That surgery makes the third part of medicine, is both universally known, and has been already observed. This does not indeed discard medicines, and a proper regimen; but yet the principal part is accomplished by the hand. And the effect of this is the most evident of all the parts of medicine. For as fortune contributes a good deal to the cure of distempers, and the same things are often salutary, often fruitless; it may be doubted, whether the recovery be owing to physic, or the constitution. In those diseases also, in which we chiefly make use of medicines, although their success be pretty evident, nevertheless it is plain, that health is both sought for by their means in vain, and often restored without them. As may be observed with regard to the eyes, which after having long suffered from the applications of physicians, sometimes recover of themselves. But in surgery it is manifest that the success, though it may be somewhat promoted by other means, is chiefly to be ascribed to this. Now this branch, though it be the most ancient, yet has been more cultivated by Hippocrates the father of all medicine, than by his predecessors. Afterwards being separated from the other parts, it began to have its peculiar professors, and received considerable improvements in Egypt, as well as elsewhere, principally from Philoxenus, who has treated of this part fully, and with great accuracy, in several volumes. Gorgias also, and Sostratus, the two Herons, and the two Apollonii, and Ammonius Alexandrinus, and many other celebrated men, have each of them made some discoveries. And at Rome too professors of no small note, and particularly of late Tryphon the father, and Euelpistus the son of Phleges, and Meges the most learned of them all, as appears from his writings, by altering some things for the better have made considerable additions to this art.

A surgeon ought to be young, or at most but middle aged, to have a strong and steady hand, never subject to tremble, and be no less dexterous with his left than his right hand; to have a quick and clear sight; to be bold, and so far void of pity, that he may have only in view the cure of him, whom he has taken in hand, and not in compassion to cries either make more haste than the case requires, or his cut less than is necessary; but to do all, as if he was not moved by the shrieks of his patient.

Now it may be asked what peculiarly belongs to this branch: because surgeons assume to themselves the curing of many wounds and ulcers, which I have treated of elsewhere. I can very well suppose the same person capable of performing all these: and since they are divided, I esteem him most, whose skill is most extensive. For my part, I have left to this branch those cases, in which the physician(1) makes wound, where he does not find one; and those wounds and ulcers, in which I believe manual operation to be more useful than medicines; lastly whatever relates to the bones. Which things I shall consider in order, and deferring the bones to another book, I shall in this explain the two former; so treating first of these, which are found indifferently in every part of the body, I shall proceed to those, that fall upon particular parts.

Contusions, in whatever part of the body they are, ought as soon as possible to be treated in this manner; the skin of the part, where the pain is, must be cut in several places, and the grumous blood issuing from them must be wiped away with the back of the knife. If it is not taken in time, and there is a redness, so much of the skin as is red must be cut; if there is a tumour too, wherever that extends, the same remedy is still the best. Then repellents are to be applied over it; and particularly sordid wool squeezed out of vinegar and oil. But if the hurt be more slight, the same applications without an incision may perform the cure. And if nothing else is at hand, ashes, especially of burnt twigs; if they are not to be got, any other ashes mixed up with vinegar, or even with water.

The foregoing case is easily managed. But there is more trouble with those tumours, that come from an internal cause, and tend to suppuration. That all these are kinds of abscesses, I have elsewhere shewn, and treated of the medicines proper for them: it now remains, that I mention the manual operations necessary for their cure. Wherefore it is requisite, before they grow hard, to cut the skin, and apply a cupping vessel to evacuate any bad and corrupted matter which may have been collected there: and this may be repeated a second and third time, till all the symptoms of an inflammation be gone. Nevertheless, it is not right to trust(2) entirely to the cupping vessel.

Sometimes also it happens, though rarely, that a collection of pus is inclosed in a covering of its own: the ancients called this a coat. Meges, because every coat is nervous, affirmed a nerve was not generated in a disorder, which destroyed the flesh, but that the pus being lodged below for a long time, was surrounded with a callosity. This however has not the least relation to the method of cure; because the same course, that ought to be pursued if it be a coat, is also necessary if it be a callosity. And though it should be a callosity, yet as it invelops something, there is no reason against calling it a coat. And then again, it is not uncommon for this to be found even before the suppuration is formed(3), and therefore what is below it cannot be extracted by a cupping vessel. But this is easily discovered, when the application of that instrument has made no change. Therefore, where-ever that happens, or when there is already a hardness, nothing is to be expected from this remedy: but as I have directed elsewhere, either the afflux of matter to the part must be diverted, or it must be discussed, or brought to a perfect suppuration. If either of the former has taken place, nothing further is necessary. If the pus has been maturated, in the armpits and groin an incision is rarely to be made: likewise where-ever the abscess is but small; also where-ever the malady is in the surface of the skin, or even in the flesh; unless the weakness of the patient obliges us to lose no time. And it is sufficient by cataplasms to assist the pus to make its own way. For the part, that has not been touched by an instrument, is generally free from a scar. If the malady lies deeper, it ought to be considered whether the part be nervous or not. For if it be nervous, it should be opened by the actual cautery; the reason of which is, that a small wound may keep open longer for evacuating the pus, and the cicatrix afterwards may be small. But if there be nerves near it, the actual cautery is improper, lest convulsions follow, which may debilitate(4) the limb; yet the assistance of the knife is necessary. The others may be opened before they be quite mature: but amongst tendons the utmost ripeness is to be waited for, that the skin may be thin, and the pus brought close to it, that it may be the sooner found. And some again require a wound(5) in a straight direction, as those in the flesh: but others render the skin extremely thin; and in such the whole surface of it above the pus must be cut away. Now in all cases where the knife is used, care must be taken, that the wounds be as small and as few in number as possible: with this caution, however, that we do all the case requires, both with regard to size and number: for larger cavities require broader incisions; sometimes even in two or three different directions. And we must endeavour that the deepest part of the sinus shall have a free discharge, lest any of the humour settle within, which by corroding the contiguous parts yet sound, may make sinuses there. Cases also sometimes occur, in which the skin must be taken off to a more considerable breadth. For when after long distempers, the habit of the whole body has been vitiated, and the sinus is enlarged to a great compass, and the skin is pale; we may take it for granted that it is already mortified, and will be useless: therefore it is more proper to cut it off: and especially if this happen about the larger joints, and the patient has been troubled with a purging while he was confined to his bed, and he gains no flesh by the nourishment he takes. But the excision should be made in the form of a myrtle leaf, that it may heal the more easily. And this rule must constantly be observed, whenever a physician upon any account cuts away the skin. After the pus is discharged, in the armpits and groin there is no need of lint, but a sponge squeezed out of wine must be laid on. In the other parts, if lint is equally needless, a little honey must be infused to cleanse it; then agglutinants are to be applied: if lint be necessary, over it also in like manner ought to be laid a sponge squeezed out of wine in the same way. When lint is necessary, and when not, has been determined elsewhere. The other directions are to be observed when the suppurated tumour is cut, which I gave for one, that has been broke by medicines.

It is soon known from the nature of the symptoms, how a cure advances, and what event is to be hoped or feared: and these are commonly the same with what have been laid down in wounds. For they are good signs to sleep, to breathe easily, not to be troubled with thirst, not to loathe food, if there has been a slight fever, to be free of it: also that the pus be white, smooth, and not fetid. The bad signs are wakefulness, difficulty in breathing, thirst, loathing of food, a fever, and the pus black, or feculent, and fetid: also a hemorrhage in the process of the cure; or if before the cavity is filled up with flesh, the lips become callous, and the flesh there be dull of sensation, and spongy. But for a person to faint either in the dressing or afterwards, is worst of all. Moreover, if the fever cease suddenly, before the suppuration is begun, or if it continue after the discharge of the pus, these are just grounds for fear. There is room to fear also, if the wound is not sensible of corrosive medicines. But whatever symptoms shall happen to arise, it is the part of a physician to endeavour the recovery of his patient. Therefore, as often as he shall open a wound, he ought to wash it, if it seems necessary to repel the humour, with a mixture of wine and rain water, or with a decoction of lentils in water: if it needs cleansing, with mulse; and to apply the same dressings again. When the humour shall appear to be stopt, and the ulcer clean, it will be convenient to promote the growth of the flesh, and dress the ulcer with equal parts of wine and honey, and apply a sponge dipt in wine and oil of roses, which things are incarning. A proper regimen however, as I have observed elsewhere, is more effectual for this purpose: that is, when the fever is removed, and the appetite restored, bathing now and then, daily but mild gestation, and such kinds of food and drink as are of the most nourishing nature. All which rules also hold with regard to an abscess, that has been broken by medicines. But because it is hardly possible to cure a large tumour without the knife, the mention of these has been reserved to this place.

With regard to fistulas, if they penetrate pretty deep, so that a collyrium cannot reach the bottom of them, if they are tortuous, or consist of several sinuses, operations are more useful than medicines; and those, that run in a transverse direction below the skin, give less trouble than such as go directly inward. Therefore, if the fistula be transverse under the skin, a probe ought to be introduced, and an incision made upon that. If it be tortuous, its windings are to be followed by the probe and knife. And the same course must be taken, if several of them appear like rivulets uniting their streams. When we have reached to the end of the fistula, all the callosity must be cut out, and fibulae applied to it with medicines to agglutinate. But if it points directly inward, when its direction is found by a probe, that sinus must be cut out: then a fibula put upon the lips of the skin, and agglutinating medicines laid over it; or if the ulcer be very foul (which sometimes happens from a carious bone) when that also is cured, medicines to promote a digestion.

It is common for fistulas to extend beneath the ribs. When this case occurs, the rib in that part must be cut through on both sides, and taken out, lest any thing corrupt be left within. It is usual for them also, when they have got through the ribs, to penetrate the transverse septum, that divides the intestines from the superior viscera. Which circumstance may be known, both from the situation, and from the violence of the pain, and because sometimes the air comes out with the matter, as it were bubbling, and particularly when the patient keeps in his breath. For this case there is no remedy. In the other kinds about the ribs, which are curable, greasy medicines are hurtful, and therefore we should use such as are adapted to wounds: but the best application is dry lint, or if any thing requires to be cleansed, the same dipped in honey.

There is no bone within the skin of the belly; but fistulas in that part are extremely dangerous; insomuch that Sostratus believed them incurable. That they are not always so, experience has shewn. And indeed, which may seem very wonderful, a fistula opposite to the liver and spleen, and stomach, is more safe than one opposite to the intestines: not that the thing is of its own nature more pernicious there, but because it exposes to a danger of another kind. The reason of which fact some authors have but little understood, though their experience convinced them of this difficulty. For the belly itself is often wounded by a weapon, and the intestines, that have fallen out, are replaced, and the wound united by sutures: the manner of doing which I shall point out presently. Therefore, when a small fistula has even penetrated the abdomen, it may be cut out, and the lips of it joined by a suture. But if the fistula spreads wider within, upon its being cut out, it must necessarily leave a pretty large vacuity, which cannot be sewed up without great violence; especially on the internal side, where there is a kind of membrane, which the Greeks call peritonaeum, that surrounds the abdomen. Therefore, as soon as a person begins to walk or move, the suture breaks, and the intestines are let loose, so that the patient must perish. But the case is not always desperate; and therefore, we must attempt the cure of smaller fistulas there.

Fistulas in the anus require a particular treatment. A probe being put into them, an incision must be made in the skin at its further end: then the probe must be drawn out at the new orifice with a thread following it, which was put through an eye made in the other end for the purpose. There the thread must be taken hold of, and tied to the other end, that it may gently take hold of the skin above the fistula: and the thread should be made of crude lint(6), double or triple, and so twisted as to make one string. In the mean time the patient may go about his business, walk, bathe, and eat, just as if he were in the most perfect health. Only loosing this knot(7) twice a day, the string must be drawn in such a manner, that the part, which was above, may then be within the fistula. And the thread must not be suffered to rot, but every third day, the knot must be untied, and at its one end must be fixed a fresh ligature, which when the old one is drawn out, must be left in the fistula with a like knot. For thus it gradually cuts the skin that is above the fistula: and, at the same time, the part that has been eat through by the thread, heals; whilst the remainder, which is pinched by the thread, continues to be cut by it. This method of cure is long, but is attended with no pain.

Those, that are for making quick dispatch, ought to tie the skin tight with the string, that it may be the sooner cut; and at night to introduce some small slips of a penecillum, that the skin may be made thin by the same means that it is distended; however this occasions pain. The dispatch, as well as the pain, is increased, if both the string and the penecillum be turned with some one of those medicines, which I mentioned, for consuming a callosity. It may happen, however, that the use of the knife may be necessary, even in this part, if the fistula points inward, or consists of several sinuses. Wherefore in these kinds, the probe must be introduced, and the skin must be cut in two lines, so that betwixt them a very small habenula may be cut out(8), to prevent the lips from uniting presently; and that room may be left for pledgits of lint, as few of which as possible ought to be laid on; and the same course must be pursued as was directed in abscesses. But if, from one orifice, there shall be several sinuses, that sinus, that runs straight, must be opened with a knife, and the others, that branch from it, which will then appear, must be tied with a ligature. If any one penetrate so deeply, that an instrument cannot be safely used, a collyrium must be put in.

The food, in all these cases, whether the treatment be by an operation, or by medicines, ought to be moist; the quantity of drink pretty liberal, and for a long time water. And when the flesh begins to sprout up, then indeed the bath may be used, but sparingly, and such food as plumps the body.

Weapons, that lodge in the body, are very often troublesome to extract. For there are some difficulties, which arise from their different forms; others from the situation of the parts, into which they have penetrated. Now every weapon is extracted, either on that side, where it entered, or on that, to which it points. In the first case it returns by the way itself made: in the other, it receives one from the knife; for the flesh is cut directly upon the point of the weapon. If the weapon does not lie deep, but is in the surface of the flesh, or at least has not past through large veins and nervous parts, the best method is to pull it out by the way it entered. But if the space, through which the weapon must return, be greater than that, which is to be laid open, and it has already past through veins and nerves, it is more expedient to open what remains, and extract it that way; for it is both nearer at hand, and is drawn out with more safety. And in one of the larger limbs, if the point of the weapon has past beyond the middle of it, it will heal the more readily for being open quite through, as the remedies will act at both extremities of the wound. But if the weapon is to be brought back the same way, the wound must be enlarged, that it may move the more easily, and occasion the less inflammation; which will be considerable, if the body be lacerated by the weapon as it returns. And in like manner, if an opening be made on the opposite part, it ought to be so large, as not to be increased afterwards by the weapon passing through it. In either case, the greatest caution must be used not to cut a tendon, or a large vein, or an artery. When any of these are exposed, it must be laid hold of with a blunt hook, and drawn aside from the knife. When an incision is made large enough, the weapon must be taken out: then also the same method, and the same precaution are to be used, lest any of the abovementioned parts should be injured, which lie under the weapon, that is to be extracted.

The foregoing directions are general: besides which, there are some particular rules for the several kinds of weapons, which I shall immediately subjoin. Nothing is so easily lodged in the body as an arrow, and it goes to the greatest depth. The reasons are, both that it moves with great force, and because it is small. Therefore, it must be extracted more frequently on the opposite part, than on that by which it entered, and especially because it is generally surrounded with beards, which lacerate more, if they be drawn backward than forward. But an orifice being made on the opposite part, the flesh ought to be opened by an instrument made in the form of the Greek letter ?; and when the point appears, if the shaft adheres to it, it must be pushed forward, till it can be taken hold of at the opposite part, and extracted. If that is already broke off, and only the iron head is within, the point must be taken hold of by the fingers, or a forceps, and thus pulled out. And there is no other method of extracting it, when it is thought adviseable to pull it out by the orifice it entered at: for after the wound is enlarged, either the shaft, if that be lodged within, must be pulled out; or if that be not there, the iron itself. But if the beards are visible, and they are short and small, they ought to be broke off with a forceps, and the weapon, when freed of them, to be brought out; if they are larger and stronger, they must be covered with writing reeds split, to prevent their lacerating any part, and thus pulled out. This is the method observed in extracting arrows.

But if a person has a broad weapon lodged within his flesh, it is not proper to draw it out at the opposite part, lest we add another great wound to the large one already made. It must therefore be pulled out with a certain kind of iron instrument, which the Greeks call the graphiscus of Diocles[ GP ], because it was invented by Diocles, whom I have already taken notice of among the ancient and greatest physicians. This is a plate of iron, or sometimes of copper, at the one end, having two claws turned downwards on each side; the other perforated and folded back on each side; bent a little at that extremity, which has the claws; and likewise on the other, which is perforated. This is introduced transversely, hard by the weapon; and then, when it has reached its point, it is turned a little, that it may receive the weapon into the perforation. When the point is in the hole, the operator, clapping two of his fingers to the claws at the other end, draws out at once his instrument and the weapon.

A third kind of weapon, which requires sometimes to be pulled out, is a leaden bullet, or a stone, or some such thing, which having broke through the skin, is entirely lodged within. In all these cases, the wound must be enlarged, and what is within must be extracted by a forceps the way it entered.

But there is an additional difficulty attending every wound, where the weapon is either fixed in a bone, or has sunk into an articulation between two bones. If, in a bone, the weapon must be moved to and fro, till the part, which gripes the point, gives way, and then the weapon must be extracted, either with the hand, or a forceps. Which is also the method of extracting the teeth. And it is very rare that the weapon does not follow in this way. But if it still remains, it may be forced out with some kind of instrument. The last resource, when it is not extracted, is to make a perforation near it by a terebra, and from that opening, to cut the bone in the form of the letter v, opposite to the weapon, in such a manner, that the opening of the lines be directed towards the weapon; when this is done, it must necessarily give way, and be easily taken out.

If it has made its way into an articulation between two bones, the two limbs must be bound up with rollers and straps, and by means of these drawn contrary ways, to stretch the tendons: which being extended, will leave a larger space between the bones, so that the weapon may be extracted without difficulty. Care must be taken, as I observed in other cases, in its extraction, that no nerve, vein, or artery be wounded by the weapon, whilst it is extracting, which is to be guarded against by the method mentioned before.

But if a person be wounded by a poisoned weapon, all that is above mentioned being, if possible, still more expeditiously executed, he must also be treated in the method prescribed for one that has drunk poison, or been bit by a serpent. The treatment of the wound itself, after the extraction of the weapon, is the same as if nothing had been lodged there; of which I have said enough elsewhere.

These are cases that occur in any part of the body indifferently: the rest have certain seats, which I am going to speak of, beginning with those in the head. In this a great number and variety of tubercles rise, called ganglia[ GQ ] melicerides[ GR ], atheromata[ GS ]; there are some other kinds, to which authors give different names; to which I shall also add steatomata[ GT ]: which though they often arise in the neck, and in the armpits, and sides, I have not mentioned separately; since all of them differ but little, and neither are threatening, nor require any different treatment from each other. Now all these rise from a very small beginning, and increase gradually for a long time, and are inclosed each in a coat of its own. Some of them are hard, and resist pressure, others are soft and yielding; some of them are bald in a part, others remain covered with hair, and are commonly without pain. What their contents are, though it may be pretty well guessed at, yet cannot be certainly known, till they be taken out. However, generally in these that resist, there are found either some stony substance, or a number of hairs concreted together: but in those that yield, something resembling honey, or thin pulticula, or the scrapings of cartilage, or insensible or bloody flesh; and these are commonly of different colours. And for the most part ganglia are elastic: the atheroma contains a liquor like thin pulticula: the meliceris a more liquid one, which therefore fluctuates upon being pressed: there is a fat substance in the steatoma, and that generally has the largest circumference, and so relaxes the whole surface of the skin above it, as to make it slide backward and forward; whereas, in the rest, it is more bound. It is proper first to shave them all if they be covered with hair, and then to cut them through the middle, that whatever was collected within may be evacuated. But the coat of the steatoma must also be cut; because it is not easily separated from the skin and subjacent flesh. In the others the coat is to be preserved entire: and immediately, when it appears white and tense, it must be separated by the handle of the knife from the skin and flesh, and taken out together with its contents. If, however, it should happen, that the lower side of the coat adheres to a muscle, lest that be wounded, the upper side must be taken away, and the lower left in its place. When the whole is extracted, the lips must be brought together, and a fibula put upon them, and over that an agglutinating medicine. When either the whole coat, or any part of it is left behind, medicines to promote a digestion must be applied.

But as the foregoing disorders do not differ much either in their nature, or method of cure, so these in the eyes, which require manual operations, are both different in their kinds, and require different methods of cure.

In the upper eye-lids then it is common for fat and heavy vesicles to rise, which scarcely allow the eye to be raised, and occasion gentle, but constant fluxes of gum in the eyes. And they commonly happen to children. In this case, it is necessary to compress the eye with two fingers, and thus stretching the skin, to cut with the knife in a transverse line, with a very light hand, in such a manner as not to wound the vesicle, and so that it may pass out when a way is made for it; then to catch hold of it with the fingers, and pull it out: for it easily separates. After this the part ought to be anointed over with any of these collyriums, that are used in lippitudes; by which means it is covered with a cicatrix in a very few days. It is more troublesome, when the vesicle is cut: for it discharges its humour, and cannot be laid hold of after, because of its smallness. If that accident should happen, one of the medicines that promotes a digestion, may be laid on.

In the eye-lid, likewise, above the lashes, there grows a small tubercle, which from its resemblance to a barley-corn, is, by the Greeks, called crithe[ GU ]. It is contained in a coat, and seldom maturates. Upon this should be applied hot bread, or wax heated now and then, provided the degree of heat be no more, than the part can easily bear: for by this method it is often discussed, sometimes maturated. If pus appear, it ought to be divided by a knife, and the contained humour squeezed out: and to be afterwards treated with the same warmth, and anointed, till it recover a sound state.

Other tubercles not unlike this, grow in the eye-lids; but however not of the same form, and also moveable, when they are impelled this way or that by the finger: which because of their resemblance to hail-stones, the Greeks call chalazia[ GV ]. These ought to be cut on the external side, if they be immediately under the skin; on the internal, if they lie below the cartilage; after that, they must be separated by the handle of the knife from the sound parts. And if the wound be on the internal side, it must be anointed at first with mild, and afterwards more acrid medicines; if, on the external, an agglutinating plaister must be applied over it.

The unguis, called by the Greeks, pterygium[ GW ], is a small nervous membrane, which arising from the angle of the eye, sometimes reaches to the pupil, and obstructs the sight. It oftener begins from the angle, near the nose, sometimes too from that towards the temples. It is no difficult matter to discuss this, when recent, by the medicines, which lessen cicatrices in the eyes. If it be of long standing, and has acquired some thickness, it ought to be cut out. After an abstinence of one day, the patient must be placed in a seat, either with his face opposite to the physician, or with his back to him, in such a manner, that he may recline his head upon his breast. Some, if the disease be in the left eye, chuse to have him set with his face to the physician; if in the right, in the reclined posture. One eye-lid ought to be opened by an assistant, and the other by the physician. If the physician face him, he must take hold of the lower one; if he be reclined, the upper one. Then the physician is to fix under the extremity of the unguis, a small sharp hook, with its point turned a little inward; and to let go the eye-lid, which is then to be held by an assistant, and taking hold of the hook, he is to lift up the unguis, and pass a needle through, drawing a thread after it; then to lay aside the needle, and take hold of the ends of the thread, and by them raising up the unguis, if it adheres any where to the eye, to separate it by the handle of the knife, till he come to the angle; then alternately sometimes to slacken, sometimes to draw it, that so both its origin and the extremity of the angle may be found. For there is a double danger attends it; either lest some part of the unguis be left, which being ulcerated is hardly ever cured, or lest the caruncle be cut away from the angle; for if the unguis be drawn away with too much force, that also follows, and comes away. If it is torn off, an orifice is opened, through which afterwards a humour always descends, which the Greeks call rhyas[ GX ]. The true termination then of the angle must be found out. When that plainly appears, the knife is to be used, the unguis not being too straight drawn; and then this small membrane is to be cut out in such a manner, that no part of the angle be wounded. Afterwards lint covered with honey must be laid on, and over that a linen cloth, and either spunge, or sordid wool. The following days the eye must be opened daily, lest the eye-lids be agglutinated together by a cicatrix (for that is also a third danger) and lint be put on in the same way: lastly, it must be anointed with a collyrium, that cicatrizes ulcers.

But this operation should be performed in the spring, or at least before winter. Which circumstance, though it belongs to several places, it will be sufficient to mention once for all. For there are two kinds of cures; one, in which we are not at liberty to chuse a time, but that must be laid hold of, that offers, as in wounds and fistulas; another, in which we are not pressed for time; but it is quite safe and easy to wait the most convenient season; as is the case in these disorders, which both increase slowly, and are not extremely painful. In such, we must defer it till spring; or if there is any urgent circumstance, the autumn however, is better than the winter or summer; and of that the middle, when the excessive heats are gone, and the colds not yet set in. Now the more necessary the part is, whose cure shall be undertaken, the greater will the danger be it is exposed to. And often by how much larger the wound is to be made, so much the more must the season of the year be regarded.

From the operation for the unguis, as I observed, disorders arise, which may also sometimes proceed from other causes. For sometimes after the imperfect excision of an unguis, or upon some other occasion, a tubercle grows in the angle, which hinders the entire opening of the eye-lids; the Greek name for it is encanthis[ GY ]. It ought to be laid hold of with a hook, and cut round; and here also the operator must be cautious not to cut away any thing from the angle itself. Then a small piece of lint must be sprinkled either with cadmia, or copperas; and the eye-lids being opened it must be introduced into that angle, and bound over in the same manner as the former; and for some following days must be dressed in like manner, first bathing it with water, just warm, or even cold water.

Sometimes the eye-lids grow together, and the eye cannot be opened. Which is often attended with this disorder besides, that the eye-lids adhere to the white of the eye; that is when an ulcer in either of them has been negligently cured. For as it heals, what might, and ought to have been separated, will be agglutinated; both species of the distemper is called by the Greeks ancyloblepharon[ GZ ]. When the eye-lids only cohere, they are separated without difficulty; but sometimes to no purpose: for they are agglutinated again. However trial ought to be made; because the case often turns out well. Therefore the broad end of the probe must be introduced betwixt them, and the eye-lids separated by that; then small penecilla are to be put between them, till the ulceration of the part be cured. But when the eye-lid adheres to the white of the eye itself, Heraclides the Tarentine advises to cut under it gently with a knife with great caution, lest any thing be cut away either from the eye, or the eye-lid; and if that cannot be entirely avoided, rather to take something from the eye-lid. After these let the eye be anointed with such medicines as cure an asperity; and the eye-lid be inverted every day, not only that the medicine may be applied to the ulcer, but also to prevent its adhesion: the patient himself must also be charged to raise it often with two fingers. I do not remember an instance of one person cured by this method. Meges too tells us he tried many ways, and never was successful; for the eye-lid always adhered again to the eye.

Again in that angle, that is next the nose, from some disorder, a kind of small fistula is opened, through which gum(9) perpetually distils; the Greeks call it Ægilops[ HA ]. And this gives constant uneasiness to the eye; sometimes also eating through the bone, it penetrates to the nostrils. This sometimes is of a cancerous nature; when the veins are tense and crooked, the colour of it is pale, the skin hard, and irritated by a slight touch, and it raises an inflammation in the contiguous parts. It is dangerous to attempt the cure of those, that are cancerous: for it even hastens death. And it is needless to meddle with such as reach to the nostrils: for neither do they heal. But the cure of these in the angle may be attempted; though it should be known however that it is difficult; and the nearer to the angle the opening is, so much the more difficult, because there is a very little room for the management of the hand; yet it is easier to cure the disorder when recent. The top of the opening must be taken hold of with a small hook; and then all the cavity as I directed in fistulas, must be cut out to the bone; and the eye and other contiguous parts being well covered, the bone must be strongly cauterized with a hot iron. But if it be already affected with a caries, that a thicker scale may cast off, some apply caustic medicines; as copperas, or chalcitis, or rasile verdigrease: which method is both slower, and not so effectual. When the bone is cauterized, the remaining part of the cure is the same as in other burns.

The hairs of the eye-lids sometimes irritate the eye; and that from two causes. For sometimes the skin of the eye-lid is relaxed, and falls down; whence it happens, that the lashes are turned in upon the eye itself, because the cartilage is not also relaxed; at other times, beside the natural row of hairs, another grows under it, which point directly inward upon the eye. The methods of cure are these. If preternatural hairs have grown, an iron needle thin and broad, like a spatha(10), must be put into the fire, and when it is red-hot, the eye-lid being lift up in such a manner, that the offending lashes are in the view of the operator, it must be passed from the angle close to the roots of the hair, till it move over the third part of the eye-lid; then it must be applied a second and third time, as far as the other angle. The consequence of which is, that all the roots of the hairs being burnt, die away. Then a medicine to prevent an inflammation must be applied: and when the eschars have cast off, it must be brought to cicatrize. This kind heals very easily. Some alledge that it is proper to pierce the external part of the eye-lid near the eye-lashes with a needle, which must be passed through with a woman’s hair doubled for a thread; and when the needle has gone through, that the offending hair must be taken up into the loop of the woman’s hair, and by that drawn upward to the superior part of the eye-lid, and there to be glued down to the flesh, and a medicine applied to close up the orifice thus made: for that this will cause the eye-lash to point afterwards externally. This in the first place cannot be practised, but upon a pretty long hair; whereas they generally grow short there. And then if there be several hairs, the patient must suffer a long torture, and the needle passing so often through will raise a great inflammation. Lastly, when any humour is settled there, the eye being irritated both before by the hairs, and afterwards by the perforations of the eye-lids, it is hardly possible to prevent the glutinous matter, which fastens the hair, from being dissolved: and thus of course the hair returns to the place, from whence it was drawn away.

The method of cure for a relaxed eye-lid, which is universally practised, never fails of success. For the eye being closed, one must take hold of the middle part of the skin of the eye-lid, whether it be the upper or the lower, with his fingers, and raise it; then consider how much must be taken away, to reduce it to its natural condition. For there are two dangers attending this case; lest if too much be cut off, the eye cannot be covered; if too little, the end be not obtained, and the patient have suffered to no purpose. The part, which it shall be thought needful to cut, must be marked by two lines with ink in such a manner, that betwixt the range of hairs and the line nearest to it, some space may be left for the needle to lay hold of. These things being determined, the knife is to be used: and if it be the upper eye-lid, the incision next the eye-lashes must be made first; if the inferior one, last: and it must begin in the left eye, at the angle next the temple; in the right, at the angle next the nose; and what lies between the two lines must be cut out. Then the lips of the wound are to be joined together by a single stitch, and the eye must be covered; and if the eye-lid does not descend far enough, it must be relaxed; if too much, it must be either straiter drawn, or a small habenula again cut off from that lip of the wound, which is farthest from the eye-lashes. When it is cut off, other stitches must be added, not above three. Moreover a scarification must be made in the upper eye-lid, under the roots of the eye-lashes, that being raised from the inferior part they may point upwards: and this alone will be sufficient for the cure, if they are but little turned in. The lower eyelid does not need this process. When these are done, a spunge squeezed out of cold water must be bound on: the day following an agglutinating plaister should be applied. On the fourth, the stitches must be taken away, and the wound anointed with a collyrium, to prevent an inflammation.

Sometimes from this operation, when too much of the skin is cut away, it happens, that the eye cannot be covered. And this sometimes proceeds from another cause. The Greeks call the disorder lagophthalmos[ HB ]. When too much of the eye-lid is wanting, there is no remedy for it; if but a small part, it may be cured. An arched incision must be made in the skin a little below the eye-brow, with its horns pointing downward. The wound ought to go as deep as the cartilage, but without injuring it: for if that be cut, the eye-lid falls down, and cannot afterwards be raised. Let the skin then be only divided, so as to allow it to descend a little in the lower part of the eye; which will be the consequence of the wound’s gaping above. Let lint be put into it to prevent the union of the divided skin, and to generate a little flesh in the middle: and when this has filled up the part, the eye is afterwards properly covered by the eye-lid.

As it is a disorder of the upper eye-lid not to descend far enough to cover the eye, so there is a disease of the lower, in which it is not raised high enough, but hangs down, and cannot be brought close to the other. And this also sometimes proceeds from a similar fault in the cure, sometimes even from old age. The Greeks call it ectropium[ HC ]. If it happens from a faulty cure, the treatment is the same as in the foregoing case: only the horns of the wound are turned towards the cheeks, and not to the eye. If it proceed from old age, the whole of it must be cauterized externally with a thin plate of iron; then anointed with honey; and from the fourth day fomented with hot water, and anointed with medicines to bring on a cicatrix.

These then are the general disorders, that commonly occur in the parts about the eye, the angles, and eye-lids. In the eye itself the external coat is sometimes raised, either from the rupture or relaxation of some of the internal membranes; and it resembles a raisin stone in its form, whence the Greeks call it a staphyloma[ HD ]. There are two methods of cure for it. One is to pass through the middle, at the root of it, a needle with a double thread; then to tie tight the ends of one of the threads above, and of the other below; which by cutting it gradually may bring it off. The other is, to cut out from its surface about the bigness of a lentil; then to rub in spodium or cadmia. When either of these is done, the white of an egg must be spread upon wool and applied; and afterwards the eye must be fomented with the steam of hot water, and anointed with mild medicines.

Callous tubercles in the white of the eye are called clavi; which name is given them from their figure. The best method is to pierce them at their very roots with a needle; and below that to cut them off, and then to anoint with mild medicines.

I have already elsewhere mentioned a cataract, because when recent, it is often removed by medicines. But when it is of long standing, it requires a manual operation, and one, which may be reckoned amongst the nicest. Before I treat of this, I shall give a short account of the nature of the eye; the knowledge of which, as it is of importance in several other parts, so it is peculiarly necessary here. The eye then has two external coats; the exterior of which by the Greeks is called ceratoides[ HE ]; and this, where it is white, is pretty thick, but before the pupil is thinner. The interior coat is joined to this, in the middle where the pupil is, and is concave, with a small aperture; round the pupil it is thin, but at a distance from it, something thicker; and by the Greeks is called chorioides[ HF ]. As these two coats surround the internal part of the eye, they again join behind it, and becoming finer, and uniting together, pass through the opening, which is between the bones, to the membrane of the brain, and are fixed to it. Under these, in the part where the pupil is, there is a void space; then again below, is an exceeding fine coat, which Herophilus called arachnoides[ HG ], the middle part of which subsides, and in that cavity is contained somewhat, which from its resemblance to glass the Greeks call hyaloides[ HH ]. This is neither liquid, nor dry; but seems to be a concreted humour; from the colour of which, that of the pupil is either black, or grey, though the external coat be white. This is inclosed by a small membrane, which proceeds from the internal part of the eye. Under these is a drop of humour resembling the white of an egg, from which proceeds the faculty of vision. By the Greeks it is called chrystalloides.

Now a humour concretes under the two?a??e?d??. coats, where I mentioned the void space to be, either from a disease, or a blow; and being gradually indurated, it obstructs the interior faculty of vision. There are several species of this malady, some of which are curable, and others not. For if the cataract be small, immoveable, of the colour of sea-water, or burnished iron, and leaves some sense of light on its sides, there remains hope. If it is large, if the black part of the eye, losing its natural appearance, is changed into some other, if the cataract be of the colour of wax(11), or gold; if it slides and moves to and fro, it is scarcely ever cured. And for the most part, the more severe the disease, or the greater the pains of the head, or the more violent the blow has been, which gave rise to it, so much the worse it is. Neither is old age a proper time of life for a cure; which without an additional disease causes a dimness of sight: nor even childhood; but the middle age betwixt these. Neither is a very small eye, nor one, that is hollow, fit for this operation. And there is also a certain maturity of the cataract itself: wherefore we must wait till it seems to be no longer fluid, but to have concreted with a certain degree of hardness.

Before the operation, the patient must use a spare diet, drink water for three days, the day immediately preceding take nothing at all. After this preparation he must be set in a light place, in a seat facing the light, and the physician must sit opposite to the patient on a seat a little higher; an assistant behind taking hold of the patient’s head, and keeping it immoveable; for the sight may be lost for ever by a slight motion. Moreover the eye itself, that is to be cured, must be rendered more fixed by laying wool upon the other, and tying it on. The operation must be performed on the left eye by the right hand, and on the right by the left hand. Then the needle sharp pointed(12), but by no means too slender, is to be applied, and must be thrust in, but in a straight direction, through the two coats, in the middle part betwixt the black of the eye and the external angle opposite to the middle of the cataract, care being taken to wound no vein. And it must not be introduced with timidity(13) neither, because it comes into a void space. A person of very moderate skill cannot but know when it arrives there; for there is no resistance to the needle: when we reach it, the needle must be turned upon the cataract, and gently moved up and down there, and by degrees work the cataract downward below the pupil; when it has past the pupil, it must be prest down with a considerable force, that it may settle in the inferior part. If it remain there, the operation is compleated. If it rises again, it must be more cut with the same needle, and divided into several pieces; which when separate, are both more easily lodged, and give less obstruction. After this the needle must be brought out in a straight direction, and the white of an egg spread upon wool must be applied, and over that something to prevent an inflammation, and then the eye be bound up.

Afterwards there is a necessity for rest, abstinence, mild unctuous medicines, and food (which it is soon enough to give on the day following) at first liquid, that the jaws may not be too much employed, then when the inflammation is gone, such as was directed in wounds. To which we must add this rule, that the patient’s drink be water for a pretty long time.

I have already treated of a flux of thin gum, which infests the eyes, so far as the cure depends upon medicines. I now come to these cases, that require manual operation. Now we observe that some people’s eyes never grow dry, but are always moistened with a thin humour; which circumstance occasions a constant asperity, and from slight causes excites inflammations, and lippitudes, and in fine renders a person uneasy all his life. And this disorder in some no remedy can relieve; in others it is curable. Which difference ought first of all to be known, that we may relieve the one, and not meddle with the other.

And in the first place, it is in vain to attempt the operation in those, who have this disorder from their infancy, because it will certainly continue to their dying day. Secondly, it is needless, where the discharge is not great, but acrid; because they are not assisted by a manual operation, but are brought to a sound state by medicines, and a proper diet for generating a thicker phlegm. Broad heads also are hardly susceptible of the remedy. Then it makes a difference whether the gum be discharged by the veins, that lye between the skull and the skin, or by those between the membrane of the brain and the skull: for the former moisten the eyes by the temples; the others by the way of those membranes, that go from the eyes to the brain. Now a remedy may be applied to those veins, that discharge above the bone, but not to those below the bone(14). Neither can relief be given, where the discharge comes from both places; because when one part is relieved, nevertheless the other remains disordered.

The source of the disorder is discovered by this method. After shaving the head, such medicines, as stop the gum in a lippitude, ought to be laid on from the eye-brows as far as the top of the head: if the eyes begin to be dry, it appears that they are moistened by those veins, which are under the skin: if the moisture is not diminished, it is manifest it descends from below the bone: if a humour still flows(15), but in less quantity, the disorder is from both. In most patients however the complaint is found to be derived from the superior veins; and therefore the greater number may be relieved. And this is very well known, not only in Greece, but amongst other nations too: so that no part of medicine has been more clearly explained in any country.

Some practitioners in Greece cut the skin of the head in nine lines; two straight ones in the occiput, one transverse above these; then two above the ears, one also transverse betwixt them; and lastly three straight ones between the top of the head and the forehead. Others drew these incisions in a straight direction from the top of the head to the temples; and discovering from the motion of the jaws the origins of the muscles, made gentle incisions in the skin above these, and separating their lips by means of blunt hooks, they inserted lint in such a manner, as to prevent the edges of the skin from uniting, and to cause flesh to sprout up in the middle, which might bind those veins, from whence the humour passes to the eyes. Others again have drawn a line with ink from the middle of one ear to the middle of the other, and another line from the nose to the crown of the head; and where these lines met, made an incision with a knife; and after the effusion of blood, cauterized the bone in that part. And notwithstanding this, they also applied the actual cautery to the rising veins both in the temples, and betwixt the forehead and crown of the head.

It is a common method of cure to cauterize the veins in the temples, which indeed are generally turgid in this kind of disorder; but that they may be more inflated and show themselves better, the neck must first be tied pretty strait. And the veins must be cauterized with small and blunt irons; till the flux of gum upon the eyes stop: for that is a sign the passages are blocked up, by which the humour was conveyed.

However it is a more effectual method, when the veins are small and lie deep, and therefore cannot be separated(16), to make a ligature about the neck in the same manner, and the patient keeping in his breath, that the veins may rise the more, to mark with ink these in the temples, and between the crown of the head and the forehead; then loosing the neck, to cut the veins, where these marks are, and discharge blood; when a sufficient quantity has flowed, to cauterize them with small irons: in the temples indeed with caution; lest the muscles lying below, which secure the jaws, be hurt; but betwixt the forehead and the crown so strongly, that a scale may cast off from the bone.

But the method of the Africans is still more efficacious, who cauterize the crown of the head to the bone, so as to make it cast off a scale. But nothing is better than what is done in Gallia Comata, where they separate the veins in the temples, and the upper part of the head. The manner of treating cauterized parts I have already explained. At present I shall add this one direction; that when veins are cauterized, we should not endeavour to hasten the separation of the eschars, nor the filling up of the ulcers; lest either an hemorrhage ensue, or the pus be quickly suppressed; since it is fit these parts be dried by the latter, and it is not proper they should be exhausted by the former. If however an hemorrhage should at any time happen, medicines for stopping blood must be rubbed in, but not such as will prove caustic. Now the method of separating veins, and what is to be done, when they are separated, I shall explain, when I come to the varices of the legs.

But as the eyes require many operations, so in the ears there are very few disorders, which come under this branch of medicine. However it sometimes happens, either immediately from the birth, or some time after, when there has been an ulceration, and the ear has been filled by a cicatrix, that there is no opening in it, and there it is deprived of the faculty of hearing. When this happens, trial must be made with a probe whether it be filled up to any depth, or be only agglutinated in the surface. For if it be deep, it does not yield to the pressure; if superficial, it presently receives the probe. The first ought not to be touched, lest a convulsion follow without any hopes of success, and from that there may be a danger of death; the other is easily cured. For where the foramen ought to be, either some caustic medicine must be applied, or it must be opened by the actual cautery, or even cut with a knife. And when that is opened, and the ulcer is clean, a quill must be introduced there, armed with a cicatrizing medicine; and round something must be applied, to promote the healing of the skin about the quill; the effect of which is, that after it is removed, the patient has the faculty of hearing.

But where the ears have been bored and give offence, it is sufficient to pass a hot needle through the cavity very quick, that its lips may be slightly ulcerated; or even to ulcerate it with a caustic medicine; then afterwards to apply something to deterge it; next somewhat to fill up the part, and bring on a cicatrix. But if this opening be large, as it generally is in those who have worn heavy ear-rings, it is proper to cut through what remains,(17) to its extremity; then above that to scarify the edges of the foramen with a knife, and afterwards to stitch them, and apply an agglutinating medicine. The third case consists in giving a supply to any part, that is deficient; which as it may also be done in the lips and nose, and the method is the same, it will be best to treat of it once for all.

Defects in these three parts, if they be small(18), may be cured: if considerable, they either do not admit of a cure, or by the cure itself are so deformed, that they were less offensive before. And in the ear indeed, and the nose, deformity is the only thing to be feared: but in the lips, if they are too much contracted, there is also a disadvantage in respect of their use; because the food is taken, and the speech is articulated with more difficulty. For flesh is not generated there; but is brought from the adjacent part. Which though in a slight mutilation it may both cause no defect, and escape observation, in a great one cannot. Now an old person is not a proper subject for this operation, nor one in a bad habit of body, nor one in whom ulcers heal with difficulty; because there is no part, where a gangrene more quickly seizes, or is harder to remove.

The method of cure is this; to reduce that, which is mutilated, into a square; from its interior angles to cut in transverse lines, so as to divide the part, that lies within these lines, from that beyond them; then to draw together the parts we have thus opened: if they do not fully meet, then beyond the lines we made before, to cut in two places in a lunated form, with the horns turned towards the wound, so as only to separate the surface of the skin: for by this means what we draw together will be more at liberty to follow; which is not to be forced by violence, but gently drawn, so as it may easily follow, and when let go, not recede far.

Sometimes however, the skin not being altogether brought from one side, renders the part, which it has left, deformed(19). In such a place an incision must be made only on one side, and the other kept untouched. Therefore we must not attempt to draw any thing either from the lower part of the ears, or the middle of the nose, or the lower parts of the nostrils, or from the angles of the lips. We may draw on both sides, where there is any defect in the upper parts of the ear, or the lower parts or the middle of the nostrils, or the middle of the lips: which however are sometimes mutilated in two places; but the method of cure is the same. If a cartilage projects in the part where the incision is made, it must be cut off; for it neither unites again, nor is safely pierced by the needle. Neither must much of it be cut away, lest between the two extremities of the skin freed from it on both sides, there should be a collection of pus. Then the lips of the wound being brought into contact, must be stitched together, the skin being taken up on both sides; and where the lines above mentioned are, there also the suture must be used. In dry parts, as the nostrils, the application of litharge does very well. Into the interior and lunated incisions lint must be put; that granulations of flesh may fill up the wound. And that the part thus sewed must be attended to with the greatest care, may appear from what I said before of a gangrene. Therefore every third day, it must be fomented with the steam of hot water, and the same medicine applied again, which commonly on the seventh day unites it. Then the stitches ought to be taken out, and the ulcer healed up.

I have elsewhere said that the knife is the principal cure for a polypus growing in the nostrils. Wherefore it is necessary to separate this from the bone with a sharp iron instrument made in the form of a spatha: care being taken not to hurt the cartilage below, which is difficult to cure. When it is cut off, it must be extracted with an iron hook. Then a piece of lint twisted, or some part of a penecillum must be sprinkled with a styptick medicine, and the nostrils be gently filled with it. The blood being stopped, the ulcer must be deterged with lint. When it is clean, a quill armed with a cicatrizing medicine must be introduced within, in the same manner as was directed in the ear, till it be entirely sound.

I do not find in the eminent surgeons any operation for the cure of that disorder, which the Greeks call ozÆna, when it does not yield to medicines. I suppose because the operation seldom works a cure, and is nevertheless attended with great pain. By some however it is directed to introduce either a small cannula, or writing reed into the nostril, till it reach up to the bone; then through this to pass a small hot iron to the very bone; next to deterge the cauterized part with verdigrease and honey; and when clean, to heal it up with lycium: Or that an incision be made in the nostril from its extremity to the bone, that the part may be seen, and the hot iron may be more easily applied; then that the nostril be stitched; and the cauterized ulcer cured as in the former method; and litharge or some other agglutinant laid upon the suture.

In the mouth also some disorders are cured by manual operation. Here in the first place the teeth are sometimes loosened, either by reason of the weakness of their roots, or from the gums decaying. It is proper in both cases to apply a hot iron to the gums, so as to touch them gently, but not to make a deep impression. The gums when cauterized must be rubbed with honey, and washed with mulse. When the ulcers begin to be clean, some dry repellent medicines must be sprinkled upon them.

But if a tooth occasions pain, and it seems proper to extract it, because medicines give no relief, it ought to be scraped all round, that the gum may be loosened from it; then it is to be shook; which must be continued till it move easily: for the extraction of a fast tooth is attended with the greatest danger, and sometimes the jaw-bone is dislocated. It is attended with more danger still in the upper teeth; because it may give a shock to the temples or eyes. After these precautions, the tooth is to be taken out, if possible, by the hand, if not, by a forceps.

But if it be corrupted before, its cavity must be filled up either with lint, or lead well adapted to it, lest it break under the forceps. The forceps must be drawn out straight, lest the thin bone, to which the tooth adheres, be fractured in some part by its bended roots. Neither is this without danger; especially in the short teeth, which generally have longer roots; for often, when the forceps cannot lay hold of the tooth, or does it without success, it takes hold of the jaw-bone, and breaks that.

One may immediately be sure, when there is a large effusion of blood, that something is broken off from the bone. Therefore the scale, that has come off, must be sought for by a probe, and taken out with a vulsella. If it does not come away, the gum ought to be cut, till the scale loosened from the bone can be taken out. And if it be not entirely broken, but the external part of the jaw swells, so that the mouth cannot open, on the outside must be applied a warm cataplasm of meal and figs, till it bring on a suppuration there; then an incision must be made in the gum. A copious discharge of pus is also a sign of a fractured bone: so that even then it is proper to extract it. Sometimes too, when it is injured, there is a fissure, which ought to be scraped.

A rough tooth ought to be scraped, where it is black, and rubbed with the powder of rose leaves, with an addition of one-fourth part of galls, and another of myrrh; and pure wine must be held in the mouth frequently. And in this case the head must be covered, the patient must walk much, make use of friction to his head, and a diet not acrid.

But if either, from a blow, or some other misfortune, some of the teeth are loosened, they must be tied with gold to those that are firm; and restringents must be held in the mouth, such as wine, in which pomegranate bark has been boiled, or in which hot galls have been infused. And if one tooth should happen to grow in children, before the former has fallen out, that, which should have dropped, must be scraped round and pulled out; that which is growing in the place of the former, must be pushed into its proper place, with the finger, every day, till it come to its just size. Whenever a tooth is extracted, and its root has been left, that also must be immediately taken out by a forceps made for that purpose, which the Greeks call rizagra.

Tonsils, that are indurated, after an inflammation, called antiades[ HI ] by the Greeks, when they are covered by a slight coat, should be disengaged all round by the finger, and pulled out. If they are not separated by this method, it is necessary to take hold of them with a small hook, and cut them out with a knife; then to wash the ulcer with vinegar, and rub the wound with a styptic medicine.

The uvula, if it is inflamed, and falls down, and is painful, and of a ruddy colour, cannot be cut without danger; for there is commonly a great effusion of blood: therefore it is better to make use of those remedies I have mentioned elsewhere. But if there be no inflammation, and nevertheless it is relaxed to a great length by a humour, and is small, sharp, and white, a portion of it ought to be cut off: and likewise, if the extremity of it be livid and thick, and the superior part small. There is no better method than to take hold of it with a vulsella (a kind of forceps), and under that, to cut off what we think fit: for there is no danger, that either too much or too little be cut off; as we have it in our power to leave no more below the vulsella, than appears to be useless, and to cut off so much as shall reduce the uvula to its natural magnitude. After the operation, the same applications are proper, which were prescribed above for the tonsils.

The tongue, in some people, is joined with the part below it from their birth; who are by that means deprived of speech. The end of their tongue must be taken hold of with a vulsella, and the membrane below it cut; great care being taken, that the contiguous veins be not wounded, and the patient hurt by an effusion of blood. The remaining part of the cure of the wound is already directed in the preceding cases. And most people speak, as soon as it is healed. But I have known an instance, where a person after the cutting of his tongue, though he could thrust it far enough beyond his teeth, did not attain the faculty of speaking. Thus it happens in the practice of physic, that what is always right to do, is not always attended with success.

An abscess also sometimes gathers under the tongue; which is generally included in a coat, and excites violent pains. If this be small, it is sufficient to make one incision into it: if larger, the surface of the skin must also be cut off to the coat, then the lips of it are to be laid hold of on both sides with small hooks, and the membrane must be freed from its connections all round; great care being taken in this operation not to wound any large vein.

The lips are frequently chopped; which besides the pain, is attended with this inconvenience, that it hinders our speaking, as that action by opening the fissures causes them to bleed, and to give pain. If these be only in the surface, it is better to treat them by those medicines, which are composed for ulcers of the mouth: if they are deeper, it is necessary to cauterize them with a thin iron; which being made in the form of a spatha, ought to slide over them as it were, and not press upon them. Afterwards, the same method must be followed, as was laid down in cauterized ulcers of the nostrils.

In the neck, between the skin and the wind-pipe, a tumour rises, which the Greeks call bronchocele[ HJ ], in which there is contained sometimes insensible flesh, at other times a humour like honey or water; sometimes also hairs mixed with small bones. Whatever that be, which is contained in the coat, it may be cured by caustic medicines, which burn the surface of the skin, together with the coat below it. When this is done, if it be a humour, it runs out; if it be any thing substantial, it is taken out by the fingers; then the ulcer is healed by lint. But the cure by the knife is more expeditious. An incision is made in one line in the middle of the tumour down to the coat; after which, the morbid body is separated by the finger from the sound parts, and is taken out entire with its coat: then it is washed with vinegar, to which either salt or nitre has been added; and the lips are joined by one stitch. The other applications are the same as in other sutures; afterwards it must be bound up gently, lest it press the fauces. If it should happen that the coat cannot be taken out, we must sprinkle escharotics into it, and dress it with lint and other digestives.

There are several disorders about the navel, concerning which, because they are very uncommon, authors are not agreed. Now it is probable, that each one omitted what he had not met with, and that none of them feigned a disease he had not seen. An indecent prominence of the navel is common to them all. The question is, what are its causes? Meges has assigned three; that sometimes the intestine makes its way into that part, sometimes the omentum, at other times a humour. Sostratus has not mentioned the omentum. To the other two he has added, that flesh sometimes grows there; which is sometimes sound, at other times of a cancerous nature. Gorgias also has omitted the omentum, but allowing the other three causes, says, that air too sometimes is forced into this part. Heron has mentioned all these four, and the omentum too; and that species also, in which there is both the omentum and the intestine.

The following symptoms discover what species it is. When the intestine is protruded, the tumour is neither hard nor soft; is lessened by cold, increases not only by heat, but even by keeping in the breath; sometimes it sounds; and when a person lies on his back, the intestine returns of itself, and the swelling subsides. When it is the omentum, the other symptoms are similar, but the tumour is softer, and from its base, tapers towards the top; and if one takes hold of it, it slips away. Where both these are together, the symptoms are also complicated, and the degree of softness is between both. But flesh is harder, and there is a swelling always, though the patient lies on his back; it does not yield to pressure, whereas the former easily does. If it be corrupted, it has the same appearances which I described in a cancer. A humour, if it be pressed, fluctuates. Air gives way to pressure, but quickly returns; and when the body is in a supine posture, the tumour retains the same figure.

Of these species, that which proceeds from air, does not admit of a cure. It is dangerous also to meddle with flesh that resembles a cancer; and therefore it must be let alone. Where it is sound, it ought to be cut out, and the wound dressed with lint. Some discharge the humour by making an incision in the top of the tumour, and cure that also by lint. With regard to the others, the opinions are various. However, the circumstances themselves make it plain, that the body must be laid in a supine posture; that whether it be the intestine or the omentum, it may fall back into the abdomen. Then the cavity of the navel being empty, by some is laid hold of by two regulae(20), and their ends being tied tight, the part mortifies: by others it is pierced to the bottom with a needle, followed by two threads, and is tied on the one side and the other by the two ends of each of these threads (as is done in the staphyloma of the eye) for by this means the part above the ligature mortifies. Others added this process to the operation: before tying, they made a single incision on the top, that, by introducing a finger, they might push back the protruded part, and then made the ligature. But it is sufficient to order the patient to hold in his breath, that the tumour may show itself in its full magnitude; then to mark the base of it with ink; and laying the person on his back, to press down the tumour, that if any part has not returned, it may be forced in by the hand; this done, to draw up the navel, and where the mark of the ink is, to tie it strongly with a thread; then to cauterize the part above the ligature, either with medicines, or the actual cautery, till it be mortified; and to dress the ulcer like other burns. This method is very successful not only when the intestine, or the omentum, or both are contained in it, but even where it is a tumour.

But some circumstances are to be considered, before proceeding to the operation, that no danger may arise from the ligature. For neither an infant, nor an adult, nor an old man are proper subjects for this method of cure; but generally such as are from seven to fourteen years old. Next, that person is in a fit condition for it, whose body is sound; but one, who is in a bad habit, and labours under papulÆ, impetigoes, and the like disorders, is not a proper subject. Slight tumours also are easily removed; but there is danger in attempting to cure those that are too large. The autumnal and winter season of the year must be avoided. Spring is most suitable: and the beginning of summer is not amiss. Besides these precautions, it is necessary to fast the day before. Nor is that sufficient; for a clyster must also be given, that all the protruded parts may the more easily subside within the abdomen.

I have elsewhere observed, that it is necessary to discharge the water in dropsical patients. I must now describe the manner of performing it. Some do it below the navel, about four fingers breadth to the left: some by perforating the navel itself. Others first cauterize the skin, and then make an incision through the interior teguments, because what is divided by the actual cautery unites less quickly. The instrument is to be introduced with great care not to wound any vein. It ought to be of such a form, that the breadth of its point should be about the third part of a finger; and it must be introduced so as to pass through the membrane also, which separates the flesh from the internal part; then a leaden or copper pipe must be introduced into it, its lips being either spread outward, or surrounded with some check to prevent its slipping through. The part that goes within ought to be a little longer than that without, that it may reach beyond the internal membrane. By this the water must be evacuated, and when the greater part of it is discharged, the pipe must be stopped with a bit of linen, and left in the wound, if it was not cauterized. Then on the following days, about a hemina must be let out every day, till no water appears to remain. Some even take out the pipe, though the skin has not been cauterized, and tie over the wound a spunge squeezed out of cold water, or vinegar, and the day following introduce the pipe again (which the recent wound, by being a little stretched open, will admit of) that so, if any humour remains, it may be evacuated; and this they recommend to be done only twice.

Sometimes the belly is perforated by a wound; upon which the intestines roll out. When this happens, it must be first of all considered, whether they be unhurt; and then whether they retain their natural colour. If the smaller intestine be perforated, I have already observed, that there is no cure for it. The large intestine may be sewed; not that there is any reliance on the cure, but because a doubtful hope is preferable to certain despair: for it sometimes reunites. However, if either the intestine be livid, or pale, or black, which symptoms also are necessarily attended with a want of sensation, all remedies are vain. But if they yet retain their proper colour, they must be treated with great expedition; for they are changed in a moment, when exposed to the external air, to which they are not accustomed. The patient must be laid on his back, with his hips raised pretty high; and if the wound be so narrow, that the intestines cannot be conveniently reduced, a sufficient opening must be made by incision. And if the intestines are already become too dry, they must be washed with water mixed with a little oil. Then the assistant ought gently to separate the lips of the wound with his hands, or even with two hooks passed through the peritonaeum, and the physician must insert those intestines first that came out last, in such a manner as to preserve the order of their several convolutions. When they are all replaced, the patient must be shook gently, which causes all the intestines to return to their proper places, and settle there. These being lodged, the omentum must also be considered; and if any part of that be already black or mortified, it must be cut off by the scissars; if any of it is sound, it must be reduced upon the intestines. Now, neither a suture of the skin alone, nor of the interior membrane is sufficient, but both of them together. And that must be performed with two threads, and sewed closer than in other places; because it may both be more easily broken by the motion of the belly, and this part is not so liable to violent inflammations. Therefore, threads are to be put into two needles, and these held in both hands; the interior membrane must be sewed first, beginning at the extremity of the wound, in such a manner, that the needle may pass from the internal towards the external part, the left hand carrying it through the right lip, and the right hand through the left, by which means, the points of the needles are always farthest from the intestines, and the blunt part next to them. When each side is pierced once, the needles must be changed in the hands, that the needle, which was in the left hand, may be in the right, and that come into the left, which the right held before: and in the same manner they must pass through the lips again; and also a third and fourth time, and so on, the hands each time interchanging the needles, and thus the wound must be closed. Then the same threads and needles must be brought to the skin, and in like manner both sutures be performed on that part too; the needles always passing from the internal part, and from the one hand to the other. Afterwards agglutinants must be applied: to which it is needless to repeat, from time to time, that it is necessary to add either spunge or sordid wool squeezed out of vinegar. When these are applied, a gentle bandage ought to be passed round the belly.

Sometimes either from a blow, or keeping in the breath too long, or by the pressure of a heavy load, the internal membrane of the abdomen breaks, when the skin above is whole: which also frequently happens to women from pregnancy; and it generally occurs about the ilia. The consequence is, that the flesh above being soft, does not bind the intestines strongly enough, and the skin distended by them forms an indecent tumour. And this disease is cured in different ways. For some passing a needle with two threads into the base of the tumour, tie it on both sides in the same manner described in the cases of the navel and the staphyloma, that whatever is above the ligature may mortify. Others cut out the middle of it in the form of a myrtle leaf (according to the rule before laid down for all cases of a like nature) and then join the lips by a suture. However, the best method is to lay the patient on his back, and try by the hand, in what part the tumour yields most, because the membrane must necessarily be ruptured there, and resist more, where it is sound: then, where it appears to be ruptured, incisions are to be made in two lines(21) by a knife, that the part betwixt them being cut out, the internal membrane may have a recent wound on both sides; because what has been long disunited does not unite by a suture. The place being laid open, if the membrane in any part should appear not to be fresh wounded, a small slip must be cut off, only to ulcerate its edges. What else relates to the suture, and the remaining part of the cure, has been above directed.

Besides these, some people have varices in their bellies; but as the method of cure here does not differ from that which is practised in the legs, and being about to describe it by and by, I shall refer it to that place.

I now come to those diseases which arise in the private parts about the testicles: which, that I may the more easily explain, I shall first give a short account of the nature of the part. The testicles then have something resembling small glands(22): for they do not discharge blood, and are void of all sensation; the coats, however(23), which contain them, are pained in wounds and inflammations. Now each of them hangs from the groin by a nerve (the vas deferens) which the Greeks call cremaster[ HK ]: and with each descends both a vein and an artery. And these are covered with a membrane, thin, nervous, not sanguineous, and white, which by the Greeks is called elytroides[ HL ]. Over that is a firmer coat, which adheres strongly in the lowest part to the interior one. The Greeks call it dartos[ HM ]. Besides, there are many small membranes, which inclose the veins and arteries, and those nerves; and betwixt the two coats in the superior part they are thin and open. Thus far then the coats and vessels are peculiar to each testicle. But there is a sinus common to both, and to all the internal part, which is also exposed to our view. The Greeks call it oscheum[ HN ]; in our language it is scrotum. And this in the lower part is slightly connected with the middle coats, above only envelopes them.

Under this then several disorders occur: which happen sometimes when these coats, which I said had their origin from the groin, are ruptured; at other times, when they are entire: for sometimes the coat, which ought to separate the intestines from the inferior parts, is either first inflamed from a distemper, and afterwards burst by the weight, or ruptured at once by some wound. Then either the omentum alone, or that and the intestine together, fall down into it by their own weight. And finding a way there, they bear down gradually from the groin upon the inferior parts, and by and by divide the nervous coats, which, for the reason I gave before, are open. The Greeks call these enterocele[ HO ] and epiplocele[ HP ]: with us an indecent, but common name for them is hernia.

Now if the omentum descends, the tumour in the scrotum is never removed either by fasting, turning the body one way or another, or placing it in any particular posture; and if the breath be kept in, it is not much increased, is unequal to the touch, and soft and slippery.

But if the intestine also descends, the tumour without any inflammation sometimes lessens, at other times increases, and it is generally free from pain, and when a person is at rest, or lies down, it sometimes entirely subsides, at other times it is so diminished, that a very small part of it remains in the scrotum; but upon vociferation, or repletion, and a violent exertion of force in bearing a great weight, it increases: by cold it is contracted, by heat dilated; and at that time the scrotum is both round and smooth to the touch, and what lies within is slippery; if it be pressed, it returns to the groin; and being let go, it rolls down again with a murmuring kind of noise, and this happens in the lesser degrees of this malady. But sometimes from the reception of excrements, the swelling is vastly enlarged, and cannot be reduced; and occasions pain at such times to the scrotum and groin, and abdomen. Sometimes too the stomach is affected, and throws up first reddish coloured bile, then green, and in some even black.

Sometimes the membranes being entire, a fluid distends this part: and there are also two species of this. For it either collects between the coats, or in the membranes, which surround the veins and arteries in that part, when they are oppressed, and have grown callous. Neither has that fluid betwixt the coats one certain seat: for sometimes it lodges between the external and middle, sometimes betwixt the middle and internal coat. The Greeks call this by the general name of hydrocele[ HQ ], of whatever species it be. Our countrymen, not being acquainted with any distinctions, include this also under the same name as the former disorders.

Now in these there are some symptoms, that belong to all, and others, that are peculiar to each particular species. The general are such as indicate the collection of a fluid; the particular, its seat. We know a fluid is contained within, if there be a tumour, that never disappears entirely, but is sometimes lessened by fasting, or a slight fever, and chiefly in children. And this is soft, if there is not a very great quantity of fluid within; but if it has greatly increased, it resists like a bottle filled, and tightly tied; the veins in the scrotum also are inflated; if we press upon it with our finger, the fluid yields, and fluctuating raises the part that is not pressed; and it appears through the scrotum, as if it were in a glass or a horn; and in itself is attended with no pain. The seat of it is thus known: If the water be betwixt the external and middle coat, when we press with two fingers, it gradually returns between them; the scrotum is somewhat lax and whitish; if it is stroked, it stretches little or nothing; the testicle can neither be seen nor felt in that part. But if it is within the middle coat, the scrotum is more stretched and raised higher, so that the penis above it is concealed under the swelling.

Besides these, when the coats are equally entire, a ramex grows there. The Greeks call it cirsocele[ HR ], when the veins swell. These being sometimes twisted, and rolled up toward the superior part, fill either the scrotum, or the middle coat, or the innermost one; sometimes they grow even within the innermost coat about the testicle itself and its nerve. Those that are in the scrotum itself are exposed to view; and those which lie upon the middle or innermost coat, as being deeper, are not indeed equally discernible, but yet are visible; besides that there is both some swelling, according to the size and capacity of the veins, and it also resists pressure more, and is unequal by reason of the varicous dilatations of the veins; and on that side where it is, the testicle is more dependent than it should be. But when this malady has grown upon the testicle itself and its nerve, the testicle hangs down much lower, and becomes less than the other, as being deprived of its nutriment.

Sometimes, though seldom, flesh grows between the coats. The Greeks call that sarcocele[ HS ].

Sometimes too the testicle itself swells from an inflammation, and also brings on fevers; and unless the inflammation has quickly ceased, the pain reaches to the groin and ilia; and these parts swell, and the nerve, by which the testicle hangs, is enlarged, and grows hard at the same time.

Besides the foregoing, the groin is also sometimes filled with ramices; which case they call bubonocele[ HT ].

These disorders being known, we must proceed to treat of their cure: in which some things are common to them all, some proper to the particular kinds. I shall first speak of the general: and now treat of those, which require the knife. For those, that are either incurable, or ought to be treated in a different manner, I shall take notice of, when I come to the particular species. Now the incision is made sometimes in the groin, sometimes in the scrotum. In either method it is necessary for the patient to drink water for three days before; and the preceding day even to fast: on the day of the operation, he must be laid on his back; and if the incision is to be in the groin, and that is covered with hair, it must first be shaved; then the scrotum being extended to render the skin tense, the incision must be made at the bottom of the belly, where the inferior coats are joined to the abdomen. It must be opened boldly, till the external coat, which is the scrotum itself, be cut, and the middle one come in view. When the wound is made, there is an opening toward the inferior parts. Into that the fore finger of the left hand must be introduced, that by separating the intervening membranes it may enlarge the sinus. And an assistant taking hold of the scrotum with his left hand, must extend it upward, drawing it away as much as possible from the groin; at first with the testicle, while the physician cuts away by the knife, if he cannot separate them by his finger, all the small membranes, that are above the middle coat; after this, letting go the testicle, that it may slip down, and come near to the wound, and be brought out thence by the finger, and laid upon the belly with its two coats. And if any part of it is corrupted, it must be cut off. And as several veins are dispersed upon it, the small ones may be cut at once, but the larger should be first tied with a pretty long thread, to prevent a dangerous hemorrhage from them.

But if the middle coat be affected, or the disease lies below it, it must be cut out in such manner, that in the higher part close to the groin it should be clean cut off: but the whole must not be taken away below; for what is strongly connected at the base of the testicle with the innermost coat, cannot be cut off without the greatest danger, and for that reason must be left there.

The same method is to be taken in the innermost coat too, if that be injured. But it must be cut off, not at the top of the wound in the groin, but a little below that; lest it bring on inflammations by wounding the membrane of the abdomen. Neither on the contrary must too much of it be left; lest afterwards it form a sinus, and afford a receptacle to the same distemper.

The testicle being thus cleansed must be gently let down through the wound, with the veins, and arteries and its nerve; and care must be taken, that no blood fall into the scrotum, and that it does not remain coagulated in any part: which will be prevented, if the physician has been careful to tie the veins. The threads, by which their ends are secured, must hang without the wound: and when a suppuration comes on, they will fall off without any pain. Upon the wound itself must be put two fibulÆ; and over them an agglutinating medicine.

It is sometimes necessary to cut off something from one of the lips, that the cicatrix may be larger and broader. When this is the case, the lint must not be pressed down upon it, but only laid on lightly; and over it some medicines to repel an inflammation, such as sordid wool, or spunge squeezed out of vinegar; every thing else must be used as when a suppuration ought to be excited. But when it is necessary to make the incision beneath, the patient being laid on his back, the left hand must be put below the scrotum; and a strong hold must be taken of it, and the incision made; if the seat of the disorder be small, the incision must be moderately sized, so as to leave a third part of the scrotum below entire, in order to support the testicle; if it be larger, the wound may be greater, a little at the bottom only being left entire, upon which the testicle may rest. But the knife at first should be held in a straight direction, with a very light hand, till it divide the scrotum itself; then the point of it must be turned aside a little, to cut the transverse membranes, that are between the external and middle coats. But the middle coat ought not to be touched, if the disease lie above it; but if it lies below the middle coat, that must be cut too; as likewise the third, if that cover the malady. Wherever the disorder is found, the assistant should squeeze the scrotum gently at the lower part; and the physician having separated the inferior part by his finger, or the handle of the knife, should bring the coat out of the wound, and make such an incision with an instrument, which from its figure is called corvus, that he may introduce his fore and middle fingers: when this is done, the remaining part of the coat must be cut, and the knife must pass between the two fingers, and whatever is noxious must either be taken out, or be allowed to run out.

Whatever coat is injured in the operation must be cut off; and the middle one, as I observed before, as high as possible at the groin; the innermost one a little lower. But before they are cut off, the vessels ought to be tied very carefully by a thread; and the ends of this thread must be left without the wound, which must be done also in other veins, where the ligature is requisite.

When that is done, the testicle must be returned into its place: and the lips of the scrotum joined together by a suture: and the stitches must not be too few, lest they be not agglutinated, and the cure prove tedious; nor yet too many, lest they increase the inflammation. And in this case too we must be cautious, that no blood remain in the scrotum: afterwards agglutinants must be applied.

If however blood has made its way into the scrotum, or any coagulated blood has fallen down into it, an incision should be made below it; and after cleansing it, a spunge moistened with sharp vinegar must be applied round it. A wound that has been made for these reasons, after it is tied up, if there be no pain, must not be opened for the first five days; but either the wool or spunge, that lies over it, must be sprinkled twice a day with vinegar alone; if there be pain, it must be opened on the third day; and where there are fibulÆ, they must be cut; and where lint, that must be changed; and what is put on, must be wet with oil of roses and wine. If the inflammation increases, to the foregoing applications must be added a cataplasm of lentils and honey, of pomegranate bark boiled in a rough wine, or a mixture of these. If the inflammation does not give way to them, after the fifth day, the wound must be fomented with plenty of hot water, till the scrotum itself be both extenuated, and become more wrinkled; then a cataplasm must be applied of wheat meal, with an addition of pine resin; which, if the patient be a robust man, must be boiled up with vinegar; if more delicate, with honey. And whatever the disorder has been, if there be a great inflammation, without doubt medicines to promote a suppuration must be applied.

But if pus is generated within the scrotum, a small incision ought to be made to give a vent; and so much lint is to be applied as to cover the orifice. When the inflammation is removed, upon account of the nerves, the last-mentioned cataplasm, and then cerate must be used. This is the peculiar treatment of wounds of this kind. All other things both in regard to the manner of dressing, and the diet, should be conformable to the directions we have given about other wounds.

These things being premised, we must descend to the particular species. And if the intestine comes down in a young child, a bandage must be made trial of before the knife: for this purpose a roller is sewed, to which in one part a bolster is used made of cloths, which is applied under the intestine to repel it; and then the rest of the roller is bound tight about him: by means of which, the intestine is often forced in, and the coats are agglutinated together. Again if the patient be advanced in years, and from the largeness of the tumour it appears, that much of the intestine has fallen down, and the case is attended with pains and vomiting (which generally proceeds from the excrements getting down into that part by a crudity) it is plain that the knife cannot be used without fatal consequences; the complaint is therefore only to be alleviated; and the intestine evacuated by other methods.

The patient ought to be bled in the arm: and then if his strength will admit, abstinence must be enjoined for three days; if he cannot bear that, at least as long as his strength will allow. At the same time must be kept upon it a cataplasm of lintseed boiled in mulse. After these both barley meal with resin must be applied, and the patient put into a bath of warm water mixed with oil; and some light and hot food must be given. Some even administer clysters. These may carry something into the scrotum, but cannot evacuate any thing from thence. The disease being mitigated by the methods above prescribed, if the pain returns at any time, the same course must be pursued.

If a great portion of the intestine has fallen down without pain, it is also needless to make an incision; not but that it may be removed from the scrotum (unless an inflammation prevent) but because when repelled thence, it stops at the groin, and raises a tumour there; and thus there is not a termination, but a change of the malady.

But where the use of the knife is proper, as soon as the wound made in the groin shall reach to the second coat, that must be taken hold of near the lips with two small hooks, while the physician disengages it by taking out all the small membranes: for that, which is to be cut, cannot be injured without danger, as the intestine must lie below it. When it shall be separated, an incision must be made from the groin to the testicle, care being taken not to wound the last; then it must be cut out. For the most part however this operation is only practicable in children, and in a moderate degree of the malady.

But if it be a robust man, and the disorder be more considerable, the testicle ought not to be taken out, but to remain in its place. The operation is performed in this manner. The groin is opened in the same way by a knife, as far as the middle coat; and this coat in like manner is taken hold of with two hooks, and the testicle is held by an assistant(24), so as to prevent its coming out at the wound; then an incision must be made downward in this coat with a knife; and below it the fore finger of the left hand is introduced to the bottom of the testicle, which it forces up to the wound: then the thumb and fore finger of the right hand separate the vein and artery, and their nerve, and coat from the external coat. And if any small membranes obstruct this, they are divided by the knife, till the coat be wholly exposed to view. When all is cut out, that requires excision, and the testicle is replaced, a pretty broad habenula is to be taken from the lip of the wound in the groin, that the wound may be the larger, and generate the more flesh.

But if the omentum descends, the groin must be opened, and the coats separated in the same manner as directed before. And it must be considered whether it be a large or small part of it. For when it is very small, it must be forced back over the groin into the abdomen by a finger or the broad end of a probe: if it is large, whatever has fallen out of the abdomen must be allowed to remain there; and it must have escharotic medicines laid on it, till it mortify and fall off. Some in this case pass through it a needle with two threads, and tie the two ends of each contrary ways; by which it mortifies with equal certainty, but not so soon. The effect is accomplished sooner, if the part of the omentum above the ligature be rubbed with eating medicines, but not corrosive; they are called septica by the Greeks. There have been others, who have cut off the omentum with scissars: which is not necessary, where the quantity is small; and if large, it may occasion an hemorrhage; for the omentum is also connected by veins, and some of them large. Neither can this practice be justified by an example drawn from the cases of the belly opened by a wound, where the part of the omentum, which falls out, is cut away by the scissars: since in this case, it is both mortified, and cannot be taken off in any other way more safely. If the omentum be reduced, the wound ought to be stitched; or if it has been large and has mortified externally, the lips must be cut off, as proposed before.

If there be a fluid within the membranes, an incision must be made, in boys upon the groin, unless too large a quantity of fluid forbid the operation in that place; but in men, and where-ever there is a large quantity, the scrotum must be opened. Then if the incision be made in the groin, the coats must be drawn out at that part, and the humour evacuated; if at the scrotum, and the disease be immediately below that coat, there is no more required but to evacuate the humour, and cut away any of the membranes, that happen to contain it; then it must be washed with water, and an addition either of salt, or nitre: if the disease lie within the middle or innermost coat, they must be taken entirely out of the scrotum and cut off.

A ramex situated upon the scrotum must be cauterized with small and sharp irons run into the veins themselves, provided they burn nothing else: it is peculiarly necessary to apply the cautery where they are twisted and rolled together; afterwards meal mixed up with cold water must be laid on; and the bandage must be applied, which I recommended for the anus; on the third day lentils with honey must be put to it: after the separation of the eschars, the ulcers must be deterged with honey, embrocated with rose oil, and brought to cicatrize by dry lint. Where the veins above the middle coat swell, the groin must be cut, and the coat brought without the orifice; after which the veins are to be separated from it by the finger, or the handle of the knife, and where they adhere, tied both above and below by a thread; then they must be cut through close to the ligatures, and the testicle replaced. But if the ramex be situated upon the innermost coat, it is necessary to cut out the middle one. And then if two or three veins swell, so that some part be affected, but the greater part be from the disease, the same method must be pursued as directed above; that is, the veins being tied both at the groin and testicle, may be cut off, and the testicle reduced to its place. But if the ramex have seized upon the whole of it, the fore finger must be introduced through the wound, and put under the veins, so as to draw them out gradually and uniformly, till the one testicle be equal to the other; then fibulÆ are to be put in the lips in such a manner, as to lay hold of these veins likewise. It is done thus. A needle passes through the lip from the external part, and then is directed not through the vein itself, but its membrane, and from thence is forced into the other lip. The veins ought not to be wounded, lest they discharge blood. There is always a membrane between these veins, which occasions no danger, and holds them fast enough, when taken up by the thread: and therefore two fibulÆ are sufficient. After this, whatever veins have been brought out, should be returned into the groin with the broad end of the probe. The time for loosing the fibulÆ is, when the inflammation is gone, and the ulcer deterged; that the cicatrix may at once bind up both the lips and the veins.

When the ramex has grown between the innermost coat, and the testicle itself and its nerve, the only cure is to cut off the whole testicle: for it does not in the least contribute to generation, and hangs down in all indecently, in some even with pain. But in this case too, an incision is to be made in the groin, and the middle coat must be drawn out and cut away; the innermost one is to be treated in the same manner; and the nerve, by which the testicle depends, to be cut off. After this, the veins and arteries must be tied by a thread at the groin, and cut off below the ligature.

If flesh happen to grow between the coats, it must certainly be taken out; and the most convenient way of doing it is by an incision in the scrotum.

But if the nerve be indurated, the disorder cannot be cured either by the hand or medicines. For the patients are oppressed with ardent fevers, and either green, or black vomitings, besides these a violent thirst, and roughness of the tongue; and generally about the third day, frothy bile is discharged by stool, which excoriates the parts; and food can neither be easily taken or retained; not long after, the extremities grow cold, a tumour comes on, the hands are expanded involuntarily; then comes on a cold sweat in the forehead, which is followed by death.

When there is a ramex in the groin, if the swelling be small, a single incision ought to be made; if it be larger, it ought to be done in two lines, that what lies between may be cut out; and then without taking away the testicle, as I have above shewn to be sometimes practised in a rupture of the intestines, the veins must be taken up, and tied, where they adhere to the coats, and cut off below these knots. The cure of this wound is no way different from others.

From those we are to proceed to the operations upon the penis. If the glans be bare, and a person chuses for the sake of decency to have it covered, that may be done; but more easily in a boy than a man; and more easily in one, to whom it is natural, than in another, who according to the custom of some nations has been circumcised; better where the glans is small, and the skin about it pretty large, and the penis itself short, than where there is quite the reverse of these circumstances. The cure of these, in whom it is natural, is performed in this manner. The skin about the glans is laid hold of, and extended till it cover it, and tied there; then near the pubes a circular incision is made on the skin of the penis, till it be laid bare; and great caution is used not to cut either the urinary pipe, or the veins in that part. When this is done, the skin is drawn towards the ligature, so that a part near the pubes is laid bare resembling a hoop; then over it is applied lint, that the flesh may grow and fill it up, and the breadth of the wound may afford a sufficient covering to the glans. But the ligature must be continued till a cicatrix be formed, leaving only in the middle a small passage for the urine. But in a person, that has been circumcised, under the circle of the glans, the skin ought to be separated by a knife from the inner part of the penis. This is not very painful, because the extremity being loosened, it may be drawn backwards by the hand, as far as the pubes; and no hemorrhage follows upon it. The skin being disengaged, is extended again over the glans; then it is bathed with plenty of cold water, and a plaister put round it of efficacy in repelling an inflammation. For the following days the patient is to fast, till he be almost overcome with hunger, lest a full diet should perhaps cause an erection of that part. When the inflammation is gone, it ought to be bound up from the pubercles to the circle of the glans; and a plaister being first laid on the glans, the skin ought to be brought over it; for thus it will happen, that the inferior part may be united, and the superior heal so as not to adhere.

On the contrary, if the glans be covered, so that it cannot be denuded (which malady the Greeks call phymosis) it must be opened: which is done in this manner. An incision is made in the prepuce below its extremity, in a right line to the frÆnum; and the upper part being thus relaxed, may be drawn back. But if this be not effectual, either upon account of the straitness or hardness of the prepuce, a piece of skin must be immediately cut out in the lower part in the form of a triangle, with its vertex at the frÆnum, and the base at the extremity of the prepuce. Then lint is to be applied over it, and other medicines to heal it. And it is necessary to continue at rest till it be cicatrized; for walking, by the attrition it causes, renders the ulcer foul.

Some have made a practice of infibulating boys, sometimes upon account of their health(25): the method of doing it is this. The skin that covers the glans is extended, and marked on both sides with ink, where it may be perforated, and then is let go. If these marks return upon the glans, too much has been taken up, and it ought to be marked nearer the extremity: if the glans is not reached by them, that part is proper for the fibula. Then where the marks are, the skin is pierced by a needle followed by a thread, and the two ends of this thread are tied together, and moved every day, till small cicatrices be formed about the orifice. When these are confirmed, the thread is taken out, and a fibula put in, which, the lighter it is, is so much the better. But this operation however is more frequently needless than necessary.

Sometimes when no urine is made, an operation is necessary to discharge it, either because the passage is collapsed from old age, or because a stone, or some other concretion from blood has obstructed it within; and a moderate inflammation also often prevents it from being evacuated in a natural way. And this is requisite not only in men, but in women too sometimes. For this purpose are made copper pipes; and that these may serve for all bodies larger and smaller, a physician must have by him three for men, and two for women. Of the male kind, the largest is fifteen fingers breadth long, the middle size twelve, the least nine; for the females, the greater is nine, and the lesser six. They ought to be curved, but more especially the male kind, and very smooth; and their diameter neither too large, nor too small.

The patient then is to be laid on his back, in the same manner as is described in the operation for the stone, either on a couch or bed. The physician standing on the right side, ought with his left hand to take hold of the penis if it be a man, and with his right to introduce the pipe into the urinary passage; and when it comes to the neck of the bladder, by an inclination of the pipe and the penis at once, to force it into the bladder, and when the urine is evacuated, to take it out again. In a woman, the urethra is both shorter, and straighter, and resembles a caruncle, being situated between the labia pudenda above the vagina; and they as frequently require assistance, but it is not attended with so much difficulty.

Sometimes a stone sliding into the urethra, sticks, where that grows narrower(26), not far from the end; if possible it ought to be drawn out either by a specillum oricularium, or the instrument, with which the stone is extracted in cutting for that distemper. If that has proved impracticable, the prepuce must be drawn out as much as possible, and the glans being covered, must be tied by a thread; then on one side a longitudinal incision must be made into the penis, and the stone extracted; after this the prepuce is let go; for by this means the sound part of the skin covers the incision in the penis, and the urine will be discharged in the natural way.

Since I have made mention of the bladder and stone, the place itself seems to require me to subjoin the chirurgical cure for calculous patients, when they can be relieved no other way. But since that is a very dangerous method, it is by no means proper to undertake it precipitately. Nor is it to be attempted in every season, nor at all times of life, nor in every degree of the disease; but only in the spring, and upon a patient, whose age exceeds nine years, and not fourteen; also if the disease has arisen to such a height that it can neither be overcome by medicines, nor protracted, but that in some time it must kill. Not but that now and then even a rash attempt succeeds; however it more frequently fails in this case, because there are more kinds and seasons of danger, all which I shall mention together with the operation itself.

Therefore when it is resolved to try the last remedy, for some days before, the body must be prepared by diet, that is, by taking moderately wholesome food, no way glutinous, and drinking water. In the mean time the patient must exercise by walking, to cause the stone to descend towards the neck of the bladder. Whether this has happened may be known by introducing the fingers, as I shall shew in the operation. When that is certain, the boy must first fast for a day; and then the operation must be performed in a warm place; which is conducted in this manner.

A strong and skilful man sits down upon a high seat, and laying the boy, whose back is towards him, in a supine posture, setting his hips upon his knees, takes hold of him, and drawing up his legs, orders the boy to put down his hands to his hams, and pull them toward his body with all his might, and at the same time he holds them in that posture. But if the patient be pretty strong, two able men must sit behind him on two contiguous seats, and both their seats, and their legs next each other must be tied together, to prevent their giving way. Then he is placed upon both their knees in the same manner, and the one according as he sits, lays hold of his left leg, and the other of his right; and at the same time he himself draws up his hams. Whether he be held by one or two, they lie forward with their breasts upon his shoulders. Whence it happens, that the sinus above the pubes, between the ilia, is extended without any wrinkles, and the bladder being compressed into a small compass, the stone may be the more easily laid hold of. Besides, two strong men are placed one at each side, who stand by, and do not suffer either the one or two, that hold the boy, to give way.

Then the physician, having carefully pared his nails, introduces his fore and middle fingers of the left hand together, being first slightly anointed with oil(27), into the anus of the patient, and lays the fingers of his right hand lightly upon the lowest part of his abdomen; lest if his fingers on both sides at once should press strongly upon the calculus, it might hurt the bladder. And this must not be done hastily, as in most cases; but so as may be safest: for hurting the bladder brings on convulsions, with a danger of death. And first of all the stone is sought for about the neck: where if it be found, it is expelled with less trouble; and therefore I said the operation was not to be attempted, unless this were known by its proper signs. If either it was not there, or has gone backward, the fingers are applied to the end of the bladder; and the right hand being removed also beyond it, it is brought gradually down.

And when the stone is found (as it must necessarily fall between the surgeon’s hands) it is drawn down with the greater caution by how much it is smaller and smoother, lest it escape, that is, lest there be a necessity to harass the bladder again and again. Therefore the right hand is always kept before the stone; and the fingers of the left force it downwards, till it come to the neck. Into which part, if it be oblong, it must be forced so as to come out prone(28); if flat, so as to be transverse; if square, that it may rest upon two angles; if it be larger at one end, so that the smallest may pass first. In a round one, from the figure itself it is plain, there is no difference, save that if it be smoother in one part than another, that should come out first.

When it is brought to rest upon the neck of the bladder, a lunated incision must be made in the skin, near the anus, as far as the neck of the bladder, with the horns pointing a little towards the ischia; then in that part where the bottom of the wound is straiter, again under the skin(29), another transverse wound must be made, by which the neck may be cut; till the urinary passage be open in such a manner, that the wound is something larger than the stone. For those, who through fear of a fistula (which in that part the Greeks call ouroruas[ HU ]) make but a small opening, are reduced to the same inconvenience with greater danger; because the stone, when it is brought away by force, makes a passage, if it does not find one. And this is even more pernicious, if the shape or asperity of the stone contribute any thing to it: whence both an hemorrhage and convulsion may ensue. But though a person escape these, the fistula will be much larger, when the neck is lacerated, than it would have been if cut.

When the opening is made, the stone comes into view; the size of which makes a material difference with respect to its management. Therefore if it be small, it may be pushed forward on one side, and drawn out on the other by the fingers. If larger, a crotchet(30) made for the purpose must be put over the upper part of it. This at its extremity is thin, beat out into the form of a semicircle, broad and blunt; on the external part smooth(31), where it comes in contact with the wound; on the inside rough, where it touches the stone. And it ought to be pretty long; for one too short has not force enough to extract it. When it is fixed, it ought to be inclined to each side, that the stone may appear, and be held fast, because if it be laid hold of, it also gives way to it. And the necessity for this is, lest when the crotchet begins to be drawn, the stone may fly inward, and the crotchet fall upon the edge of the wound, and lacerate it, the danger of which I have already shewn.

When it appears that the stone is securely held, a triple motion must be made, almost at the same instant, to both sides, and then externally; but this must be done gently, and the stone must be first drawn a little forward; after this, the end of the crotchet must be raised upward, that it may be farther within the bladder, and bring it out the more easily. But if the stone cannot be conveniently held at the superior part, its side must be taken hold of. This is the most simple method.

But a variety of circumstances requires some particular observations. For there are some stones not only rough, but also full of sharp points, which falling of themselves into the neck of the bladder, are extracted without any danger. But if they are within the bladder, it is neither safe to seek them, nor draw them forward; because when they wound it, they bring on convulsions and death; and more especially if any point is fixed in the bladder, and causes it to fall into folds, as it is brought down towards the neck. Now a stone is discovered to be in the neck, when the urine is made with greater difficulty than ordinary; and to be pointed, when it comes away bloody; and this is particularly to be tried by the fingers, and the operation is not to be attempted unless we are sure it is there. And even then the fingers must be introduced, and opposed to it behind tenderly, lest they wound by pushing it with violence; then the incision must be made. And in this case also many have made use of the knife. Meges (because the knife being weak might fall on some prominence of the stone, and after having cut the flesh above it, would not divide where there is a hollow, but leave what will require a second incision) made an iron straight instrument, with a broad back on its upper part, and its lower part semicircular and sharp. This being taken between his fore and middle fingers, and his thumb laid upon it, he prest it so, that together with the flesh, he might cut any part of the stone that was prominent: by which he gained this advantage, that he made a sufficient opening at once. Now in whatever method the incision in the neck is made, a rough stone ought to be extracted gently; no violence being used for the sake of expedition.

But a sandy stone is easily discovered both before the operation, from the discharge of sandy urine, and in the operation; because it makes but a faint resistance to the fingers, and that not equally, and besides is apt to slide away. Also urine, that brings off with it something like scales, discovers the stones to be soft, and that they are composed of several small ones not firmly united together. All these it is proper to bring away gently, changing alternately the fingers in such a manner, that they may not hurt the bladder, and no broken relics stay behind, which may afterwards render the cure difficult. Any of these, that come into view, must be extracted either by the fingers or crotchet.

But if there are several stones, they must every one be taken out; but if any very small one remain, it may rather be left: for it is difficult to find it in the bladder; and when found, it quickly escapes. Thus by long search the bladder is hurt, and mortal inflammations are brought on; in so much that some, though they were not cut, when the bladder has been long, and to no purpose, roughly handled, by the fingers, have died. Besides all which, a small stone being brought to the wound afterwards by the urine, drops out.

In case the stone appears so large, that it cannot be extracted without lacerating the neck, it must be split. The author of this contrivance was Ammonius, who upon that account was called Lithotomus[ HV ] (the stone-cutter.) It is done in this manner. A crotchet is fixed upon the stone with so sure a hold as to prevent it from recoiling inward: then an iron instrument of moderate thickness, with a thin edge, but not sharp, is made use of. This is applied to the stone, and being struck on the other side, cleaves it; great care being taken, that neither the instrument come to the bladder, nor any thing fall in by the breaking of the stone.

These operations are performed upon females much in the same manner, concerning whom a very few peculiarities must be mentioned. For in them, where the stone is very small, cutting is unnecessary; because it is forced by the urine into the neck, which is both shorter, and laxer than in men: therefore it often drops out of itself, and if it sticks in the urinary passage, which is narrower, it is however extracted without any harm by the abovementioned crotchet. But in larger stones the same method is necessary. However, in a virgin, the fingers should be introduced into the rectum as in a man, in a married woman by the vagina. Again, in a virgin, the incision must be made below the left lip of the pudendum; but in a married woman, between the urinary passage, and the bone of the pubes; the wound also must be transverse in both places, and we need not be alarmed if the hÆmorrhage be considerable from a female body.

When a stone is extracted, if the patient be strong, and not greatly spent, we may let the blood flow to lessen the inflammation. And it is not amiss for the patient to walk a little, that if any grumous blood remain within, it may drop out. But if it does not cease of itself, it must be stopped, lest the strength be entirely exhausted; and this is to be done immediately after the operation in weak patients. For as a person is in danger of a convulsion, whilst the bladder is fatigued, so there is another fear, when the applications are removed, lest there be such an hÆmorrhage as to prove mortal: to prevent which, the patient ought to sit down in sharp vinegar with the addition of a little salt; by which means both the blood commonly stops, and the bladder is contracted, and therefore is less inflamed. But if that does little service, a cupping vessel must be applied, both in the knees(32) and hips, and above the pubes too.

When either a sufficient quantity of blood has been evacuated, or the hÆmorrhage stopped, the patient must be laid upon his back, with his head low, and his hips a little raised; and over the wound must be applied a double or triple linen cloth wet with vinegar. Then after an interval of two hours, he must be let down in a supine posture into a bath of hot water, so that he may be under water from the knees to the navel, the other parts being covered with clothes, only with his hands and feet bare, that he may be both less exhausted, and be able to continue there the longer. This commonly produces a plentiful sweat; which in the face is to be now and then wiped off by a spunge. And the rule for the continuance of this bathing is, till it hurts by weakening. After that the patient must be anointed plentifully with oil, and a handful of soft wool saturated with warm oil, must be laid on, so as to cover the pubes and hips, and groin, and the wound itself, which must still remain covered with the linen beforementioned; and this is to be moistened now and then with warm oil; that it may both prevent the admission of cold to the bladder, and gently mollify the nerves. Some make use of healing cataplasms. These do more hurt by their weight, which by pressing upon the bladder(33) irritates the wound, than service by their heat: and for that reason, not so much as any kind of bandage is necessary.

On the day following, if there be a difficulty in breathing, if the urine is not evacuated, or if the part above the pubes has immediately swelled, we may be assured, that grumous blood has staid within the bladder. Therefore the fingers being introduced in the same manner as above, the bladder must be handled gently, and whatever has happened to be coagulated there dispersed; by which means it is afterwards discharged from the bladder through the wound. Neither is it improper to inject through the wound into the bladder by a syringe, a mixture of vinegar and nitre; for if there be any bloody concretions, they are discussed in that way. And these may be done even the first day, if we are afraid of any thing being within; especially when weakness has prevented the evacuation of it by walking. The other methods laid down for the preceding day, the putting him into the bath, applying the cloth, and wool in the manner above described, are to be continued.

But a boy is neither to be put so often into the warm water, nor kept there so long at a time, as a youth; the weak, as the strong; one affected with a slight inflammation, as another, in whom it is more violent; one whose body is disposed to evacuations, as he that is bound. But in the mean time, if the patient sleep, and his breathing be equal, his tongue moist, his thirst tolerable, his lower belly not at all swelled, and the pain and fever moderate, we may take it for granted that the cure goes on well.

But in such patients the inflammation ceases commonly about the fifth or seventh day: when that is abated, the bath is needless. Only the wound, as the patient lies in a supine posture, must be fomented with hot water, that if the urine corrodes, it may be washed away. Digestive medicines must be laid on; and if the ulcer appears to want deterging, honey may be applied. If that corrodes, it must be tempered with rose oil. The enneapharmacum plaister seems fittest for this intention, for it both contains suet to promote digestion, and honey to deterge the ulcer, marrow also, and especially that of veal, which is particularly efficacious in preventing a fistula from remaining. And at that time lint is not necessary over the ulcer; but is properly laid above the medicine to keep that on. But when the ulcer is cleansed, it must be brought to cicatrize by lint alone.

At this time, however, if the cure has not proceeded happily, various dangers arise: which one may quickly prognosticate, if there be a continual watching, or a difficulty of breathing, if the tongue be dry, if there be a violent thirst, if the bottom of the belly swells, if the wound gapes, if the urine that makes its way through it, does not corrode it; in like manner, if before the third day some livid stuff drops out; if the patient makes no answers to questions, or very slowly; if there are vehement pains; if after the fifth day violent fevers come on, and a nausea continues; if lying upon the belly is the most agreeable posture. However nothing is worse than a convulsion, and a bilious vomiting before the ninth day. But there being reason to fear an inflammation, it must be obviated by abstinence, and moderate food seasonably administered; and by applying, at the same time, fomentations, and the other means above prescribed.

The next danger is that of a gangrene. This is known by a discharge of fetid sanies both by the wound and the penis, and together with that, something not very different from grumous blood, and little films like small locks of wool; it is also known by the lips of the wound being dry, by a pain in the groin, by the continuance of the fever, and its increase at night, and by the accession of irregular shudderings. Now it must be considered to what part the gangrene spreads. If to the penis, that part grows hard and red, and is painful to the touch, and the testicles swell, if to the bladder, a pain of the anus follows, the hips swell, the legs cannot be easily extended; but if to one side, it is apparent to the sight, and has these same symptoms on either side, but not so violent.

The first circumstance of importance is, that the body lie in a proper posture, that the part into which the disease is propagated be always laid highest. Thus if it tends to the penis, the patient should lie supine; if to the bladder, upon his belly; if to one side, upon the other, which is sound. Then as to the means of cure, the patient must be put into a bath made of a decoction of horehound, or cypress, or myrtle, and the same liquor must be injected into the wound by a syringe; then a mixture of lentils and pomegranate bark both boiled in wine must be laid on; or bramble, or olive leaves boiled in the same manner, or other medicines, which we have prescribed for restraining and cleansing gangrenes. And if any of these shall be in a dry form, they must be blown in through a writing reed.

When the gangrene begins to stop, the ulcer should be washed with mulse. And at this time cerate must be avoided, which softens the flesh, and prepares it for receiving the infection. Rather let washed lead with wine be laid on; over which shall be applied the same spread upon a linen cloth: by which a cure may be accomplished. Nevertheless we should not be ignorant, that when a gangrene has begun, the stomach, which has a certain sympathy with the bladder, is often affected; whence it happens, that the food can neither be retained, nor if any is retained, can it be concocted, nor the body nourished; and therefore the wound can neither be deterged nor incarned: which must of necessity soon bring on death.

But as it is not possible, by any means, to save patients under these circumstances, from the first day however, the method of cure must be regularly observed. In the conduct of which some caution is also necessary with regard to the food and drink: for at the beginning, none but moist food ought to be given; when the ulcer is deterged, of the middle kind; greens and salt fish are always hurtful. A moderate quantity of drink is required: for if too little is drunk, the wound is inflamed, the patient labours under a want of sleep, and the strength of the body is diminished: if too much be taken, the bladder is frequently filled, and by that means irritated. It is too plain to require a frequent repetition, that the drink must be nothing but water.

It generally happens from a diet of this kind, that the belly is bound. A clyster must be given of a decoction of fenugreek or mallows in water. The same liquor mixed with rose oil, must be injected into the wound by a syringe, when the urine corrodes it, and prevents it from being cleansed. For the most part, at first, the urine is discharged by the wound; whilst it is healing, it is divided, and part begins to be discharged by the penis, till the wound be entirely closed: which happens sometimes in the third month, sometimes not before the sixth, at other times after a whole year.

And we should not despair of a solid agglutination of the wound, unless where the neck has been greatly lacerated, or many and large caruncles, and at the same time some nervous substances have come away by a gangrene. But the greatest precaution must be used, that no fistula, or at least a very small one, be left there. Therefore, where the wound tends to cicatrize, the patient should lie with his thighs and legs extended: unless the stones have been soft or sandy; for in that case the bladder is not so soon cleansed: and, therefore, it is necessary for the wound to be longer open; and never to be brought to cicatrize till nothing more of that nature be discharged.

But if the lips have united before the bladder was cleansed, and the pain and inflammation have returned, the wound must be separated by the fingers, or the broad end of a probe, to allow a passage to what causes the pain: which being evacuated, and the urine having come away pure for a pretty while, cicatrizing medicines must at length be laid on, and the feet extended, as I directed before, as close to one another as possible.

But if from those causes, which I mentioned, there appears to be danger of a fistula, to close it the more easily, or at least to contract it, a leaden pipe must be introduced into the anus(34); and the legs being extended, the thighs and ancles must be tied together, till there be a cicatrix as good as we can obtain.

The foregoing diseases may happen both to men and women. But some are peculiar to women; as in the first place, where the vagina, by its lips being joined, does not admit of coition. And this happens sometimes in the womb of the mother; at other times, from an ulcer in those parts, and the lips, in healing, having by bad management been united. If it be from the birth, a membrane obstructs the vagina: if from an ulcer, it is filled up with flesh.

In the membrane an incision must be made in two lines crossing each other, in the form of the letter X, great care being taken not to wound the urinary passage; and then the membrane is to be cut out. But if flesh has grown there, it is necessary to open it in a straight line; then taking hold of it with a vulsella or hook, to cut off a small habenula, as it were, from the orifice of the vagina, after which must be introduced a piece of lint rolled in a long form (by the Greeks called lemniscus) dipped in vinegar; and over this sordid wool moistened with vinegar is to be bound on; the third day, these are to be removed, and the part dressed like other wounds. And when it begins to heal, it is proper to introduce into the part a leaden pipe armed with a cicatrizing medicine; and over that to apply the same medicine, till the wound be cicatrized.

When a woman conceives, if the foetus dies in the womb, near the time of delivery, and cannot come away of itself, an operation is necessary. This may be reckoned amongst the most difficult: for it both requires the highest prudence and tenderness, and is attended with the greatest danger. But above all, the wonderful nature of the womb, as in other cases, so in this also, is easily discovered.

In the first place, it is proper to lay the woman on her back, across a bed, in such a posture, that her ilia may be compressed by her thighs: whence it happens, that both the bottom of her belly is presented to the view of the physician, and the child is forced to the mouth of the womb; which is close shut, when the foetus is dead, but at intervals opens a little. The physician, making use of this opportunity, having his hand anointed, ought to introduce, at first, the fore-finger, and keep it there till the mouth be opened again, and then he must introduce another finger, and the rest upon the like opportunities offering, till his whole hand be within it. Both the capacity of the womb, and the strength of its nerves, and the habit of the whole body, and even the fortitude of the mind conduce much to the facility of doing this: especially, as in some cases, it is necessary to have both hands within the womb.

It is of importance, that both the bottom of the belly, and the extremities of the body be as warm as possible; and that an inflammation be not begun, but that help be administered instantly, while the case is recent. For if the body be already swelled, the hand can neither be introduced, nor the foetus brought away without the greatest difficulty; and together with a vomiting and tremor, there generally follow mortal convulsions. When the hand is introduced upon the dead foetus, it immediately discovers its posture: for it is either turned upon the head, or the feet, or lies transverse but commonly in such a manner; that either its hand or foot is near.

The intention of the physician is, by his hand, to turn the child, either upon its head, or even upon its feet, if it happened to be in a different posture. And if there is no other hinderance, taking hold of the hand or foot puts the body in a better posture: for the hand being laid hold of, will turn it upon the head, and the foot upon its feet. Then if the head is nearest, a crotchet should be introduced, in every part smooth, with a short point, which is properly fixed, either in the eye, or the ear, or the mouth, sometimes even in the forehead; and then being drawn outwards, brings away the child. Yet it is not to be extracted at any moment of time indifferently: for should it be attempted, when the mouth of the womb is shut, there being no exit for the child, it breaks to pieces, and the point of the crotchet slips upon the mouth of the womb itself, and there ensue convulsions, and extreme danger of death. Therefore, it is necessary to forbear, when the womb is shut; and when it opens, to draw gently; and every such opportunity to extract it gradually. The right hand must draw the crotchet, the left being kept within, must pull the child, and at the same time direct it.

It sometimes happens, that the child is distended with water, and there is a foetid sanies discharged from it. If this be the case, the body must be perforated with the fore-finger, that its bulk may be lessened by the discharge of the humour: then it must be taken out gently by the hands only: for the crotchet being fixed in a putrid body, easily loses its hold. The danger attending which, I have already pointed out.

But a child being turned upon its feet, is not difficult to extract: for these being taken hold of, it is easily brought away by the hands alone.

If it be transverse, and cannot be got into a proper direction, a crotchet must be fixed in the armpit, and gradually pulled: in this case, the neck is generally doubled, and the head turns back upon the body. The remedy is, to cut through the neck, that the two parts may be brought away separately. This is done by a crotchet, which resembles the former, save that it is sharp all along the internal part. Then we must endeavour to bring away the head first, after that, the rest of the body: because generally, when the largest part is extracted, the head slips back into the womb, and cannot be extracted without the greatest danger.

However, if this has happened, a double cloth must be laid upon the belly of the woman, and a strong and skilful man ought to stand at her left side, and put both his hands upon the lower part of her belly, and press with one upon another: by which means the head is forced into the mouth of the womb, and may then be extracted by the crotchet, in the manner above described.

But if one foot be found at the mouth of the womb, and the other is behind, with the body, whatever is protruded, must be gradually cut away. And if the buttocks begin to press upon the mouth of the womb, they must be thrust back again, and the other foot sought for and brought forward. There are also some other difficulties, which make it necessary to cut the child into pieces, when it cannot be brought away entire.

Whenever a foetus is brought away, it must be delivered to an assistant; who must take it in his hands, and then the physician ought to draw the umbilical cord gently with his left hand, but not to break it, and with the right to follow it, as far as what they call the secundines, which were the covering of the foetus within the womb; and taking hold of the extremities of these, to separate all the small veins and membranes in the same manner, by his hand, from the womb, and to extract the whole of it, and any concreted blood that remains within. Then the woman’s thighs must be laid close together, and she placed in a room moderately warm, without any thorough air. To the bottom of her belly must be applied sordid wool dipped in vinegar and rose-oil. The remaining part of the cure ought to be the same, as is used in inflammations, and such wounds as are in nervous parts.

Diseases of the anus also, when they are not removed by medicines, require the assistance of the hand. Therefore, if any fissures, in that part, by long continuance, have become indurated, and are already callous, it is most proper to give a clyster; then to apply a hot spunge, in order to relax them, and bring them to the external part, when they are in view, to cut off each of them with a knife, and renew the ulcers; then to lay on soft lint, and over it honey spread upon a linen cloth; and to fill up the part with soft wool, and thus bind it up; on the next and following days, to dress with mild medicines, which I have elsewhere prescribed for the same disorders when recent; and in the first days to diet the patient with gruels, after that gradually to add to the food, but something of that kind, which I have directed in the same place. If at any time, from an inflammation, pus arises in them, as soon as that appears, an incision must be made to prevent the anus itself from suppurating. But we must not be in a hurry to do it before; for if it be cut while crude, the inflammation is much increased, and a greater quantity of pus is generated. In these wounds too, there is a necessity for mild food, and the same kind of medicines.

But the tubercles called condylomata, when they have grown hard, are cured in this manner. First of all, a clyster must be given. Then the tubercle being laid hold of by a vulsella, must be cut out near its roots. When this is done, the same course must be followed, that I prescribed after the preceding operation; only if there is any fungus, it must be kept under by copper scales.

The mouths of the hÆmorrhoidal veins, discharging blood, are taken off thus. When there is a discharge of sanies besides blood, an acrid clyster must be administered, that the mouths of the veins may be pushed the farther outward; which causes all the vessels to appear like small heads. Then if a head be very little, and have a small base, it must be tied with a thread a little above the point, where it joins the anus; and a spunge squeezed out of hot water must be laid over it, till it grow livid; then above the knot it must be scarified either by the nail or the knife. If this is not done, violent pains ensue, and a difficulty in making water. If it be pretty big, and the base broad, it must be taken hold of with a small hook or two, and an incision made round the tumour, a little above the base; and neither any part of the head must be left, nor any thing taken off the anus: which a person may accomplish, if he neither draws the hooks too much nor too little. Where the incision has been made, a needle should be put in, and below that the head tied with a thread. If there be two or three of them, the inmost must be cured first; if more than that number, not all at once, lest there be(35) sore places all round the part at the same time. If there is a discharge of blood, it must be received in a spunge; then lint must be applied; the thighs, groin, and what lies contiguous to the ulcer, be anointed, and cerate laid over it, and the part filled with warm barley meal, and thus bound up. The day following, the patient ought to sit down in warm water, and be dressed with the same cataplasm. And twice in the day, both before and after the dressing, the ischia and thighs must be anointed with liquid cerate, and the patient kept in a warm place. After an interval of five or six days, the lint is to be taken out with a specillum oricularium; and if these heads have not dropped off at the same time, they must be pushed off by the finger. Afterwards, the ulcer must be brought to heal by mild medicines, such as I have prescribed before. The proper treatment, when the disease is cured, I have already mentioned elsewhere.

From these disorders we go on to the legs. Varices in these are not difficult to remove. To this place I have deferred the cure of those small veins, which hurt in the head, as also the varices in the belly, because it is the same in them all. Therefore any vein that is troublesome, either is cauterized, and so decays, or is cut out. If it be straight, or though transverse, yet simple, it is better to cauterize it. If it be crooked, and as it were twisted into orbs, or several of them are involved within each other, it is more convenient to cut them out.

The method of cauterizing is this. An incision is made in the skin over it; then the vein being laid bare, is moderately pressed by a small and blunt iron instrument red hot: and we must avoid burning the lips of the wound itself, which it is easy to draw back with small hooks. This is repeated over the whole varix, at the distance of about four fingers breadth; and after that a medicine for healing burns is laid on.

But it is cut out in this manner. An incision being made in the same way in the skin over the vein, the lips are taken up with a small hook; and the vein is separated all round from the flesh by a knife, but in this great care is taken not to wound the vein itself; and a blunt hook is put under it; and generally, at the same distance mentioned before, in the same vein, the same operation is repeated. The course of it is easily discovered by extending it with the hook.

When this has been done, as far as the varices go, the vein, being brought forward in one part by the hook, is cut through, then where the next hook is, it is drawn up and pulled away, and is cut off there again. And in this manner the leg being entirely freed from the varices, the lips of the wounds are then brought together, and an agglutinating plaister is laid over them.

If the fingers, either from the birth, or by an ulceration in their opposite sides, have afterwards adhered together, they are separated by the knife; round each of them a plaister, not greasy, is put on, and thus they heal separately.

But if there has been an ulcer in a finger, and afterwards a cicatrix injudiciously brought on, has rendered it crooked; in the first place a malagma must be tried. If that does no good (which generally happens both in an old cicatrix, and where the tendons are hurt) then we ought to see whether the fault be in the tendon or the skin. If in the tendon, it ought not to be touched, for it is not curable: if in the skin, the whole cicatrix must be cut off, which being generally callous, prevents the fingers from being extended. Then being kept extended, it must be brought to cicatrize afresh.

I have elsewhere observed, that a gangrene comes about the nails, armpits or groin; and that if it does not yield to medicines, the member ought to be cut off.

But even this is attended with very great danger: for the patients often die in the operation, either by a hÆmorrhage, or faintings. But in this, as well as other cases, it is not to be considered, whether the remedy is very safe, which is the only one we have. Between the sound and corrupted part then, an incision must be made with a knife in the flesh, as far as the bone. But this must not be done over a joint; and some of the sound part must rather be cut off, than any of the corrupt left. When we come to the bone, the sound flesh must be drawn back from it, and cut below round the bone, that some part of the bone may also be laid bare under it; then the bone must be cut off with a saw, as close as we can to the sound flesh, that still adheres to it; and then the fore part of the bone, that has been roughened with the saw, must be smoothed, and the skin brought over it; which in a cure of this kind ought to be lax, that it may cover the bone as much as possible all round. The part, which the skin does not reach, must be covered with lint, and above that a spunge squeezed out of vinegar must be tied on the place. The remaining part of the cure must be the same, as I have directed in wounds which are brought to digestion(36).

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A. CORNELIUS CELSUS

OF

MEDICINE.

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