaments. I come now to cases which demand surgical treatment. But we have remarked that in some the eyes never dry up, but are always moistened by a thin rheum; this keeps up trachoma, and upon slight provocation excites inflammations and ophthalmia, so troubling the patient all his life; and sometimes this cannot be remedied at all, but sometimes it is curable. This is the first thing to be decided, that in the latter case the patient may be relieved, in the former no surgical treatment may be applied. And in the first place, the treatment is useless in those who have had the disorder from infancy, of necessity it will continue to their dying day; again, it is not necessary in those cases where the discharge is scanty, though acrid, since they will derive no benefit from surgery; by medicaments and by the regulation of diet which renders the rheum thicker, they come back to health. Further, broad heads are hardly ever adapted to the treatment. Then it makes a difference whether
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the rheum comes from blood vessels between the skull and the scalp, or from those between the membrane of the brain and the skull. Generally those above the skull irrigate the eyes by way of the temples, those under it by way of membranes connecting the eyes with the brain. Now it is possible to apply a remedy to those blood vessels which lie above the bone — to those below it is not. Neither can patients be relieved in whom rheum is flowing down both ways, because although relieved in one direction, none the less trouble continues by the other. How the matter stands is to be learnt as follows. The head having been first shaved, those medicaments by which the rheum is checked in ophthalmia are smeared on from the eyebrow to the crown of the head. If the eyes begin to dry, it is clear that the moisture comes from those blood vessels which are beneath the scalp; if in spite of the application, they continue moist, it is manifest that the downflow of rheum is from under the skull. If there is humour but in less amount, the lesion is double. In the majority of patients, however, it is found that the superficial blood vessels are involved, and so also the majority can be relieved. This is well known, not in Greece only, but among other races too, so that no portion of the Art of Medicine has become more widespread among the nations of the earth. Some Greek practitioners made nine linear incisions into the scalp, two vertical ones in the occipital region, a transverse one above
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them; then two above the ears, with a cross-cut uniting them, three vertical ones between the crown and the forehead. Others were found who drew those lines directly from the vertex to the temples and having ascertained where the muscles began from the movements of the jaws, cut through the scalp over them with a light hand, and after the margins of the incisions had been retracted by blunt hooks, inserted lint, in order that the former edges of the skin should not unite, and that flesh should grow up in between so as to constrict the veins carrying humour to the eyes. Some even marked out with ink two lines, from the middle of one ear to the middle of the other, and from the nose to the crown. Then, where the two lines meet, they cut with a scalpel, and after blood has flowed out, they cauterized the bone there. But further, both on the temples and also between the forehead and crown, they likewise applied the red hot cautery to prominent blood vessels. A treatment frequently used is to cauterize the blood vessels on the temples, which indeed in this malady are usually rather swollen, but in order that they may be more distended and show up better, the neck is first bandaged moderately tight and the blood vessels then burnt with fine blunt cautery points until the flow of rheum to the eyes ceases. For that is a sign of the blocking up as it were of the channels by which humor was being carried. There is a more effectual means, however, when the blood vessels are thin and deep-seated, and so cannot be picked out, whereby the neck is bandaged as before, and the patient holds his breath, so as to make the vessels more prominent, and then those on the temples and between the fore-
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head and vertex are marked out with ink; upon this the neck is released, the blood vessels are cut into where marked and blood let flow; when enough has been let out, the vessels are burnt with fine cauteries; over the temples this is done cautiously lest the underlying muscles controlling the jaws feel it; between the forehead and the crown the cautery is applied firmly in order that a scale may become detached from the skull. Even more efficacious is the African method; they burn the crown of the scalp through down to the bone so that it may cast off a scale. But there is nothing better than the practice in transalpine Gaul; there they pick out blood vessels in the temples and crown of the head. Now I have already explained the treatment after cautery. I here add that there should be no haste, either in detaching crust, or in letting the ulceration heal after cauterization of blood vessels, lest haemorrhage burst out, or pus be too quickly suppressed, for whilst it is the object by the ulceration to dry up these parts, it is not the object to drain them out by bleeding; but if there is bleeding, such medicaments should be sprinkled on as suppress bleeding, but do not cauterize. With regard to the selection of blood vessels, and what is to be done when they are picked out, I will speak when I come to varicose veins in the leg.
8 Whilst the eyes demand many kinds of surgical treatment, there are but few affections of the ears which are dealt with by this branch of medicine. It does happen, however, whether from birth, or later when there has been ulceration and the ear becomes filled up by scarring, that there is no passage in the ear and so it cannot hear. When this
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is the case, we must try with a probe whether the part is filled up deeply, or whether there is merely a superficial agglutination. For if deeply, there is no yielding to pressure made on the probe; if superficial, the probe enters freely. The former should not be touched, lest, where there is no hope of success, a spasm may be set up, and from that may follow danger of death. The latter is easily treated. For where the passage should be, either one of the caustic medicaments is to be applied, or an opening made with the cautery, or the place may even be cut through with a scalpel. After it has been laid open, and the ulceration has been cleaned, a quill is to be inserted, smeared with a medicament to induce a scar, and the same medicament applied around, until the skin has healed round the quill; by this means when the quill has been removed, the faculty of hearing follows. But where the ears, in a man for instance, have been pierced and have become offensive, it is enough to pass a red hot needle quickly though the hole in order to blister its margins superficially or even to produce the same effect by a caustic; then afterwards to put on applications to clean the place and later what will make the flesh grow there and induce a scar. But if the hole is enlarged, as is usually the case with those who have worn heavy ear-rings, the rest of the lobule should be cut through; then the edges above made raw with a scalpel, and the wound sutured, and agglutinating medicaments put on. A third method, where there has been some mutilation, is to patch, and since this can be done in the case of the lips and nostrils as well, and the procedure is the same, the description too should be given at the same time.
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9 Mutilations then occur in these three parts and can be treated if they are small; if they are large, either they are not susceptible of treatment, or else may be so deformed by it as to be more unsightly than before. And indeed in the ear and nostrils the deformity is the only trouble; but in the case of the lips, if these have become too much contracted, there is also loss of a necessary function, because it becomes less easy both to take food and to speak plainly. Now new substance is not produced at the place itself, but it is drawn from the neighbourhood; and when the change is small this hardly robs any other part and may pass unnoticed, but when large, it cannot do so. And again, this procedure in unsuited to the aged, to those in bad bodily condition, and to those whose wounds heal with difficulty; because there are no cases in which canker sets in more quickly, or is more difficult to get rid of. The method of treatment is as follows: the mutilation is enclosed in a square; from the inner angles of this incisions are made across, so that the part on one side of the quadrilateral is completely separated from that on the opposite side. Then the two flaps, which we have freed, are brought together. If they cannot be sufficiently brought together, at each end beyond the original incisions semilunar cuts which only divide the skin are made with the horns pointing towards the incisions. This enables the edges to be brought together more easily. No force should be used, but the traction should be such that the edges easily approximate and, when left free, do not recoil much. At times, however, if the skin has been drawn across from one side to a considerable extent, or even at all, it
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makes the part which it has left unsightly. In a case of that sort, leaving that side untouched, an incision should be made only on the other side. For instance we should not attempt to make traction upon the lobules of the ears, the bridge of the nose, the margins of the nostrils, or the corners of the lips. But we shall try traction from either side if anything is required for the upper part of the ears, the tip of the nose, the bridge of the nose, the skin between the nostrils, and the middle of the lips. At times the mutilation is in two places, but the method of treatment is the same. Cartilage if it projects into the incision is to be cut away; for it does not agglutinate nor is it safely transfixed by a needle. But it should not be much cut away lest pus collect on each side between the two margins of loose skin. Then the margins after being brought together are to be sutured by taking up from each skin only, and the earlier incisions are also to be sutured. In dry parts such as the nostrils, it is sufficient to spread on litharge. But into the more distance semilunar wounds lint is to be placed in order that flesh may grow and fill the wound; and it is clear that the greatest attention should be paid to what is thus sutured, from what I mentioned above about canker. Consequently every third day the part should be steamed, then dressed as before; and generally the wound has adhered by the seventh day. Then the sutures should be removed, and the wound allowed to heal.
10 As for the polypus which grows in the nostrils, I have already laid down elsewhere that the best treatment is with the knife. Therefore this too should be loosened from the bone by a sharp instru
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ment, shaped like a spear head, care being taken not to injure the cartilage under it, which is difficult to treat. When detached it is to be extracted by an iron hook; then the nostril is gently filled with lint folded or in a roll, soaked in something to stop the bleeding; when the bleeding has stopped, the ulceration is to be cleaned with a lint plug. When it is clean, insert a quill (as described above in the case of the ear), smeared with the medicament which causes a scar to form until healing is completed.
11 Now as to the lesion called by the Greeks ozaena, I have found nothing in the writings of great surgeons about surgical treatment if it did not yield to medicaments. I believe this is because it seldom heals quite completely, though the treatment its involves considerable pain. Some, however, lay down that either an earthenware tube, or a smooth quill, is to be inserted into the nostril until it reaches the bone, and then a fine cautery point is passed down that tube right to the bone. The cauterized spot is afterwards dressed with verdigris and honey, and when clean is healed by applying lycium. Or the nostril may be laid open from its base as far as the bone, so that the place can be seen, and the cautery more easily applied; then the nostril must be sewn up, and the cauterized ulceration treated as above; the fine suture is dressed with litharge or other agglutinant.
12 In the mouth too some conditions are treated by surgery. In the first place, teeth sometimes become loose, either from weakness of the roots, or from disease drying up the gums. In either case the cautery should be applied so as to touch the
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gums lightly without pressure. The gums so cauterized are smeared with honey, and swilled with honey wine. When the ulcerations have begun to clean, dry medicaments, acting as repressants, are dusted on. But if a tooth gives pain and it is decided to extract it because medicaments afford no relief, the tooth should be scraped round in order that the gum may become separated from it; then the tooth is to be shaken. And this is to be done until it is quite moveable: for it is very dangerous to extract a tooth that is tight, and sometimes the jaw is dislocated. With the upper teeth there is even greater danger, for the temples or eyes may be concussed. Then the tooth is to be extracted, by hand, if possible, failing that with the forceps. But if the tooth is decayed, the cavity should be neatly filled first, whether with lint or with lead, so that the tooth does not break in pieces under the forceps. The forceps is to be pulled straight upwards, lest if the roots are bent, the thin bone to which the tooth is attached should break at some part. And this procedure is not altogether free from danger, especially in the case of the short teeth, which generally have shorter roots, for often when the forceps cannot grip the tooth, or does not do so properly, it grips and breaks the bone under the gum. But as soon as there is a large flow of blood it is clear that something has been broken off the bone. It is necessary therefore to search with a probe for the scale of bone which has been separated, and to extract it with a small forceps. If this does not succeed the gum must be cut into until the loose scale is found. And if this has been done at once, the jaw outside the tooth hardens, so that the patient cannot
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open his mouth. But a hot poultice made of flour and a fig is then to be put on until pus is formed there: then the gum should be cut into. A free flow of pus also indicates a fragment of bone; so then too it is proper to extract the fragment; sometimes also when the bone is injured a fistula is formed which has to be scraped out. But a rough tooth is to be scraped in the part which has co black, and smeared with crushed rose-petals to which a fourth part of ox-galls and the same amount of myrrh has been added; and at frequent intervals undiluted wine is to be held in the mouth; and in this case the head is to be wrapped up, and the patient should have much walking exercise, massage of his head and food which is not too bitter. But if teeth become loosened by a blow, or any other accident, they are to be tied by gold wire to firmly fixed teeth, and repressants must be held in the mouth, such as wine in which some pomegranate rind has been cooked, or into which burning oak galls have been thrown. In children too if a second tooth is growing up before the first one has fallen out, the tooth which ought to come out must be freed all round and extracted; the tooth which has grown up in place of the former one is to be pressed upwards with a finger every day until it has reached its proper height. And whenever, after extraction, a root has been left behind, this too must be at once removed by the forceps made for the purpose which the Greeks call rhizagra.
Now tonsils which have become hardened after
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inflammation (they are called by the Greeks antiades) since they are enclosed in a thin tunic, should be scratched round with a finger and drawn out. But if they cannot be so detached they should be seized with a hook and excised with a scalpel; and the hollow then swilled out with vinegar and the wound smeared with something to check the blood.
If the uvula, owing to inflammation is elongated downwards, and is painful and dusky red in colour, it cannot be cut away without danger; for usually much blood flows: and so it is better to employ the treatment described elsewhere. But if, though there is no inflammation, it has become drawn so far downwards owing to phlegm, and is thin, pointed and white, it should be cut away; so also when the tip is bluish black and thick, but the base thin. There is no better way than to seize it with a small forceps and below this to cut off as much as we wish. And there is no danger of cutting off too much or too little since we can leave below the forceps only that part which is clearly useless; and cut away what is in excess of the natural length of the uvula. After the operation the same treatment should be carried out as I have just described for the tonsils.
Again the tongue in some persons is tied down from birth to the part underlying it, and on this account they cannot even speak. In such cases the extremity of the tongue is to be seized with a forceps, and the membrane under it incised, great care being taken lest the blood vessels close by are injured and bleeding causes harm. The treatment of the wound afterwards has been described above. And indeed many when the wound has healed have
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spoken; I have, however, known a case when, though the tongue has been undercut so that it could be protruded well beyond the teeth, nevertheless the power of speech has not followed. So it is that in the Art of Medicine even where there is a rule as to what ought to be done, yet there is no rule as to what result ensues.
Sometimes also under the tongue an abscess occurs which is generally enclosed in a coat and causes much pain. If it is small, one cut is enough; if large, the skin over it is to be excised down to the coating; then the two margins are laid hold of with hooks, and the coating is to be freed from what it surrounds and completely extracted, taking great care throughout the operation that no large blood vessel is cut into.
The lips often split, and this not only is painful but has the inconvenience that speech is hindered; as this is apt to enlarge the cracks painfully and so causes them to bleed. If the cracks are superficial they are better treated by the medicaments used for ulcerations of the mouth. But if the fissures have penetrated deeper, it is necessary to burn them with a fine cautery, spearhead shaped, which should as it were skim over them without being pressed down. Afterwards the same is to be done as for cauterization of the ears.
13 Now in the neck between the skin and the trachea, a tumour occurs which the Greeks call bronchocele, it contains now soft flesh, now a humour
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somewhat like honey or water, sometimes also hairs mixed up with minute bones; whatever the contents, they are enclosed in a coat. Treatment is possible by caustics which eat away the skin together with the underlying tunic. When this has been done, if there is humour inside, it flows out; if anything solid, it is turned out with the finger; the wound then heals under lint dressings. But treatment by the knife is shorter. A linear incision is made over the middle of the tumour down to the tunic; then the morbid pouch is separated by the finger from the sound tissue, and the whole is removed along with its covering. Next the wound is washed out with vinegar to which either salt or soda has been added, and the margins brought together by one suture; the rest of the applications are the same as in other cases of sutured wounds and after that it is lightly bandaged so as not to trouble the throat by pressure. But if it is impossible to take out the tunic, caustics are to be dusted into its interior, and it is then dressed with lint and other suppuratives.
14 There are also around the navel many lesions about which, owing to their rarity, there is little agreement among authorities. But it is probable that each has passed over what was unknown to himself; while no one has depicted what he had not seen. Common to all cases is an ugly prominence of the umbilicus, and the causes are sought for. Meges gave three; rupture into it of the intestine, of the omentum, or of humour. Sostratus said nothing about the omentum; in addition to the other two he said that at times there was increase of flesh in that part, sometimes sound, sometimes cancerous. Gorgias himself also omitted mention of the
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omentum; but he gave the same number of causes, three, and said that occasionally wind also ruptured into it. Heron having given all these four causes, made mention of both the omentum and of that form which was caused simultaneously by the omentum and intestine. But which of these causes it is, may be recognized by the following indications. When intestine has prolapsed the swelling is neither hard nor soft; it is reduced by anything cold; and it increases not only under heat of all kinds but also when the breath is held. At intervals it rumbles, and if the patient lies down on his back the swelling subsides, as the intestine has slipped back. But when it is the omentum, whilst other signs are similar, the swelling is softer, broad at its base, thinned out towards its apex; if any one grasps it, it slips away. When both intestine and omentum have prolapsed, the signs are mingled, and the softness is intermediate between the two; but the flesh is harder, and even when the patient lies on his back there is always swelling, and it does not yield to pressure, to which the preceding forms yield readily. If it is malignant the signs are the same as I have stated for cancer. Humour fluctuates when pressed upon; wind, on the other hand yields under pressure, but returns at once, also the swelling retains the same shape when the patient lies down on his back. Of these varieties, the disorder due to wind does not admit of treatment; also cancerous flesh is dangerous to treat, so should be left alone. Sound flesh ought to be cut away and the wound dressed with lint. Some let out humour, either by perforating with a needle, or by cutting into the apex of the tumour, and then similarly dressing the wound with lint. As to the
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rest of the treatment opinions vary. Of course the patient must be laid on his back, in order that the swelling, whether it be intestine or omentum, may slip back into the abdomen. But when the navel sac was then empty, some caught it between two little rods, and fastened the ends of the rods tightly together, so that it mortified there; some passed a needle doubly threaded through the base of the sac, then knotted the two ends of each thread on opposite sides, as is done also in staphyloma of the eye; from in this way that part beyond the ligatures mortifies. Some, in addition, before tying the ends also cut into the protrusion along a marked line and excised it: in order that they might more easily insert a finger and push back whatever had ruptured into the sac; then at length they tied the ligatures. But it is quite enough to order the patient to hold his breath so that the tumour shows itself at its largest; then to mark its base with ink; next with the patient on his back, to compress the tumour with the fingers, so that whatever has not slipped back of itself is forced back by the hand. After this the umbilicus is drawn forwards, and tightly constricted with flaxen thread along the marks of the ink; next the part beyond the ligature is either burnt with caustics or with the cautery, until it mortifies, after which the wound is dressed like other burns. This method answers best, not only when it is intestine or omentum or both, but even when it is humour. But first precautions must be taken against any danger from the ligature. For neither an infant nor a robust adult nor an old man is suited to this treatment, but a child between seven and fourteen years of
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age. Secondly a suitable body for it is one that is sound, but where there is general ill-health, or pustules or eruptions, and such like, it is not suitable. The smaller tumours also are readily curable, but there is danger in the treatment of those which are excessively large. Moreover the autumn and winter seasons should be avoided, the spring is the best season, early summer is not unfavourable. The patient should also fast on the day before the operation, and that is not enough, but the bowels also are to be moved by a clyster, in order that all that has extruded may more readily return into the abdomen.
15 I have said elsewhere that in those who are dropsical the water ought to be let out: here I must describe how this should be done. Now some make the perforation about four fingers breadth below the navel, and to the left; some make it by perforating the navel itself; some first burn through the skin and then cut into the abdominal cavity, because flesh which has been divided by cautery heals less quickly. Now when entering the knife great care should be taken that no blood vessel is cut into. The knife must be such that its point should be about the third of a finger's breadth, and it should be so entered as to penetrate the membrane separating the flesh from the interior; then a lead or bronze tube should be inserted, either with lips curved back at its outer end, or with a collar round the middle so that the whole of it cannot slip inside. The part of the tube within the abdominal cavity should be a little longer than the part outside, in order that it may project inwards beyond the deeper membrane. Through this tube
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the humour is let out; and when the greater part has escaped, the tube is to be closed by a lint plug, and left in the wound if it was not burnt with a cautery; then on each of the following days about one hemina is let out, until there appears no trace of fluid. Some, however, even when the skin has not been cauterized, take out the tube forthwith, and then bandage on the wound a squeezed-out sponge; then on the next day they pass in a tube again (which the recent wound admits if it is slightly stretched) in order that any remaining fluid may be let out. They are satisfied when this has been done twice in this manner.
16 Sometimes the abdomen is penetrated by a stab of some sort, and it follows that intestines roll out. When this happens we must first examine whether they are uninjured, and then whether their proper colour persists. If the smaller intestine has been penetrated, no good can be done, as I have already said. The larger intestine can be sutured, not with any certain assurance, but because a doubtful hope is preferable to certain despair; for occasionally it heals up. Then if either intestine is livid or pallid or black, in which case there is necessarily no sensation, all medical aid is vain. But if intestines have still their proper colour, aid should be given with all speed, for they undergo change from moment to moment when exposed to the external air, to which they are unaccustomed. The patient is to be laid on his back with his hips raised; and if the wound is too narrow for the intestines to be easily replaced, it is to be cut until sufficiently wide. If the intestines have already become too dry, they are to be bathed with water
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to which a small quantity of oil has been added. Next the assistant should gently separate the margins of the wound by means of his hands, or even by two hooks inserted into the inner membrane: the surgeon always returns first the intestines which have prolapsed the later, in such a way as to preserve the order of the several coils. When all have been returned, the patient is to be shaken gently: so that of their own accord the various coils are brought into their proper places and settle there. This done, the omentum too must be examined, and any part that is black dead is to be cut away with shears; what is sound is returned gently into place in front of the intestines. Now stitching of the surface skin only or of the inner membrane only is not enough, but both must be stitched. And there must be two rows of stitches, set closer together than in other places, partly because they can be broken here more easily by the abdominal movement, partly because that part of the body is not specially liable to severe inflammations. Therefore two needles are to be threaded and one is to be held in each hand; and the stitches are to be inserted, first through the inner membrane, so that the surgeon's left hand pushes the needle from within outwards through the right margin of the wound, and his right hand through the left margin, beginning from one end of the wound. The result is that it is the blunt end of the needle which is always being pushed away from the intestines. When each margin has been once traversed, the hands interchange needles, so that into the right hand comes the needles which was in the left, and into the left the needle which was in the right; and again, after the same
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method they are to be passed through the margins; and when for the third and fourth time, the needles have changed hands the wound is to be closed. Afterwards the same thread and the same needles are now transferred to the skin, and stitches are to be inserted by a like method into this as well, always directing the needles from within outwards, and with the same change, between the hands. It is too obvious to need constantly repeating that agglutinants are then to be put on with the addition either of a sponge or of greasy wool, squeezed out of vinegar. Over this application the abdomen should be lightly bandaged.
17 Sometimes, however, whether from some blow, or from holding the breath too long, or from carrying a heavy weight, the inner membrane of the abdomen is ruptured, whilst the skin over it is entire. This often occurs too in the case of women from childbearing, and it particularly takes place in the iliac regions. But it follows since the overlying flesh is soft, that it does not hold the intestines properly in place and that the skin is stretched by them and forms an ugly swelling. And this too is treated differently by different surgeons. For some pass two threads through the base by means of a needle, and then tie on each side, as has been described for the navel and for staphyloma, in order that what is beyond the ligature may mortify; some excise the middle of the swelling by a myrtle-leaf shaped incision, which as I said is the method which should always be adopted, and then they unite the edges by stitching. But the best way is with the patient on the back, to try with the hand in which part the swelling is most yielding, for of necessity it is at
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that part that the inner membrane is ruptured, and where it is entire the swelling is more resistant. Where the rupture is seen to be, two linear incisions are made with a scalpel, so that when what lies between has been excised, the inner membrane has a wound freshly made on each side, because stitching will not unite a lesion of long standing. When on exposure any part of the membrane presents not a recent but an old rupture, a thin strip is to be pared away, which only just makes the margins raw. All the directions for stitching and further treatment have been given above.
Besides the above there are sometimes varicose veins upon the abdominal wall, and because there is no other treatment for these than what is usual for the legs since I shall treat of that part later, I will defer this too till then.
18 Now I come to those lesions which are apt to arise in the genital parts around the testicles; and to explain them more easily, the nature of the said region must briefly be described first. The testicles then are somewhat like marrow, for they do not bleed and they lack all feeling; but the coverings by which they are enclosed give pain both when injured and inflamed. Now the testicles hang from the groins, each by a cord which the Greeks call the cremaster with each of which descend a pair of veins and a pair of arteries. And these are ensheathed in a tunic, thin, fibrous, bloodless, white, which is called by the Greeks elytroides. Outside this is stronger tunic, which at its lowest part is
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closely adherent to the inner one; the Greeks call it dartos. Further, many fine membranes hold together the veins, and the arteries, and the cords aforesaid, and also in between the two tunics there are some fine and very small membranes, descending from the parts above. Thus far the coverings and supports belong to each testicle separately; next common to both and to all within is the pouch which is now visible to us; the Greeks call it oscheon, we the scrotum; and at its lowest part this is slightly connected with the middle coverings, higher up it is only surrounded by them. Now, underneath the scrotal covering many lesions are apt to occur, sometimes after the rupture of the coverings which, as I have said, begin from the groins, sometimes when they are uninjured. Since at times either owing to disease there is first inflammation, then afterwards a rupture from the weight; or after some blow there, there is a direct rupture of the covering which ought to separate the intestines from the parts below; then either omentum, or it may be intestine, rolls down by its own weight; this having found a way gradually from the groins into the parts below as well, there separates by its pressure the coverings which are fibrous and therefore give way. The Greeks call the condition enterocele and epiplocele, with us the ugly but usual name for it is hernia.
Now if omentum has come down, the tumour in the scrotum never disappears, either if the patient fasts, or if his body is turned from side to side, or lies in some special position; again, if the breath is held, it does not increase to any extent; to the touch it seems uneven and soft and slippery. But if intestine has also come down this tumour is with-
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out inflammation, sometimes it diminishes, sometimes increases, and it is generally painless and soft. When the patient is quiescent or lying down, it disappears, at times altogether; sometimes it becomes divided so that very small remnants stay in the scrotum. But after shouting or over-eating, or if the patient has been strained by a weight of any sort, it increases; under all kinds of cold it shrinks, under heat it enlarges; then the scrotum becomes globular and smooth to the touch; and within the scrotum the intestine slips about, when pressed upon it reverts towards the groin, when released it rolls down again with a sort of murmur. That is what happens in slight cases; but at times, when faeces have been taken in, it swells more largely, it cannot be forced back, and it then brings on pain both in the scrotum and in groins and abdomen. At times the stomach also becomes affected, and there is an issue from the mouth, first of red, then of green, and even in some of black bile. At times too, whilst the membranes remain entire, fluid distends the scrotum. There are two forms of this affection: for the fluid collects either between the coverings or in the membranes surrounding the veins and arteries, and then these membranes become thickened and weighted down. And even if the fluid lies between the membranes it is not confined to one place; it may lie between the superficial and middle membrane, or between the middle and inner membranes. The Greeks have one general name, they call it hydrocele, whichever kind it is; our people, not knowing enough perchance to make distinctions, call it by the same name as the preceding disorder. Now
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there are signs, some common to all cases, some particular: the common one is the existence of the fluid; the particular, the situation of it. We learn that there is fluid underneath, if the swelling never disappears entirely although it is at times less, whether from fasting or feverishness, and especially in boys; the tumour is soft when the fluid contained is only small in amount; but if it increases to a great extent, the tumour becomes tense like a wineskin which has been filled and tightly tied. Also veins in the wall of the scrotum are distended; and upon pressure with the finger the fluid recedes, and as it flows round raises up the part where there is no pressure and is seen through the scrotal wall as if it were contained in a glass or horn vessel; and however much is there is no pain. But the situation of the fluid is recognized as follows: if it is between the scrotal wall and the middle membrane, when we press with two fingers, the humour gradually comes up, returning as the fingers are withdrawn; the scrotal wall is whiter than natural; if it is drawn upon, it stretches either not at all, or very little; the testicle on that side cannot be seen or felt. But if it is under the middle membrane, the scrotum is stretched and more raised up, so that the root of the penis is concealed under the swelling. Besides the above a varicose affection which the Greeks call cirsocele occurs, in which also the membranes are intact. The veins become swollen, and when twisted, and massed together at the upper part, they distend the scrotum generally, or the middle or the inner covering; sometimes they grow even beneath the inner covering around the actual
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testicle and its cord. Of these the veins in the scrotal wall can be seen; but those situated in the middle or inner coverings, being more deeply placed, are not indeed equally visible but even these can be seen, especially because there is a certain amount of swelling in proportion to the size and form of the veins, and this is more resistant to pressure, and also is rendered irregular owing to the bulgings of the veins, whilst the testicle on that side hangs lower down than it ought. But when the disease has spread also over the testicle and its cord, the testicle sinks a little lower, and becomes smaller than its fellow, in as much as its nutrition has become defective. Sometimes, though rarely, flesh also grows between the tunics; the Greeks call this sarcocele. At times also the testicle itself swells owing to inflammation and this causes fever as well. And unless this inflammation quickly subsides, pain spreads to the inguinal and iliac regions, and these parts swell; the cord from which the testicle hangs becomes fuller, and at the same time it hardens. Besides this it happens sometimes that the groin is occupied by a rupture; they call it bubonocele.
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.