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Book VI

This webpage reproduces a section of
De Medicina (On Medicine)

A. Cornelius Celsus

published in Vol. III
of the Loeb Classical Library edition, 1935

The text is in the public domain.

This text has not yet been proofread.
If you find a mistake though,
please let me know!


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(Vol. III) Celsus
On Medicine

 p295  Book VII


The third part of the Art of Medicine is that which cures by the hand,1 as I have already said,2 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. 2 [Legamen ad versionem Latinam]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. 3 [Legamen ad versionem Latinam]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  p297 several volumes. Gorgias also and Sostratus and Heron and the two Apollonii and Ammonius, the Alexandrians,3 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.

4 [Legamen ad versionem Latinam]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.

5 [Legamen ad versionem Latinam]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.4 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  p299 with cases which occur anywhere in the body5 I shall pass on to those which occur in special situations.6

1 1   [Legamen ad paginam Latinam] First then the displacements,7 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. 2 [Legamen ad versionem Latinam]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 1   [Legamen ad paginam Latinam] 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 elsewhere8 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 shouldº 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  p301 third day until every indication of inflammation has gone. 2 [Legamen ad versionem Latinam]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 callus9 being called a coat, since it covers. 3 [Legamen ad versionem Latinam]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 elsewhere10 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. 4 [Legamen ad versionem Latinam]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;  p303 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 ensuesº 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. 5 [Legamen ad versionem Latinam]Most abscesses require a linear incision; but in that termed panus,11 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. 6 [Legamen ad versionem Latinam]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  p305 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. 7 [Legamen ad versionem Latinam]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 elsewhere12 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.13

3 1   [Legamen ad paginam Latinam] 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.14 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. 2 [Legamen ad versionem Latinam]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  p307 has been let out. And one cause for anxiety is if the wound is insensible to corrosives. But while it is chance15 that makes the signs point now one way, now another, it is the practitioner's part to strive to bring about healing. 3 [Legamen ad versionem Latinam]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. 4 [Legamen ad versionem Latinam]Although the growth of flesh is helped by these medicaments, this is better attained, as I have said elsewhere, by a careful regimen;16 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 1   [Legamen ad paginam Latinam] 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;17 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  p309 the same way with the probe and knife; so also when they present multiple branchings. bWhen the end of the fistula is reached, all the callus should be cut out, then pins18 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 bone19 has been treated, suppuratives are put on.

2 [Legamen ad versionem Latinam]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 septum20 separating the viscera above from the intestine. bThis 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.

3 [Legamen ad versionem Latinam]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  p311 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.21 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.22 bTherefore 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.23 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.

4 [Legamen ad versionem Latinam]Special consideration is required in the case of those in the anus.24 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  p313 make one. Meanwhile the patient can do his business, walk, bathe, and take food as if in the best of health. bOnly 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. cThis 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.25 Even here, however, the knife must be used, if the fistula extends inwards, or is multiple. dIn 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.26 If, however, from one  p315 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 bougie27 is to be put in. eBut 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 1   [Legamen ad paginam Latinam] Missiles28 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. bBut 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  p317 heals more easily because it can be dressed with a medicament at both ends. cBut 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,29 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.

2 [Legamen ad versionem Latinam]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. bWhen a passage out has been laid open, the flesh ought to be stretched apart by an instrument like a Greek letter;30 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  p319 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. cNor 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.

3 [Legamen ad versionem Latinam]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.31 The instrument32 consists of two iron or even copper blades, bone 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  p321 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.

4 [Legamen ad versionem Latinam]There is a third kind of missile which at times has to be extracted such as a lead ball,33 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. bWhen 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.34 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. cIf 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  p323 while the weapon is being extracted by the same method which was described above.35

5 [Legamen ad versionem Latinam]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.36 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.37

6 1   [Legamen ad paginam Latinam] 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 tumours38 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 areº dangerous and all are treated in the same way. 2 [Legamen ad versionem Latinam]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  p325 porridge or something like grazed cartilage or bruised and bloody flesh, and the contents generally vary in colour. 3 [Legamen ad versionem Latinam]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.39 4 [Legamen ad versionem Latinam]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 1   [Legamen ad paginam Latinam] 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  p327 a slight but persistent discharge of rheum from the eyes; and these generally occur in children. bWhen 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.

2 [Legamen ad versionem Latinam]A very small tumour forms in the same upper eyelid, above the line of the eyelashes, which from its resemblance to a barleycorn40 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,41 and ointment applied until it heals.

3 [Legamen ad versionem Latinam]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  p329 with the finger; and so the Greeks call them chalazia.42 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.

4 [Legamen ad versionem Latinam]An unguis43 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;44 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,45 or turned away, so that he lies on his back, his head in the surgeon's lap. bSome 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  p331 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. cFor 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.46 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. dAfter 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 danger47 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. eFor 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  p333 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.

5 [Legamen ad versionem Latinam]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,48 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.

6 [Legamen ad versionem Latinam]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 ancyloblepharus49 to one who suffers from both lesions. When the eyelids only stick together they  p335 are separated without difficulty, but sometimes this is useless for they stick together again. bSeparation 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. cThe eyeball should afterwards be anointed with the medicaments with which trachoma is treated;50 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.

7 [Legamen ad versionem Latinam]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.51 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. bOf  p337 these affections it is dangerous to treat those which resemble carcinoma, for that even hastens52 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. cWhen 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 general53 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.

8 [Legamen ad versionem Latinam]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. bIf 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  p339 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. cThis 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. dBut 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. eBut 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  p341 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. fNext 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 ready54 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. gNext 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. hWhen these things  p343 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.

9 [Legamen ad versionem Latinam]But in the course of the above treatment it sometimes happens that when too much skin has been excised,55 the eyeball is not covered; and occasionally this also occurs from some other cause: the Greeks call the condition lagophthalmus.56 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. bThe 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.

10 [Legamen ad versionem Latinam]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,57 sometimes from old age: the Greeks call it ectropion.58  p345 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.

11 [Legamen ad versionem Latinam]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.59 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.60 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.

12 [Legamen ad versionem Latinam]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.

13 [Legamen ad versionem Latinam]I have already made mention elsewhere61 of  p347 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.62 In that part of the eye which is white it is fairly thick; over the region of the pupil it is thin. bTo 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.63 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.64 cAt its middle the arachnoides is cupped, and contained in that hollow is what, from its resemblance to glass, the Greeks call hyaloides;65 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  p349 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.66

14 [Legamen ad versionem Latinam]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;67 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. bGenerally too the case is worse when the cataract has arisen from a severe disease, from severe pains68 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  p351 treatment the patient should eat in moderation and for three days beforehand drink water, for the day before abstain from everything. cThen 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. dThereupon 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.69 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. eWhen 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.70 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. fAfter this the  p353 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,71 and in addition to these directions it is necessary that water should for some time be the only drink.

15 [Legamen ad versionem Latinam]Also with regard to the discharge of a thin rheum which troubles the eyes, I have already explained72 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. bThis 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.73 Further, broad heads74 are hardly ever adapted to the treatment. cThen it makes a difference whether  p355 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.75 dThe 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.76 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. eSome Greek practitioners made nine linear incisions into the scalp, two vertical ones in the occipital region, a transverse one above  p357 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. fSome 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. gA treatment frequently used77 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. hThere 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 forehead  p359 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; iover 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. kNow I have already explained the treatment after cautery.78 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.79

8 1   [Legamen ad paginam Latinam] 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  p361 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. 2 [Legamen ad versionem Latinam]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. 3 [Legamen ad versionem Latinam]But where the ears,80 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. 4 [Legamen ad versionem Latinam]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.81

 p363  9 1   [Legamen ad paginam Latinam] 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. 2 [Legamen ad versionem Latinam]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.82 3 [Legamen ad versionem Latinam]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  p365 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. 4 [Legamen ad versionem Latinam]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. 5 [Legamen ad versionem Latinam]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 1   [Legamen ad paginam Latinam] As for the polypus which grows in the nostrils, I have already laid down elsewhere83 that the best treatment is with the knife. Therefore this too should be loosened from the bone by a sharp instrument, 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 form84 until healing is completed.

11 [Legamen ad paginam Latinam] Now as to the lesion called by the Greeks ozaena,85 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 1   [Legamen ad paginam Latinam] 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  p369 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.86 bAnd 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. cThe 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. dIt 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  p371 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. eA 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 become 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. fIn 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.87

2 [Legamen ad versionem Latinam]Now tonsils88 which have become hardened after  p373 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.

3 [Legamen ad versionem Latinam]If the uvula,89 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.90 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. bAnd 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.91

4 [Legamen ad versionem Latinam]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 areº injured and bleeding causes harm. The treatment of the wound afterwards has been described above. And indeed many when the wound has healed have  p375 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.

5 [Legamen ad versionem Latinam]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.92

13 1   [Legamen ad paginam Latinam] Now in the neck between the skin and the trachea,93 a tumour occurs which the Greeks call bronchocele, it contains now soft flesh, now a humour  p377 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. 2 [Legamen ad versionem Latinam]But treatment by the knife is shorter.94 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 1   [Legamen ad paginam Latinam] 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. 2 [Legamen ad versionem Latinam]Gorgias himself also omitted mention of the  p379 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. 3 [Legamen ad versionem Latinam]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.95 4 [Legamen ad versionem Latinam]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,96 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  p381 rest of the treatment opinions vary. 5 [Legamen ad versionem Latinam]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;97 from in this way that part beyond the ligatures mortifies. 6 [Legamen ad versionem Latinam]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. 7 [Legamen ad versionem Latinam]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  p383 age. 8 [Legamen ad versionem Latinam]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 1   [Legamen ad paginam Latinam] I have said elsewhere that in those who are dropsical the water ought to be let out:98 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;99 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; 2 [Legamen ad versionem Latinam]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  p385 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 hemina100 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 1   [Legamen ad paginam Latinam] 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.101 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. 2 [Legamen ad versionem Latinam]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  p387 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. 3 [Legamen ad versionem Latinam]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. This102 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 membrane103 only is not enough, but both must be stitched. 4 [Legamen ad versionem Latinam]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. 5 [Legamen ad versionem Latinam]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  p389 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 1   [Legamen ad paginam Latinam] 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. bFor some pass two threads through the base by means of a needle, and then tie on each side, as has been described for the navel104 and for staphyloma,105 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 said106 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  p391 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.

2 [Legamen ad versionem Latinam]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.107

18 1   [Legamen ad paginam Latinam] 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 cremaster108 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.109 2 [Legamen ad versionem Latinam]Outside this is stronger tunic, which at its lowest part is  p393 closely adherent to the inner one; the Greeks call it dartos.110 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,111 we the scrotum; and at its lowest part this is slightly connected with the middle coverings, higher up it is only surrounded by them. 3 [Legamen ad versionem Latinam]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 enterocele112 and epiplocele, with us the ugly but usual name for it is hernia.

4 [Legamen ad versionem Latinam]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 without 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. 5 [Legamen ad versionem Latinam]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. 6 [Legamen ad versionem Latinam]At times the stomach also becomes affected, and there is an issue from the mouth,113 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.114 7 [Legamen ad versionem Latinam]The Greeks have one general name, they call it hydrocele,115 whichever kind it is; our people, not knowing enough perchance to make distinctions, call it by the same name as the preceding disorder. Now  p397 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. 8 [Legamen ad versionem Latinam]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:116 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. 9 [Legamen ad versionem Latinam]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 cirsocele117 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  p399 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.118 11 [Legamen ad versionem Latinam]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.119

19 1   [Legamen ad paginam Latinam] 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  p401 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. 2 [Legamen ad versionem Latinam]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 membranes120 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 tunics121 upon the abdominal wall. 3 [Legamen ad versionem Latinam]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  p403 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; 4 [Legamen ad versionem Latinam]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 membrane122 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.123 5 [Legamen ad versionem Latinam]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.

6 [Legamen ad versionem Latinam]But when an incision is required lower down, then with the man on his back, the left hand is to  p405 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. 7 [Legamen ad versionem Latinam]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,'124 he lays it open so that his index and middle finger can enter. 8 [Legamen ad versionem Latinam]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 too125 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  p407 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. 9 [Legamen ad versionem Latinam]Here also it must be seen to that no blood remains in the scrotum.126 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. 10 [Legamen ad versionem Latinam]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. 11 [Legamen ad versionem Latinam]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  p409 incision; and enough lint must be put on to cover the opening. When the inflammation is at an end, for the sake of the cords127 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.128

20 1   [Legamen ad paginam Latinam] After this introduction, we come to particular conditions. And if in a young child intestine prolapses, bandaging should be tried before the knife. For this a strip of linen is taken, to one end of which is stitched a ball of rags which is placed on the prolapse itself so as to push back the intestines: then the rest of the strip of bandage is firmly tied all round; under this the intestines are often forced inside and the tunics become agglutinated together. 2 [Legamen ad versionem Latinam]Again, if the patient is older, and the large size of the swelling shows that much of the intestines has come down, and if in addition there is pain and vomiting, which generally happens because faeces from undigested food have slipped down, then it is clearly impossible to employ the knife except harmfully; the trouble can only be mitigated, and must be drawn out by other measures. Blood should be let from the arm, then if the patient's strength permits, fasting for three days should be prescribed, or else at least for as long as the strength allows. 3 [Legamen ad versionem Latinam]Meanwhile a plaster of linseed first boiled in honey wine is to be kept on over the hernia. Later one of barley meal with resin is to be applied, and the patient immersed in a bath of hot water to which olive oil also has been added; after which some light warm food is to be given. Some also employ a clyster; but that can only bring down something  p411 into the scrotum, and cannot evacuate anything from it. When by the measures just described, the disease has been mitigated, if at any time pain recurs, the same measures will have to be repeated which we have just found to be beneficial. 4 [Legamen ad versionem Latinam]If without causing any pain, a large amount of intestine has prolapsed, it is useless to operate; not that it is impossible to push back the intestines out of the scrotum, unless inflammation prevents it, but because as they are forced back they may become impacted in the groins and give rise to a swelling, so that the trouble is not ended but only changed in position. But in a case which is suitable for treatment by the knife, as soon as the incision made in the groin reaches the middle tunic, this must be seized near the margins by a couple of hooks, when, after drawing down all the fine membranes the surgeon sets it free. Nor is there any danger in wounding what has to be cut out, since the intestine must lie underneath it. 5 [Legamen ad versionem Latinam]When the middle tunic has been thus drawn down, it is slit open from the groin to the testicle, but so as not to injure the latter; then it is cut away.129 Generally, however, this treatment is only admissible in boyhood and when the trouble is limited. For a robust man with a more extensive disorder the testicle should not be turned out, but kept in position. The procedure is as follows. The groin is laid open as before down to the middle tunic, and this tunic is seized as described above with two hooks, whilst the assistant keeps the testicle in its place, so that it does not come out of the wound; 6 [Legamen ad versionem Latinam]then the middle tunic is cut into with a scalpel towards its lower part, and through the opening the index finger of the left hand is passed beneath the testicle which  p413 is forced up into the wound; then the thumb and forefinger of the right hand separate the vein, the artery and the cord, and their tunic130 from the one above them. Any little membranes in the way are divided with a scalpel until now the entire tunic comes into view. After cutting away what has to be excised, and replacing the testicle, a rather broad strip is to be pared off from the edges of the wound in the groin, so that by making the wound broader it may form more flesh.

21 1   [Legamen ad paginam Latinam] But if omentum comes down, the groin is to be cut into as described above, and the tunics131 drawn down. Then it must be considered whether the mass is rather large or only small. For when quite small the omentum may be pushed back beyond the groin into the abdominal cavity, either with the finger, or with the opposite end of a probe; if the mass is larger what has prolapsed from the belly should be left hanging out of the wound, and smeared with caustic medicaments until it mortifies and falls off. bIn this condition too some transfix the tumour with a doubly threaded needle, and tie the two ends of each thread on opposite sides, under which treatment it mortifies, but more slowly. This may, however, be hastened by smearing the omentum beyond the ligature with medicaments which eat it away but do not erode; the Greeks call them septa.132 cSome have cut away the omentum with shears. If it is quite small, this is unnecessary; if larger, bleeding may follow, because the omentum itself is connected with blood vessels, some rather large. And although in the case of an abdominal wound, prolapsed omentum is cut away  p415 with shears after it has mortified and there is no other safe way of removing it, no precedent can be drawn from that for this case. As to the treatment of the wound when the omentum has been replaced, it should be stitched; if the quantity was large, and has been left outside to mortify, the margins should be pared as described above.133

2 [Legamen ad versionem Latinam]But if a hydrocele134 occurs, in boys an incision is to be made in the groin, unless in their case too the large quantity of liquid prevents it; in men, and when there is a large amount of fluid, a scrotal incision is made. So then if the incision is in the groin, when the tunics have been drawn forwards the humour must then be evacuated there; if in the scrotum, and if the trouble is immediately beneath, there is nothing to do but to let out the fluid and cut away any membranes which are keeping it in; then the incision is washed with water to which salt or nitre has been added. If the fluid is under the middle tunic, or under the inner one, these tunics have to be brought out of the scrotal wound, and cut away.

22 1   [Legamen ad paginam Latinam] Now a varix,135 when in the scrotal skin, must be burnt with finely pointed cauteries, which penetrate into the veins themselves, but so that nothing deeper than the veins is burnt; the cautery is to be applied especially where the veins form a twisted mass. Then flour which has been steeped in cold water is put on and over this the bandage I have described as suitable after anal operations.136 On the third day lentil meal with honey is applied: after the crusts have separated the ulcers are to be cleaned with honey, filled with rose oil, and cicatrized with dry lint. 2 [Legamen ad versionem Latinam]But when the veins overlying the middle tunic swell, the groin is to be  p417 incised and the tunic pressed out into the wound; from it the veins are separated by a finger or the handle of the scalpel. But at the part where they are still attached, the veins are to be tied with linen thread both above and below that part; then cut away just beyond the ligatures and the testicle replaced. But when the varix is situated upon the inner tunic, it is necessary to cut through the middle tunic; then, if but two or three veins are swollen and some part only is involved, so that most of it is still free of the disease, the same is to be done as described above, so that the veins after being ligatured on the side of the groin and testicle respectively are cut away, after which the testicle is replaced. 3 [Legamen ad versionem Latinam]But if the varix involves the whole of one testis, the index finger is to be passed into the wound and under the veins, so as to draw them gradually forward, and they must be brought up until the testicle of that side is level with the opposite one. Then pins are passed through the edges so that at the same time they take up the veins as well. It is done in this way: the pin perforates from without through one edge of the wound, then it is passed not through an actual vein but through its membrane, and is pushed out through this to the opposite margin of the incision. 4 [Legamen ad versionem Latinam]There is always a membrane between these veins, and no danger is involved, and when the pin137 has been fixed by a thread it holds the veins fast enough. Then whatever veins have been drawn forwards should be pushed back within the inguinal wound by the reverse end of the specillum.a The time to take out the pins is when the inflammation  p419 has ceased and the wound has cleaned, so that one and the same scar may bind together simultaneously both the margins of the incision and the veins. 5 [Legamen ad versionem Latinam]But if a varix has developed between the inner tunic and the testicle itself and its cord, there is but one method of treatment, to excise the testicle entirely. For it is now useless for generation, and always hangs down in an ugly way, while it is sometimes painful as well. But in this case also the groin is to be cut into, the middle tunic pressed out and cut away, and the inner tunic likewise. Then the cord by which the testicle is suspended138 is to be cut through. After this the veins and arteries towards the groin are to be ligatured with linen thread, and cut away below the ligature.

23 1   [Legamen ad paginam Latinam]Flesh also, if it ever grows between the tunics, must certainly be cut out; but it is better to make an incision through the scrotum itself. But if the cord has become indurated, the condition cannot be cured either by surgery, or by medicaments. For burning fevers and green or black vomit oppress the patients, and besides these great thirst and roughness of the tongue; and generally from the third day frothy bile is passed in a smarting motion. But the patient cannot readily either take food, or retain it; not long after the extremities grow cold, tremor arises, the hands are outstretched involuntarily; then a cold sweating on the forehead is followed by death.

24 1   [Legamen ad paginam Latinam] But when there is a varix actually situated in the inguinal region, if it forms a moderate swelling, a linear incision is made, if larger two incisions, and the included skin excised. Then without drawing out the testicle, as I directed to be done for cases  p421 of prolapse of the intestines,139 the veins are to be taken up, and ligatured where they are attached to the tunics, then cut away below the ligature knots. The treatment of the wound presents nothing novel.

25 1   [Legamen ad paginam Latinam] From the above we pass to operations on the penis itself. And, if the glans is bare and the man wishes for the look of the thing to have it covered, that can be done; but more easily in a boy than in a man; in one in whom the defect is natural, than in one who after the custom of certain races has been circumcised; and in one who has the glans small and the adjacent skin rather ample, while the penis itself is shorter, rather than in one in whom the conditions are contrary.

bNow the treatment for those in whom the defect is natural is as follows. The prepuce around the glans is seized, stretched out until it actually covers the glans, and there tied. Next the skin covering the penis just in front of the pubes is cut through in a circle until the penis is bared, but great care is taken not to cut into the urethra, nor into the blood vessels there. This done the prepuce slides forwards towards the tie, and a sort of small ring is laid bare in front of the pubes, to which lint is applied in order that flesh may grow and fill it up. It is seen that a large enough part of the penis has been bared, if the skin is distended little or not at all, and if the breadth of the wound above supplies sufficient covering. But until the scar has formed it must remain tied, only a small passage being left in the middle for the urine. cBut in one who has been circumcised140 the prepuce is to be raised from the underlying penis around the circumference of the glans by means of a scalpel. This is not so  p423 very painful, for once the margin has been freed, it can be stripped up by hand as far back as the pubes, nor in so doing is there any bleeding. The prepuce thus freed is again stretched forwards beyond the glans; next cold water affusions are freely used, and a plaster141 is applied round to repress severe inflammation. And for the following days the patient is to fast until nearly overcome by hunger lest satiety excite that part. When the inflammation has ceased, the penis should be bandaged from the pubes to the corona; over the glans the plaster is applied with the other end of the probe. This is done in order that the lower part142 may agglutinate, whilst the upper part143 heals without adhering.

2 [Legamen ad versionem Latinam]On the other hand, if the glans has become so covered that it cannot be bared, a lesion which the Greeks call phimosis,144 it must be opened out, which is done as follows: underneath the foreskin is to be divided from its free margin in a straight line back as far as the frenum, and thus the skin above is relaxed and can be retracted. But if this is not successful, either on account of constriction or of hardness of the skin, a triangular piece of the foreskin is cut out from underneath, having its apex at the frenum, and its base at the edge of the prepuce. Then lint dressing and other medicaments to induce healing are put on. But it is necessary that the patient should lie up until the wound heals, for walking rubs the wound and makes it foul.

Some have been accustomed to pin up the prepuce in adolescents either for the sake of the voice, or for health's sake. This is the method: the foreskin covering the glans is stretched forwards and  p425 the point for perforation marked on each side with ink. Then the foreskin is let go. If the marks are drawn back over the glans too much has been included, and the marks should be placed further forward. If the glans is clear of them, their position is suitable for the pinning. Then the foreskin is transfixed at the marks by a threaded needle, and the ends so this thread are knotted together. Each day the thread is moved until the edges of the perforations have cicatrized. When this is assured the thread is withdrawn and a fibula inserted, and the lighter this is the better. But this operation is more often superfluous than necessary.

26 1   [Legamen ad paginam Latinam] Sometimes we are compelled to draw off the urine by hand when it is not passed naturally; either because in an old man the passage has collapsed, or because a stone, or a blood-clot of some sort has formed an obstruction within it; but even a slight inflammation often prevents natural evacuation; and this treatment is needed not only for men but sometimes also for women. For this purpose bronze tubes are made, and the surgeon must have three ready for males and two for females, in order that they may be suitable for every body, large and small: those for males should be the longest, fifteen finger-breadths in length, the medium twelve, the shortest nine; females, the longer nine, the shorter six. bThey ought to be a little curved, but more so for men, and they should be very smooth and neither too large nor too small. Then the man must be placed on his back, in the way described for anal treatment, on a low seat or couch; while the practitioner stands on his right side, and taking the  p427 penis of the male patient in his left hand, with his right hand passes the pipe into the urethra; and when it has reached the neck of the bladder, the pipe together with the penis is inclined and pushed on right into the bladder; and when the urine has been evacuated, it is taken out again. cThe woman's urethra is both shorter and straighter, like a nipple placed between the inner labia over the vagina, and this requires assistance no less often though it is attended by somewhat less difficulty. Sometimes too a stone slips into the urethra itself, and lodges not far from its orifice, because this becomes narrower further down. The stone should if possible be extracted either by an earscoop or by the instrument145 with which a stone is drawn out in the course of lithotomy. If this cannot be done, the foreskin is drawn as far forwards as possible over the glans and tied there by a thread. Then to one side of the penis a longitudinal incision is to be made and the stone taken out, after which the prepuce is released. This is done in this way so that an intact portion of skin covers the incision into the penis, and urine flows out naturally.

2 [Legamen ad versionem Latinam]Now that mention has been made of the bladder and of stone, this seems the proper place to describe what treatment is to be adopted in cases of calculus, when it is impossible otherwise to afford relief; but it is most inadvisable to undertake it hastily, since it is very dangerous. This operation is not suitable for every season or at any age or for every lesion, but it must be used in the spring alone, in a boy146 who is not less than nine years of age and not more than fourteen, and if the disease is so bad that it cannot be relieved by medicaments, or  p429 endured by the patient without shortly bringing his life to a close. bSometimes even a rash line of treatment is successful, but it generally disappoints, especially in this sort of case, where the types and seasons of danger are very numerous, and these I will describe along with the treatment itself.147 Therefore when it has been decided to make trial of this last resource, for some days beforehand the patient's body is to be prepared by dieting, so that he takes a moderate amount of food which is wholesome, and not glutinous, and drinks water. Meanwhile he should also take walking-exercise to encourage the stone to descend to the neck of the bladder. cWhether this has happened is recognized by the insertion of the finger, as I shall point out in the course of the treatment. When that is assured and the boy has been kept fasting from the previous day, then the operation is carried out in a warm room, and in the following manner. A strong and well-trained man, seated on a high stool, seizes the boy from behind and draws him backwards until his buttocks rest on the man's knees. When the boys' legs have been drawn up, the man orders him to put his hands behind his knees, and to pull upon them as much as he can, and at the same time the man keeps them in this position. dBut if a stronger person is to be treated, two strong men are seated on stools, side by side, and both the stools and the adjacent legs of the men are lashed together, so that they cannot be separated. Then the patient is seated in the same way as above upon the knees of the two men; and according to their position, one man takes hold of the patient's left leg, the other of the right, whilst at the same  p431 time the patient pulls upon his own hams. Whether one or two men hold the patient, they press downwards with their chests upon the patient's shoulders. eHence it results that the hollow between the iliac regions above the pubes is outstretched without any folds, and as the bladder is crammed into a narrow space the calculus can easily be seized hold of. In addition, moreover, two strong men should be put to stand at the sides, and they by standing there prevent the man or men who holding the boy from slipping. Then the surgeon having carefully pared his nails and anointed his left hand, gently introduces two fingers, the index and the middle, first one and then the other, into the anus; next he places the fingers of his right hand upon the hypogastrium, but lightly, lest if the two sets of fingers should press around the calculus with any force, the bladder may be injured. fAnd in this procedure we must not act with haste, as in most cases, but so that safety is the first consideration; for an injury to the bladder causes spasm with danger of death. And the stone is first sought for about the neck of the bladder; when found there it is expelled with less trouble. And this is why I said there should be no operation except when the stone has been recognized by its special signs.148 gBut if the stone is not found at the neck of the bladder, or if it has slipped backwards, the fingers149 are placed against the base of the bladder, while the surgeon's right hand too is placed above the stone and gradually follows it downwards. When the stone has been found, and it must fall between his hands, it is guided downwards with special care the smaller and the smoother it is, lest it escape. This is that the bladder may not  p433 be too often disturbed. Therefore the right hand of the surgeon is always kept above the stone whilst the fingers of the left press it downwards until it arrives at the neck of the bladder: and it must be pressed towards this so that if oblong, it comes out end on; if flat it lies crossways; if cubical, it rests on two of its angles; if any part is larger, the smaller part comes out first. hIn the case of a spherical stone, it is clear that the shape makes no difference, except that if any part is the smoother this should be in front. When the stone has now got there, then the skin over the neck of the bladder next the anus should be incised by a semilunar cut, the horns of which point towards the hips; then a little lower down in that part of the incision which is concave, a second cut is to be made under the skin, at a right angle to the first, to open up the neck of the bladder until the urinary passage is opened so that the wound is a little larger than the stone. iFor those who make a small opening for fear of a fistula, which in this situation the Greeks call rhyas,150 incur this same danger to a greater degree, because the stone, when it is pressed down with force, makes a way out for itself unless it is given one. And this is even more harmful if the shape of the stone or its roughness has caused any additional trouble. As a consequence bleeding and spasm may be set up. And even if the patient survives he will have, nevertheless, a much wider fistula if the neck of the bladder has been torn, than he would have had if it had been cut. Now when the urethra has been laid open, the stone comes into view; its colour is of no importance. kIf it is small, it can be pushed outwards with the fingers  p435 on one side, and extracted by those on the other. If large, we must put over the upper part of it the scoop made for the purpose. This is thin at the end, beaten out into a semicircular shape, smooth on the outer side, where it comes into contact with the body, rough on the inner where it touches the stone. The scoop must be rather long, for a short one has not the strength to extract. When the scoop has been put in, it should be moved to each side to see whether the stone is held, because if it has been well grasped, it is moved with the scoop. lThis is required lest when the scoop begins to be drawn forward, the stone should slip inwards and the scoop cut into and lacerate the wound opening, and I have noted above how dangerous this is. When it is certain that the stone is sufficiently held, almost simultaneously a triple movement is to be made; first towards each side, then outwards, this in such a way that the movement is gentle and the stone is at first drawn outwards but little; this done the one end is to be raised so that the scoop may stay further in, and more easily draw out the stone. But if at any time the stone cannot be properly caught from above, it will have to be taken hold of from one side. This is the simplest method of operation. mBut various contingencies call for some further observations. There are some stones which are not merely rough but also spinous, which if they have come down to the neck of the bladder of their own accord may be extracted without any danger. But it is not safe to search for these within the bladder and draw them out, for when they have wounded the bladder they cause a speedy death from spasm, and much more  p437 so if a spinous stone sticks to the bladder, and when being drawn down has folded it over. nNow it may be inferred that the stone is at the neck of the bladder, when the patient has difficulty in passing water: or that the stone is spinous, when he passes bloody urine in drops. And it is most important that the calculus should be felt under the fingers, and that the operation should not be proceeded with unless this is assured. And then too the fingers must be applied gently, lest they wound by pressing forcibly: the incision is then made. Many use a scalpel here also. Since this is rather weak, and may meet some projecting part of the stone, and while cutting the flesh over the projection fail to divide what is in the hollow beneath, but leave something which necessitates a second operation. Meges made a straight blade, with a wide border on its upper part, semicircular and sharp below. oThis knife, with its handle grasped between the two fingers, index and middle, and the thumb put into the back of the blade, was so pressed down that any projection upon the stone might be cut through along with the flesh. By this means it followed that he made one opening of a sufficient size. But in whatever way the neck of the bladder is laid open, any rough stone should be extracted gently, and no force used to hasten matters.

3 [Legamen ad versionem Latinam]A sandy stone is made evident before the operation by the sandy urine which is passed, and in the course of it, since it does not present a uniform resistance to the fingers in the rectum, and in addition it breaks up. Again soft stones and those composed of numerous small ones which only lightly adhere together, are indicated when the urine  p439 shows scalelike particles. All these should be brought out gently by changing as before the position of the fingers in turn, without injury to the bladder, yet so as not to leave behind in it any scattered remnants which will render the after-treatment difficult. bWhen anything of this kind comes into view it is to be extracted by the fingers or scoop. And if there are several stones they are to be extracted one by one, but if a very small stone remains over it had better be left. For it is difficult to find it in the bladder, or when found it easily escapes again. In such a prolonged search the bladder is injured and fatal inflammations set up; so that some who have not been operated on have died after the bladder has been for a long while and in vain pushed about by the fingers. There is the additional reason that a small stone is later moved forward with the urine into the wound and so removed. If, however, at any time the stone appears too large to extract without tearing the neck of the bladder, it is to be split up; hence Ammonius the inventor of this process was surnamed lithotomus.151 This is done as follows: the scoop is passed over the stone, so that it easily keeps hold of the stone, even when it is struck; next an instrument is used of moderate thickness, its front end tapering yet blunt, and when this is put against the calculus, and its other end struck, it splits up the stone, great care being taken that the instrument does not come into contact with the bladder itself, and that no fragment from the broken calculus cuts into it.

4 [Legamen ad versionem Latinam]Now these operations are similar in females too, yet there are some particulars to be mentioned  p441 about them. Since in women when the stone is small, the use of the knife is unnecessary because the stone is forced by the urine into the neck of the bladder which is shorter and more yielding in females than in males. Therefore the stone often escapes of itself, and if it sticks in the first part, which is narrower, yet it may be extracted by the scoop described above152 without any harm. But for larger stones the treatment is the same.153 Except that in the case of a virgin the fingers are passed as in males, in the case of a woman into the vagina. Then the incision is to be made in a virgin just under the left labium, in a woman between the urethra and pubic bone, and in both instances by a transverse wound.154 There is no need to be frightened if there is freer bleeding from a woman.

5 [Legamen ad versionem Latinam]When the stone has been extracted, if the patient is strong and has not suffered excessively, it is well to let the bleeding go on, so that less inflammation may follow. Besides it is not unfitting for him to move about a little, in order that any blood clot still inside may drop out. But if again the bleeding does not cease of its own accord, it must be stopped lest all his strength be used up; and in weaker patients this is to be done immediately after the operation; since just as there is the risk of spasm from pushing about the bladder, so there is a second danger that in the absence of medicaments so much blood may be lost as to prove fatal. bTo prevent this the patient should be seated in a bath of strong vinegar to which a little salt has been added; under this treatment the bleeding generally stops, and it also has an astringent effect on the bladder so that the inflammation there is lessened. But if this  p443 is not successful, cups are to be applied on groins and hips and above the pubes. As soon as sufficient blood has been drawn away or the bleeding checked, the patient should be so placed on his back that his head is low, his hips a little raised; and two or three layers of linen soaked in vinegar are to be applied over the wound. cThen after two hours he should be put into a hip bath and lean back in the hot water, so that the water covers him from his knees to his navel, while the rest of his body is wrapped up, except that his hands and feet are exposed, in order that he may be less exhausted and remain in the bath longer: the usual result is free sweating. And his mouth and face must be wiped with a sponge from time to time, and an end put to this hot bath whenever it becomes harmful by weakening the patient. Afterwards the patient is freely rubbed with oil, and a dressing155 of soft wool applied, soaked in warm oil, covering the pubes and hips and groins as well as the wound itself, which had previously been covered with a similar dressing, but of lint. From time to time this dressing is to be saturated with the warm oil in order that cold may not reach the bladder, and that the sinews may be gently softened. dSome make use of heating plasters; these do more harm by their weight pressing upon the bladder, and by irritating the wound, than they do good by their heating. For the same reason not even a bandage is required. On the next day if there is difficulty in breathing, if urine is not passed, if the region about the pubes swells prematurely it may be recognized that a blood clot has collected in the bladder; for this the fingers are introduced into the rectum as before and the bladder stroked gently so as to break up  p445 clots; thus they subsequently escape by the wound. eIt is not inappropriate to inject vinegar mixed with soda into the bladder through the wound by means of an ear syringe, for in this way also clotted blood is broken up; and it is proper to do this even on the first day if we are afraid that there is a clot inside, especially when weakness prevents the patient from moving about to eliminate it. The treatment afterwards is the same, sitting in a hot bath, a pad and wool prepared as before as dressings. fBut a boy should not be put so often into the hot water nor kept in so long as an adolescent; a weak patient as a robust one; one with a slight inflammation as one severely inflamed; a patient with a relaxed body as one in good tone. Meanwhile, if the patient sleeps and breathes regularly and his tongue is moist and there is only moderate thirst and the hypogastrium is flat, if there is not much pain and but moderate fever, we may assume that the treatment is doing well. In such cases the inflammation generally ends on the fifth or seventh day; when it has passed off, the hip bath becomes unnecessary; gwhilst the patient is on his back the wound is just to be fomented enough with hot water to wash away any urine that irritates. Now the medicaments to be applied should be suppuratives, and if the wound seems to need cleaning, it is to be smeared with honey, or if that irritates it can be tempered with rose oil. The nine-drug plaster156 seems the most suitable at this stage of the treatment for it contains both suet as a suppurative, and honey to clean the wound, also marrow, best from a calf; its contents are particularly efficient in preventing the establishment of a fistula. hBut lint at this period is not to be  p447 applied directly to the wound, but it may be properly put on over medicaments to keep them in place. When, however, the wound is clean, it is to be healed by applying plain lint. During this period, however, when the course of the treatment has not gone well, various dangers arise. These may be expected: if there is persistent insomnia, laboured breathing, a dry tongue, great thirst, ia distended hypogastrium; if the wound gapes; if the urine as it escapes does not irritate157 the wound; if there is some livid discharge by night and day alike before the third day; if the patient does not answer or replies slowly; if there are severe pains; if after the fifth day high fever oppresses the patient and a distaste for food persists; if he finds more ease by lying on his stomach. But the worst complication is spasm of the sinews and bilious vomiting before the ninth day. But when there is danger of inflammation the best treatment is by abstinence, food in small quantities and at stated intervals, and at the same time fomentations and the other things described above.

27 1   [Legamen ad paginam Latinam] The nearest danger is canker.158 This is recognized if the discharge, whether from the wound, or through the penis, is a malodorous sanies, also something of the nature of blood-clot, and thin bits of flesh like flocks of wool; and in addition to this if the margins of the wound become dry; if there is pain in the groins; if the fever does not subside and it increases at night, if there are irregular shivering-fits as well. We must examine in what direction the canker is spreading. If to the penis, that part becomes hard and red and is painful to the touch, and the testicles swell; if into the bladder itself, anal pain follows, the hips harden, the legs  p449 cannot be easily stretched. 2 [Legamen ad versionem Latinam]But if to either side, this fact is clear to the eyes, and the gangrene shows the same marks on both sides, but smaller on that less affected.— But first it is important that the patient shall lie properly, that is, that the same part should always be uppermost and that that should be the part where the disease is spreading. Thus if the direction is into the penis, the patient is laid on his back; if into the bladder, on his belly; if into one side, then he lies on the more sound one. Coming to the treatment, the man should be placed in a bath containing a decoction of horehound or of cyprus or of myrtle; and the same fluid boiled is injected into the wound with a syringe; 3 [Legamen ad versionem Latinam]then is put on a plaster of lentils with pomegranate rind, both of which have been boiled in wine, or a similar decoction of blackberry, or of olive leaves, or of other material which I have set out159 as suitable for arresting and cleaning wounds affected by canker. Dry medicaments of this sort may be blown in through a quill. When the gangrene begins to come to a standstill, the wound is washed with honey wine, but at this stage a cerate should be avoided, for by softening the tissues it predisposes to that very malady: we must rather smear on washed lead with wine, over that the same spread on linen. 4 [Legamen ad versionem Latinam]By such measures it is possible to effect a cure, but we must not ignore the fact that when canker has once started, the stomach is often affected, since the bladder is closely associated with it; hence, it happens that food is not kept down, or when it is retained, not digested, nor is the body nourished; and thus the wound cannot clean, nor gain flesh: and these facts necessarily hasten death. But while it is in no way  p451 possible to save such cases as these, yet a method of treatment should be observed from the very first for a long while, in which of course due regard must be had to food and drink. 5 [Legamen ad versionem Latinam]For at first only fluid food should be given; when the wound has cleaned food of the middle class;160 greens and salted fish are always unsuitable. The amount of drink should be moderate, for if too little is drunk, the wound becomes inflamed, the patient suffers from insomnia and gets weaker; if too much is drunk, the bladder fills frequently and so is irritated. It is too obvious to need repetition that nothing except water is to be drunk.161 Now it generally happens under such a diet that the bowels do not act. 6 [Legamen ad versionem Latinam]They are to be moved by a clyster containing either fenugreek or mallow. The same decoction mixed with rose oil is to be injected into the wound itself through an ear syringe whenever the urine causes irritation and stops the wound from cleaning. General all the urine escapes at first through the wound; then in the course of healing it divides, and part begins to pass through the penis until the wound has completely closed; and this occurs at times in the third month, at times not before the sixth month, and occasionally not for a year. 7 [Legamen ad versionem Latinam]And we need not despair of the firm healing of the wound, unless the neck of the bladder has been roughly ruptured, or when owing to gangrene many large portions of the flesh have sloughed away and some fibrous tissue too. But the greatest care must be taken that no fistula, or only a very small one, is left there. With this object as the wound tends to form a scar, the patient should lie with his thighs  p453 and legs stretched out, except only when the stones have been soft and sandy: for then the bladder is slower in cleaning itself: and so it is necessary to keep the wound open longer, and only when there is nothing more to come out of the bladder is the wound allowed to heal. 8 [Legamen ad versionem Latinam]If the margins of the wound stick together, before the bladder has been cleaned, and pain and inflammation recur, the wound should be reopened, either by the finger, or by the reversed end of a probe, in order that what is causing the pain may be let out; and after such evacuation, when for some time clear urine has passed, then at length cicatrizing applications are put on; and as prescribed above, the legs are kept extended with the feet close together as much as possible. But if there seems to be danger of a fistula, from the causes mentioned above,162 a leaden tube should be put into the anus to make the closing of the fistula easier, or at any rate to narrow it, whilst the legs are kept extended and the thighs and ankles tied together until the scar has assumed its final form.

28 1   [Legamen ad paginam Latinam] And whilst the foregoing can occur both in males and females, there are also some troubles which are peculiar to females, especially that occasionally their genitals do not allow of coitus, the orifices having coalesced. And this sometimes happens even in the mother's womb; sometimes when ulceration has occurred in those parts, and through bad treatment there the margins have become united during healing. If the condition is congenital a membrane obstructs the vulvar orifice; if due to ulceration flesh has filled the same. 2 [Legamen ad versionem Latinam]The membrane should be incised along two lines crossing  p455 one another like the letter X, great care being taken that the urethra is not injured; then the membrane is to be cut away all round. But if flesh has grown there, it must be laid open with a single straight cut; next when the margin has been seized either with a forceps or hook, a fine strip must be cut away from it, after which there is inserted wool rolled lengthwise (the Greeks call it lemniscus),163 dipped in vinegar, and over this is bandaged on greasy wool wetted with vinegar: this is changed on the third day and the wound treated like other wounds; and as soon as it begins to heal, a lead tube smeared with a cicatrizing ointment is passed in, and over this the same application applied until the cut surface has cicatrized.

29 1   [Legamen ad paginam Latinam] Again when a woman has conceived, if the foetus, already nearly at term, dies inside and cannot get out of itself, an operation must be done, which may be counted among the most difficult; for it requires both extreme caution and neatness, and entails very great risk. But this shows, and not this only, how marvellous beyond all else is the woman. To begin with then the woman should be placed on her back across the bed, so that the iliac regions are compressed by her own thighs; by this means both her hypogastrium is in full view of the surgeon and the foetus is forced towards the mouth of the womb. 2 [Legamen ad versionem Latinam]This, after the death of the foetus contracts, but later on usually dilates a little. The surgeon making use of this opportunity should first insert the index finger of his greased hand, and keep it there until the mouth  p457 is opened again, and then he should insert a second finger, and the other fingers on the like opportunity, until the whole hand can be put in. To allow of this, much depends both on the size of the vagina, and the resistance of its sinewy tissues, and the patient's constitution, and also her strength of mind, especially since on occasion even both hands have to be passed in. 3 [Legamen ad versionem Latinam]It is also important that the hypogastrium and extremities should be kept very warm, that inflammation should not have begun, but that the treatment should be adopted without delay. For if the abdomen is already distended, the hand cannot be inserted nor can the foetus be extracted without the greatest suffering, and fatal spasm of the sinews often follows, accompanied by vomiting and tremor. But when the hand has reached the dead foetus its position is immediately felt. For it lies head on or feet foremost, or crosswise; generally, however, so that there is either a hand or foot within reach. 4 [Legamen ad versionem Latinam]It is the object now of the surgeon to direct it with his hand either into a head or even into a foot presentation, if it happens to be presenting otherwise: and if there is no other course, when a hand or foot is grasped, the trunk is straightened: for grasping a hand converts the presentation into a head one, grasping a foot into a foot presentation. Then if the head is nearest, a hook must be inserted which is completely smooth, with a short point, and this it is right to fix into an eye or ear or the mouth, even at times into the forehead,164 then this is pulled upon and extracts the foetus. But not every moment is proper for the extraction; for should this be attempted when the mouth of the womb is contracted, as there is no way out, the foetus is torn  p459 away from the hook, and its point then slips into the mouth of the womb itself; and there follows spasm of the sinews and great risk of death. Therefore whilst the mouth is contracted we should wait, and draw gently on the hook when it dilates, and so at these opportunities gradually extract the foetus. Now the right hand should pull the hook whilst the left is inserted within and pulls the foetus, and at the same time guides it. 6 [Legamen ad versionem Latinam]It also often happens that such a foetus is distended by fluid, and from it a foul sanies discharges. If so, the abdomen of the foetus is bored into by the index finger, when by escape of the fluid, the foetus is made smaller; then it is gently to be delivered by the hands alone. For if a hook is inserted it readily slips out of the soft little body, when the danger noted above is incurred. If the foetus has been turned to present by the feet it is also not difficult to extract; for the feet are grasped by the doctor's hands, and it is readily drawn out. 7 [Legamen ad versionem Latinam]But if the foetus is lying crosswise and cannot be turned straight, the hook is to be inserted into an armpit and traction slowly made; during this the neck is usually bent back, and the head turned backwards to the rest of the foetus. The remedy then is to cut through the neck, in order that the two parts may be extracted separately. This is done with a hook which resembles the one mentioned above, but has all its inner edge sharp. Then we must proceed to extract the head first, then the rest, for if the larger portion be extracted first, the head slips back into the cavity of the womb, and cannot be extracted without the greatest risk. 8 [Legamen ad versionem Latinam]Should this, however, happen, a folded pad is placed upon the woman's hypogastrium, and then  p461 a man strong, but not untrained, must stand on her left side, and place his two hands over the hypogastrium and press one over the other so that the head is forced to the mouth of the womb, when it must be extracted by the hook as described above. But if one foot presents whilst the other remains behind with the trunk, anything which has been drawn out must be cut away piecemeal; and if the buttocks begin to engage in the mouth of the womb they are to be pushed back and the foot of the foetus found and then drawn forwards. 9 [Legamen ad versionem Latinam]There are also other difficulties, which make it necessary to cut up and extract a foetus which does not come out whole. Now as soon as the foetus has been extracted it should be handed to the assistant to hold on his upturned hands, and the surgeon with his left hand must draw gently upon the navel cord, so as not to rupture it, whilst he passes his right hand along it up to what they called the secundines, which was the envelope of the foetus within the womb. When his hand has grasped the secundines including the whole of the blood vessels and membranes he brings them down from the womb in the same manner, and extracts the whole together with any retained blood clot. 10 [Legamen ad versionem Latinam]Then when the thighs have been tied together the woman is put to bed in a moderately warm room, which is free from draughts. Over the hypogastrium is placed greasy wool dipped in vinegar and rose oil. The rest of the treatment followed is the same as for inflammation and for wounds which are in the sinews.165

30 1   [Legamen ad paginam Latinam] Lesions of the anus also, when they do not yield to medicaments,166 require the aid of surgery.  p463 If, therefore, any fissure167 has persisted so long that it has become hard and callous, it is best to move the bowels by a clyster, then apply a hot sponge to soften the fissures and cause them to protrude. When brought into view each is excised and made into a fresh wound; then soft lint is put on and over this a pad smeared with honey, and all is covered with soft wool, fixed by a bandage; on the next and following days all the other emollient medicaments are to be used, which I said above,168 were required by such lesions when recent, band for the first few days at any rate the patient must live on fluids; then some food is gradually added, but of the class prescribed in the same passage. If however any pus arises in these fissures as the result of inflammation, as soon as it becomes evident, it is to be cut into, lest the anus itself suppurate. But this must not be done hastily, for if cut before it matures the inflammation is very much increased, and pus is somewhat more freely formed. Here too a light diet and emollient dressings are necessary.169

2 [Legamen ad versionem Latinam]The tumours, which are called condylomata,170 when hardened are treated by the following method. First of all the bowel is clystered; then the tumour is seized with a forceps close to its roots and cut away. After this, the same course of treatment is followed as that described above; only if there is any excrescence it is repressed by copper scales.

3 [Legamen ad versionem Latinam]The mouths of veins which discharge blood171 are removed as follows. When any patient is losing  p465 blood, fasting is indicated, and a rather severe clystering of the bowel, to make the openings more prominent, and thus what may be called the little heads of the veins all come into view. Then if a head is very small and has a thin base it must be tied by a flax thread, a little above where it joins the anus. A sponge squeezed out of hot water is next to be applied until it becomes livid, then with a finger-nail or scalpel it is to be scratched off above the knot. bUnless this is done great pain follows, and sometimes even difficulty in urinating. If the head is larger and the base broader, it is seized by one or two hooks, and an incision made a little above the base; in doing this nothing of the head should be left nor anything taken away from the anus. This is accomplished by not drawing upon the hooks either too much or too little. When the incision has been made, a pin should be passed through, and under the pin the head is tied round with a linen thread. cIf there are two or three, the lowest must be dealt with first; if more, they are not all treated at once, to avoid having tender scars in several places at once. If there is bleeding, it is taken up in a sponge; then lint is put on, the thighs and groins anointed, as well as the parts near the wound; over it is applied a cerate and a poultice of barley meal, and this part must be filled up with soft wool and then bandaged. The next day, the patient should sit in hot water and after that have the same poultice applied. dTwice a day, before and after the operation, the necks and thighs are to be anointed with a liquid cerate; and the patient must be kept in a warm room. After five or six days, the bits of linen172 are removed  p467 by the aid of an earscoop. If the little heads do not come away at the same time, they are to be removed by the finger; then by the same soothing medicaments which I have described above, the wounds are healed up. After the trouble has been ended I have already noted elsewhere what must be done.173

31 1   [Legamen ad paginam Latinam] We next pass from the foregoing subjects to the legs, and if varicose veins occur there, they are removed by a procedure which is not difficult.b To this place I have put off also the treatment of the small veins which cause trouble in the head, also of varicose veins on the abdomen, because it is all the same. Any vein therefore which is troublesome may be shrivelled up by cauterizing or cut out by surgery. If a vein is straight, or though crooked is yet not twisted, and if of moderate size, it is better cauterized. 2 [Legamen ad versionem Latinam]This is the method of cauterization: the overlying skin is incised, then the exposed vein is pressed upon moderately with a fine, blunt, hot cautery iron, avoiding a burn of the margins of the incision, which can easily be done by retracting them with hooks. This step is repeated throughout the length of the vein, generally at intervals of four fingers' breadth, after which a dressing is put on to heal up the burns. But excision is done in the following way: the skin is similarly incised over the vein, and the margins held apart by hooks; with a scalpel the vein is separated from surrounding tissue, 3 [Legamen ad versionem Latinam]avoiding a cut into the vein itself; underneath the vein is passed a blunt hook; the same procedure is repeated at the intervals noted above throughout  p469 the course of the vein which is easily traced by pulling on the hook. When the same thing has been done wherever there are swellings, at one place the vein is drawn forward by the hook and cut away; then, where the next hook is, the vein is drawn forwards and again cut away. After the leg has thus been freed throughout from the swellings the margins of the incisions are brought together and an agglutinating plaster put on over them.

32 1   [Legamen ad paginam Latinam] But if the fingers, either before birth or later on account of ulceration of their adjacent surfaces, adhere together, they are separated by the knife; after that each finger is separately enclosed in a plaster without grease, and so each heals separately. If after ulceration of a finger, a badly formed scar has made it crooked, in the first place a poultice is tried, and if this is of no avail, which is generally the case with old scars and tendon injuries, we must see whether the trouble is in the tendon, or in the skin only. If it is in the tendon, it should not be touched, for the condition is incurable; if in the skin, the whole scar should be cut out, which had generally become hard and so did not allow the finger to be extended. When it had been thus straightened a new scar must be allowed to form there.

33 1   [Legamen ad paginam Latinam] When gangrene has developed between the nails and in the armpits or groins, and if medicaments have failed to cure it, the limb, as I have stated elsewhere,174 must be amputated. But even that involves very great risk; for patients often die under the operation, either from loss of blood or syncope. It does not matter, however, whether the remedy is safe enough, since it is the only  p471 one. Therefore, between the sound and the diseased part, the flesh is to be cut through with a scalpel down to the bone, but this must not be done actually over a joint, and it is better that some of the sound part should be cut away than that any of the diseased part should be left behind. 2 [Legamen ad versionem Latinam]When the bone is reached, the sound flesh is drawn back from the bone and undercut from around it, so that in that part also some bone is bared; the bone is next to be cut through with a small saw as near as possible to the sound flesh which still adheres to it; next the face of the bone, which the saw has roughened, is smoothed down, and the skin drawn over it; this must be sufficiently loosened in an operation of this sort to cover the bone all over as completely as possible. The part where the skin has not been brought over is to be covered with lint; and over that a sponge soaked in vinegar is to be bandaged on. The remaining treatment is that prescribed for wounds in which suppuration is to be brought about.175

The Editor's Notes:

1 χειρουργία or surgery (Prooemium 9).

2 Prooemium 9.

3 See index. The Alexandrian school of medicine flourished from the third century B.C.

4 V.26‑28.

5 VII.1‑5.

6 VII.6‑33.

7 Luxata. This word is regularly used in Latin writers to mean displacements or dislocations (Cato, R. R. 157; Seneca, Ep. 104.18; Plin. H. N. 31.6.37, etc.); but Celsus, who only uses the word here, never applies it to dislocations when describing these leasions in Book VIII.11, and the description given here suggests that he has in view rather injuries from blows as in boxing, where the use of the caestusº caused abrasions of the skin as well as subcutaneous haemorrhage (p299)(ecchymosis), and where immediate incision prevented widespread suppuration. See Hippocrates III.30 (Head Wounds, XIII.21). V. d. Linden emended to vexata which would have the more general meaning of parts injured.

8 III.27.4-V.28.1D.

9 II.8.10, 28.

10 V.28.11B, C.

11 V.18.19; 28.10.

12 V.28.11E.

13 V.28.11D.

14 V.28.26. Hippocrates IV.202 (Aphor. VII.44).

15 III.1.4.

16 III.27.4-V.26.34C.

17 V.28.12.

18 V.26.23B and note c.

19 VIII.2.

20 IV.1.4.

21 Prolapse of the intestines, described below, §B fin.

22 VII.16.4.

23 IV.1.13.

24 VI.18.7.

25 V.28.12.

26 V.28.11, 12.

27 III.6.10, 17. Hippocrates IV.106 (Aph. I.16).

28 Celsus here gives us the only information which we possess on the treatment of wounds in Roman warfare; the treatment which he describes was in most respects that followed by such well-known surgeons as Paulus Aegineta, Abulkasim and later Paré and Italian surgeons of the renaissance even after the introduction of gunpowder had largely altered the type of wound inflicted.

29 II.10.15.

30 Upsilon (Υ) seems the most probable letter to fill the lacuna (see critical note). The shape of the instrument and the method of use would then correspond to the modern glove-stretchers.

31 Vol. I, p4.

32 The shape and use of this instrument were similar in principle to those of the present-day midwifery forceps.

33 The glans was in shape like an acorn, pointed at one end, which travelled point forwards and penetrated by the point, like the modern bullet.

34 VII.12.1A.

35 VII.5.1C.

36 V.27.

37 V.26.21 et seq.

38 Dermoid cysts or wens. The ganglion was named from its resemblance to the resistant swelling of tendon sheaths which is still so called; the other varieties from the nature of their contents, like honeycomb (μελικήριον), porridge (ἀθάρη), or fat (στέαρ) respectively.

39 VII.7.1B.

40 Crithe (κριθή) resembled a grain of pearl (peeled) barley, it is now commonly known as a Meibomian cyst, which when it becomes inflamed forms a stye.

41 Eodem vapore, i.e. by steam from the wax mentioned above.

42 Hail-stones. When above the tarsal cartilage these are called dermoid cysts; when beneath it Meibomian cysts.

43 An inflammatory swelling at the inner canthus or angle of the lower lid which is still called a pterygium. Celsus also applied the name to a paronychia, whitlow (VI.19.1, note).

44 VI.6.25B.

45 The surgeon must be able to use his right hand in a good light on the affected eye without his hand blocking the light. Hence the two positions.

46 Rhyas (ῥυάς) here is used of a lacrimal fistula but in VII.26.2I of a perineal fistula formed after lithotomy.

47 Cf. p332, note b.

48 ἐγκανθίς in the angle of the eye (κανθός).

49 ἀγκυλοβλέφαροι, patients with contracted eyelids, cf. V.18.28, where the adjective ἀγκύλος is applied to contracted joints.

50 VI.6.27.

51 Aegilops, "goat eye" (αἴξ); in ruminants, goats, deer, etc., there is a gland below the inner canthus discharging mucus.

52 Carcinoma. See V.28.2A, C, D, also VII.14.1.3, where treatment is said often to make the condition more dangerous; see Appendix I p592.

53 VII.4.1.B.

54 i.e. the eyelid marked and the patient on his back with his head in the surgeon's lap.

55 VII.7.8E.

56 λαγώφθαλμος, from the likeness to the widely opened eye of the frightened hare.

57 Cf. §9.

58 ἐκτπρόπιον = eversion (of the lower eyelid in particular). In extant Greek writers the word in this sense is first found in Galen, writing 150 years later (XIX.439).

59 The term staphyloma (from the Greek σταφυλή, a bunch of grapes) is still used for the condition which arises when a puncture through the outer sclerotic coat lets the blue iris protrude through, and gives rise to a grape-like swelling.

60 See diagram, p344.

61 VI.6.35 and note.

62 When he speaks of the ceratoides (tunic) Celsus includes both the cornea (the horn-like coat of the eye, κερατοειδὴς χιτών) and the sclerotic coat (σκληροειδὴς χιτών) which is hard in character. Later these were distinguished.

63 χοριοειδὴς ὑμήν (the chorioid membrane), which like the foetal chorion, contains very numerous blood vessels.

64 ἀραχνοειδὴς ὑμήν, the arachnoid (cobweb-like) membrane; also called ἀμφιβληστροειδής (net-like), Latin retina, the name by which it is still known.

65 ὑαλοειδὲς (glass-like) ὑγρόν, the vitreous humour (vitrum, glass).

66 κρυσταλλοειδὲς (ice-like) ὑγρόν. The seat of vision was placed in the crystalline lens. Biconvex lenses were not understood or made before the time of Kepler, and Celsus does not use the word lens. See daigram, p350.

67 Locus vacuus: the posterior chamber between the pupil and iris in front, and the lens behind, the ancients held to be like the anterior chamber, and to contain similar fluid (p349)which underwent hardening. It was only when dead bodies were examined that the seat of cataract was found to be in the lens, and the so‑called empty space only a potential one.

68 The cases of severe pains in the head or of violent injuries were not cases of cataract at all.

69 See diagram.

70 deducere . . . insidat: in this paragraph Celsus describes the operation for "couching" (med. English) or "pricking" a cataract. The word "pricking" is a translation of the Greek word παρακέντησις, and the operation (performed by an implement παρακεντητήριον) continued in use from antiquity until in recent times it was replaced by extraction. The old operation is still practised in the East by native oculists because septic infection is so rare after it. The breaking up of the cataract by the needle continues to be the regular treatment for soft forms of cataract where absorption of fragments may be anticipated.

71 V.26.30B.

72 V.6.16.

73 VI.6.17, etc.

74 Broad heads in contrast with Long heads had already been noted by Hippocrates I.110 (Airs, XIV. et seqq.); but the point of Celsus' statement is not clear.

75 This operation, which was performed by experts, was common all over the ancient world. Hippocrates (Littré IV.185) mentioned its use among the Libyans and the practice has prevailed up to recent times in North Africa and the Soudan. It was based on the idea that the discharge originated within the head beneath the skull and that the "peccant humour" (pituita) was carried down to the eyes by the superficial veins, or by veins from within the skull to the back of the eyes. The operation withdrew it by way of the wounds but avoided loss of blood (see below). Celsus omits the more severe operation Hypospathismus, described (p355)by Galen (XIV.781, 784) and Paulus Aegineta (VI.6) in which a double-edged raspatory (ὑποσπαθιστήρ) was forced under the scalp from one incision through to another.

76 VI.6.1H, to 9C.

77 e.g. in Gaul, see below, §I.

78 V.27.13.

79 VII.31.

80 Piercing the lobe of the ear for the wearing of ear-rings was a common practice from very early times (Exodus xxi.6). An enlarged lobe, due to wearing heavy ear-rings, can still be often seen among native women in India or Africa.

81 VII.9.1‑3.

82 See diagram.

83 VI.8.2.

84 II.44.

85 For ozaena, cf. III.11.3 and vol. II p242, note a.

86 Paulus Aegineta, VI.28, copies this description. Such "shaking" is still advisable even when extracting teeth under anaesthesia.

87 ῥιζάγρα ("root-catcher"). Such an instrument has actually been found among a collection of Roman surgical instruments, and there is one in the Budapest Museum. Paulus Aegineta VI.28 (where he is epitomizing Celsus) refers to it.

88 The Greek name ἀντιάδες (Paulus Aegineta, VI.30) was derived from the position of the tonsils opposite each other. The Latin tonsillae was derived from the same idea that the position of the tonsils was like that of a pair of oars (tonsae). The more usual Greek name was παρίσθμια — Hippocrates, IV.130 (Aph. III.26); Littré, VIII.560 (Glands); Galen, VI.674.

89 Hippocrates, II.46 (Prognostica, XXIII).

90 VI.14.

91 Section 2C, supra.

92 VII.8.2.

93 Under the name bronchocele Celsus describes an enlargement of the thyroid gland consisting of dark red soft material, which may have undergone cystic degeneration into a honey-like liquid, and also a dermoid cyst of the neck containing hair and calcified material. The term βρογχοκήλη was defined by Galen, XIX.443, who mentions topical applications for the condition several times, and is used by Paulus Aegineta, VI.38. Hippocrates, Epid. VI.3.8 (Littré,º V.296) uses γογγρώνη for the swelling on the trachae, popularly known as goître. This word is derived from guttur, cf. Juvenal, XIII.162, quis tumidum guttur miratur in Alpibus, and this reference shows that the disease was well known in his day, but it was not until 1541 that Vesalius (Fabrica) first drew and described the thyroid gland.

94 Galen, VIII.53, mentions two cases of this operation in which the surgeon had injured the recurrent laryngeal nerves lying behind the thyroid gland and had so caused loss of voice.

95 vitiosa = κακοήθης, malignant, V.28A, and Appendix, p592.

96 VII.15.1.

97 VII.7.11; and diagram, p344.

98 III.21.14.

99 VII.14.4.

100 250 cc.

101 V.26.2.

102 The following directions assume that the surgeon stood on the patient's left side with his back to the patient's face so that the latter could not see when a stitch was to be inserted.

103 The parietal layer of the peritoneum and the muscular wall.

104 VII.14.5.

105 VII.7.11; and diagram, p344.

106 VII.2.6.

107 VII.31.

108 κρεμαστῆρες (Galen IV.635) = "suspenders"; these muscles, with other structures, formed the spermatic cord.

109 ἐλυτροειδὴς χιτών (the sheath-like coat) = tunica vaginalis.

110 This membrane is immediately below the skin and closely connected with it.

111 Scrotum = scortum (hide); the more usual Greek form was ὄσχη, which is always found in Hippocrates.

112 κήλη = hernial swelling (hernia carnosa); ἐντεροκήλη is intestinal hernia, ἐπιπλοκήλη omental hernia.

113 VII.20.2.4.

114 That is, between the scrotum (combined with the dartos) and the tunica vaginalis, or between the tunica vaginalis and the tunica albuginea; the latter is not referred to in the description given above, §§1 and 2.

115 ὑδροκήλη (ὑδωρ, water), hernia aquosa.

116 Here Celsus describes an everyday test to see if the fluid "fluctuates."

117 κιρσός = varix or ramex. A scrotal varix is described VII.22, an inguinal varix VII.24. Varicocele, the term now used, is not found in Celsus.

118 σαρκοκήλη (fleshy tumour) = hernia carnosa (VII.23).

119 βουβωνοκήλη (groin tumour) = inguinal hernia.

120 V II.18.2.

121 See p394, note b.

122 The peritoneum.

123 VII.19.9.

124 ὀξυκόρακον σμιλίον (Paulus Aegineta, VI.78) "raven's bill knife."

125 See sections 3 and 5.

126 VII.12.4.

127 The cords (deferent ducts of the testes) were called πόροι by Galen and vasa deferentia by later Latin writers; cf. p391, notes b, c.

128 V.26.24‑30.

129 VII.19.3, 4.

130 i.e. separate the tunica albuginea from the tunica vaginalis.

131 See VII.18.1, notes.

132 The exedents (for septa, cf. II, 41, note a) are milder than erodents and while eating away the diseased part their action does not spread so as to injure the surrounding tissues; certain essential oils were used as "antiseptics" (see Medicamenta(p413)s.v.) to counteract the effect of σῆψις, the eating away of tissue, when this was due to disease.

133 VII.20.6.

134 VII.18.7, note c.

135 VII.18.9, note b.

136 VI.18.8B.

137 The pins were fixed by a thread twisted round them in a figure of 8. Vol. II. Introduction, p. lxi, fibula.

138 See p391, note b and p408, note a.

139 VII.20.5.

140 The treatment is first referred to in Maccabees i.14, 15. "Wherefore they built a place of exercise at Jerusalem according to the custom of the heathen and made themselves uncircumcised."

141 V.28.3.D and VI.18.2A.

142 i.e. between the pubes and the corona.

143 Covering the glans.

144 Vol. II p268, note a.

145 2K below.

146 Stone was evidently common among schoolboys then as it continued to be in this country up to within living memory. There was a sudden change from great frequently to rarity, corresponding to the change from drinking small beer (which included an infusion of the bitter constituent of hops) to the universal adoption of tea (which has a diuretic property).

147 Prooemium 49 and III.9.4, 5 (vol. I, 26 p270).

148 Cf. 2C, D and N, where the symptoms are described which occur when the stone is situated in this position, i.e. at the neck of the bladder.

149 i.e. of the surgeon's left hand.

150 VII.7.4C, note.

151 "The stone cutter." Cf. Book VII. Prooemium 3. The words λιθοτομία (λιθοτόμος) primarily used of stone quarrying became from the 3rd century B.C. onwards technical terms in connection with the operation which Celsus describes, and were still so used nearly a thousand years later (cf. Paulus Aegineta, VI.60).

152 VII.26.2K.

153 As in males, VII.26.3C.

154 VII.26.2H.

155 Absus (Hapsus, ἅψος). Celsus uses the word here and in IV.13.3 for a woollen bandage.

156 V.19.10.

157 A bad symptom, as it shows the patient is too ill to feel.

158 See Appendix I, p589 ff.

159 V.26.32‑34.

160 Vol. I p193 ff. (II.18).

161 VII.16.5.

162 VII.26.2.1.

163 Lemniscus (λημνίσκος), taenia, was a strip of wool (or of linen) used as a bandage.

164 i.e. into the anterior fontanelle.

165 It is noteworthy that there is no mention of midwife or other female assisting at the operation, or of so‑called Caesarean section, which was often performed after the death of the mother.

166 VI.18.7‑11.

167 VI.18.7A, B.

168 VI.18.7A, 9B.

169 Fistula in ano, VII.4.4.

170 VI.18.1A, B, C.

171 VI.18.9A.

172 linamenta refers to the threads described in § B above.

173 p463; see also II p284.

174 V.26.34D.

175 V.26.27B. The amputation described by Celsus was often used in the war of 1914‑18 for stumps which had become pointed after emergency amputations. In doing the operation arteries which have already become closed are not re-opened.

Thayer's Notes:

a specillum: The word usually means "probe", and Spencer so translates it throughout, except this once. I had marked this as an oversight, but a kind e‑mail from Clive Hewitt, a Roman medical reënactor, set me straight: paraphrasing him, specillum seems to have been a term, somewhat generic in nature, of wider application than the modern "probe" — and Spencer, not knowing which tool was meant, may be erring here on the side of caution.

b varicose veins in the legs are removed by a procedure which is not difficult: Makes it sound quite straightforward, doesn't it? And indeed the procedure is not difficult, from the surgeon's point of view; but from the patient's, in that age without anesthetic, it was horrific. For further details on the operation and the experience of a particularly brave man, see Plutarch's Life of Marius, 6.3.

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