viii. These are powdered and mixed with honey, and against poison the

bigness of a sweet almond is given in wine. In other disorders of the body, according to their violence, either the bigness of an Egyptian bean, or a vetch, will be sufficient.

CHAP. XXIV.

OF ACOPA.

[Sidenote: _Acopon for the nerves._]

Acopa(62) are useful to the nerves. Such is that, which contains flower of round cyperus p. *. ii. z. z. costus, long cyperus, bay berries, ammoniacum, cardamom, each p. *. iv. z. myrrh, calcined copper, each p. vii. *. Illyrian iris, wax, each p. iv. *. Alexandrian reed, round cyperus, calambac wood, xylo-balsam, each p. xviii. *. suet p. i. *. iris ointment a cyathus.

[Sidenote: _Another called elæodes._]

There is another, which they call elæodes[EL]; it is made in this manner: of wax p. *. z. oil a like quantity, and of turpentine resin the bulk of a walnut; these are boiled together: then being poured into a mortar, are rubbed, and an acetabulum of the best honey is gradually dropped into it, then three cyathi of iris ointment and of rose oil.

[EL] ἐλαιω̃̃δες.

[Sidenote: _Of enchrista. One for cleansing and filling ulcers._]

The Greeks call liquids, that are daubed on, by the name of enchrista[EM]. Such as is that for cleansing and incarning ulcers, especially amongst nerves. It consists of a mixture of equal parts of butter, veal marrow, veal suet, goose fat, wax, honey, turpentine resin, rose and cicine oil. These are all melted separately, then mixed while they are liquid, and afterwards rubbed together. And this composition is indeed more cleansing: but it would be more emollient, if instead of the rose oil, that of cyprus be infused.

[EM] ἔγχριστα.

[Sidenote: _For the ignis sacer._]

For the ignis sacer: of litharge p. vi. *. ox-horn burnt p. ii. *. these are beat up together, and there is added alternately wine, and myrtle wine, till three cyathi of each be used.

CHAP. XXV.

OF CATAPOTIA.

[Sidenote: _1. Anodyne catapotium for concoction._]

There are catapotia of various kinds, and composed for different intentions. They call those anodyna[EN], which mitigate pain by sleep: which it is not fit to use, unless there be a very great necessity. For they consist of medicines strong and ungrateful to the stomach. Yet that even promotes concoction, which contains poppy tears, galbanum, of each p. i. *. myrrh, castor, pepper, each p. ii. Of these it is sufficient to swallow the bigness of a vetch.

[EN] ἀνώδυνα.

[Sidenote: _2. Another stronger._]

Another, which is more powerful to promote sleep, but worse for the stomach, consists of the following ingredients. Of mandrake p. *. z. seeds of smallage and henbane, each p. iv. *. which are rubbed down with wine. The same quantity of this, as was directed of the other, is a plentiful dose.

[Sidenote: _3. A quieting catapotium for pains of the head, &c._]

If there be pains of the head, or ulcers, or a lippitude, or tooth-ach, or difficulty of breathing, or pains of the intestines, or inflammation of the womb, or the hip, or a pain in the liver, spleen, or side, or if a woman falls into hysterick fits, and loses her speech, a catapotium of the following kind removes the pain by sleep. Sil(63), acorum, seed of wild rue, each p. ii. *. castor, cinnamon, each p. ii. *. poppy-tears, root of panaces, dry mandrake fruit, flower of round cyperus, of each p. ii. *. pepper lvi. grains. These being powdered separately, are again all rubbed together, dropping in now and then passum, till they acquire the consistence of sordes. A little of this is either swallowed, or diluted in water, and given to drink.

[Sidenote: _4. Another of more general use._]

Moreover a handful of wild poppy, when it is just ripe for gathering the tear, is put into a vessel, and upon it is infused a sufficient quantity of water to cover it, and thus it is boiled. When this handful has been well boiled, let it be squeezed and thrown away; and with the liquor let an equal quantity of passum be mixed, and let them boil together, till it be as thick as sordes. When it has cooled, it is made into catapotia of the bigness of our bean, which have an extensive use. For they both procure sleep, either taken alone, or given in water, and with the addition of a little juice of rue and passum mitigate ear-aches: and dissolved in wine they stop a dysentery: and mixed with cerate made of rose oil, to which a little saffron is added, they restrain an inflammation of the womb. And spread upon the forehead with water, they stop the flux of gum to the eyes.

[Sidenote: _5. For a pain of the womb._]

Again, if a pain of the womb prevent sleep, a mixture is made of saffron p. ii. *. anise, myrrh, each p. i. *. poppy tears p. iv. *. hemlock seed p. viii. *. and these incorporated with old wine, and the bigness of a lupin is diluted with three cyathi of water. But this is dangerous to give in a fever.

[Sidenote: _6. Catapotium for healing the liver._]

For healing the liver, of nitre p. *. z. saffron, myrrh, Gallican nard, each p. i. *. are mixed with honey, and the bigness of an Egyptian bean serves for a dose.

[Sidenote: _7. For pains in the sides._]

For removing pains of the sides, equal parts of pepper, birthwort, nard, and myrrh are mixed together.

[Sidenote: _8. Of the thorax._]

For pains of the thorax, of nard p. i. *. frankincense, cassia, each p. iii. *. myrrh, cinnamon, each p. vi. *. saffron p. viii. turpentine resin a quadrans, honey three heminæ.

[Sidenote: _9. Athenio’s for a cough._]

For a cough is that of Athenio: of myrrh, pepper, each p. i. *. castor, poppy tears, each p. i. *. which are bruised separately, and afterwards mixed, and two catapotia of the bulk of our bean are given in the morning, and two, when the patient is going to sleep at night.

[Sidenote: _10. Heraclides’s anodyne catapotium for a cough._]

But if a cough prevents sleep, that of Heraclides the Tarentine is calculated for both disorders: of saffron p. i. *. cinnamon, castor, poppy tears, each p. i. *. myrrh, long pepper, costus, galbanum, each p. *. z.

[Sidenote: _11. Catapotium for foul ulcers in the fauces._]

But if ulcers in the fauces of patients labouring under a cough require to be cleansed, of panaces, myrrh, turpentine resin, each p. v. *. galbanum p. *. z. hyssop p. *. z. are to be rubbed together, and to these a hemina of honey is added, and as much as can be taken upon the finger must be swallowed.

[Sidenote: _12. The colice of Cassius._]

The colice of Cassius consists of the following ingredients: of saffron, anise, castor, each p. iii. *. parsley p. iv. *. pepper both long and round, each p. v. *. poppy-tears, round cyperus, myrrh, nard, each p. vi. *. which are incorporated with honey. And this may be both swallowed alone, and taken in warm water.

[Sidenote: _13. For expelling a dead fœtus._]

A draught of water mixed with sal ammoniac p. i. *. or dittany of Crete p. i. *. expels a dead fœtus or the secundines.

[Sidenote: _14. To forward labour._]

To women in labour hedge mustard ought to be given in tepid wine, when they are fasting.

[Sidenote: _15. For the voice._]

The voice is assisted by p. i. *. of frankincense given in two cyathi of wine.

[Sidenote: _16. For a dysury._]

Against a difficulty of urine: of long pepper, castor, myrrh, galbanum, poppy tears, saffron, costus, each one ounce, storax, turpentine resin, of each a sextans, wormwood, honey, a cyathus. Of these the bigness of an Egyptian bean ought to be given in the morning, and after supper.

[Sidenote: _17. The composition of arteriace._]

Arteriace is made in this manner: of cassia, iris, cinnamon, nard, myrrh, frankincense, each p. i. *. saffron, p. i. *. pepper thirty grains, are boiled in three sextarii of passum, till they acquire the consistence of honey. Or saffron, myrrh, frankincense, of each p. i. *. are mixed with the same quantity of passum, and boiled in the same manner. Or three heminæ of the same passum are boiled, till a drop of it grows hard; and p. i. *. of powdered cassia is added to it.

CHAP. XXVI.

OF FIVE DIFFERENT KINDS OF DISORDERS INCIDENT TO THE BODY; AND OF THE NATURE, SYMPTOMS, AND CURE OF WOUNDS.

Having explained the virtues of medicines, I shall next consider five different kinds of disorders, to which the body is incident. When it is hurt externally, as in wounds. When any part is corrupted internally, as in a gangrene. When any thing grows within some part, as the stone in the bladder. When any part is preternaturally enlarged, as a vein, which swelling is called a varix. Lastly, when somewhat is deficient, or maimed. In some of these medicines, in others manual operations are most useful. Deferring the consideration of the disorders, which chiefly require manual operations, I shall now treat of such, as stand mostly in need of medicines. And I shall divide this part of medicine in the same manner as the former, and first speak of those, which may happen in any part of the body; next of these, which attack certain parts. I shall begin with wounds.

[Sidenote: _Rules for the conduct of the physician._]

Now a physician should above all things know, what are incurable, what difficult to cure, and what more easy. For it is the part of a prudent man first, not to undertake one, whose case is desperate, lest he appear to have killed him, whom his own destiny has destroyed. Next, in a case of great danger, but not quite desperate, to discover to the friends of the patient, that it is a matter of difficulty: that if the malady should prevail against the art, he may neither seem to have been ignorant himself, nor to have deceived them. But as this is the proper conduct for a prudent person, so on the contrary it is the part of a quack to exaggerate a small matter, that he may appear to have performed the greater cure. Where a case is easy, it is reasonable that the physician by a free declaration of its easiness be obliged to the greater diligence and circumspection; that what is in itself small may not by his negligence become more considerable.

[Sidenote: _Incurable wounds._]

A person cannot be preserved, when the basis of the brain, or the heart, or the gullet, or the portæ of the liver, or the spinal marrow is wounded; or when the middle of the lungs, or the jejunum, or smaller intestine, or stomach, or kidneys are wounded; or when the large veins or arteries about the throat are cut through.

[Sidenote: _Wounds difficult to cure._]

The cure is difficult in such as are wounded either in any part of the lungs, or the thick part of the liver, or the membrane that contains the brain, or in the spleen, or womb, or bladder, or any intestine, or the diaphragm. Such also are in a very dangerous situation, in whom the point of a weapon has penetrated as far as the large blood vessels, that lie deep in the arm-pits and hams. And all wounds are dangerous, wherever there are large blood-vessels, because they may exhaust a person by the profusion of blood. And this happens not only in the arm-pits and hams, but likewise in the veins, which go to the anus and testicles. Besides these, any wound in the arm-pits, or the inside of the thighs, or in any cavity, or between the fingers(15)is bad. Also by which a muscle, or nerve, or artery, or membrane, or bone, or cartilage, is hurt.

[Sidenote: _Safe wounds._]

A wound in the flesh is safest of all, and these again from their situation are either worse or better. But a wound when large is dangerous from its size.

[Sidenote: _The nature and figure of wounds._]

The nature of the wound also and its figure make some difference; for when a part is both cut and bruised, it is worse than when it is only cut asunder; so that it is better to be wounded by a sharp weapon, than a blunt one. And that wound is worse, out of which any substance is cut, or where the flesh is carried off on one part, and hangs on the other. In general, those wounds are the worst, that are crooked: and those safest that are of a straight direction. And then, the nearer the wound approaches to the first or second of these forms, it is more or less dangerous.

[Sidenote: _Consideration of the age, constitution, and season._]

Moreover the age, constitution, the way of life _of the patient_, and the season of the year, are of some importance: for a boy or a youth recovers more easily than one that is older; the strong than the infirm; one, that is neither too slender nor too plethoric, than one, that is on either of these extremes; one of a sound than one of a corrupt habit; one, that takes exercise, than an indolent person; the sober and temperate than one given to wine and venery. Again, the most convenient season of the year for curing a wound is the spring; or at least when it is neither hot nor cold: for both excessive heat and intense cold are prejudicial to wounds; but most of all an alternate change of these: and for that reason the autumn is very hurtful.

[Sidenote: _Of wounds of the internal parts._]

Most wounds are exposed to our view: but there are some, of which we judge from the situation of the parts, which we explained elsewhere, when we demonstrated the position of the internal parts. Nevertheless, because some of these lie superficial, and it makes a difference, whether a wound be in the surface, or has penetrated deeper; it is necessary to mention the appearances, by which we may know what is hurt within; and from which we are either to hope or despair.

[Sidenote: _Symptoms of the heart being wounded._]

When the heart is wounded, there is a great effusion of blood, the pulse is languid, the skin very pale, cold sweats with a bad smell come on, the same as in sickness: the extremities grow cold, and death quickly follows.

[Sidenote: _Of the lungs._]

When the lungs are wounded, there is a difficulty of breathing; frothy blood is discharged from the mouth, and red blood from the wound; also along with the latter the air issues with a noise; the patient has an inclination to lie upon the wound; some start up without any reason. Many when they are lying upon the wound, are able to speak: if upon another part, they lose that faculty.

[Sidenote: _Of the liver._]

The symptoms of a wounded liver are these: there is a great effusion of blood under the right side of the præcordia; the præcordia are drawn backward towards the spine; there is a pleasure in lying upon the belly; there are prickings and pains reaching as far as the clavicle and the broad bone of the shoulder, that is joined to it; to these there is sometimes added also a bilious vomiting.

[Sidenote: _Of the kidneys._]

When the kidneys are wounded, the pain reaches to the groin and testicles; the urine is made with difficulty; and it is either bloody, or grumous blood is voided.

[Sidenote: _Of the spleen._]

But when the spleen is wounded, black blood issues out from the left side; the præcordia and stomach on the same side grow hard; a great thirst ensues; and a pain strikes up to the clavicle, as when the liver is wounded.

[Sidenote: _Of the womb._]

But when the womb is wounded, there is a pain in the groin, and hips, and inside of the thighs; the blood is partly discharged by the wound, partly by the vagina; and a bilious vomiting follows. Some women lose their speech; some are delirious; others sensible, but complain, that they are tormented with a pain of their nerves and eyes: and when dying, have the same symptoms, as attend a wounded heart.

[Sidenote: _Of the brain or its membrane._]

If the brain or its membrane has received a wound, blood is discharged by the nose, in some also by the ears and generally a bilious vomiting follows. The senses of some are impaired, and they do not perceive when they are called upon: the countenance of others is fierce; and their eyes roll different ways, as in a palsy; and commonly on the third or fifth day a delirium comes on. Many are likewise convulsed. Before death most of them tear the bandages, with which their head is bound up, and expose the naked wound to the cold.

[Sidenote: _Of the gullet._]

When the gullet is wounded, a hiccough and bilious vomiting follow; if any meat or drink has been taken, it is quickly returned; the pulse grows languid; thin sweats come on, in which the extremities grow cold.

[Sidenote: _Of the stomach and jejunum, and other intestines._]

The signs of a wound in the jejunum and stomach are the same; for the food and drink pass through the wound: the præcordia grow hard; sometimes bile is vomited. Only it must be observed, that the jejunum is situated lower than the stomach. When the other intestines are wounded, they emit either excrement, or its smell.

[Sidenote: _Of the spinal marrow._]

When the spinal marrow is cut through, there follows either a palsy or convulsions; the patient becomes insensible; and after some time, the lower parts discharge involuntarily either seed, or urine, or excrement.

[Sidenote: _Of the diaphragm._]

But if the diaphragm is wounded, the præcordia are drawn upward; there is a pain in the spine, an oppression of the breath, and a discharge of frothy blood.

[Sidenote: _Of the bladder._]

When the bladder is wounded, the groin is pained, there is a tension of the parts immediately above the pubes; instead of urine comes blood; and the urine is discharged at the wound; the stomach is affected, so that the patients either vomit bile, or have a hiccough; a coldness seizes them, and after that death.

[Sidenote: _Of the discharge from wounds and ulcers._]

[Sidenote: _Blood, sanies, and pus._]

[Sidenote: _Ichor._]

[Sidenote: _Melicera._]

[Sidenote: _Elæodes._]

These things being known, there still remain some other particulars to be observed relating to the wounds and ulcers, which we are to treat of. From wounds then and ulcers are discharged blood, sanies, and pus. Blood is known to every one. Sanies is thinner than blood, unequally thick, glutinous, and coloured. Pus is very thick and white, also more glutinous than either blood or sanies. Now blood is discharged from a recent wound, or one that is just healing: sanies appears betwixt these times: pus in an ulcer beginning to heal. Further, both sanies and pus are distinguished into several species by Greek names; for there is one kind of sanies, which is called ichor[EO], another melicera[EP]. There is also a species of pus called elæodes[EQ]. Ichor is thin, of a whitish colour, and proceeds from a bad ulcer, and especially where a nerve has been hurt, and an inflammation has followed. Melicera is thicker, more glutinous, whitish, and somewhat resembling white honey: this also is discharged from malignant ulcers, where the nerves about the joints are hurt; and amongst the joints principally from the knees. Elæodes is thin, whitish, somewhat unctuous, in colour and fatness not unlike to white oil; and appears in large ulcers, that are healing. Now blood is bad that is either too thin or too thick, in colour either livid or black; or mixed with phlegm, or of various colours: the best is warm, red, moderately thick, and not glutinous. Therefore from the first the cure of a wound, which has yielded good blood, is more easy and quick: and afterwards there is more hope of those, from which the several discharges have been of the best kind. Sanies then is bad, where it is in great quantity, over thin, livid, or pale, or black, or glutinous, or fetid, or such as corrodes the ulcer itself and the adjacent skin. It is better, when the quantity is small, indifferently thick, of a reddish colour, or inclining to white. Ichor again is the worst, that is plentiful, thick, inclining to a livid or pale colour, glutinous, black, hot, fetid. It is more tolerable, if inclining to white, and when in all other respects it is the reverse of the former. But melicera is bad, when it is in great quantity, and very thick; better, when thinner, and less in quantity. Pus is the best amongst these. But even that too is bad, when it is copious, thin, diluted; and the more so, if it be such from the beginning; also if in colour it resemble serum, if it be pale, or livid, or feculent; moreover if it be fetid; unless the smell arises from the nature of the particular part, where the ulcer is. The less there is of it, and the thicker, and whiter, so much the better; and also if it be smooth, if it have no smell, if it be homogeneous. In quantity, however, it ought to correspond both with the size and age of the wound: for a greater quantity is discharged naturally from a larger one; and more before the inflammation is removed, than afterwards. Elæodes also when plentiful, and containing but little fat, is bad: but the less there is of it, and the more oily so much the better.

[EO] ἰχὼρ.

[EP] μελίκηρα.

[EQ] ἐλαιω̃δες.

[Sidenote: _Cure of a hæmorrhage from a wound._]

These things being considered, when any person is wounded, that can be cured, two things are immediately to be regarded: that he do not perish either by a hæmorrhage, or an inflammation. If we are afraid of a hæmorrhage (which may be known from the situation of the wound and its largeness, and from the force of the stream of blood) the wound is to be filled with dry lint, and over it a sponge squeezed out of cold water must be applied, and pressed down with the hand. If this does not stop the blood, the lint is to be frequently changed: and if it have not strength enough dry, it must be moistened with vinegar. This is very powerful in stopping blood: and therefore some people pour it into the wound. But here again it is to be feared, that the matter being too forcibly retained there, may afterwards raise a great inflammation. Which is the reason why neither corroding medicines, nor such as are caustic, and therefore forming a slough, are to be used, although most of these stop blood: but if recourse is ever had to them, such ought rather to be employed, as are the mildest in their operation. But if even these do not prevail against the hæmorrhage, the vessels, which discharge the blood are to be taken hold of, and tied in two places about the wounded part, and cut through, that they may both unite together, and nevertheless have their orifices closed. When the circumstances do not even allow of this measure, they may be cauterized with a hot iron. And in this case too, when there is a considerable hæmorrhage from a part, where there is neither nerve, nor muscle, in the forehead for instance, or upper part of the head, it is very proper to apply a cupping vessel to the opposite part, that the current of blood may be diverted thither.

[Sidenote: _Cure of the inflammation in wounds._]

These then are the remedies against a haemorrhage: but for an inflammation the flux of blood itself is the cure. This may be apprehended, when either a bone has been hurt, or a nerve, or a cartilage, or a muscle, or when the haemorrhage has been too small in proportion to the size of the wound. Therefore when any thing of this kind happens, it will not be proper to stop the blood quickly, but to suffer it to flow as long as it is safe; insomuch that if the discharge has appeared small, it ought also to be taken from the arm; especially if the patient be young and robust, and used to exercise; much more, if he was intoxicated before he received the wound. And if a muscle shall appear to be wounded, it must be cut through: for when it is only divided in part, it is mortal; cut quite through it admits of a cure.

[Sidenote: _The agglutination of wounds._]

The blood then being either stopped, when the haemorrhage is excessive, or _more_ taken away _by phlebotomy_ when too small, it is far the best method to agglutinate the wound. Now this may be done, either when it is in the skin, or even in the flesh, if nothing else is hurt. It may be done, where the flesh is hanging down in one part, and adhering in another; provided however it be still sound, and nourished by its continuity with the body.

In wounds to be agglutinated there is a double method of cure. For if the wound be in a soft place, it ought to be sewed: and especially, if the extremity of the ear, or the lower part of the nose be cut, or the forehead, or the cheek, or the eye-brow, or the lip, or the skin about the throat, or the belly. But if the wound is in the flesh, and gapes, and its lips cannot be easily brought together, a suture is improper: and in this case fibulæ(64) are to be put on (the Greeks call them ancteres[ER]) to draw the lips a little closer; that the cicatrix may be the less broad after the cure.

[ER] ἀγκτη̃ρες.

Hence now it may be collected, whether a wound, in which the flesh is in one part depending, and in another adhering, if it is not yet corrupted, requires a suture, or a fibula. But neither of them ought to be applied before the wound be cleansed within, lest any concreted blood be left there. For that turns to pus, raises an inflammation, and prevents the wound from being agglutinated. Even the lint, that is put into it to stop the bleeding, must not be left there; for that also inflames.

It will be necessary to take up with the needle, or the fibula, not only the skin, but also some of the flesh below it, that it may adhere the more strongly, and not break away the skin. Both of them are best done with soft thread(65), not too much twisted, that it may be the less uneasy to the part. Neither of them are to be applied at too great distances, nor too frequently: if at too great distances they will not hold; if too frequently they are very hurtful; because the oftener the needle has passed, and the more places are gauled by the fibula, so much the greater will the inflammation be; and especially in the summer-time. Neither of them requires any force; but the operation is only so far useful, as the skin follows the hand as it were of its own accord. Now the fibula commonly allows a wound to be broader: a suture joins its lips, but these should not touch one another in every part; that if any humour be collected within, there may be a passage for it to escape. But if a wound admits of neither of these, it ought nevertheless to be cleansed.

In the next place, upon every wound should be applied first a sponge squeezed out of vinegar: if any patient is not able to bear the strength of vinegar, wine must be made use of: a slight wound is helped by laying on a sponge squeezed even out of cold water. But in whatever way it is put on, it does good no longer than it is moist: therefore it must not be suffered to dry. A wound may be cured without foreign, scarce, and compound medicines. But if one has not confidence in that method, he ought to apply a medicine, that is composed, without suet, of those things, which I mentioned to be proper for bloody wounds; and particularly if it be in the flesh, the barbarum: if it be a nerve, or cartilage, or any of the prominent parts, as the ears, or lips, the sphragis of Polybus. The green Alexandrian also is fit for the nerves; and for the prominent parts that, which the Greeks call rhuptousa[ES].

[ES] ῥύπτουσα.--Our author has not mentioned this plaister before, at least not under the same name.

It is common also, where there is a contusion, for the skin to be a little broken. When this happens, it is not improper to make a larger opening with a knife; unless there be muscles and nerves near to it, which it is not fit to cut. When it is sufficiently opened, a medicine must be applied. But if the bruised part cannot admit the opening, though too small, to be enlarged, upon account of nerves or muscles, such applications are to be used, as may draw out the humour gently; and of that kind the fittest for the present purpose is the composition, which I said was called rhypodes. It is not improper also, wherever there is a severe wound, after applying(66) what is agreeable to it; to cover the whole with sordid wool moistened with vinegar and oil; or if the part be soft, a mild restringent cataplasm; if nervous, or muscular, an emollient.

[Sidenote: _The proper bandages for wounds._]

For binding up a wound a linen roller is most convenient: and this ought to be bandages for so broad, that a single application of it may not only cover the wound, but take in a little on each side of it. If the flesh has shrunk away more on one side, it is better to begin the rolling from thence; if equally on both sides, it ought to lay hold of the lips transversely; or if the nature of the wound does not admit of that, the middle of it is first put on, that it may be drawn afterwards both ways. Now it is to be bound on in such a manner, that it may both hold, and not be over tight. When it does not hold, it slides off; and that, which is over tight, hazards a gangrene. In the winter-time the roller ought to be carried round oftener; in the summer, no more than necessity requires. Then the extremity of it is to be sewed to the lower part of the bandage. For a knot hurts a wound, unless it be at a distance from it.

Moreover every person ought to know, that the viscera, which I mentioned before, require a particular method of cure. For the external wound is to be cured either by a suture, or some other method. In the bowels nothing is to be touched, unless some bit in the extremity of the liver, or spleen, or lungs be hanging out, which may be cut away. Otherwise the internal wound is to be cured by the diet and medicines, which I mentioned in the former book as agreeable to each viscus.

[Sidenote: _Directions for the patient’s diet._]

These steps being taken on the first day, the patient must be put to bed: and if the wound be severe, he ought to abstain from food, as much as his strength will permit, before the inflammation comes on; to satisfy his thirst with warm water, or if it be in summer, and he have neither fever nor pain, the water may be cold. However no rule is so constant, but that a regard must always be had to the strength of the patient; so that his weakness may render it necessary to take food immediately, but such as is thin, and in small quantity, just sufficient to support him. And many sinking under a hæmorrhage, before any thing else be done, are even to be refreshed with wine; which is otherwise very prejudicial to a wound.

[Sidenote: _Good and bad symptoms in wounds._]

It is dangerous for a wound to swell too much: not to swell at all is extremely dangerous. The first is a sign of a violent inflammation; the other of a mortification. If the patient be sensible, and no fever has come on, we may at once conclude, that the wound will be soon healed: and even a fever ought not to alarm us, if in a large wound it continue, while the inflammation subsists; it is bad, when it either supervenes to a slight wound, or lasts longer than the inflammation, or brings on a delirium; or if it does not remove a tetanus, or convulsion, that arose from the wound. Also an involuntary bilious vomiting coming on either immediately after the wound is received, or while the inflammation continues, is a bad symptom in those only, whose nerves, or nervous parts are wounded. However to take a vomit is not hurtful; especially in those, who have been accustomed to it; but neither immediately after meat, nor when the inflammation has begun, nor when the wound is in the superior parts.

[Sidenote: _Dressings for wounds._]

The wound being kept thus for two days, on third it must be opened, and the sanies must be wiped off with cold water, and the same kind of dressings put on. On the fifth day it will be easy to judge to what height the inflammation is to rise. On which day the wound must be uncovered again, and its colour observed. And if it be livid, or pale, or variegated, or black, we may be sure it is a bad wound: and whensoever this appearance is observed, it may alarm us. It is best for a wound to be white, or ruddy. Also a hard, thick, and painful skin denotes danger. It is a good sign, when this is free from pain, thin and soft. But if the wound is closed, or there be a slight swelling, the same application must be used as at first.

If the inflammation is violent, with no hopes of an agglutination, and does not yield, the use of warm water too is necessary, that it may dissipate the matter, and soften the hardness, and promote a suppuration. It must be of such a degree of warmth, as to be agreeable to the hand; and be continued so long, till it appear to have diminished in some measure the swelling, and restored a more natural heat to the ulcer. After this fomentation, if the wound does not gape much, a plaister should be applied immediately, and if it be a large wound, the tetrapharmacum would be best; in the joints, fingers, or cartilaginous parts, the rhypodes. But if it gapes pretty much, that same plaister must be softened with ointment of iris, and lint spread with it must be laid over the wound; then the plaister applied above, and over that sordid wool; and the rollers must be also less tight than at first.

[Sidenote: _Peculiar directions for wounds in the joints._]

But there are some peculiarities to be attended to in the joints. If the nerves, which secure them, are cut through, a weakness of that part follows. If that is uncertain, and the wound is from a sharp weapon, and that in a transverse direction, it is more easy to cure: and if it be from a blunt and heavy one, the figure of it makes no difference: but it must be observed whether the pus comes from above or below the joint. If it come from under it, and continue a long time white and thick, it is probable that a nerve is cut through, and the more so, the greater the pains and inflammations are, and the sooner they began. But although the nerve be not cut through, yet if a hard tumour continue round it long, the ulcer of necessity must be tedious, and even when that is healed, the tumour will remain; and it will be a considerable time before that limb recover its power either of extension or contraction. And it is longer before it can be extended, when the cure has been conducted with the joint bent, than it is before one can be bent, which we have kept straight. The limb, that is wounded, ought to be placed also in a certain position: if it is to be agglutinated, it must be laid high; if it is inflamed, so as to incline to neither side; if the pus has begun to flow, it must be kept in a depending posture.

Rest too is an excellent remedy. Motion and walking are prejudicial, except to people in health: however, less dangerous to such as are wounded in the head or arms, than those, that are wounded in the lower parts. And walking is least of all proper, when the hurt is in the thigh, or the leg, or the foot. The place, where the patient lies, ought to be warm. Bathing also, while the wound is not clean, is extremely bad: for that renders it both tumid and foul; from whence the transition to a gangrene is common. Gentle friction is good; but in those parts, that are at a great distance from the wound.

[Sidenote: _Deterging of wounds._]

After the inflammation is gone, the wound must be deterged. That end is best obtained by lint dipt in honey; and over that must be applied either the tetrapharmacum plaister, or the enneapharmacum. Now that ulcer is clean, which appears red, and is neither too dry nor too moist. But any ulcer that is deprived of its sensibility, or whose feeling is unnaturally exquisite, or that is either too dry or too moist, or that is either whitish or livid, or black, that ulcer is not clean.

[Sidenote: _Incarning of wounds._]

After a wound is deterged, it must next be incarned; and for that purpose warm water is so far necessary, as to remove the sanies. The use of sordid wool is improper; it is better to cover it with such as has been washed. And there are also some medicines, which conduce to the filling up of the wound; therefore it is not amiss to make use of them: such as butter with oil of roses, and a small proportion of honey; or the plaister tetrapharmacum with the same proportion of honey, or with the oil of roses; or lint dipped in oil of roses. But the bath used sparingly is more efficacious; and food of a good juice, avoiding every thing acrid. When they are almost filled up, birds and venison and boiled pork may be given. Wine is always hurtful, while there is a fever or inflammation; and indeed, till it be cicatrized, if either nerves or muscles are wounded; or even the flesh, if it be deep. But if the wound is of the safer kind, and only superficial, wine not very old, given in moderate quantities however, may promote the incarnation. If any thing is to be softened, which is necessary in nervous and muscular parts, cerate must also be laid upon the wound. But if fungous flesh has grown upon it, dry lint restrains it gently; copper scales more powerfully. If the quantity to be taken away be more considerable, things still stronger must be applied to eat down the flesh. After these a cicatrix is very well formed by lycium diluted in passum or milk; or dry lint laid on alone is still more efficacious.

[Sidenote: _Bad consequences from unsuccessful cures._]

This then is the process of a successful cure. But at times things will happen to take a dangerous turn. For sometimes the ulcer grows ancient, a callosity comes over it, and its lips are thick, and of a livid colour: after which, whatever medicine is applied, does little good; and this generally happens to an ulcer negligently treated.

Sometimes from an excessive inflammation, or violent heats, or excessive cold, or too tight bandages, or the old age or bad habit of the patient, a gangrene seizes upon it. This kind of disorder by the Greeks is divided into several species, for which we have no terms in our language. Now every gangrene not only corrupts that, which it has seized upon, but also spreads. But then the distinction is to be made between the species by different symptoms. For sometimes beyond the inflammation a redness surrounds the ulcer, and spreads with pain; the Greeks call it erysipelas[ET].; sometimes the ulcer is black, because the flesh of it is corrupted, and the blackness is greatly increased as the putrefaction goes on, when the wound is moist, and from the black ulcer is discharged a pale fetid liquor, and the flesh within is corrupted(67): sometimes also the nerves and membranes are dissolved, and a probe put in descends either laterally or downwards; sometimes the bone is affected with that disorder: and sometimes there follows what the Greeks call gangræna[EU].

[ET] ἐρυσίπελας.

[EU] γάγγραινα.

The former kinds happen in any part of the body: the last mentioned about the extremities, that is, the nails, the armpits, or groin; and generally in old people, or in such as are in a bad habit of body. The flesh of such an ulcer is either black or livid, but dry and withered, and the contiguous skin is for the most part covered with pustules of a dark brown colour; then the next to that is either pale or livid, and commonly of an æruginous colour, and void of sensation; the skin a little farther off(68) is inflamed. And all these spread at once; the ulcer into the pustulous part; the pustules to the part that is pale or livid; the paleness or livor to that which is inflamed; and the inflammation proceeds to that which is sound. In the mean time an acute fever comes on, and a vehement thirst; some are also delirious; others, though they be sensible, stammer, and with great difficulty can make their meaning understood; the stomach begins to be affected; the breath itself acquires a fetid smell. Now this disorder in the beginning admits of a cure; but when it is thoroughly rooted, it is incurable; and most of them die with a cold sweat.

[Sidenote: _The cure of an old ulcer._]

These are the dangers, to which wounds are liable. But when the ulcer is old, it must be cut round with a knife, and its lips cut off, and whatever beyond them is livid, must likewise be scarified. If there be a small varix within, which prevents its healing, that also must be cut out. Afterwards when blood has been discharged, and a new face thus given to the wound, the same method of cure must be pursued, which has been directed for recent wounds. If any person does not chuse to make use of a knife, the plaister, which is composed of labdanum, may incarn it, and when the ulcer has been eaten down by that, a plaister, which brings on a cicatrix.

[Sidenote: _Of an erysipelas._]

Now that, which I said has the name of an erysipelas, is not only consequent upon a wound, but often happens without it, and is sometimes very dangerous; especially if its seat be about the neck or head.

It is proper, if the strength will admit, to bleed; then to apply at once repellents and coolers, and particularly cerus with the juice of nightshade, or cimolian chalk with rain water; or meal made into a paste with the same water, with the addition of cypress, or if it be in a tender part, with lentils. Whatever is applied, must be covered with a beet leaf, and upon that must be laid a linen cloth dipped in cold water. If coolers alone do little service, the following mixture must be made; of sulphur p. i. *. ceruss, saffron, each p. x. *. and these to be rubbed down with wine, and spread over the part: or if the place is not tender, leaves of nightshade powdered must be mixed with hog’s lard, and applied spread upon linen.

But if there be a blackness, which does not yet spread, such applications must be used, as will gently eat away the putrid flesh; and the ulcer being thus cleansed, must be dressed in the same manner as others. If it be more putrid, and already begins to advance and spread, there is a necessity for stronger corrosives. If even these do not overcome it, the part must be cauterized, till no moisture flow from it; for whatever is sound, is dry when it is burnt. After the burning of a putrid ulcer, such applications must be used, as may separate the sloughs from the quick part; the Greeks call them apescharotica[EV]. When they have fallen off, the ulcer must be cleansed, particularly with honey and resin; but it may be cleansed also by those things with which purulent ulcers are dressed, and healed up by the like methods.

[EV] ἀπεσχαρωτικὰ.

[Sidenote: _Of a gangrene._]

It is not very difficult to cure a gangrene, if it has not got full possession, but is only beginning, especially in a young person: and easier still, if the muscles are sound; or if the nerves are either untouched, or but slightly affected; and no large joint laid bare; or there be but little flesh in that part, and consequently not much to putrify, and if the disorder is confined to one place, which chiefly happens in a finger. In such a case the first thing to be done, if the strength will allow, is to let blood: after that, to cut through to the sound flesh, whatever is dry, which by a kind of tension is uneasy to the contiguous parts.

While the disorder is spreading, no suppurating medicines are to be applied; and for that reason not so much as warm water. Ponderous medicines also, although they be repellent, are hurtful; but the lightest of that nature are required; and over the parts, which are inflamed, coolers must be applied. If the disease is not stopped by these, so much as is betwixt the sound and corrupted parts, ought to be cauterized.

And in this case particularly help must be sought not from medicines alone, but from a due regimen: for this disease never appears but in a corrupt and vitiated habit. Wherefore in the first place, unless weakness forbid, the patient must live abstemiously: and then for food and drink must be given what will bind the belly, and consequently the body also; but these must be of a light nature. Afterwards if the disorder stop, the same applications must be used as have been prescribed in a putrid ulcer. And then also a fuller diet may be allowed of the middle class: only such however as tends to dry the belly and the whole body; and the drink must be cold rain water. The bath, unless we are confident of a cure, is hurtful; for the ulcer softened by that means is quickly affected again with the same disorder. But sometimes it happens, that all these remedies do no service, and notwithstanding all their force, the gangrene spreads. In which case the miserable but sole remedy is to cut off that limb, which is perishing by degrees, to save the rest of the body.

[Sidenote: _The cure of more slight wounds._]

This then is the method of treating the most severe wounds. But even such are not to be neglected, where the skin is entire, but the flesh within(69) is bruised; or where any thing is razed or rubbed off the surface; or when a splinter is fixed into the flesh; or when a wound, though small, has penetrated deep.

In the first case it is a very proper remedy to boil pomegranate bark in wine, and bruising the inner part of it, to mix it with a cerate of the oil of roses, which is to be laid upon the part; then where the skin is razed, to cover it with a mild medicine, such as the lipara[EW].

[EW] λιπαρὰ.

Upon the part, that has its surface razed and rubbed off, the tetrapharmacum plaister must be applied, and the quantity of food diminished, and wine denied. Nor should such a hurt be looked upon as contemptible, because the wound is not deep: for from such accidents gangrenes often arise. But if it be slight and of small extent, the mild medicine abovementioned may be sufficient for the cure.

A splinter, if possible, must be extracted either by the hand or by an instrument: if it has either broke or penetrated deeper than to admit of this, it must be drawn out by a medicine. Now the best application for that purpose is the root of a reed; which if tender, must be immediately bruised; if grown hard, it may be first boiled in mulse: to this honey must always be added; or birthwort with honey must be applied. The worst splinter is that of a reed, on account of its asperity: the fern is also equally hurtful: but it has been found by experience, that each of these bruised and applied is a cure for the other. Every medicine, that has the faculty of drawing, has the same effect in all splinters. The same kind of medicine is also finest for deep and small wounds: the plaister of Philocrates is best adapted to the former, that of Hecatæus to the latter case.

[Sidenote: _Of cicatrizing ulcers._]

In any wound, when we are to form the cicatrix (which is necessary after the ulcers are thoroughly cleansed and incarned) in the first place lint dipped in cold water must be applied, while the growth of flesh is encouraged; afterwards when that is to be restrained, it must be put on dry, till a cicatrix be formed; then white lead ought to be bound over it, which both compresses the cicatrix, and gives it a colour resembling the sound part of the body. The root of wild cucumber has the same effect. Also the composition, which contains of elaterium p. i. *. litharge p. ii. *. myrobalans p. iv. *. to which is added turpentine resin, till the whole be brought to the consistence of a plaister. But black cicatrices are gently cleansed by a mixture of equal parts of verdigrease, and washed lead, and the same resin boiled, whether the cicatrix be anointed with this, which may be practised in the face, or it be applied like a plaister, which is more convenient in other parts of the body.

But if the cicatrix is either protuberant or hollow, it is ridiculous, merely in regard to the appearance to submit a second time to the pain and trouble of a cure; otherwise both cases might be remedied. For either of these cicatrices may be converted into a wound by the knife. If one rather chuses a medicine, the same purpose is answered by those compositions, which eat down flesh. When the skin is taken off, upon the prominent one must be applied eating medicines, upon the hollow one such as tend to fill up, till both these kinds of ulcers be brought to the level of the sound skin, and then they may be cicatrized.

CHAP. XXVII.

OF WOUNDS CAUSED BY BITES; POISONS TAKEN INTERNALLY; AND BURNS.

I have treated of those wounds, which are most commonly inflicted by weapons. It follows, that I speak concerning those, which are occasioned by the bite, sometimes of a man, sometimes of an ape, often of a dog, sometimes of wild beasts, or other animals, or serpents. Now almost all bites(70) are in some degree venomous.

Therefore if the wound be severe, a cupping vessel must be applied; if slight, a plaister must be immediately put on, particularly that of Diogenes; if that is not to be had, any of those, which I have prescribed against bites; if these are not to be got, the green Alexandrian; if that is not at hand neither, any of those, which are not greasy, that are calculated for recent wounds. Salt is also a remedy for them, and particularly for the bite of a dog, if it be applied dry, and the part be chaffed with two fingers; for it brings out the sanies. It is also of use to bind salt fish over such a wound.

[Sidenote: _The bite of a mad dog._]

If the dog was mad, it is more especially necessary to extract the poison by cupping. After that, if the part is neither nervous nor muscular, the wound must be cauterized. If it cannot be cauterized, it is proper for the patient to be bled. Then upon the wound, after burning, must be applied what is proper for other cauterized ulcers. Such as have not been cauterized must be treated with those medicines, that powerfully corrode the flesh. After which the wound must be filled up, and healed by no other than the common method already laid down. Some presently after the bite of a mad dog order such a patient into the bath, and allow him to sweat there as long as he is able, with the wound bare, that the poison may the more readily be discharged; then they refresh him with plenty of strong wine, which is an antidote to all poisons. And when this method has been pursued for three days, the patient is thought out of danger.

But it is usual for such a wound, if not effectually treated, to produce a fear of water. The Greeks call it hydrophobia[EX]: a most miserable kind of disease, in which the patient is tormented at once with thirst, and a dread of water. When this happens, there is very little hope left. But yet there is one remedy: to throw the patient unawares suddenly into a pond, and if he cannot swim, to suffer him to sink sometimes, and thus drink, and sometimes to lift up his head; if he can swim, to keep him down at times, that even against his will he may be satiated with water: for thus at once both the thirst and dread of water is removed. But this practice is attended with another danger, which is, that a weak body fatigued in cold water, may be destroyed by a convulsion. To prevent which, from the pond he must immediately be put into warm oil. An antidote (particularly that which I mentioned first, or in its stead another) if the patient is not possessed with the horror of water, may be given to drink in water; if he be offended with its bitterness, honey must be added; but if that disease has already come on, it may be taken in the form of catapotia.

[EX] ὑδροφοβία.

[Sidenote: _Of the bites of serpents in general._]

The bites of serpents do not require a very different treatment: although in this the ancients varied greatly; in so much that they prescribed as many distinct methods as there were kinds of snakes; in which too they differed widely from each other. But generally the same remedies have the best success in all of them. Wherefore in the first place the limb must be tied above the wound; but not too tight, lest it become torpid. Then the poison must be extracted. This is best done by cupping. Neither is it improper to cut round the wound first with a knife, that the more of the blood already vitiated may be extracted. If a cupping vessel cannot be had (which can scarcely happen) then any other similar vessel will do, which will serve the same purpose. If none such can be got, a person must be employed to suck the wound.

Nor indeed have those, that are called Psylli(71), any peculiar skill, but a boldness confirmed purely by custom. For the poison of a serpent, as also some of those, which hunters make use of, and especially in Gaul(72), are not hurtful, taken in by the mouth, but injected by a wound: and for that reason even a snake itself is safely eaten: its bite is mortal, and when it is in a state of stupidity (which dealers in legerdemain can produce by the force of some drugs) if one puts his finger into its mouth, and is not bit, he receives no hurt from the saliva. Therefore any person that, like a Psyllus, shall suck the wound, will both be safe himself, and save the patient. In the mean time he ought to attend to this first, that he have no ulcer either in his gums, or palate, or any other part of his mouth. Afterwards the patient must be laid in a warm place, in such a posture, that the part, which is wounded, may be in a depending posture.

If no body can be got to suck the wound, nor a cupping vessel is at hand, the patient ought to sup goose or veal broth, till he vomit. A chicken must also be cut through the middle alive, and immediately applied warm over the wound, with the internal part next the body. The same effect is produced by a kid, or a lamb cut up, and the warm flesh immediately laid upon the wound, and by the plaisters, that have been mentioned before: the most proper of which is the Ephesian, or that, which follows it. To take some antidote too immediately, is a powerful protection against the danger. But if that cannot be had, it is necessary to sup a little pure wine with pepper, or any thing else, which serves to excite heat, and does not suffer the humour to coagulate within. For the greatest part of poisons kills by cold. All diuretics too, because they attenuate the humour, are useful.

[Sidenote: _Of the bite of an aspis._]

The former remedies are general, and good against bites: but experience itself has taught us, that a person, who has been bit by an aspis, ought rather to drink vinegar. Which is said to have been discovered by the case of a certain boy, who, when he had been wounded by one, and partly from the wound itself, and partly from the excessive heat of the weather, was tormented with thirst, and the country being dry, could find no other liquor, drank off vinegar, which he chanced to have by him, and was cured. The reason of the effect in my opinion is, that vinegar, though it refrigerate, yet has a faculty of dissipating at the same time. Whence it happens, that earth sprinkled with it rises in a froth. From the same virtue therefore it is very probable, that the fluids of the human body beginning to be coagulated are dissipated by it, and health thereby restored.

[Sidenote: _Of the scorpion._]

Against the poison of some other serpents also peculiar remedies are well known. For the scorpion is a most excellent remedy against itself. Some drink it bruised with wine. Some apply it in the same form to the wound. Others laying it upon live coals fumigate the wound with it, keeping a cloth all round it, that the smoke may not escape; and then bind it on when burnt to a coal. Now it is proper to drink in wine the seed, or at least the leaves of turnsole (which the Greeks call heliotropium[EY].) And over the wound it is fit to apply bran with vinegar, or wild rue, or salt toasted with honey. But I have known physicians, who have done nothing else to people stung by a scorpion, but bled them in the arm.

[EY] ἡλιοτρόπιον.

For the sting of a scorpion also, and a spider, garlick mixed with rue, and rubbed down with oil, is a proper application.

[Sidenote: _Of the cerastes, dipsas, and hæmorrhois._]

For a wound given by a cerastes(73), or dipsas(74), or hæmorrhois(75), the remedy is dried asphodel, about the bigness of an Egyptian bean, with the addition of a little rue given in drink, and divided into two doses. Trefoil also and horse-mint, and panaces with vinegar are equally good. Also costus, and cassia, and cinnamon are proper to take in drink.

[Sidenote: _Of a chersydrus._]

Against the wound of a chersydrus(76), panaces or laser, or each scruples p. ii. *. Or the juice of a leek is to be taken with a hemina of wine, and savory eaten plentifully. And let goat’s dung boiled in vinegar be laid upon the wound; or barley meal in the same manner with vinegar; or rue, or cat-mint, powdered with salt and mixed with honey. And this is equally efficacious against the bite of a cerastes.

[Sidenote: _Of a phalangium._]

When a phalangium(77) has given a wound, beside the chirurgical part of the cure, the patient should be frequently plunged into the warm bath, and an equal quantity of myrrh and stavesacre is to be given in a hemina of passum; or radish-seed, or darnel-root with wine; let there be also applied to the wound bran boiled with vinegar, and he must be ordered to continue quiet.

[Sidenote: _Of Italian snakes._]

But the kinds of serpents mentioned hitherto are foreign, and much more dangerous than ours; especially those, which are in very hot countries. Italy and the colder climates, besides that they are more healthful in other respects, have the advantage in this, that they produce snakes less formidable. Their bites are well enough cured by the herb betony, or bindweed, or centory, or agrimony, or germander, or burdock, or pastinaca fish(78), either singly, or any two of them taken together powdered, and thus given to drink in wine, and also applied upon the wound. It is necessary to observe, that the bite of every serpent is more hurtful, when either the animal or the wounded person is fasting, and therefore they are most pernicious when they are hatching; and it is adviseable, when any one is apprehensive of meeting serpents, not to go out, before he has taken some food.

[Sidenote: _Of poisons._]

It is not so easy to relieve those, who have swallowed poison, either in their food or drink. In the first place, because they do not perceive it immediately, as those do, who are bit by a snake; and therefore cannot instantly apply the remedy. In the next place, because the hurt does not begin in the skin, but in the internal parts. However it is best, as soon as one discovers it, immediately to drink largely of oil, and to vomit. And then, when he has emptied his praecordia, to take an antidote in his drink; if that is not to be got, pure wine.

[Sidenote: _Remedies against cantharides._]

Nevertheless there are some peculiar remedies against certain poisons, and chiefly of the milder kind. For if any person has drunk cantharides, he ought to take panaces bruised with milk, or galbanum, with the addition of wine, or milk by itself.

[Sidenote: _Against hemlock._]

If hemlock, let the patient drink as much hot pure wine with rue as he can; then he must be forced to vomit; after that, laser with wine must be given; and, if he be free of a fever, he must be put into the warm bath; if not, be anointed with warm ingremedies. After these, rest is necessary for him.

[Sidenote: _Henbane._]

If henbane, hot mulse must be drunk, or any kind of milk, but more particularly asses milk.

[Sidenote: _Ceruss._]

If ceruss, the juice of mallows, or of a bruised walnut with wine are most serviceable.

[Sidenote: _A leech._]

If one happens to swallow a leech in drinking, vinegar with salt must be given. If milk has curdled in the stomach, either passum, or laser with vinegar.

[Sidenote: _Poisonous mushrooms._]

If a person has eaten poisonous mushrooms, let him take radish either out of vinegar and water, or salt and vinegar. These may both be distinguished from the good by their form, and also be rendered innocent by the manner of dressing. For they are perfectly freed from all noxious qualities, by boiling them in oil, or with a twig of a pear-tree.

[Sidenote: _Of burns._]

Burns are also to be reckoned amongst the effects of external violence. The plan laid down, therefore, seems to oblige me to speak of them in this place. They are best cured by the leaves either of lilly, or hound’s-tongue, or betes boiled in wine and oil. Any of these presently applied heals them.

But the method of cure may also be divided into those things, which being gently eating and repellent, at first both prevent pustules, and excoriate the part; and those, which being lenient, restore the part to its soundness. Of the former is the meal of lentils with honey, or myrrh with wine; or Cimolian chalk, powdered with the bark of frankincense, and worked up to a paste with water, and when it is to be used, diluted with vinegar. Of the second class any of the lipara. But the most suitable is that, which contains the dross of lead, or yolks of eggs.

Another way also of treating burns is, while the inflammation continues, to apply to them lentils with honey; when that is gone off, meal with rue, or leeks, or horehound, till the crusts fall off, then vetches with honey, or iris, or turpentine resin, till the ulcer be clean; last of all, dry lint.

CHAP. XXVIII.

OF EXTERNAL DISORDERS PROCEEDING FROM AN INTERNAL CAUSE, AND THEIR CURE.

[Sidenote: _Of a carbuncle._]

From external injuries, we proceed to disorders which have an internal origin, when some part of the body is corrupted. Amongst these none is worse than a carbuncle. The marks of it are these. There is a redness, and above that pustules rise, not very high, mostly black, sometimes inclining to a livid colour, or pale. There seems to be sanies in them; below, the colour is black. The flesh is parched, and harder than it ought to be naturally. And about it, there is a sort of crust; which is surrounded with an inflammation. Neither can the skin be lifted up in that place, but is, as it were, bound down to the flesh below. There is a propensity to sleep. Sometimes a shuddering, or fever comes on, or both. And this disease shoots out roots, as it were, below, and spreads, sometimes quickly, sometimes more slowly. At the surface also it spreads and grows white; then becomes livid; and all round it small pustules break out. And if it happen to be near the gullet or fauces, it often stops the breath suddenly.

Nothing is better than to sear it immediately. Neither is that painful, for it has no feeling, because such flesh is mortified. And the burning should be continued, till there is a sense of pain on every side. After this, the ulcer is to be cured in the same manner, as other burns. For by eating medicines is produced an eschar, which being entirely separated from the quick flesh, draws with it whatever was corrupted; and the sinus, by this time clean, may be dressed with incarning medicines. But if the disorder be in the surface of the skin, medicines barely eating, or at most caustic, may be sufficient. The violence of the cure is to be proportioned to the malady. Whatever medicine is applied, if it has the desired effect, will immediately separate the corrupted part from the quick.

And we may generally be confident of success, if the corrupted flesh falls off, wherever such medicine eats down; if that does not happen, and the medicine is overcome by the disease, an immediate recourse must be had to the actual cautery. But in such a case, the patient must abstain from food and wine. It is also proper to drink water plentifully. And these directions are to be observed more strictly, if a febricula be added to the other complaints.

[Sidenote: _Of a Cancer._]

There is not so great danger of a cancer[EZ], unless it be irritated by the imprudence of the physician. This disease generally happens in the superior parts, about the face, the nose, ears, lips, and breasts of women. It also rises from the liver, or spleen. About the place there are pricking pains; it is immoveable, and unequally swelled; it is also sometimes insensible. Around it the veins are inflated, and tortuous; and either pale or livid; in some also, they are concealed from view. Touching the part gives pain to some, to others none. Sometimes it is harder, or softer, than it ought naturally to be, without any ulcer; at other times, all other circumstances being as above described, there is likewise an ulcer. Sometimes it has no peculiar characteristic to distinguish it; at other times it resembles those which the Greeks call condylomata[FA], but has an asperity and magnitude peculiar to itself. And its colour is red, or resembling that of a lentil. Neither is it safe to cut it; for immediately there follows either a palsy, or a convulsion. Often when a person receives a blow upon it, he loses his speech and faints. In some also if the tumour itself be compressed, the contiguous parts grow tense and swell. Now this is a very bad kind(79). Its general progress is this; first appears what the Greeks call a cacoethes[FB], then it becomes a carcinoma, without an ulcer. From that an ulcer; and from an ulcer a thymium.

[EZ] καρκίνωμα.

[FA] κονδυλώματα.

[FB] κακόηθες.

None of these can be removed but the cacoethes(80); the rest are irritated by every method of cure; and the more violent the operations are, the more angry they grow. Some have made use of caustic medicines; others of the actual cautery; others cut them out with a knife. Nor was any person ever relieved by medicine; but after cauterizing, the tumours have been quickened in their progress, and increased till they proved mortal; when they have been cut out, and cicatrized, they have, notwithstanding, returned, and occasioned death. Whereas, at the same time, most people, by using no violent methods to attempt the extirpation of the disease, but only applying mild medicines, to sooth it, protract their lives, notwithstanding the disorder, to an extreme old age. But no body can pretend to distinguish a cacoethes, which is curable, from a carcinoma, which is not, otherwise than by time and experiments.

Therefore, so soon as this disease is perceived, caustic medicines ought to be applied; if the disorder is alleviated, and its symptoms grow milder, we may proceed both to incision and the actual cautery; if it is immediately irritated, we may conclude, that it is already a carcinoma; and every thing acrid and severe is to be taken away. But if the part is hard, without any ulcer, it is sufficient to apply a very mellow fig, or the plaister called rhypodes. If there is an ulcer, but not rising _above the surface of the skin_, the cerate of rose oil is to be put on, with the addition of a powdered shell, with smith’s forge water. If it grows fungous, copper scales (which is the gentlest caustic) must be tried, till there is no rising above the other parts; provided still that it does not exasperate; if it does, we ought to be content with the same cerate.

[Sidenote: _Of a therioma._]

There is also an ulcer, which the Greeks call therioma[FC]. This both comes of itself, and sometimes is consequent upon an ulcer produced from another cause. The colour is either livid or black; the smell is bad; it discharges copiously a humour like mucus; it is sensible neither of the touch, nor of medicine; and is only disturbed by itching. About it there is a pain and inflammation. Sometimes also a fever comes on. Sometimes there is a haemorrhage from the ulcer, and this disorder spreads, by which all the symptoms often increase. From these proceeds the ulcer which the Greeks call herpes esthiomenos[FD], _voracious herpes_; because by spreading quickly, and penetrating even to the bones, it devours the body. The surface of this ulcer is unequal, resembling dirt; and there is in it a great quantity of glutinous humour, an intolerable smell, and an inflammation more violent, than is found in an ulcer of that size. Both of them, as indeed all the kinds of gangrenes, happen chiefly to old people, or those, who are in a bad habit of body.

[FC] θηρίωμα.

[FD] ἕρπης ἐσθιόμενος.

The manner of curing both is the same; but the greater disease requires the sharper remedy. And the regimen must first be regulated; the patient must rest in his bed, for some days abstain from food, drink water very plentifully, and have a clyster given him. Then, when the inflammation is gone, let him take food of a good juice(81), avoiding every thing acrid; he may drink as much as he will, provided he be content in the day-time with water but at supper, he may also drink some rough wine. But the abstinence should not be equally severe in a herpes, and a therioma. This then is the regimen necessary.

Externally upon the ulcer, must be sprinkled powder of dry aloes, and if that does but little service, chalcitis. But if any nerve, by the flesh being destroyed, be laid bare, it must be covered first with linen, lest it be burnt by that medicine. If there is need of remedies still more powerful, we must make use of those compositions, that cauterize more strongly. Now when any medicine is sprinkled on, it ought to be done by the broad end of a probe(82). Over it should be applied either lint with honey, or olive leaves boiled in wine, or horehound: and these must be covered with linen dipped in cold water, and then well squeezed. And all round, where there is a tumour from the inflammation, repellent cataplasms must be applied. If by these methods it grows no better, the place ought to be cauterized with a _hot_ iron; the nerves that are in view being first covered. By what has been said on other occasions, it will be clear enough to any body, that a part, which is burned either by medicines or the actual cautery, must first be cleansed, and then filled up.

[Sidenote: _Of the ignis sacer._]

The ignis sacer ought also to be numbered amongst bad ulcers. There are two species of it. The one is of a colour inclining to ruddy, or a mixture of red and pale, and the surface is roughened by contiguous pustules, of which no one is bigger than another, but they are very numerous, and exceeding small. In these there is almost always pus, and often a redness attended with heat; and that spreads, sometimes when the part first affected is healing, sometimes when it is ulcerated, in which case, the pustules breaking, one continued ulcer is formed, discharging a humour, which seems to be betwixt sanies and pus. It attacks chiefly the breast, or sides, or extremities, and particularly the soles of the feet. The other kind comes with an ulceration in the surface of the skin, but without going deep, broad, inclining to a livid colour, but unequal; and the middle part of it heals, while the extremities spread; and often that, which seemed to be sound, ulcerates again. But the skin round about it, which is to receive the disease, grows tumid, and hardish, and the colour of it is a blackish red. And this disease too generally attacks old people, or those, that are in a bad habit, but chiefly in their legs.

Now every ignis sacer, though it be the least dangerous of those disorders, which have the disposition to spread, yet is, I had almost said, the hardest to cure of them all. The most effectual remedy is a fever for one day, which consumes the noxious humour. The thicker and whiter the pus is, so much the less is the danger. It does good also to excoriate the part below the ulcer by scourging, that the more pus may be evacuated, and the matter drawn out, which corrupts the flesh there. But notwithstanding if a slight fever comes on, there is a necessity for abstinence, lying a-bed, and clysters. In every ignis sacer, neither mild and glutinous food, nor salt and acrid are proper; but what is betwixt these: such as unleavened bread, fish, kid, birds, and except the wild boar, almost all venison. If there is no febricula, both gestation and walking are serviceable, and rough wine, and the bath; and in this disorder, as well as that mentioned before, the drink ought to be more plentiful than the food.

As for the ulcers themselves, if their progress be moderate, they must be fomented with hot water; if more rapid, with hot wine. Next wherever there are any pustules, they must be opened with a needle. Then such applications used, as may consume the putrid flesh. When the inflammation is removed, and the ulcer cleansed, a lenient medicine ought to be applied. In the second species, quinces boiled in wine and bruised may do good; as likewise the plaister of Hera, or the tetrapharmacum, with the addition of a fifth part of frankincense; likewise black ivy boiled in a rough wine, and if the disorder spread fast, nothing is more efficacious. When the ulcer, which I observed to be in the surface of the skin, is cleansed, the same lenient medicines are sufficient to the cure.

[Sidenote: _Of the Chironian ulcer._]

The ulcer named Chironian(83) is large, and has hard, callous, and swelled lips. A sanies is discharged not copious, but thin; the smell is bad. There is no inflammation either in the ulcer or in the tumour about it. The pain is tolerable. It does not spread, and therefore is not dangerous; but it does not easily heal. Sometimes a thin cicatrix comes on, and then breaks again, and the ulcer is renewed. It occurs chiefly in the feet and legs.

The application to it ought to contain both something lenient, and something strong, and repellent. Such as the following composition made for the purpose: of copper scales, calcined lead washed, each p. vi. *. cadmia, wax, each p. viii. *. oil of roses a sufficient quantity to soften the wax with the other ingredients.

[Sidenote: _Of ulcers occasioned by cold._]

There is a kind of ulcer occasioned by the cold of the winter. It is most common in children, chiefly in their feet and toes, sometimes also in their hands. There is a redness with a moderate inflammation. Sometimes pustules break out, which are followed by an ulceration. The pain is not great, the itching greater. Sometimes a humour is discharged, but in small quantity, which seems to resemble either pus or sanies.

In the first place it must be fomented plentifully with a hot decoction of turnips, or if these are not to be had, some of the repellent vervains. If it is not yet ulcerated, copper, as hot as a person is able to bear it, must be applied. When it is already ulcerated, allum, powdered with an equal quantity of frankincense, ought to be put to it, with the addition of wine; or pomegranate bark boiled in water, then beat. If the surface of the skin be excoriated, in that case lenient medicines succeed best.

[Sidenote: _Of the scrophula._]

The scrophula is a tumour, in which there are formed some concretions of pus and blood, resembling small glands. These are extremely troublesome to physicians, because they both generate fevers, and never maturate kindly; and whether they be cured by incision or medicines, for the most part they rise again close to the cicatrices; which they are much more ready to do, after being treated with medicines; and what is more, they are of long continuance. They grow chiefly in the neck; but also in the armpits, the groin and the sides. Meges the surgeon assures us, that he has met with them in the breasts of women too.

For these reasons, it is proper to give internally white hellebore, and that even frequently, till they be discussed; and externally to apply medicines which may either draw out the humour, or discuss it; such as have been mentioned before. Some also make use of caustics, which eat down and constringe the part with an eschar; and then treat it like an ulcer. Whatever method of cure be pursued, when the ulcer is clean, the body must be exercised and nourished, till it come to a cicatrix. These are the methods prescribed by physicians(84): but the experience of some peasants has discovered, that eating a snake cures a scrophulous patient.

[Sidenote: _Of a furuncle._]

A furuncle is an acute tubercle, attended with inflammation and pain; and especially when it is just turning to pus. When this is opened, and the pus is discharged, part of the flesh below appears converted into pus, part corrupted, of a whitish colour, and reddish; which some call the ventricle of the furuncle. There is no danger in it, though no means be used for its cure, for it maturates of itself, and breaks. But the pain makes a medicine, that can hasten the cure, eligible.

The proper medicine for it is galbanum, but other things have also been mentioned before. If none of these can be had, the first application ought to be a plaister not greasy, to repel it; then if that has not succeeded, something to promote a suppuration. If that cannot be got, either resin or leaven(85). When the pus is squeezed out, no further cure is necessary.

[Sidenote: _Of phymata._]

The name of phyma is given to a tubercle resembling a furuncle, but rounder, and flatter in the surface, and often larger. For a furuncle seldom rises to the bulk of half an egg, and never exceeds it: a phyma is commonly of greater extent; but the inflammation and pain in it are less. When it is broken, the pus appears in the same manner; no ventricle is found here, as in the furuncle; but all the corrupted flesh is turned into pus. Now this grows more frequently in children, and is more easily cured; in young men it occurs more seldom, and is more difficult to cure: when age has given firmness to the body, it does not appear at all. The proper medicines for discussing it have been mentioned before.

[Sidenote: _Of a phygethlon._]

A phygethlon is a low, but broad tumour, in which there is something like to a pustule. The pain and tension are violent, and greater than in proportion to the size of the tumour; sometimes also attended with a slight fever. It ripens slowly, and no great part of it is converted into pus. It is formed chiefly either in the neck, or in the armpits, or the groin. From its figure our authors call it panus(86). The proper medicine for this also we have pointed out before.

[Sidenote: _Of abscesses._]

But though all the foregoing are nothing else but small abscesses, yet a larger collection, that tends entirely to suppuration, appropriates to itself the general name of abscess. And this collection happens generally after fevers or pains of some particular parts, and especially after pains in the belly. It commonly shews itself externally, for it sometimes swells to a pretty large compass, like the phyma, and is red and hot, and in a little time contracts a hardness. It is more troublesome as it advances, and occasions thirst and watchfulness. But sometimes there is none of these appearances in the skin; and more especially when the suppuration is pretty deep; but inward prickings are felt, attended with thirst and watchfulness. It is more kindly when it does not become hard of a sudden; and when, though it be ruddy, yet it is changing to a white colour. Which symptoms occur when the suppuration is beginning; for the swelling and redness comes on long before.

If the abscess be forming in any of the nobler parts, the accession of matter there must be prevented by cataplasms, which are at the same time repellent and cooling; such as I have mentioned under the erysipelas and elsewhere. If it is grown pretty hard, we must have recourse to discutients and resolvents; such as a dry fig bruised, or lees of wine mixed with cerate, made up with hog’s lard; or the root of wild cucumber, with the addition of two parts of meal, first boiled in mulse. We may also mix equal parts of ammoniacum, galbanum, propolis, viscum, adding of myrrh not half the quantity of any of the other ingredients: and the plaisters and malagmas I have mentioned before, have the same effect.

What is not discussed by these, must necessarily maturate. And to hasten this, must be applied barley meal mixed with water; to which also it will be proper to add some herbs. The same applications(87) are fit for the lesser abscesses too, whose names and properties I have recited above. The general method of cure is the same in them all; and only differs in the degree. Now that tumour is crude, in which there appears a strong pulsation of the arteries, a weight, heat, tension, pain, redness, and hardness; and if the abscess be large, a shuddering, as also a slight fever continues; and the suppuration being pretty deep and concealed, instead of the marks, which otherwise shew themselves in the skin, there are prickings. When these have abated, and the part begins to itch, and either becomes somewhat livid or whitish, the suppuration, is perfected. And when it either breaks of itself, or is opened by medicines, or by incision, the pus ought to be discharged. And if it happens in the armpits or groin, it must be dressed without lint. In other parts too, if it is narrow at the bottom, if the suppuration has been moderate, if it has not penetrated deep, if there is no fever, if the patient be strong, lint is equally needless. In other circumstances it ought to be used, sparingly however, and not unless the wound be large. It does well to spread honey upon the lint; or without it, to apply lentils with honey, or pomegranate bark boiled with wine. And these things are proper both alone and mixed.

If any parts round it should be too hard, to soften them may be applied either mallows beat, or fenugreek, or lintseed boiled in passum. And then whatever is to be applied, ought to be secured not by a tight, but an easy bandage. Every body ought to know, that in this kind of disorder cerate may be used. What else belongs to the cleansing of the ulcer, filling it up, and bringing on a cicatrix, and equally relates to wounds, has been already pointed out.

[Sidenote: _Of fistulas._]

But sometimes from abscesses of this kind and other ulcers, arise fistulas. That is the name of a deep, narrow and callous ulcer. It occurs almost in every part of the body; and it has some peculiarities in each place. I shall first treat of the general properties. There are then several kinds of fistulas; for some are short, others deeper; some point inward in a straight line; others, and by far the greatest part, are transverse; some are simple, others are double, or triple, which beginning from one orifice, branch out within, into three or more sinuses; some straight, others bent and tortuous; some end in the flesh, others penetrate to bones or a cartilage; or where neither of these lies beyond them, reach to the more internal parts; some again are easily cured, others with difficulty, and some are even found incurable.

The cure of a simple and recent fistula in the flesh is easy. It is an advantage to it, if the person be young, and the constitution firm: the contrary are very unfavourable circumstances; as also if the fistula has injured a bone, or cartilage, or nerve, or muscles; if it have seized upon a joint, or has penetrated either to the bladder, or the lungs, or to the womb, or to the large veins or arteries, or to the jaw-bones, throat, stomach, or thorax. When it points towards the intestines too, it is always dangerous, and often mortal. In these cases it greatly increases the malady, if the patient be either sick, or old, or of a bad habit.

First of all, it is proper to put a probe into the fistula, that we may find its direction and depth: and at the same time whether it be altogether moist, or drier than it should be, which appears upon drawing out the probe. It may also be determined, whether the bone be affected or not; and if the fistula has penetrated there, how far it has injured it. For if that part is soft, which is touched by the end of the probe, the disorder is confined to the flesh; if it resists more, it has made way to the bone. And again, if the probe slides, there is no caries begun: if it does not slip out(88) of the point where it is placed, the caries is begun, but is slight yet: if it feels unequal also, and rough, the bone is very much corroded. The situation itself shews when there is a cartilage below; and that the fistula has reached it, appears by its resistance.

Now from these circumstances may be learnt the seats and extents of fistulas, and what parts they have damaged. From the quantity of the pus it may be known, whether they be simple, or divided into more parts. If more of that comes away, than can issue from a single cavity, it is evident there are more sinuses. And as flesh, nerves, and some nervous substances, such as the greatest part of the coats and membranes are, commonly lie together, the nature of the pus will discover whether the several sinuses have eaten through these different sorts of bodies. For from flesh a smooth and white pus is discharged pretty copiously; from a nervous place the discharge is of the same colour indeed, but thinner, and less in quantity; from a nerve fat and not unlike to oil. Lastly, the posture of the body also discovers whether the fistulas have penetrated into several parts, because often, when one lies down with his body and limb in a different position, the pus begins to flow again, which had before stopped, and shews not only that there is another sinus, from whence it descends, but also that it proceeds in a different direction.

If it be confined to the flesh, and is recent and simple, neither consisting of sinuses, nor having a large cavity: also if it be not in a joint, but in a part, which is immoveable by itself, and is never put in motion but with the whole body, a plaister for recent wounds will be sufficient, if that contain either salt, or allum, or copper scales, or verdigrease, or any of the metallic substances. And of this a collyrium(89) ought to be made, at the one end smaller, and at the other somewhat thicker. And this ought to be introduced with the small end foremost into the fistula, till pure blood begins to appear. This is universal in the application of all collyriums for fistulas. And then the same plaister is to be put over it spread upon linen; and above that must be applied a sponge first dipt in vinegar; and it is sufficient to open the dressings on the fifth day. Such diet must be used, as I have recommended for generating flesh.

But if the fistula is at a distance from the præcordia, it is necessary for the patient now and then to eat radishes fasting and then to vomit.

When the fistula by time becomes callous (and it is impossible to be mistaken in a callosity, because it is hard, and either white or pale) then there is a necessity for stronger medicines. Such as that composition, which contains of poppy tears p. i. *. gum p. iii. *. cadmia p. iv. *. copperas p. viii. *. these are incorporated with water, and made into a collyrium. Or that, which consists of galls p. i. *. verdigrease, sandarach, Egyptian allum, each p. i. *. calcined copperas p. ii. *. Or that, which is composed of chalcitis and stone-lime, to which is added of orpiment less by one half than each of the other ingredients; and these are mixed up with boiled honey. The most expeditious is the prescription of Meges: to reduce to powder of rasile verdigrease p. ii. *. then to dissolve in vinegar, of ammoniacum thymiama p. ii. *. and with this to bring the verdigrease to a consistence: and this is one of the choicest medicines. But though the foregoing compositions are the most efficacious, yet if these are not to be had, it is easy to destroy the callosity by some caustic medicines: and it is sufficient to arm with these a twisted paper reed, or some part of a penecillum, formed after the manner of a collyrium. Squills also boiled, and mixed with lime consume a callus.

If the fistula happen to be pretty long, and transverse, after introducing a probe, it is very proper to make an incision over against its origin, and to put in any collyrium you chuse.

But if we judge the fistula to have two or more sinuses, provided it be short and confined to the flesh, we ought not to make use of a collyrium, which may cure one part, and not touch the rest; but the same medicines dry are to be put into a writing reed, which being applied to the orifice, the medicines must be blown into the fistula. Or the same things may be dissolved in wine; or if the fistula be somewhat foul, in mulse; if somewhat, callous, in vinegar; and whatever is injected, must be infused in this liquid form. Coolers and repellents must be applied above; for generally the parts about a fistula are a little inflamed. Neither is it improper, when one has removed the dressings, before he make another injection, to wash the fistula by means of a syringe; if there be much matter, with wine; if the callosity be pretty hard, with vinegar; if it is already cleansing, with mulse, or a decoction of vetches in water, with a little honey added to it. It commonly happens that the membrane, which is betwixt the orifice and the sound flesh, being overcome by so many medicines, casts off, and the ulcer is clean below. Whenever this happens, agglutinants are to be applied, and especially spunge armed with boiled honey. I know it is a practice approved of by many in this case, to have lint rolled up into the form of a collyrium, and dipt in honey, introduced for incarning. But this method more quickly agglutinates, than incarns. And there is no fear, that clean flesh brought into contact with clean flesh can fail to unite, especially when medicines proper for that purpose are made use of; since often an ulceration of the fingers, unless great care is taken to prevent it, will join them together in the healing.

[Sidenote: _Of the cerion ulcer._]

There is also a kind of ulcer, which from its resemblance to a honeycomb, by the Greeks is called cerium[FE]. And of this there are two species: the one is of a whitish colour, and like to a furuncle, but larger, and attended with great pain. When it maturates, it has openings, through which is discharged a glutinous and purulent matter; nevertheless it does not come to a due ripeness. If it be divided by incision, there appears to be a great deal more corruption within, than in a furuncle, and it reaches deeper. It seldom occurs but amongst the hair of the head.

[FE] κηρίον.

The other is less, and eminent upon the top of the head, hard, broad, of a pale green colour, and more ulcerated; for there are openings at the roots of each of the hairs, through which issues a glutinous, palish humour, in consistence like honey, or viscum, or sometimes oil; and if an incision be made upon it, the flesh within appears green. There is a great pain and inflammation, insomuch that they often bring on an acute fever.

To that kind, which has fewer openings, it is proper to apply dry figs, and lintseed boiled in mulse, and drawing plaisters and malagmas, or the medicines, of that quality above recited.

Upon the other, the same medicines, likewise meal boiled in mulse, and half the quantity of turpentine resin added to it; and a fig boiled in mulse; to which a little powdered hyssop is added; likewise a fourth part of stavesacre added to the fig. But if medicines do but little service in either kind, the whole ulcer must be cut out to the sound flesh. When the ulcer is taken away, medicines must be applied over the wound; first such as promote pus, next detergents, then such as incarn.

[Sidenote: _Of the acrochordon, acrothymium, myrmecia, and the clavus._]

There are also some resembling warts, which have different names, as they are different disorders. The Greeks call that an acrochordon[FF], where a substance pretty hard is collected within the skin, which sometimes is rough, and of the same colour with the adjacent parts; near the skin it is narrow, and broader above. This is small, rarely exceeding the size of a bean. They are hardly found to grow single; generally a number together, and chiefly in children. They sometimes suddenly disappear, sometimes they excite a moderate inflammation. Some are also converted into pus.

[FF] ἀκροχορδὼν.

That is called acrothymium[FG], which rises like a small wart above the flesh, broader at the skin, smaller above, hardish and very rough upon the top, where in colour it resembles thyme, whence it has its name; and it is easily divided there, and made bloody; sometimes it discharges some blood; and is generally about the bigness of an Egyptian bean, seldom larger, sometimes very small. Sometimes only one, at other times more grow in the palms of the hands, and soles of the feet; they are worst in the private parts, and aptest to bleed there.

[FG] ἀκροθύμιον.

Those called myrmecia[FH] are lower and harder than an acrothymium, fix their roots deeper, and occasion a greater pain; below they are broad, and above small, and less blood comes from them: in size they scarce ever exceed a lupine. These likewise grow either in the palms of the hands, or lower parts of the feet.

[FH] μυρμήκια.

The clavus grows elsewhere sometimes, but chiefly in the feet, and principally form a contusion, though sometimes from other causes; and it gives pain, if not at other times, at least when one is walking.

Of these the acrochordon, and the acrothymium often terminate of themselves, and the more readily, the less they are. Myrmecia and clavi are scarce ever removed without medicine. If the acrochordon be cut off, it leaves no root, and for reason does not grow again. When the acrothymium and clavus are cut off, a small roundish root grows, which descends deep into the flesh, and that being left, they sprout up again. The myrmecia adhere by very broad roots, and therefore cannot be taken off without a great ulceration. It is very proper to pare the clavus now and then: for thus without any violence it grows soft: but if a little blood be let out, it often dies away. It is also removed, if one cleans it round, and then applies to it resin mixed with a little of the powder of a milstone. But the other kinds are to be eaten away by medicines. For the two first, that which is made from the lees of wine; for the myrmecia the most proper is that, which consists of alum and sandarach. But the contiguous parts ought to be covered with leaves, lest they also be corroded; and after that a lentil must be applied. A fig also boiled in water destroys an acrothymium.

[Sidenote: _Of pustules._]

Pustules break out chiefly in the spring season. Of these there are several kinds. For sometimes there is a certain asperity over the whole body, or a part, resembling those pustules, which are occasioned by a nettle, or from sweat; the Greeks call them exanthemata[FI]. And they are sometimes red, at other times of the same colour with the skin. Sometimes a great many grow resembling vari, sometimes larger. The pustules are livid or pale, or black, or otherwise different from the natural colour; and there is a humour contained in them. When they are broke, the flesh below appears as it were ulcerated. By the Greeks they are called phlyctænæ helcodes[FJ]. They arise either from cold, or from fire, or from medicines.

[FI] ἐξανθήματα.

[FJ] φλύκταιναι ἑλκώδεις.

The phlyzacium[FK] is a pustule somewhat harder, of a whitish colour, and sharp pointed. What is squeezed from it is moist. The pustules sometimes turn to small ulcers, either dry or moist; and sometimes attended only with an itching, at other times with an inflammation and pain: pus or sanies issues from them, or both. And this occurs in children chiefly; seldom in the trunk of the body; often in the extremities.

[FK] φλυζάκιον.

The worst kind of pustule is that, which is called epinyctis[FL]. Its colour either inclines to livid, or is a dark brown, or white. There is a violent inflammation round it; and when it is opened, a mucous ulceration is found within, in colour resembling its humour. The pain of this is greater than in proportion to its bulk; for it is not larger than a bean. And this likewise grows in the extremities, and generally in the night-time: whence the Greeks have given it the name of epinyctis.

[FL] ἐπινυκτὶς.

Now in the cure of all pustules, the first thing is to walk much, and to take exercise: if that cannot be complied with, to use gestation. The second rule is, to lessen the quantity of food; to abstain from every thing acrid and extenuating. And nurses ought to observe the same rules, if their sucking child is thus affected. Besides these, one, that can bear it, if the pustules be small, ought to sweat in the bagnio; and at the same time to sprinkle nitre over them; and to anoint the part with a mixture of wine and oil; then to go into the bath. If no benefit accrues from these, or if the pustules be of a larger kind, a lentil must be applied, and when the surface of the skin is taken off, we must have recourse to lenient medicines. After the lentil, the epinyctis is to be treated with blood-herb, or green coriander.

The ulcers formed from pustules are cured by litharge mixed with fenugreek seed; and in compounding them, rose oil, or juice of endive, are used alternately, till the mixture have the consistence of honey. The proper composition for those pustules, which attack, infants, is of that stone, which the Greeks call pyrites p. viii. *. with fifty bitter almonds, and an addition of three cyathi of oil. But the pustules ought to be first rubbed with ceruss, and then anointed with this.

[Sidenote: _Of the scabies._]

The scabies is a hardness of the skin, of a muddy colour, from whence pustules arise, some of them moist, others dry; from some of them issues a sanies; and in these there follows a continued itching ulceration, which in certain cases spreads very fast. In some people it goes entirely off, in others it returns at a certain season of the year; the greater its asperity, and the more it itches, the more difficult it is to cure. And therefore this species of it the Greeks call agria[FM], that is, cruel.

[FM] ἀγρία.

In this also the same diet is necessary, as above prescribed. The medicine proper for this in its beginning, consists of spodium, saffron, verdigrease, each p. i. *. white pepper, verjuice, each p. i. *. cadmia p. viii. *. But where there is already an ulceration, that, which is composed of sulphur p. i. *. wax p. iv. *. liquid pitch a hemina, two sextarii of oil. These must be boiled together to the consistence of honey. There is also another, which is said to have been invented by Protarchus. It contains a sextarius of lupine meal, four cyathi of nitre, a hemina of liquid pitch, half a pound of liquid resin, and three cyathi of vinegar. It is also proper to mix saffron, lycium, verdigrease, myrrh, ashes, in equal quantities, and boil them in passum. This heals every kind of scabies. And if there be nothing else at hand, lees of oil boiled to a third part, or sulphur mixed with liquid pitch, as I prescribed for cattle, relieve men also labouring under the scabies.

[Sidenote: _Of the impetigo._]

Of the impetigo there are four species. The least malignant is that, which resembles the scabies. For it is red, hardish, ulcerated, and corrosive. But it differs widely from that, which is more ulcerated(90), and has pustules like to vari; and there appear to be in it somewhat like air bubbles, from which, after a time, something like scales come off; and this is more certain in its returns.

The second kind is worse, and is not unlike the papula, but of greater asperity and a more ruddy colour, having various figures; scales fall off from the surface of the skin, there is a greater erosion, it spreads more quickly, and broader, and both comes and goes at more certain intervals than the former. It is called the red.

The third kind is still worse. For it is both thicker and harder, and more swelled; it causes fissures in the surface of the skin, and corrodes more vehemently. This also is scaly, but black; it spreads wide(91), and does not stay long at a time; but is less uncertain as to its periods of coming and going; and is not to be entirely removed. This has the epithet of the black.

There is a fourth kind absolutely incurable, very different from the rest in colour. For it is whitish, and resembling a recent cicatrix; it has scales of a pale colour, some whitish, others resembling a lentil; which being taken off, blood sometimes follows. Otherwise the humour of it is white, the skin is hard and chopped, and it spreads wider.

All these kinds happen chiefly in the feet and hands; and they also infest the nails. There is no medicine more efficacious than that I mentioned for the scabies, which bears the name of Protarchus. Serapion made use of the following composition, nitre p. ii. *. sulphur p. iv. *. incorporated with plenty of resin.

[Sidenote: _Of the papula._]

There are two species of the papula. One is, where the skin is made rough by very small pustules, and is both red, and gently corroded; in the midst of them is a space somewhat smoother; it spreads slowly. And this disorder is of a round form in its beginning, and proceeds in the same manner circularly.

The second, the Greeks call agria: which has a similar appearance, but the skin is more unequal and ulcerated, and it corrodes more vehemently, is redder, and sometimes also loosens the hairs.

That which is less round, heals with greater difficulty; and unless it be cured, it turns to an impetigo. But a slight papula, if it be rubbed every day with fasting spittle, will heal. The greater kind is very well cured by feverfew rubbed over it. But for the compound medicines, that same prescription abovementioned of Protarchus is so much the more powerful here, as the distemper is less. There is another of Mico’s for the same purpose; of red nitre, frankincense, each p. i. *. cantharides cleansed p. ii. *. crude sulphur a like quantity, liquid turpentine resin p. xx. *. meal of darnel three sextantes, three cyathi of git, and one sextans of crude pitch.

[Sidenote: _Of the vitiligo._]

The vitiligo also, though of itself not dangerous, yet is both nasty, and proceeds from a bad habit of body. There are three species of it. It is called alphos[FN], when it is white; it is commonly a little rough, and not continued, but appears like drops dispersed here and there. Sometimes it spreads wider, leaving some, places between free. The melas[FO] differs from that in colour, being black, and like a shadow. In other respects it is the same. The leuce[FP] has some resemblance to the alphos, but is whiter, and penetrates deeper; and has white downy hairs in it. All these spread; but in some more quickly, in others slower. The alphos and melas come and go in some people without any regularity. The leuce does not easily quit a person it has once seized.

[FN] ἄλφος.

[FO] μέλας.

[FP] λεύκη.

The two first are not very difficult to cure; the last scarce ever heals; and though the disorder be in some degree mitigated, yet the natural colour is never fully restored. Whether any of these be curable or not, is easily known from an experiment. For the skin should be cut, or pricked with a needle. If blood issues, which generally happens in the two former, there is room for a remedy; if a white humour starts, it will not admit of a cure. And therefore it should not he meddled with.

To the curable kinds must be applied lentils mixed with sulphur and frankincense, the lentils being bruised and dipped in vinegar. Another composition for the same purpose is that, which goes under the name of Irenæus. Bastard spunge, nitre, cummin, dry fig-leaves, of each equal parts, are bruised with the addition of vinegar. With this the part affected is anointed in the sun; and in a little time, it is washed off, lest it corrode too much. Some following the practice of Mico, anoint the alphi with the following medicine; they mix of sulphur p. ii. *. nitre p. iv. *. dry myrrh powdered an acetabulum; then in the bath sprinkle upon the vitiligo bean flour, and afterwards put the other over it. Those which I called melanes, are cured by the following things beat up together; bastard spunge, frankincense, barley, and beans; these are sprinkled upon them without oil in the bagnio, before a sweat comes on, and then that species of vitiligo comes off by rubbing.

A. CORNELIUS CELSUS

OF

MEDICINE.

_BOOK VI._

CHAP. I.

Having done with the disorders, which break out in any part of the body indifferently, and require the assistance of medicines; I shall now proceed to those, that are confined to particular parts, beginning with the head.

[Sidenote: _Of hairs falling off the head._]

When the hairs of the head fall off, the principal remedy is frequent shaving: though labdanum mixed with oil, conduces also towards keeping them on. I here speak of the hair, which falls off after an illness. For no remedy whatever can prevent the heads of some people from becoming bald by age.

CHAP. II.

OF A PORRIGO.

We call that disorder a porrigo, _scurf_, when certain small scales arise amongst the hair, and are loosened from the skin; they are sometimes moist, much more frequently dry. It happens sometimes without any ulcer, sometimes in a part that is ulcerated, and is sometimes attended with a bad smell, sometimes with none. It usually occurs in the hair of the head, more rarely in the beard, sometimes also in the eye-brows. And as it never comes without some antecedent disorder in the body, so it is not altogether useless. For when the head is free from disorders, then it does not appear: when there is any disorder there, it is more expedient, _in such a case_, that the surface of the skin should be here and there corrupted, than that the noxious matter should be turned in upon a more noble part.

It is more proper then to cleanse it by frequent combing, than to repel it entirely. But if that method makes it more offensive (which may happen by the excessive discharge of humour, and more so, if the humour be fetid) the head is to be shaved often; and treated with some gentle repellents, such as nitre with vinegar, or labdanum with myrtle oil, and wine, or myrobalans with wine. If these have little effect, we may use some of the more powerful ones; but, at the same time, we should be aware, that this practice is hurtful, when the disorder is recent.

CHAP. III.

OF THE SYCOSIS.

There is an ulcer, which from its resemblance to a fig, by the Greeks, is called sycosis[FQ], because flesh sprouts up from it. And this is the general name. Under it are included two species. The one is a hard and round ulcer; the other is moist and unequal in its surface. From the hard one the discharge is very small and glutinous; from the moist, it is in greater quantity and fetid. Both kinds occur in the parts covered with hair: but that which is callous and round, most frequently in the beard; the other, which is moist, chiefly in the hair of the head.

[FQ] σύκωσις.

To both of them it is proper to apply elaterium, or lintseed powdered, and made into a paste with water, or a fig boiled in water, or the tetrapharmacum plaister softened with vinegar. Eretrian earth also liquified with vinegar is proper to lay upon them.

CHAP. IV.

OF AREAE.

There are two kinds of areae. Both of them agree in this, that the surface of the skin mortifying, the hairs first decay, and then fall off; and if the part is wounded, thin and fetid blood is discharged; and both kinds increase in some people quickly, in others slowly. It is then worst, when it has rendered the skin thick and fat, and entirely smooth. That, which is called alopecia[FR], spreads in no certain form. It is found both in the hair of the head, and in the beard. But that, which from its likeness to a serpent is called ophiasis[FS], begins at the hinder part of the head; its breadth not exceeding two fingers; it creeps with two heads to the ears; in some, even to the forehead, till the two heads are joined in the fore part. The former species happens at any age; the latter commonly to infants. The first hardly ever terminates without medicine; the other often goes away of itself.

[FR] ἀλωπεκία.

[FS] ὀφίασις.

Some scarify these kinds of areae gently with a knife. Others anoint them with escharotic medicines mixed with oil; and especially burnt paper. Others apply turpentine resin with thapsia. But nothing is better than daily shaving with a razor; because, when the cuticula is gradually cut off, the small roots of the hairs are laid bare. Nor should this be given over, till it appears, that the hair grows thick. It is sufficient to rub the part, that is frequently shaved, with copperas.

CHAP. V.

OF VARI, LENTICULAE, AND EPHELIDES.

It is almost a folly to cure vari, lenticulae, and ephelides: but it is impossible to prevent women from being nice in what regards their beauty. Of these disorders, which I have just mentioned, vari and lenticulae are universally known; however, that species is more rare, which the Greeks call phacia[FT], though that is only of a more ruddy colour, and more unequal surface than the common lenticula. The ephelis[FU] is unknown to most people; and is nothing else than a certain ill coloured asperity and hardness. The others are peculiar to the face; the lenticulae sometimes appear in other parts, of which I did not think it worth while to treat separately elsewhere.

[FT] φακία.

[FU] ἐφηλὶς.

But vari are well cured by the application of resin mixed with an equal quantity of scissile alum, and a little honey. Equal quantities of galbanum and nitre, beat up with vinegar to the consistence of honey, remove a lenticula. The part is to be rubbed with these, and after an interval of several hours, washed clean in the morning, and gently anointed with oil.

An ephelis is cured by resin, with the addition of a third part of fossile salt and a little honey. And for all these disorders, and likewise for giving a proper colour to cicatrices, that composition is good, which is said to be invented by Tryphon the father. In it there are equal parts of myrobalans crocomagma, the bluish Cimolian chalk(92), bitter almonds, flour of barley, and vetches, white struthium, seed of mellilot: all these are powdered and brought to a consistence with the bitterest honey, and being rubbed on in the evening, are always washed off in the morning.

CHAP. VI.

OF THE DISORDERS OF THE EYES.

The foregoing are indispositions of small account. But our eyes are exposed to grievous and various maladies. And because they contribute so large a share both to the conveniency and pleasure of life, they deserve our utmost care to preserve them.

Presently after the appearance of a lippitude, there are certain indications, from which we may form a presage of the event. For, if a discharge of tears, and a tumour, and a thick gum too(2) have commenced at once; if that gum is mixed with tears, and the tears are not hot, also if the gum is white and soft, and the tumour not hard, there is no danger of the disorder continuing long. But if the tears are copious, and hot, the gum little in quantity, the tumour small, and these are confined to one eye; the case will prove tedious, but without danger. And this species of lippitude is not at all painful; but is hardly ever removed before the twentieth day; sometimes it continues for two months, and sometimes not so long.

If the gum begins to be white and soft, and is mixed with tears, or both these have attacked the two eyes at once; the lippitude may be of shorter continuance, but there is a danger of ulcers. Now a dry and parched gum occasions pain, but terminates sooner; unless it have produced some ulcer.

A large tumour, if it be without pain, and dry, is void of all danger; if it be dry, but attended with pain, it commonly ulcerates; and sometimes, from this case it happens, that the eye-lid is agglutinated to the eye. There is room also to fear an ulceration in the eye-lids or the pupil, when besides great pain, there is a discharge of salt and hot tears; or even when after the tumour is removed, the tears flow for a long time mixed with the gum.

It is worse still, where the gum is pale or livid, the tears are scalding, or in great quantity, the head hot, and the pain reaches from the temples to the eyes, also if the person is distressed with wakefulness in the night; for in such circumstances, generally the eye bursts, when it were to be wished, it would only ulcerate. A slight fever is of service to an eye that bursts inwardly. If it breaks and is protruded externally, the case admits of no remedy. If from a black colour, some part of it has become whitish, it continues long. But if it be rough and thick, even after the cure, it leaves some mark.

Hippocrates, the most ancient author we have, has observed in his writings, that the eyes are cured by bleeding, by medicines, the bath, fomentations, and drinking of wine. But he has not explained the proper time for these, and the reasons for their use; in which the principal part of medicine consists. There is also much benefit received from abstinence and clysters.

They are sometimes seized with an inflammation; in which they are at once pained and swelled; and there follows a discharge of gum; sometimes more, sometimes less plentiful, or acrid. In such a case, the principal remedies are rest and abstinence. Wherefore, for the first day, the patient ought to lie in a dark place, and even refrain from speaking; to take no food at all; if he can command himself, not so much as water; if he cannot do that, at least as little of it as possible.

But if the pains are severe, blood must be taken away, and preferably on the second day; but if the case be urgent, on the first; especially if the veins in the forehead swell, the patient be strong, and there is a redundancy of matter: but if the illness be less severe, it calls for a milder cure. It is not necessary to give a clyster, till the second or third day. But a small inflammation requires neither of these remedies; and it is sufficient to rest and fast.

Nevertheless, long fasting is not proper in lippitudes, lest it render the gum more fetid and acrid; but on the second day, some of the gentlest of those things, that generate a thicker phlegm(3), ought to be given, such as sorbile eggs; if the disorder be but slight, pulticula, or bread sopped in milk. On the following days, as much as the inflammation decreases, so much may the quantity of food be increased; but of the same kind; so that above all, nothing salt, or acrid, or extenuating be taken; and nothing be used for drink but water. And with respect to diet, such a regimen is highly necessary.

Now on the first day of the distemper, it is proper to mix p. i. *. of saffron, and p. ii. *. of the finest, whitest flour, with the white of an egg to the consistence of honey; and to spread this upon a piece of linen, and apply it to the forehead, that by compressing the veins, it may restrain the violent flux of gum. If saffron cannot be had, frankincense has the same effect. It makes no difference whether it be spread upon a bit of linen, or wool. The eyes ought to be anointed with the following composition: as much saffron as can be held with three fingers, myrrh, the bigness of a bean, of poppy tears, the bigness of a lentil, are rubbed down together with passum, and daubed over the eyes with a probe. Another for the same purpose consists of myrrh, p. i. *. mandrake juice p. ii. *. poppy tears p. ii. *. rose leaves, hemlock seed, each p. iii. *. acacia p. iv. *. gum p. viii. *. And these are applied in the day time; but in the night, for promoting rest, it is not improper to lay on the crumb of white bread mixed up with wine. For that both restrains the flux of gum, and if any tears are discharged, it absorbs them, and does not suffer the eyes to be glued up.

If the pain of the eyes be so great as to make this application uneasy and too hard, both the white and yolk of an egg must be dropped into a cup, and a little mulse added to them, and these mixed with the finger; when they are incorporated, soft wool combed, ought to be dipped in it, and saturated with it, and applied over the eyes. This is light, and by cooling restrains the gum; besides, it does not grow dry, nor suffer the eye to be glued. Barley-meal also boiled and mixed with a boiled quince is a proper application. And it is no absurd practice to use rather a pencillum squeezed out of water, if the disorder be less severe, if more so, out of vinegar and water. The former applications are to be bound on with a roller, lest they fall off in the time of sleep: but it is sufficient to lay the pencillum on the eyes; both because it can be conveniently replaced by the patient himself, and because, when it has grown dry, it must be moistened again. If the disorder is so great as to prevent sleep for a long time, some of the medicines are to be given, which the Greeks call anodyne: and for a boy, the bigness of a vetch is a sufficient dose; for a man, the bigness of a bean. On the first day, it is not fit to inject any thing into the eye, unless the inflammation be very great: for the gum is often rather invited than diminished by that means. But on the second day, even in a severe lippitude, it is proper to relieve by the injection of medicines, when either the patient has been bled, or a clyster has been given; or it appears, that neither of these was necessary.

There are many collyriums proper for this purpose, invented by different authors; and new ones may still be made; since lenient and gently repelling medicines may be easily mixed in various proportions. I shall mention the most celebrated of them.

[Sidenote: _Philon’s collyrium._]

The collyrium of Philon contains of washed ceruss, spodium, gum, each p. i. *. poppy tears toasted p. i. *. It is fit to know, that all the ingredients must first be powdered separately, after that mixed and beat up again, dropping in from time to time, either water or some other liquid. Gum, as it possesses some other qualities, so has this peculiar effect upon collyriums, that when they have been long made, and are grown dry, they continue firmly united, and are not friable.

[Sidenote: _Dionysius’s._]

Dionysius’s collyrium: of poppy tears toasted till tender p. i. *. toasted frankincense, gum, each p. ii. *. spodium p. iv. *.

[Sidenote: _Cleon’s._]

Cleon’s is a very famous one: of poppy tears toasted p. i. *. saffron p. i. *. gum p. *. v. to these, while they are powdered, is added juice of roses. Another, by the same, stronger; of iron scales, which is called stomoma[FV] p. i. *. saffron p. ii. *. spodium p. iv. *. lead, both washed and calcined p. i. *. and the same quantity of gum. There is still another of the same author’s, chiefly useful where there is a great flux of gum: of castor p. *. i. aloes p. *. i. myrrh p. *. ii. prepared cadmia p. viii. *. a like quantity of antimony, juice of acacia p. xii. *. the mixture may be kept in a small box. But Theodotus added to this composition toasted poppy tears p. *. i. copper calcined and washed p. ii. *. date kernels toasted p. x. *. gum p. xii. *.

[FV] στόμωμα.

[Sidenote: _The acharistum of Theodotus._]

But Theodotus’s own, which by some is called acharistum[FW], is thus made: of castor, Indian nard, each p. i. *. lycium p. *. poppy tears the same quantity; myrrh p. ii. *. saffron, washed ceruss, aloes, each p. iii. *. cadmia botryitis washed, calcined copper, each p. viii. *. gum p. xviii. *. juice of acacia, p. xx. *. antimony the same quantity; to these is added rain water.

[FW] ἀχάριστον.

[Sidenote: _The cythion, or tephrion._]

Besides these, amongst the most common collyriums is that, which some call cythion, others from its ash colour, teprion. It contains of starch, tragacanth, acacia juice, gum, each p. i. *. poppy tears p. ii. *. washed ceruss p. iv. *. washed litharge p. viii. *. these in the same manner are beat up with rain water.

[Sidenote: _The trygodes of Euelpides._]

Euelpides, who was the greatest oculist in our age, made use of one, which he had composed himself, and called it trygodes. It contains of castor p. ii. *. lycium, nard, poppy tears, each p. i. *. saffron, myrrh, aloes, each p. iv. *. calcined copper p. viii. *. cadmia and antimony, each p. xii. *. acacia juice p. xxvi. *. gum the same quantity.

The more violent any inflammation is, so much the more it requires to be alleviated by medicines, with the addition either of the white of an egg, or breast milk. But if neither a physician nor a medicine can be got, it mitigates the disorder to infuse either of these into the eyes by a penecillum made for the purpose. But when relief is obtained, and the flux of gum stops, the slight relics of the disorder, that might perhaps otherwise continue, are discussed by bathing and drinking wine. Therefore the patient ought to bathe moderately, being first rubbed over with old oil, and longer in his legs and thighs than the rest of his body; and to foment his eyes with plenty of warm water; next to have warm water first, and afterwards water with the cold just taken off, poured over his head; after bathing, he must guard against being exposed to cold, or wind. After this, his diet ought to be somewhat fuller than formerly(4); but he should abstain from all extenuants of phlegm: the wine he drinks should be mild, inclining to rough, of a moderate age; and in this he ought neither to indulge to excess, nor be too sparing, that the former extreme may not occasion crudity, but that by a just quantity sleep may be procured, and the acrimony lurking within may be sheathed. But if a person in the bath has felt more uneasiness in his eyes than he did before (which usually happens to those, who have made too much haste to get into it, while the flux of gum still continued) he ought to come out immediately; to drink no wine that day; and eat even less than he did the day before. Afterwards, as soon as the discharge of gum is sufficiently stopt, he must return again to the use of the bath.

Nevertheless, it sometimes happens, from some unfavourable circumstance either in the weather, or habit of the patient, that for several days neither the pain, nor the inflammation, and least of all, the discharge of gum ceases. When this is the case, and time itself has brought the disorder to a full maturity for it, relief is to be sought from the same remedies, that is, the bath and wine. For though they are hurtful, while these complaints are recent, because they may irritate and inflame them; yet in the inveterate, which have not yielded to any other remedies, they are commonly very efficacious. For in this, as well as in other cases, when seemingly proper medicines have been tried in vain, those of a contrary nature give relief. But it is expedient for the patient, in the first place, to have his hair clipped close to the skin; next, to foment his head and eyes in the bath, very plentifully, with warm water; then to wipe both with a penecillum, and anoint his head with ointment of iris; to lie in bed, till all the heat acquired in the bath is gone off, and the sweat cease, which was necessarily collected in his head. Then he should make use of the same kind of food and wine above recommended, the latter undiluted; and cover his head, and continue at rest. For after these, either a sound sleep, or a sweat, or a purging, often puts an end to the discharge of gum. If the disorder abates (which sometimes does not happen soon) the same course ought to be pursued for several days, till the cure be completed. If, on these days, he has no stool, a clyster must be injected for relieving the superior parts.

But sometimes a great inflammation arises, and of so violent a nature, that it propels the eyes from their cavity. The Greeks call this proptosis[FX], because the eyes fall forward. It is plain such patients require bleeding, if their strength will admit of it: if that cannot be done, a clyster is necessary, and long fasting. The mildest medicines are required _in this case_. Therefore, some use the first of Cleon’s two collyriums mentioned above. But that of Nileus is the best, and all authors agree to give it the preference to any other.

[FX] πρόπτωσις.

[Sidenote: _Nileus’s collyrium._]

It is this: Indian nard, poppy tears, of each p. *. gum p. i. *. saffron p. ii. *. fresh rose leaves, p. iv. *. which are brought to a consistence, either by rain water, or light wine, inclining to rough. And it is not improper to boil pomegranate bark, or melilot, in wines, then to bruise it; or to mix black myrrh with rose leaves; or henbane leaves boiled with the white of an egg; or meal, with acacia juice, or passum, or mulse. And if poppy leaves too be added, they will be somewhat more efficacious. When some one of these is prepared, the eyes ought to be fomented with a penecillum squeezed out of a warm decoction of myrtle or rose leaves in water; after that, the medicine is to be applied. Besides, the skin in the back of the head is to be cut, and a cupping vessel applied to it.

If, by these means, the eye is not restored to its place, but continues prominent as before, we may conclude the eye-sight is gone; and that the eye will next grow hard, or be converted into pus. If the suppuration appears in that angle, which is next the temple, an incision must be made in the eye, that vent being given to the matter, the inflammation and pain may cease, and the coats _of the eye_ fall inward, so that the face may be less disfigured afterwards. And then must be used, either the same collyriums with milk, or an egg; or else saffron mixed with the white of an egg. But if it has grown hard, and is mortified, without turning to pus, so much of it must be scooped out, as to prevent a shocking projection; which must be done thus. The external coat must be laid hold of with a hook, and below that the incision made with a knife; then these medicines are to be injected, till the pain be entirely gone. The same medicines are also necessary for an eye, that is first protruded, and afterwards bursts in several places.

[Sidenote: _Of carbuncles of the eyes._]

It is not uncommon for carbuncles to proceed from an inflammation, sometimes in the eyes themselves, sometimes in their lids; and in the last, they are sometimes in the inside, at other times on the outside. In this case, a clyster must be given; the quantity of food lessened; milk allowed for drink; that the offending acrimony may be sheathed. As to cataplasms and medicines, we must use such as have been proposed against inflammations. And here also the collyrium of Nileus is the best. But if the carbuncle be on the external part of the eye-lid, lintseed boiled in mulse is the most proper for a cataplasm; or if that is not to be had, wheat meal boiled in the same manner.

[Sidenote: _Of pustules of the eyes._]

Sometimes pustules also proceed from inflammations. If this happens in the beginning of the inflammation, the former directions about bleeding and rest are even to be more punctually observed; if later than to admit of bleeding, yet a clyster must be given. If for any reasons that likewise is impracticable, at least the proper diet must be used. In this case too, the mild medicines are necessary; such as that of Nileus or Cleon.

[Sidenote: _Collyrium of Philes._]

The collyrium which takes its name from Philes, is also suited to this disorder. For it contains of myrrh, poppy tears, each p. i. *. washed lead, Samian earth, which is called after, tragacanth, each p. iv. *. burnt antimony(5), starch, each p. vi. *. washed spodium, washed ceruss, each p. viii. *, which are incorporated with rain water. This collyrium is used mixed either with an egg, or milk.

From pustules sometimes are generated ulcers; and these, when recent, are to be dressed with the like lenient medicines, and mostly the same as I have prescribed above for pustules. There is also a particular application for them, which is called dialibanou[FY]. It contains of copper calcined and washed, poppy tears toasted, each p. i. *. spodium washed, frankincense, antimony calcined and washed, myrrh and gum, each p. ii. *.

[FY] διὰ λιβάνου.

[Sidenote: _Wasting of the eyes._]

It happens likewise, that the eyes, either one or both, become less than they ought to be naturally. And this is caused by an acrid flux of gum in a lippitude, also by continual weeping, and wounds badly cured. In such cases, the same mild medicines with breast milk are to be used; and such food as most nourishes and fills the body; and the patient must carefully avoid whatever occasions weeping, and all the anxiety of domestic affairs: and if any misfortune happens likely to disturb him, it must be concealed from his knowledge: acrid medicines and acrid food hurt by occasioning tears, as much as any other way.

[Sidenote: _Lice in the eye-lids._]

There is a peculiar kind of disorder, in which lice are generated amongst the hair of the eye lids. This the Greeks call phthiriasis[FZ]. Which arising from a bad habit of body, seldom stops there; but generally after some time there follows a smart flux of gum; and the eyes themselves being greatly ulcerated, it even destroys the sight.

[FZ] φθειρίασις.

Such patients must be purged by clysters; the hair of their head clipped close to the skin, and the head rubbed for a long time every day fasting. They must diligently practise walking, and other exercises; gargle with a decoction of catmint and a mellow fig in mulse; foment the head often in the bath with plenty of warm water; avoid acrid food; use good milk and wine, and also drink more freely than they eat. Medicines too are to be given internally, of a mild nature, that they may not generate any acrid gum; and others externally applied to kill the lice, and prevent the production of more. For this purpose, of aphronitre p. i. *. sandarach p. i. *. stavesacre p. i. *. are powdered together, and then equal quantities of old oil and vinegar are added, till the whole come to the consistence of honey.

Thus much of those distempers of the eyes, which are cured by mild medicines. There are besides these, other kinds, which require a different treatment, commonly proceeding from inflammations, but continuing even after they

[Sidenote: _Collyrium of Andreas._]

are gone. And in the first place, a flux of thin gum continues in some. To such patients clysters should be given, and their quantity of food diminished. Neither is it improper to anoint the forehead with the composition of Andreas: which consists of gum p. i. *. ceruss, antimony, each p. ii. *. litharge boiled and washed p. iv. *. the litharge is boiled in rain water; and the dry medicines are rubbed with the juice of myrtle. These being spread upon the forehead, a cataplasm of meal is also to be applied over it, made into a paste with cold water, and with the addition either of acacia juice or cypress. It is proper also to make an incision on the top of the head, and apply a cupping vessel there; or to bleed at the temples. The eye ought to be anointed with that composition, which contains of copper scales, poppy tears, each p. *. hartshorn calcined and washed, washed lead, gum, each p. iv. *. frankincense p. xii. *. Now this collyrium, because horn is one of the ingredients, is called diaceratos[GA]. As often as I do not subjoin what kind of moisture is to be added, I would be understood to intend water.

[GA] διὰ κέρατος.

[Sidenote: _The memigmenon of Euelpides._]

For the same purpose is that of Euelpides, which he called memigmenon[GB]. In it there are poppy tears and white pepper, of each an ounce, gum a pound, calcined copper p. i. *. During this course, with some intervals, the bath and wine are serviceable. And as extenuating food must be avoided by all that labour under a lippitude; so particularly by those that have for a long time a flux of thin humour. But if they be surfeited with such food as generates a thicker phlegm, as is most common in this kind of diet, they must have recourse to that, which because it binds the belly, constringes the body too.

[GB] μεμιγμένον.

But ulcers, that do not go off with the inflammation, generally either grow fungous, or foul, or at least inveterate. Their excrescences are best suppressed by the collyrium called memigmenon. The foul ones are deterged both by the same, and by that, which is called smilion.

[Sidenote: _Smilion._]

This contains of verdigrease p. vi. *. gum the same quantity, ammoniacum, minium from Sinope, each p. xvi. *. these are rubbed down by some with water, by others, to make them stronger, with vinegar.

[Sidenote: _Phynon of Euelpides._]

That of Euelpides, which he called phynon, is also suitable to this case; of saffron p. i. *. poppy tears, gum, each p. ii. *. copper calcined and washed, myrrh, each p. iv. *. white pepper p. vi. *. But the application of this must be preceded by an ointment.

[Sidenote: _Sphærion of the same author._]

The collyrium of the same author, to which he gave the name of sphærion, is of like virtue; of bloodstone washed p. ii. *. pepper six grains, cadmia washed, myrrh, poppy tears, each p. iii. *. saffron p. iv. *. gum p. viii. *. which are rubbed down with Aminæan wine.

[Sidenote: _A liquid medicine by the same._]

He likewise compounded a liquid medicine for the same purpose, in which were the following things; of verdigrease p. *. minium calcined, copperas, cinnamon, each p. iii. *. saffron, nard, poppy tears, each p. i. *. myrrh p. ii. *. calcined copper p. iii. *. aromatick ashes p. iv. *. pepper fifteen grains. These are rubbed with a rough wine, and then boiled with three heminæ of passum, till the whole unites. And this medicine becomes more efficacious by keeping.

For filling the cavities of ulcers _of the eyes_, the best of all those we have mentioned are the sphærion and the collyrium of Philes. The same sphærion is an excellent medicine for inveterate ulcers, and such as can scarcely be brought to cicatrize.

[Sidenote: _Hermon’s._]

There is also a collyrium, which though it be serviceable in many cases, yet seems to be most efficacious in these ulcers. It is said to be invented by Hermon. It contains of long pepper p. i. *. z. *. white pepper p. *. cinnamon, costus, each p. i. *. copperas, nard, cassia, castor, each p. ii. *. galls p. v. *. myrrh, saffron, frankincense, lycium, ceruss, each p. viii. *. poppy tears p. xii. *. aloes, calcined copper, cadmia, each p. xvi. *. acacia, antimony, gum, each p. xxv. *.

[Sidenote: _Asclepias._]

[Sidenote: _Canopite._]

[Sidenote: _Pyxinum of Euelpides._]

Cicatrices formed from ulcers are liable to two defects; of being either concave, or protuberant. If they be concave, they may be filled by the sphærion collyrium; or that called asclepias. This consists of poppy tears p. ii. *. sagapenum, opopanax, each p. iii. *. verdigrease p. iv. *. gum p. viii. *. pepper p. xii. *. cadmia washed, ceruss, each p. xvi. *. But if the cicatrices are thick, they are rendered thin by the smilion, or canopite collyrium, which last contains cinnamon, acacia, of each p. i. *. cadmia washed, saffron, myrrh, poppy tears, gum, each p. ii. *. white pepper, frankincense, each p. iii. *. calcined copper p. ix. *. with rain water. Or the pyxinum of Euelpides, which consists of the following ingredients; of fossile salt p. iv. *. ammoniacum thymiama p. viii. *. poppy tears p. xiii. *. ceruss p. xv. *. white pepper, Cilician saffron, each p. lii. gum p. xiii. *. cadmia washed p. ix. *. Yet the composition, which contains gum p. iii. *. verdigrease p. i. *. crocomagma p. iv. *. seems to be the best for removing a cicatrix.

There is also another kind of inflammation, in which if the patient’s eyes swell, and are distended with pain, it is necessary to bleed in the forehead; and to foment the head and eyes plentifully with hot water; to gargle with lentils, or cream of figs; to anoint with the acrid medicines mentioned above; particularly that, which is called sphærion, and which has blood-stone in it. And others are useful too, which are calculated to lessen the roughness; of which I am going to speak.

This commonly follows an inflammation of the eyes; sometimes it is more violent, at other times more slight. Sometimes too a roughness occasions a lippitude, and that again increases the roughness, and in some is short, in others it continues long, and so as to be hardly ever cured.

In this kind of disorder some scrape the thick and hard eye-lids both with a fig-leaf and a specillum asperatum(6), and sometimes with a knife; and turning them up, they rub them every day with medicines. Which ought not to be practised, unless in a considerable and inveterate roughness, nor that often. For the same end is better obtained by a suitable regimen and proper medicines. Therefore we shall use exercises and the bath more frequently: and foment the eye-lids with plenty of warm water. The food must be acrid and extenuating.

[Sidenote: _Cæsarian._]

The medicine, which is called Cæsarian, contains of copperas p. i. *. misy p. *. white pepper p. v. *. poppy tears, gum, each p. ii. *. cadmia washed p. iii. *. antimony p. vi. *. And this collyrium is allowed to be a good remedy against every kind of disorder in the eyes, except those, that are treated by mild medicines.

[Sidenote: _Hierax’s._]

That also, which is called Hierax’s, is powerful against a roughness. It consists of myrrh p. *. ammoniacum thymiama p. ii. *. rasile verdigrease p. iv. *. with rain water. For the same purpose that also is proper, which is called canopite, and the smilion, and the pyxinum, and the sphærion. But if compound medicines are not at hand, a roughness may be easily enough cured by goat’s gall or the best honey.

[Sidenote: _Dry lippitude._]

There is likewise a kind of dry lippitude, which the Greeks call xerophthalmia[GC]. In this the eyes neither swell, nor run, but are only red, and heavy with some pain, which is commonly slight, also an itching, and the eye-lids without any hardness stick together in the night-time by means of a very troublesome gum: and the less violent in its degree this species is, so much the longer does it continue.

[GC] ξηροφθαλμία.

In this disorder it is necessary to walk much, to take much exercise, to bathe often, and sweat in the bagnio, to use much friction. The proper diet is neither such as is filling, nor over acrid, but the middle kind betwixt these. In the morning, when it is evident that the concoction is completed, it is not improper to gargle with mustard, and alter that to rub the head and face a considerable time.

[Sidenote: _Rhinion._]

The collyrium best adapted to this case is that called rhinion. Which contains of myrrh p. i. *. poppy tears, acacia juice, pepper, gum, each p. i. *. blood-stone, Phrygian stone, lycium, scissile stone, each p. i. *. calcined copper p. iv. *. The pyxinum also is suitable for the same purpose.

[Sidenote: _Basilicon of Euelpides._]

But if the eyes be scabrous, which mostly happens in the angles, the rhinion mentioned already may be serviceable. For the same purpose that may be useful, which contains, of rasile verdigrease, long pepper, poppy tears each p. ii. *. white pepper, gum, each p. iv. *. cadmia washed, ceruss, each p. vi. *. However, there is none better than that of Euelpides, which he called basilicon. It contains of poppy tears, ceruss, Asian stone, each p. ii. *. gum p. xiii. *. white pepper p. iv. *. saffron p. vi. *. psoricum(7) p. xiii. *. Now there is no simple, which by itself is called psoricum; but a certain quantity of chalcitis and a little more than half its quantity of cadmia are rubbed together with vinegar; and this being put into an earthen vessel, and covered over with fig leaves, is deposited under ground for twenty days, and being taken up again it is powdered, and thus is called psoricum. The basilicon collyrium too is generally allowed to be proper for all disorders of the eyes, that are not treated by mild medicines.

But when compound medicines are not to be had, both honey and wine mitigates an asperity in the angles. These and a dry lippitude too are relieved by an application of bread, softened with wine, over the eyes. For since there is generally a humour, which exasperates sometimes the eye itself, sometimes the angles, or eyelids; by this application, if any humour is discharged, it is drawn away, and if it happens to be lodged near, is repelled.

[Sidenote: _Of a dimness of the eyes._]

A dimness comes upon the eyes, sometimes from a lippitude, at other times even without that, from old age, or weakness. If the disorder proceeds from the relics of a lippitude, the collyrium called asclepias is serviceable. Likewise that, which is composed of crocomagma.

The collyrium which is called diacrocou[GD] is composed peculiarly for this. It contains of pepper p. i. *. Cilician saffron, poppy tears, ceruss, each p. ii. *. psoricum, gum, each p. iv. *.

[GD] διὰ κρόκου.

But if it arises from old age, or weakness, it may be proper to anoint with the best honey, and cyprine and old oil. But it is most expedient to mix together one part of balsam, and two of old, or cyprine oil, and three parts of the most pungent honey. The medicines prescribed above for a dimness _from a lippitude_, and those mentioned before for diminishing cicatrices, are useful in this case too.

Whoever is troubled with a dimness must walk much, use exercise, frequent bathing, at which time the whole body must be rubbed, but principally the head, with iris ointment till it sweat; after that it must be veiled, and not uncovered, till after he has got home, and the sweat and heat have ceased. Then he must keep to an acrid and extenuating diet; and after the interval of some days use a gargarism of mustard.

[Sidenote: _Of a cataract._]

A suffusion also, which the Greeks call hypochysis[GE], sometimes obstructs the pupil of the eye, where vision is performed. If this disorder be inveterate, it requires an operation to remove it. At the beginning sometimes it is discussed by certain methods adapted to the case. It is expedient to bleed in the forehead, or nose; to cauterize the veins in the temples; by the use of gargarisms to evacuate phlegm; to use fumigations; to anoint the eyes with acrid medicines. The best diet is such as extenuates phlegm.

[GE] ὑπόχυσις.

[Sidenote: _A palsy of the eyes._]

Nor is a palsy of the eyes (which the Greeks call paralysis) to be cured by any different diet, or different medicines, so that it is needless to do more than describe the distemper. It happens then sometimes in one eye, sometimes in both, either from a blow, or from an epilepsy, or spasms, where the eye itself is strongly convulsed, so that it can neither be directed to any particular object, nor be kept fixed; but moves to and fro involuntarily; and therefore cannot see any thing distinctly.

[Sidenote: _Of a mydriasis._]

What the Greeks call a mydriasis[GF] is not very different from this distemper. The pupil is dilated, the sight grows dull, and almost dim. This kind of weakness is extremely difficult to remove. Against both disorders, that is, the palsy and mydriasis, we must use the same remedies as have been prescribed in the dimness of the eyes, with a few alterations; thus for the head, to the iris oil must be added sometimes vinegar, sometimes nitre; it is sufficient to anoint the eyes with honey. In the latter disorder some have made use of hot waters(8), and been relieved; others without any apparent cause have suddenly lost their sight. Some of these, after continuing blind for some time, from a sudden purging have recovered their sight: whence it seems the less improper, both when the disorder is recent, and when it is of some standing, to procure stools by medicines, in order to force all the noxious matter into the lower parts.

[GF] μυδρίασις.

[Sidenote: _A weakness of the eyes._]

Besides these, there is a kind of weakness of the eyes, in which patients see well enough in the day-time, but not at all in the night: which never happens to a woman, when her menstrual discharge is regular. But persons labouring under this disorder ought to be anointed with the blood of a liver (particularly the liver of a he-goat; if that cannot be had, of a she-goat) that drops from it while roasting; and they ought to eat the liver itself. They may nevertheless not improperly make use of the same medicines, that extenuate either cicatrices, or an asperity. Some powder the seed of purslane, and add honey to it, till the mixture be of such a consistence, as not to drop off a probe, and anoint with that. They must also use exercises, bathing, frictions.

[Sidenote: _Of external hurts in the eyes._]

These disorders all arise from internal causes. But externally the eye may be hurt by a blow, so as to become bloodshot. There is nothing more proper for this case than anointing with the blood of a pigeon, or ringdove, or swallow. Nor is this practice without reason; since the sight of these birds being hurt by some accident, in a little time is restored, and that of the swallow soonest; which gave rise to the fable, that their parents perform by an herb the cure, which is really the work of nature. Their blood therefore is a very proper remedy for our eyes in external hurts, in these different degrees of efficacy; the blood of a swallow is best, next to that of a ringdove; that of a pigeon is least medicinal both to itself and us.

Over an eye that has received a blow, in order to assuage the inflammation, it is also proper to apply cataplasms. Now sal ammoniac, or any other, ought to be very finely powdered, oil being dropped in by degrees, till it acquire the consistence of strigment. Then this is to be mixed with barley-meal boiled in mulse. Upon a review of all the cures published, even by physicians, it is easy to see, that there is hardly one of the abovementioned disorders of the eyes, which may not be sometimes removed by very simple and obvious remedies.

CHAP. VII.

OF THE DISEASES OF THE EARS.

Thus far we have recited those disorders of the eyes, in which medicines are most efficacious; we must now proceed to the ears; the part, which nature has bestowed upon us next in usefulness to the eyes. But in these the danger is much greater. For the mischief arising from the distempers of the eyes is confined to themselves; whereas inflammations and pains of the ears sometimes occasion madness and death: which makes it the more necessary to administer speedy relief in their beginnings, to prevent any greater danger.

Wherefore, when a person first feels a pain, he ought to fast, and observe a strict regimen; the day following, if the disorder increases, to clip the hair of his head, and anoint it all over with ointment of iris warm, and to cover it. But a violent pain attended with a fever, and watching, requires also bleeding. If particular circumstances prevent that, the body must be kept open. Hot cataplasms too, frequently changed, are serviceable; either of the meal of fenugreek, or lint-seed, or any other, boiled in mulse. Spunges also squeezed out of hot water are proper to apply now and then. When the pain is eased, cerate made either of iris or cyprine oil ought to be put round it. In some, however, that which is made of oil of roses, succeeds better. If a violent inflammation prevents sleep entirely, to the cataplasm ought to be added half its quantity of poppy heads toasted and powdered; and then these may be boiled together in passum, or mulse. It is proper too to infuse some medicine into the ear: which ought always to be made tepid first, and is most conveniently dropped in by a strigil(9). When the ear is filled, soft wool is to be put into it to keep the liquor from returning. And these are general remedies.

Now the medicines _for injection_ are the juice of roses, and the roots of reeds, and oil, in which worms have been boiled, and the liquor of bitter almonds, or that, which is pressed from a peach kernel. The compositions for alleviating the inflammation and pain are generally these; of castor, poppy tears, equal quantities powdered, and afterwards mixed with passum. Or equal quantities of poppy tears, saffron, and myrrh are beat, rose oil and passum being added alternately. Or the bitter part of an Egyptian bean is powdered, and rose oil added to it: with which some also mix a little myrrh, or poppy tears, or frankincense with breast milk, or the juice of bitter almonds with rose oil. Or castor, myrrh, and poppy tears in equal quantities, with passum. Or of saffron p. i. *. myrrh, scissile allum, each p. iii. *. and in powdering these, three cyathi of passum are to be gradually mixed with them, and less than a cyathus of honey. This is one of the principal remedies. Or poppy tears with vinegar. We may also use Themison’s composition, which consists of castor, opopanax, poppy tears with vinegar, each p. ii. *. aphronitre p. iv. *. which being powdered are incorporated with passum, till they be of the consistence of cerate; and so laid by. When they are wanted for use, the medicine is again rubbed down by a pistil, with the addition of passum. This is a constant rule, whenever a medicine is too thick for dropping into the ear, that liquor must be added, with which it ought to be compounded, till it be sufficiently fluid.

[Sidenote: _Of pus in the ears._]

But if there is pus in the ears, it is proper to infuse lycium by itself; or ointment of iris; or juice of leek, with honey; or juice of centory with passum; or juice of a pomegranate warmed in its own shell, with the addition of a small proportion of myrrh. A proper mixture is also made of the myrrh called stacte p. i. *. the same quantity of saffron, twenty five bitter almonds, a cyathus and half of honey; which being rubbed together, are to be warmed in a pomegranate shell, when they are to be used. Those medicines, which are compounded for an ulcerated mouth, are equally sanative to ulcers of the ears. If these be of pretty long standing, and there is a great discharge of sanies, the proper composition is that generally ascribed to Erasistratus. It contains of pepper, saffron, each p. i. *. myrrh, misy calcined, each p. ii. *. calcined copper p. ii. *. These are rubbed down with wine; when they are grown dry, three heminae of passum are added, and they are boiled together. When they are to be used, honey and wine are added to them. There is also a medicine of Ptolemaeus the surgeon; which contains mastich, galls, of each p. i. *. omphacium p. i. *. juice of the pomegranate. That of Menophilus is very efficacious, which consists of the following things; of long pepper p. i. *. castor p. ii. *. myrrh, saffron, poppy tears, Syrian nard, frankincense, pomegranate bark, the inner part of an Egyptian bean, bitter almonds, the best honey, each p. iv. *. When they are powdered, the sharpest vinegar is added, till the whole be of the consistence of passum. There is also a composition of Crato’s; of cinnamon, cassia, each p. i. *. nard, lycium, myrrh, each p. i. *. aloes p. ii. *. honey, three cyathi, wine a sextarius. Of these the lycium is boiled with the wine; after that mixed with the other ingredients. But if the quantity of pus be great, and there is a bad smell; of rasile verdigrease, frankincense, each p. ii. *. honey, two cyathi, of vinegar four, are boiled all together. When the composition is to be used, it is mixed with sweet wine. Or scissile allum, poppy tears, juice of acacia are mixed in equal quantities, and to these is added juice of henbane less than half the quantity of any of the other ingredients; and these being powdered are diluted with wine. The juice of henbane too by itself is pretty good.

Asclepiades compounded a general remedy against all disorders of the ears, which is now approved by experience. In it there are of cinnamon, cassia, each p. i. *. flowers of round cyperus, castor, white pepper, and long, amomum, myrobalans, each two scruples, male frankincense, Syrian nard, fat myrrh, saffron, aphronitre, each p. ii. *. Which being powdered separately, and afterwards mixed, are rubbed down with vinegar; and being thus preserved are diluted with vinegar when used. In the same manner, the sphragis of Polybus liquified with sweet wine, is a general remedy for disorders in the ears; which composition is contained in the former book.

But if sanies is discharged, and there is a tumour, it is not improper to wash it with diluted wine by a syringe; and then to infuse rough wine mixed with oil of roses, and the addition of a little spodium, or lycium with milk, or the juice of the blood herb, with oil of roses, or juice of pomegranate with a very small proportion of myrrh.

If there are also foul ulcers, it is better to wash them with mulse; and after that, some one of the compositions mentioned above, that contains honey, is infused. If the pus flows more plentifully, in that case, the hair of the head is to be clipped close, and plenty of warm water poured over it; also gargarisms must be used, and walking to lassitude, with a sparing diet. If blood likewise appears from the ulcers, lycium with milk ought to be infused; or a decoction of roses in water; with the addition of the juice either of blood herb, or acacia.

But if a fungus has grown upon the ulcers, which is fetid, and discharges blood, it ought to be washed with tepid water; and after that, the composition infused, which is made of frankincense, verdigrease, vinegar, and honey; or honey boiled with verdigrease. Copper scales too with sandarach, powdered, is proper to be dropped in by a pipe.

[Sidenote: _Of worms in the ears._]

When worms are generated there, if they be within reach, they must be drawn out with a specillum oricularium(10), if farther in, they must be killed by medicines; and means used to prevent the breeding of more. White hellebore powdered with vinegar, answers both these intentions. The ear ought to be washed also with a decoction of horehound in wine. Thus, the worms being killed slide down into the entrance of the ear, from whence they may be taken out with very great ease.

[Sidenote: _Obstructions in the ears._]

If the orifice of the ear be straitened, and a thick sanies is contained within, the best honey ought to be put into it. If that does little good, to a cyathus and half of the best honey must be added of rasile verdigrease p. ii. *. which are to be boiled together, and made use of. Iris also with honey is good for the same purpose. Likewise of honey and oil of roses two scruples. Also of galbanum p. ii. *. myrrh with honey, and ox-gall, each p. ii. *. wine a sufficient quantity to dilute the myrrh.

[Sidenote: _Dulness of hearing._]

When a person grows dull of hearing, (which most commonly happens after long pains of the head) in the first place, it is proper to inspect the ear itself. For there will appear either a crust, such as grows upon ulcers, or a collection of the cerumen. If there is a crust, either warm oil must be infused, or verdigrease with honey, or juice of leek, or a little nitre with mulse. And when this crust falls forward, it must be washed with tepid water, that after it has fairly disengaged itself it may be the easier pulled out by the specillum oricularium. If there be cerumen, and this is soft, it must be taken out with the same instrument. But if it be hard, vinegar, and a little nitre with it must be injected; and when it is softened, the ear should be washed in the same manner, and cleansed. And if a heaviness of the head remain, the hair must be clipped, and the head gently rubbed, but a long time, with the oil of iris or laurel, and with either of these may be mixed a little vinegar: then the patient must take a long walk, and after anointing, foment the head gently with warm water; and make use of food of the weakest and middle class, and more especially take diluted drinks; sometimes use gargarisms. Into the ear must be infused castor, with vinegar and laurel oil, and the juice of radish rind, or the juice of wild cucumber, with the addition of rose leaves powdered. The juice also of unripe grapes infused with oil of roses, is pretty good against a deafness.

[Sidenote: _Of a noise in the ears._]

The disorder is of a different nature, where there is a noise within the ears themselves: and this prevents them from receiving an external sound. This is slightest, when it proceeds from a gravedo; worse, when it is occasioned by a distemper or inveterate pains of the head; worst of all, when it is the harbinger of some violent disease, and particularly of an epilepsy. If it happens from a gravedo, the ear ought to be cleansed, and the patient hold in his breath, till some frothy moisture issue from it. If, from a distemper, or pain of the head, the same rules _as prescribed in a dulness of hearing_, must be practised with regard to exercise, friction, pouring on of cold water, and the use of gargarisms; no food but such as extenuates must be used; juice of radish, with oil of roses, or with the juice of the root of wild cucumber, must be infused into the ear, or castor with vinegar and laurel oil. Hellebore is also rubbed with vinegar, then incorporated with boiled honey, and being made into a collyrium, is introduced into the ear. If it has begun without these, and therefore gives reason to fear the approach of some terrible disease, castor ought to be infused into the ear with vinegar, or oil, either of iris or laurel; or together with the last, castor and the juice of bitter almonds; or myrrh and nitre with oil of roses and vinegar. But a proper diet is more serviceable in this case too. And the same rules are to be observed, which I prescribed above, even with greater exactness; besides which, the patient must refrain from wine, till the noise cease.

But if, at the same time, there are both a noise and an inflammation, it is sufficient to inject laurel oil, or that, which is expressed from bitter almonds; with which, some mix either castor or myrrh.

[Sidenote: _Of extraneous bodies in the ears._]

It sometimes happens too, that something falls into the ear, as a small stone, or some animal. If a flea has got into it, a little wool must be pressed in; and if it comes upon that, it is drawn out along with it. If it has not followed it, or it be any other animal, a probe wrapt in wool must be dipped in the most adhesive resin, particularly turpentine, and this is to be introduced into the ear, and turned round there: for it will certainly catch hold of it, and bring it away. But if it be any lifeless thing, it must be drawn out by the specillum oricularium, or a blunt hook, but little bent. If these means do not succeed, it may be drawn out by resin, in the same manner as directed in the preceding case. Sternutatories also are very proper to force it out, or water strongly injected by a syringe. _The following method is also practised in this case_; a board is laid down(11), supported in the middle, with both ends hanging over, and the patient is tied upon that, lying on that side, the ear of which is affected, so that he does not reach over the board; then the end of the board, where his feet are, must be struck with a hammer, and thus by shaking the ear, what is within it drops out.

CHAP. VIII.

OF THE DISEASES OF THE NOSE.

Ulcers in the nostrils must be fomented with the steam of hot water. This is done both by applying a squeezed sponge, and putting under the nostrils a narrow-mouthed vessel filled with hot water. After this fomentation, the ulcers are to be anointed either with dross of lead, or ceruss, or litharge. When a person powders any of these, he may add, while they are rubbed, alternately, wine and myrtle oil, till he make it of the consistence of honey. But if these ulcers be near the mouth, and have several crusts, and a fetid smell, which kind the Greeks call ozaena[GG], we may take it for granted, that it is hardly possible to cure that disease. Nevertheless, the following things may be tried; to clip the hair of the head close to the skin, and daily to rub it briskly, and pour plenty of warm water over it; to walk much; to eat sparingly, and such food as is neither acrid nor of the strongest kind. Then to put into the nostril honey, with a very little turpentine resin (which is done by a probe, wrapt up in wool) and let this moisture be drawn in by the breath, till the taste of it be perceived in the mouth. For by these means, the crusts are loosened, which ought then to be discharged by sneezing. The ulcers being thus cleansed must be fumigated with the vapour of hot water; afterwards should be applied, either lycium diluted with wine, or the lees of oil, or omphacium, or juice of mint, or of horehound; or copperas that has been burnt white, and then powdered; or the pulp of a squill bruised; to any of these honey may be added, of which in the other mixtures there ought to be only a very small part; with the copperas so much as to make it liquid; but with the squill a considerable quantity; then the end of a probe must be wrapped in wool, and dipped in the medicine; and by that the ulcers are to be incarned. And further, a piece of lint is to be rolled up in an oblong form, and dipped in the same medicine, which is to be introduced into the nostril, and loosely tied at the lower part. This ought to be done twice a day, in the winter and spring, and thrice in the summer and autumn.

[GG] ὄζαινα.

[Sidenote: _Of fleshy caruncles in the nostrils._]

Sometimes in the nostrils there grow caruncles resembling womens’ nipples, and these adhere to its extremities, where it is cartilaginous. These ought to be treated with escharotic medicines; by which they are certainly consumed. A polypus[GH] is a caruncle sometimes white, sometimes inclining to a red colour, which sticks to the bones of the nostrils; and sometimes spreading towards the lips, it fills the nostril, at other times reaching backward through the opening, by which the breath passes from the nose to the fauces, increases so much, that it may be seen behind the uvula; and almost suffocates the patient, especially when the south or east wind blows. It is generally soft, seldom hard; and the latter obstructs the breath more, dilates the nostrils, and is commonly of the cancerous nature, and therefore ought not to be touched. The other kind is generally cured by cutting; sometimes, however, it withers, if by means of lint or a pencillum, that composition be thrust up into the nose, which contains of Sinopian minium, chalcitis, lime, sandarach, each p. i. *. copperas p. ii. *.

[GH] πολύπους.

CHAP. IX.

OF THE TOOTHACH.

In the toothach, a disorder, that may justly be ranked even amongst the greatest torments, the use of wine must be entirely forbid; and at first a total abstinence from food must be observed; afterwards it may be taken sparingly, but soft, lest the teeth be irritated by chewing. Then externally, by means of a sponge, the steam of hot water is to be applied, and a cerate made of cyprine, or iris oil spread upon wool, and the head must also be covered. But if the pain be more severe, a clyster is useful, with hot cataplasms applied to the cheek, as also some medicinal hot liquor held in the mouth, and frequently changed. For which purpose is used a decoction of cinquefoil root in diluted wine; and henbane root, either in vinegar and water, or diluted wine, with the addition of a little salt to either of them; and poppy heads not over dry, and mandrake root prepared in the same manner. But in these three, care must be taken not to swallow what is in the mouth. The bark of the root of white poplar, boiled in diluted wine, does very well for this purpose; or hartshorn shavings in vinegar, and catmint with teda(12), and a mellow fig; also a mellow fig, either in mulse or in vinegar and honey, and when the fig is dissolved by boiling, the liquor is strained. A probe also wrapt up in wool is dipped into hot oil; and used to touch the tooth itself. Moreover, something like cataplasms are put into the tooth. For which end the inner part of the shell of an acid and dry pomegranate is powdered, with an equal quantity of galls and pine bark, and with these is mixed minium; which being powdered, are brought to a consistence with rain water; or panaces, poppy tears, hog’s fennel, stavesacre without its seeds, powdered in equal proportions; or three parts of galbanum, and a fourth of poppy tears. Whatever is applied to the teeth, a cerate, such as is directed above, ought, nevertheless, to be kept upon the cheek, and covered with wool. Some also bruise and spread upon linen, myrrh, cardamoms, of each p. i. *. saffron, pellitory, figs, pepper, each p. iv. *. mustard p. viii. *. and apply this to the arm of that side, where the painful tooth is; if it be in the upper jaw, in the part next the scapula; if in the lower, on that next the breast; and this relieves the pain; and when it has given ease, it must be immediately taken away.

Now if the tooth be spoilt, we need not be hasty in extracting it, unless there be a necessity for it; but in such a case, to all the fomentations directed before, must be added some stronger compositions to ease the pain. Such as is that, which contains of poppy tears p. i. *. pepper p. ii. *. sory(13) p. x. *. these are powdered and mixed up with galbanum, and put round the affected tooth; or that of Menemachus principally for double teeth, in which are of saffron p. i. *. cardamoms, soot of frankincense, figs, pepper, pellitory, each p. iv. *. mustard p. viii. *. Some mix of pellitory, pepper, elaterium, each p. i. *. scissile allum, poppy tears, stavesacre, crude sulphur, bitumen, bay-berries, mustard, of each p. ii. *. But if the pain make it necessary to take it out, a pepper corn stript of its bark, and in the same manner an ivy berry put into its opening, splits the tooth, so that it comes away in scales. The prickle of the planus fish also (which we call pastinaca, the Greeks trygon) is toasted, then powdered, and mixed with resin, which being put round the tooth loosens it. Scissile alum likewise put into the opening disposes the tooth to come away. But it is more expedient to wrap this in a little wool, and then put it in: because in that way it both preserves the tooth, and eases the pain. These are the prescriptions of physicians; but the experience of our peasants has discovered, that for the toothach the herb horsemint ought to be pulled up by the roots, and put into a bason, and water infused upon it, and that the patient should sit down close by it, covered all over with clothes; and then red hot flints are to be thrown into the bason, so as to be covered with the water, and the patient with his mouth open must receive the vapour, close wrapt up as before directed. For both a plentiful sweat follows, and a continued stream of rheum runs from the mouth, which secures health for a pretty long time, and frequently for a whole year.

CHAP. X.

OF THE DISEASES OF THE TONSILS.

If the tonsils swell from an inflammation without an ulcer, the head must be covered as in the last disorder, and the part fomented externally with the vapour of hot water; the patient must walk much; lie in bed with his head raised; and use gargarisms of the repellent medicines. The liquorice root too bruised, and boiled in passum or mulse, has the same effect. And it is not amiss to touch them gently with some medicines, which are made in this manner: the juice is squeezed from a sweet pomegranate, and a sextarius of this is boiled over a gentle fire to the consistence of honey; then saffron, myrrh, scissile alum, of each p. ii. *. are powdered separately, and to these are added gradually two cyathi of mild wine, of honey one; after that, they are mixed with the first mentioned juice; and again gently boiled; or a sextarius of the same juice is boiled in the same way, and the following things powdered in like manner are added to it; of nard p. *. omphacium p. i. *. cinnamon, myrrh, cassia, each p. i. *. And these same compositions are proper both for purulent ears and nostrils. The food in this disorder also ought to be mild, lest it exasperate the inflammation.

But if the inflammation is so great as to obstruct the breath, the patient must rest in bed, abstain from eating, and take nothing else but warm water: a clyster must also be given, and a gargarism used of figs and mulse; and the part touched with honey and omphacium. Externally the hot vapour must be applied, but for a longer time, till they suppurate and break of themselves. If pus is contained within, and the tumours do not break, they must be cut. Afterwards the patient must gargle with warm mulse.

But if with an inconsiderable swelling there is an ulceration, for a gargarism there must be added to the cream of bran a little honey, and the ulcers are to be anointed with the following medicines: three cyathi of the sweetest passum are boiled into one; then is added of frankincense p. i. *. saffron, myrrh, each p. *. and the whole is set upon the fire again, till it boil. When the ulcers are clean, he must gargle with the same cream of bran, or with milk. And in this case also a mild diet is necessary; to which may be added sweet wine.

CHAP. XI.

OF ULCERS OF THE MOUTH.

Ulcers of the mouth, if they be attended with an inflammation, and are foul and red, are best treated by the medicines prepared from pomegranates mentioned before. And a repellent cream, with the addition of a little honey, is to be held in the mouth often; the patient must walk, and avoid all acrid food. When the ulcers begin to be clean, a mild liquor, and sometimes the best water is to be kept in the mouth: and the use of wine undiluted does service, also a fuller diet, provided it be not at all acrid. The ulcers ought to be sprinkled with scissile allum, and a little more than half its quantity of unripe galls.

If they are already covered with crusts, such as we find in burns, the compositions which the Greeks call antherae[GI] are to be applied. These contain of long cyperus, myrrh, sandarach, allum, equal parts; or, of saffron, myrrh, each p. ii. *. iris, scissile allum, sandarach, each p. iv. *. long cyperus p. viii. *. Or, of galls, myrrh, each p. ii. *. scissile allum p. ii. *. rose leaves, p. iv. *. But some mix together of saffron p. *. scissile allum, myrrh, each p. i. *. sandarach p. ii. *. long cyperus p. iv. *. The former are sprinkled on dry; the last is applied with honey; and not only to these ulcers, but to the tonsils also.

[GI] ἀθηραὶι.

But those ulcers, which the Greek call aphthae, are by far the most dangerous; that is, in children; for they often kill them: in men and women there is not the same danger. They begin at the gums, next possess the palate, and the whole mouth; then descend to the uvula and fauces. When these are affected, it is not easy for the child to recover. And the case is more deplorable, if the infant is yet sucking; because it is more difficult to apply any remedy. But in the first place the nurse must be obliged to exercise by walking and such employments as move the superior parts; she must be sent to the bath, and ordered to pour warm water there over her breasts; next, her food must be mild, and such as is not easily corrupted; and if the child have a fever, she must drink water; if not, diluted wine. And if the nurse is costive, she must have a clyster; if phlegm collects in her mouth, a vomit. Then _for the infant_, the ulcers must be anointed with honey, to which is added that kind of rhus(14), which is called Syrian, or bitter almonds; or with a mixture of dry rose leaves, pine kernels, and mint incorporated with honey; or that medicine may be used, which is made up with mulberries; the juice of which is boiled in the same manner as that of the pomegranate to the consistence of honey; and in the same way, saffron, myrrh, allum, wine and honey are mixed with it. Nor is any thing to be given, which may provoke the discharge of humour. If the child is come to more strength, he ought to gargle with such mixtures, as have been mentioned before. And if the milder medicines do but little service here, such are to be used, as by their caustic quality may cover the ulcers with crusts. The scissile allum is powerful, or chalcitis, or copperas. Fasting too, in as great a degree as the patient can bear, does service. The food ought to be mild; however to cleanse the ulcers, it is proper to give sometimes cheese spread with honey.

CHAP. XII.

OF ULCERS OF THE TONGUE.

Ulcers of the tongue require no other medicines than those, that have been laid down in the former part of the last chapter. But such as arise upon the side of it continue longest. And it is necessary to inspect whether some tooth opposite to it is not too sharp, which often prevents an ulcer in that part from healing, and for that reason must be filed.

CHAP. XIII.

OF PARULIDES AND ULCERS IN THE GUMS.

Some painful tubercles also grow sometimes in the gums, near the teeth; the Greeks call them parulides[GJ]. It is proper at the beginning, to rub these gently with powdered salt, or with a mixture of fossile salt calcined, and cypress and catmint; then to wash the mouth with the cream of lentils, withal holding the mouth open, till the phlegm is sufficiently discharged. In a greater inflammation the same medicines are to be used, as were directed before, for ulcers of the mouth; and a little soft lint is to be rolled up in one of those compositions, which I said were called antherae, and that must be put betwixt the tooth and the gum. But if the tumour be too hard to admit of that, the steam of hot water, by means of a spunge, must be used externally, and cerate applied. If a suppuration appears, the steam must be used longer; and a hot decoction of figs in mulse, must also be held in the mouth. And the tubercle must be cut before it be quite ripe, lest the pus, by continuing there too long hurt the bone. If the tumour be pretty large, it is better to cut it out entirely, so that the tooth may be freed on both sides. When the pus is discharged, if the wound be slight, it is sufficient to hold warm water in the mouth, and to foment externally with the same vapour; if it be larger, to make use of the cream of lentils, and the same medicines, by which other ulcers in the mouth are cured.

[GJ] παρουλίδες.

Other ulcers, likewise, frequently arise in the gums, which are relieved in the same manner, as those in the other parts of the mouth. However, it is highly proper to chew privet, and hold the juice of it in the mouth. It sometimes happens, too, that from an ulcer in the gum, whether it be a parulis or not, pus is discharged for a long time, when a tooth is either rotten, or broke, or the bone otherwise spoilt; and that commonly proceeds from a fistula. When this is the case, the part must be opened, and the tooth extracted; if there be any exfoliation, it must be taken out; if any part of it is spoilt, it must be scraped. After which, the same methods must be taken, as were prescribed before in the cure of other ulcers. But if the gums leave the teeth, the same antherae are helpful. It does good also to chew pears or apples not very ripe, and to keep their juice in the mouth. And mild vinegar held in the mouth may have the same effect.

CHAP. XIV.

OF AN INFLAMMATION OF THE UVULA.

A violent inflammation of the uvula may justly excite our fears. Therefore, in this case, abstinence is necessary, and it is proper to bleed; and if there is any good reason against that, a clyster is serviceable. Besides, the head must be covered, and kept pretty high; next, a decoction of bramble and lentils in water, must be used as a gargarism; and the uvula itself be touched with honey, mixed either with omphacium, or galls, or scissile allum. The medicine also, which is called andronium is suitable to this case. It consists of scissile allum, scales of red copper, copperas, galls, myrrh, and misy; which are powdered separately, and being mixed, they are again rubbed with the addition of rough wine, to the consistence of honey. It does great service also to apply to the uvula the juice of celandine, by means of a spoon. When the uvula is moistened with any of these, a great quantity of phlegm runs out; and when that ceases, the patient must gargle with hot wine.

But if the inflammation be slight, it is sufficient to powder laser, and add to it cold water, and to put this water into a spoon, and hold it below the uvula. And when it is not much swelled, cold water alone, used in the same way, constringes it. The patient must also use a gargarism of water, either with laser, or without it. But the chirurgical cure for a lengthened uvula I shall describe afterwards.

CHAP. XV.

OF A GANGRENE OF THE MOUTH.

If a gangrene seizes ulcers of the mouth, it is to be considered in the first place, whether the body be in a bad habit: if it be, that must be rectified; and then we may proceed to the cure of the ulcers. But if that disorder be on the surface, it does well enough to sprinkle a dry anthera upon the ulcer, if moist: if it be somewhat dry, it must be laid on with a small portion of honey: if a little deeper, two parts of burnt paper, and one of orpiment: if the disorder is of a considerable depth, three parts of burnt paper, and a fourth of orpiment, or equal parts of salt and iris both toasted; or equal parts of chalcitis, lime, and orpiment. But it is necessary to dip lint in rose oil, and apply over that escharotic medicines, to prevent their hurting the sound contiguous part. Some also throw in so much toasted salt into a hemina of strong vinegar, till it will dissolve no more; next, they boil away this vinegar till the remainder be dry; and powder the salt, and sprinkle it on the ulcers. Now, as often as a medicine is applied, both before and after, the mouth must be washed, either with cream of lentils, or a decoction of vetches, or olives, or vervains in water; and with any of these must be mixed a little honey. Vinegar of squills, also held in the mouth, has no small efficacy against these ulcers; and vinegar mixed again with the salt, boiled in vinegar, as before directed. But when either of these is used, it must be kept in the mouth a long time together, and be repeated twice or thrice in a day, as the malady is more or less severe. And if the patient be a child, a probe must be wrapped in wool, and dipped into a medicine, and held upon the ulcer; lest for want of thought, he should swallow the escharotics. But if there be a pain in the gums, and some of the teeth be loosened, they ought to be pulled out: for they very much obstruct the cure. If medicines do no service, the ulcers will require to be cauterized: which, however, is not necessary in the lips, because it is more convenient to cut them out. And both that which is cauterized, and that which is cut out, are equally incapable of being filled up without the manual operation. Now the bones of the gums, which have but little life in them, when once stripped by burning, continue bare ever after: for the flesh never grows again there. Upon the burnt places, however, lentils must be applied, till they recover their soundness, as far as the case will admit.

CHAP. XVI.

OF PAROTID SWELLINGS.

These are the disorders in the head, which generally require the help of medicines, but under the ears, it is common for parotides[GK] to arise; sometimes in health, when an inflammation commences there; sometimes after long fevers, when the violence of the disease settles in that part. This is a kind of abscess: and therefore requires no peculiar method of cure. This one caution, however, is necessary, that if the swelling came without any preceding distemper, repellents should first of all be tried: if the disorder proceeds from any illness, that method is hurtful; and it is more expedient to have it maturated and opened as soon as possible.

[GK] παρωτίδες.

CHAP. XVII.

OF A PROMINENT NAVEL.

In the case of a prominent navel, to prevent the necessity of any chirurgical operation, trial must first be made of abstinence, and a clyster must be given; over the navel may be applied that composition, which consists of hemlock and soot, each p. i. *. ceruss washed, p. iv. *. lead washed p. viii. *. with two eggs; to which is likewise added the juice of night-shade. This ought to lie on for a pretty long time; and, in the mean while, the patient is to be restrained from motion, use a spare diet, and avoid every thing flatulent.

CHAP. XVIII.

OF THE DISEASES OF THE PRIVATE PARTS.

The next disorders we are to treat of, are those of the private parts. The names of which amongst the Greeks are both more tolerable, and already established by custom; since they are of common use in almost every book and discourse of physicians: with us the terms are more indecent, and have had no sanction from the conversation of modest men to qualify their coarseness. This makes it difficult to treat of them so, as at once to preserve a delicacy of expression, and deliver plainly the precepts of the art. Nevertheless this circumstance ought not to deter me from writing. In the first place, because it is my intention to comprehend every thing, that I have learned to be useful; in the next place, because every body should know how to cure those disorders, which we are so unwilling to expose to another.

Therefore, if the penis be swelled from an inflammation, and the prepuce cannot either be drawn back, or brought forward again, the part must be fomented plentifully with warm water. And when the glans is covered, warm water must also be injected by a syringe, betwixt it and the skin. If the skin, mollified and extenuated by this means, can be drawn back, the subsequent part of the cure is more easy; if the swelling prevails _against this remedy_, lentils, or horehound, or olive leaves boiled in wine must be applied, and to any of these, while it is rubbed, a little honey is added; and the penis is to be tied up to the belly; which is necessary in the cure of all its disorders; and the patient ought to confine himself to a strict regimen, and abstain from eating, and relieve his thirst by nothing but water. The day following, the fomentation of water must be applied in the same way, and trial made, even with some degree of violence, to pull back the prepuce; if it will not give way, the surface of it must be slightly cut with a knife. For when the sanies is discharged, the part will be extenuated, and the prepuce more easily drawn back.

Whether it has yielded to the latter method, or has never resisted, ulcers will be found, either in the inner part(15) of the prepuce, or in the glans, or in the penis beyond that; which must, of necessity, be either clean and dry, or humid and purulent. If they be dry, they must be first fomented with hot water; then lycium, with wine applied, or oil lees boiled with the same, or rose oil with butter. If there is a thin humour in them, they must be washed with wine; then a little honey and oil of roses with butter, and a fourth part of turpentine resin must be used. But if pus is discharged from them, first of all they ought to be washed with warm mulse; after which is applied of pepper p. i. *. myrrh p. ii. *. saffron, calcined milsy, each p. ii. *. which are boiled with a rough wine, to the consistence of honey. The same composition is also proper for the tonsils, a moist uvula, and ulcers of the nostrils and mouth. Another for the same purpose: of pepper p. i. *. myrrh p. i. *. saffron p. ii *. milsy p. i. *. calcined copper p. ii. *. which are first rubbed down with a rough wine, then when they have grown dry, they are again rubbed with three cyathi of passum, and boiled to the consistence of viscum. Verdigrease too, with boiled honey, and those compositions, which were mentioned before, for ulcers of the mouth, cure these. But the composition of Erasistratus, or Crato, is a proper application for purulent ulcers of the parts of generation. Olive leaves also are boiled in nine cyathi of wine(16), and to these are added of scissile allum p. iv. *. lycium p. viii. *. honey a cyathus and half; and if the quantity of pus be pretty great, this medicine is diluted with honey; if small, with wine. This is a constant rule; after dressing, while the inflammation continues, to apply over it such a cataplasm, as before directed, and to dress the ulcers every day in the same manner. But if pus begins to be discharged in a great quantity, and is fetid, the _ulcer_ ought to be washed with cream of lentils, with the addition of a little honey, or a decoction of olive, or mastich leaves; or a decoction of horehound used in the like manner with honey. And the same dressings must be applied; or else omphacium with honey; or that composition for the ears, which is made of verdigrease and honey; or the composition of Andron; or an anthera, with the addition of a little honey. Some dress all the ulcers, which we have yet mentioned, with lycium and wine.

If the ulcer increases in breadth and deepness, it ought to be washed in the same manner; and either verdigrease, or omphacium with honey, applied; or Andron’s composition; or of horehound, myrrh, saffron, scissile alum calcined, dry rose leaves, galls, each p. i. *. Sinopian minium, p. ii. *. which are first powdered separately; then mixed and rubbed together in honey, till they acquire the consistence of liquid cerate; after which they are boiled in a copper vessel, gently, so as not to boil over; when the drops of it grow hard, the vessel is taken off the fire; and this medicine, as occasion requires, is softened, either with honey or wine. The same composition, by itself, is also good for fistulas.

Sometimes too, the ulcer penetrates to the nerves; and there is a plentiful discharge of humour, and thin sanies and fetid, of no consistence, but like water, in which recent flesh has been washed; there are pains and prickings in the parts. Although this be of the purulent kind, yet it must be cured by mild medicines; such as the tetrapharmacum plaister, liquified with rose oil, and mixed with a little frankincense; or that, which is made of butter, rose oil, resin, and honey, already mentioned. Above all, this ulcer is to be fomented with abundance of warm water, and covered, and not exposed to the cold.

Sometimes also, by these ulcers, the penis under the skin is so consumed, that the glans falls off. In which case, the prepuce itself must be taken off by circumcision. And it is a general rule, whenever the glans, or any part of the penis falls off, or is cut off, that the skin be kept from falling in contact and uniting with the ulcer(17), so that it cannot be drawn back afterwards, and perhaps may even obstruct the urinary passage.

Tubercles likewise, which the Greeks call phymata, arise about the glans; which are cauterized either by medicines, or the actual cautery; and when the sloughs cast off, copper scales are sprinkled upon them, to prevent any thing growing there again.

[Sidenote: _Of a gangrene._]

In what we have hitherto described there is still no gangrene; to which, as in the other parts, so more especially here, ulcers are liable. It begins with a blackness. If this seizes the prepuce, a probe must be immediately put under it, and an incision made; then the extremities are to be laid hold of with a vulsella(18), and whatever is corrupted must be cut away, and even some of the sound part taken off, and the place cauterized. Whenever any part is burned, the next step is to apply lentils; afterwards, when the sloughs have cast off, the cure is the same with that of common ulcers.

But if a gangrene has seized the penis itself, some of the escharotic medicines must be sprinkled upon it, chiefly that, which is composed of lime, chalcitis, and orpiment. If medicines fail of success, here also whatever is corrupted is to be cut out with a knife, in such a manner as that some of the sound part be taken with it. This rule is as universal as the former, when a gangrened part is cut away, that the wound must be cauterized. But if either by means of medicines, or the actual cautery, the sloughs have grown callous, there is great danger, that when they cast off, a profusion of blood from the penis may follow. Therefore long rest is necessary, and keeping the body almost immoveable, till the sloughs be gently loosened from it in proper time. But if a person either wittingly, or inadvertently, by walking too soon has separated the sloughs, and there ensues a hæmorrhage, cold water must be applied. If that does not prevail, recourse must be had to those medicines, which stop blood. If even these do not relieve, the part must be cauterized carefully and cautiously; and not afterwards exposed to the same danger by any motion whatsoever.

[Sidenote: _Of a phagedaena._]

Sometimes also in the same place there happens that kind of gangrene, which the Greeks call phagedæna[GL]. In which no time is to be lost, but the same remedies must be immediately applied; and if these are not successful, it must be burnt by the actual cautery. There is likewise a certain blackness, which gives no pain, but spreads, and if we do not resist it, it makes its way to the bladder; and cannot be cured afterwards. But if it be at the end of the glans near the urinary pipe, a small probe should be introduced into that first, to prevent its closing; and then the actual cautery must be applied to the ulcer. But if it has penetrated deep, whatever is tainted must be cut off. For the rest, it must have the same treatment with other gangrenes.

[GL] φαγέδαινα.

[Sidenote: _A callosity or carbuncle._]

There is likewise sometimes a callous excrescence from the penis, which is almost void of all sensation, and ought to be cut out. A carbuncle, as soon as it appears there, must be washed by means of a syringe; then it must be cauterized too with medicines, particularly chalcitis with honey, or verdigrease with boiled honey, or sheep’s dung toasted and powdered with honey. When it falls off, liquid medicines must be used, which are composed for the lips of ulcers.

[Sidenote: _Diseases of the testicles._]

If any inflammation begins in the testicles without a blow, blood must be taken from the ancle; the patient must abstain from eating; that composition must be applied, which consists of bean meal boiled in mulse, then mixed with powdered cummin, and worked up to a consistence with honey; or powdered cummin with cerate made of rose oil; or lintseed toasted, powdered, and boiled in mulse; or wheat meal boiled in mulse with cypress; or lily root bruised. But if the testicles are grown hard, lint or fenugreek seed, boiled in mulse, should be applied; or cerate made of cyprine oil; or fine flour rubbed with wine and the addition of a little saffron. If the hardness be already of pretty long standing, the root of wild cucumber boiled in mulse and then bruised does a great deal of service.

If they are swelled from a blow, it is necessary to let blood, and more so if they are livid besides; and either of these compositions made with cummin above mentioned must be applied; or that composition, which contains of nitre calcined p. i. *. pine resin, cummin, each p. ii. *. stavesacre without the seeds p. iv. *. honey, a sufficient quantity to bring them to a consistence. But if from the blow the testicle ceases to receive nourishment, there is generally a collection of pus at the same time, and there is no other remedy for it, than by making an incision in the scrotum, to discharge the pus, and extirpate the testicle itself.

[Sidenote: _Diseases of the anus. Rhagadia._]

The anus too is liable to many and very tedious disorders; and these are cured by methods not very different from one another. In the first place it is a common ailment here, that the skin is chopped, and that in several places: the Greeks call it rhagadia[GM]. When this is recent, the patient ought to rest, and sit down in hot water. Pigeons eggs are also to be boiled, and when they are hard, the shells taken off, after that one of them ought to lie in water well heated, while the part is fomented with the other warm; and thus each of them must be used alternately for some time. Then the tetrapharmacum or the rhypodes must be softened with rose oil; or recent œsypum mixed with liquid cerate made of rose oil; or to the same liquid cerate must be added washed lead; or myrrh to turpentine resin; or old oil to litharge: and the part anointed with any of these. If the part affected be external, and not concealed within, a piece of lint dipped in the same medicine ought to be applied to it, and whatever is laid first on, must be covered with cerate. In this case neither acrid food, nor austere, nor binding must be used; nothing even dried is good, unless the quantity be very small. Liquid, mild, fat and glutinous food is better. There is no reason to refrain from the use of mild wine.

[GM] ῥαγάδια.

[Sidenote: _Of condylomata._]

A condyloma is a tubercle, which commonly proceeds from some inflammation. When it appears, the directions must be observed, which were just now given, with regard to rest, meat, and drink. It is proper to foment this tubercle with eggs, as in the other case. But the patient should first sit down in a decoction of repellent vervains in water; then it is fit to apply lentils with a small proportion of honey, mellilot boiled with wine, and bramble leaves bruised with cerate made of rose oil; and with the same cerate either a quince bruised, or the inner part of pomegranate bark boiled in wine; and chalcitis burnt, and powdered, then mixed with œsypum and rose oil; and some of that composition, which contains of frankincense p. i. *. scissile alum p. ii. *. ceruss p. iii. *. litharge p. v. *. to these, while they are powdered, is instilled alternately oil of roses and wine. The bandage for that part is a square piece of linen or woollen cloth, which at two of its corners has two loops, and at the other as many fillets; and when it is put under the patient, the loops being turned toward the belly, the two fillets from behind are put through them, and when drawn tight, the right one must be extended to the left, and that on the left to the right, and lastly both being brought round are tied in a knot over the belly. But if the condyloma be inveterate, and is grown hard, and does not give way to these methods, it may be cauterized by a medicine, which consists of the following ingredients; of verdigrease p. ii. *. myrrh p. iv. *. gum p. viii. *. frankincense p. xii. *. antimony, poppy tears, acacia, each p. xvi. *. with which medicine some chuse to renew those ulcers of which I was lately treating. If this has no effect upon the condyloma, even stronger caustics may be used. When the tumour is consumed, we must change to the mild applications.

[Sidenote: _Of the hemorrhoids._]

The third disease of the anus is when the orifices of the _hemorrhoidal_ veins grow turgid, and shoot out something like small heads, which often discharge blood; the Greeks call them the hæmorrhoides[GN]. And this frequently happens to women in the mouth of the womb. And it is not safe to stop it in some people, who are not weakened by the discharge of blood: for this serves for a drain, and is not a disease. And therefore some that have been cured, as the blood had no exit, have been seized with sudden and very dangerous distempers, from the matter settling upon the præcordia and bowels. But a man that feels bad effects from this discharge, ought to sit down in a decoction of vervains; and to apply principally pomegranate bark powdered, with dry rose leaves; and some of those things, which stop blood. An inflammation sometimes comes on, especially when hard excrements hurt the part. Then the patient must sit down in pure water, and foment the part with eggs, and apply the yolks with rose leaves beat up with passum; and if the disorder be within, this must be put to it with the finger; if without, it must be applied spread upon a cloth. Those medicines too, which are calculated for recent fissures, are suitable here. And the same diet must be used in this, as in the former cases. If these methods give but little relief, it is usual by the application of caustic medicines to consume these small heads. But if they be inveterate, by the direction of Dionysius, sandarach is to be sprinkled upon them; after that the following composition must be applied: of copper scales, orpiment, each p. v. *. stone lime p. viii. *. the next day, they must be punctured with a needle. By cauterizing these small heads a cicatrix is formed(19), which prevents the effusion of blood. But whenever this is stopped, to avoid any dangerous consequence from the suppression, the matter must be dissipated by much exercise; and besides both men, and such women, whose menstrual discharge is stopped, ought sometimes to be bled in the arm.

[GN] αἱμοῤῥοἱδες.

[Sidenote: _Of a prolapsus of the anus or womb._]

But if the anus itself, or the mouth of the womb fall down (for that sometimes happens) it ought to be considered whether the part, which is protruded, be clean, or covered with a mucous humour. If it be clean, the patient ought to sit down in salt water, or a decoction of vervains or of pomegranate bark in water: but if moist, it must be washed with a rough wine, and rubbed with burnt lees of wine. When it has been treated in either way, it must be replaced; and an application made of bruised plantain, or willow leaves boiled in vinegar; over that, linen and wool: these must be tied on, and the legs bound close together.

[Sidenote: _Of a fungous ulcer._]

There sometimes appears an ulcer in the same part resembling a mushroom. This, if it be the winter-time, must be fomented with water just warm; if any other season, with cold; afterwards it must be sprinkled on copper scales, and over that cerate applied made of myrtle oil, with the addition of a little scales, soot, and lime. If it is not removed in this method, it must be consumed either by stronger medicines(20) or the actual cautery.

CHAP. XIX.

OF ULCERS IN THE FINGERS.

The best cure for ulcers of long standing in the fingers is either lycium or lees of oil boiled; to either of which wine is added. A caruncle here also sometimes recedes from the nails with great pain; the Greeks call it pterygion[GO]. It is proper to dissolve as much round Melian alum in water, as to make it of the consistence of honey; then to pour into it the same quantity of honey as there was of alum, and to stir it with a spatula, till it becomes of a saffron colour, and rub that over it; some people for the same purpose chuse to mix equal quantities of dry alum and honey, and boil them together to the due consistence. If they are not extirpated by this method, they must be cut off; then the fingers must be fomented with a decoction of vervains, and a medicine applied over them compounded thus; chalcitis, pomegranate bark, and copper scales are incorporated with a mellow fig gently boiled, and honey; or equal quantities of burnt paper, orpiment, and crude sulphur are mixed with cerate made of myrtle oil; or of rasile verdigrease p. i. *. copper scales p. ii. *. are brought to a consistence with a cyathus of honey; or equal parts of stone lime, chalcitis, and orpiment are mixed together. Which ever of these is applied, it must be covered with a linen cloth dipped in water. On the third day, the finger must be opened, and what is dry, must be cut away as before, and the like dressing applied. If it does not yield to this method, it must be cleansed with a knife, and burnt with small irons, and cured like other burns.

[GO] πτερύγιον.

But where the nails are scabrous, they ought to be opened round, where they are joined to the flesh; then some of the following composition must be applied over them; of sandarach, sulphur, each p. ii. *. nitre, orpiment, each p. iv. *. liquid resin p. viii. *. And this is to be taken off on the third day. This medicine causes the spoiled nails to fall off and better to grow in their place.

A. CORNELIUS CELSUS

OF

MEDICINE.

_BOOK VII._

PREFACE.

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.

CHAP. I.

OF CONTUSIONS.

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.

CHAP. II.

OF THE OPERATIONS NECESSARY IN SUPPURATED TUMOURS.

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.

CHAP. III.

OF THE GOOD OR BAD SYMPTOMS OF SUPPURATIONS.

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.

CHAP. IV.

OF FISTULAS.

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.

[Sidenote: _Of fistulas amongst the ribs._]

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.

[Sidenote: _Of fistulas in the belly._]

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.

[Sidenote: _Of fistulas in the anus._]

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.

CHAP. V.

OF EXTRACTING WEAPONS OUT OF 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.

[Sidenote: _Of arrows._]

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 ν; 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.

[Sidenote: _Of broad weapons._]

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.

[GP] γραφίσκος Διοκλέους.

[Sidenote: _Of leaden bullets, &c._]

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.

[Sidenote: _Of poisonous weapons._]

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.

CHAP. VI.

OF A GANGLION, MELICERIS, ATHEROMA, STEATOMA, AND OTHER TUBERCLES OF THE HEAD.

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.

[GQ] γάγγλια.

[GR] μελικηρίδες.

[GS] ἀθερώματα.

[GT] στεατώματα.

CHAP. VII.

OF THE DISEASES OF THE EYES, WHICH ARE CURED BY MANUAL OPERATIONS.

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.

[Sidenote: _Of vesicles in the upper eye-lids._]

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.

[Sidenote: _Of a crithe._]

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.

[GU] κριθὴ.

[Sidenote: _Of chalazia._]

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.

[GV] χαλάζια.

[Sidenote: _Of the unguis._]

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.

[GW] πτερύγιον.

[GX] ῥυὰς.

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.

[Sidenote: _Of an encanthis._]

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.

[GY] ἐγκανθὶς.

[Sidenote: _Of the ancyloblepharon._]

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.

[GZ] ἀγκυλοβλέθαρον.

[Sidenote: _Of the aegilops._]

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.

[HA] αἰγίλωψ.

[Sidenote: _Of hairs in the eye lashes irritating the eye._]

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.

[Sidenote: _Of the lagophthalmus._]

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_.

[HB] λαγώφθαλμος, or hare’s eye, outward.

[Sidenote: _Of an ectropium._]

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.

[HC] ἐκτρόπιον, from turning.

[Sidenote: _Of the staphyloma._]

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.

[HD] σταφύλωμα.

[Sidenote: _Of clavi._]

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.

[Sidenote: _Description of the eye._]

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.

[HE] κερατοειδὴς.

[HF] χοριοειδὴς.

[HG] ἀραχνοειδὴς.

[HH] ὑαλοειδὴς.

[Sidenote: _Of a cataract._]

Now a humour concretes under the twoὑαλοειδὴς. 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.

[Sidenote: _Of a flux of gum._]

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.

CHAP. VIII.

OF THE OPERATIONS REQUISITE IN THE EARS.

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.

CHAP. IX.

THE OPERATION NECESSARY IN A WANT OF SUBSTANCE IN THE EARS, LIPS, AND NOSE.

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.

CHAP. X.

OF THE EXTIRPATION OF A POLYPUS IN THE NOSE.

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.

CHAP. XI.

OF THE CHIRURGICAL CURE OF AN OZÆNA.

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.

CHAP. XII.

OF THE OPERATIONS REQUISITE IN THE MOUTH.

[Sidenote: _Of the teeth._]

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.

[Sidenote: _Of indurated tonsils._]

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.

[HI] ἀντιάδες.

[Sidenote: _Of the uvula._]

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.

[Sidenote: _Of the tongue._]

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.

[Sidenote: _An abscess under the tongue._]

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.

[Sidenote: _Of chopped lips._]

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.

CHAP. XIII.

OF THE BRONCHOCELE.

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.

[HJ] βρογχοκήλη.

CHAP. XIV.

OF THE OPERATIONS PERFORMED AT THE NAVEL.

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.

CHAP. XV.

THE METHOD OF DISCHARGING THE WATER IN HYDROPICK PEOPLE.

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.

CHAP. XVI.

OF WOUNDS OF THE BELLY AND INTESTINES.

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.

CHAP. XVII.

OF A RUPTURE OF THE PERITONAEUM.

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.

[Sidenote: _Of varices in the belly._]

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.

CHAP. XVIII.

A DESCRIPTION OF THE TESTICLES, AND THEIR DISEASES.

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.

[HK] κρεμαστὴρ.

[HL] λυτροειδὴς.

[HM] δαρτὸς.

[HN] ὀσχεὸν.

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.

[HO] ἐντεροκήλη.

[HP] ἐπιπλοκήλη.

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.

[HQ] ὑδροκήλη.

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.

[HR] κιρσοκήλη.

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

[HS] σαρκοκήλη.

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].

[HT] βουβωνοκήλη.

CHAP. XIX.

GENERAL DIRECTIONS FOR OPERATIONS IN THE FOREGOING DISEASES ABOUT THE TESTICLES.

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.

CHAP. XX.

OF THE CURE OF A RUPTURE OF THE INTESTINE INTO THE SCROTUM.

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.

CHAP. XXI.

OF THE CURE OF A RUPTURE OF THE OMENTUM INTO THE SCROTUM.

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.

[Sidenote: _Of a hydrocele._]

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.

CHAP. XXII.

OF A RAMEX IN THE SCROTUM.

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.

CHAP. XXIII.

OF A SARCOCELE.

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.

CHAP. XXIV.

OF A RAMEX IN THE GROIN.

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.

CHAP. XXV.

THE OPERATIONS REQUISITE IN THE DISORDERS OF THE PENIS.

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.

[Sidenote: _Of infibulating boys._]

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.

CHAP. XXVI.

OF THE OPERATION NECESSARY IN A SUPPRESSION OF URINE, AND LITHOTOMY.

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.

[HU] Οὐρορυὰς: this word, as far as I can find, occurs no where else. It is variously written in the different editions. The sense seems to determine it to what I have expressed in the translation, with which the etymology of it agrees.

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.

[HV] λιθοτόμος.

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.

CHAP. XXVII.

OF A GANGRENE AFTER CUTTING FOR THE STONE.

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.

CHAP. XXVIII.

OF THE OPERATIONS REQUIRED WHEN A MEMBRANE, OR FLESH OBSTRUCTS THE VAGINA IN WOMEN.

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.

CHAP. XXIX.

THE METHOD OF EXTRACTING A DEAD FOETUS OUT OF THE WOMB.

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 fœtus 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 fœtus, 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 fœtid 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 fœtus 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 fœtus 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.

CHAP. XXX.

THE OPERATIONS REQUIRED IN DISEASES OF THE ANUS.

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.

CHAP. XXXI.

OF VARICES IN THE LEGS.

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.

CHAP. XXXII.

OPERATIONS REQUIRED IN COHERING AND CROOKED FINGERS.

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.

CHAP. XXXIII.

OF THE OPERATION REQUIRED IN A GANGRENE.

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).

A. CORNELIUS CELSUS

OF

MEDICINE.

_BOOK VIII._

CHAP. I.

OF THE SITUATION AND FIGURE OF THE BONES OF THE HUMAN BODY.

It now remains, that I speak of what relates to the bones: for the easier understanding of which, I shall first describe their situations and forms. The first then is the skull, which is concave on the internal side, externally gibbous, and on each side smooth, both where it covers the membrane of the brain, and where itself is covered by the skin, from which the hair grows. In the occiput and temples it is simple; but double from the forehead to the vertex. And the bones of it in their external part are hard; on the inside, where they are connected with each other, softer. And veins are distributed between them, which probably supply them with nourishment.

Now the skull is rarely entire without sutures; but in hot countries it is more frequently found so. And such a head is strongest, and the most safe from pain; of others, the fewer sutures there are, so much the freer is the head from complaints; for their number is not certain, nor indeed their situation. However, for the most part two above the ears divide the temples from the upper part of the head; the third running to each side through the vertex, separates the occiput from the top of the head; the fourth goes from the vertex along the middle of the head to the forehead; and this ends in some at the point, to which the hair extends, in others between the eye-brows, dividing the forehead itself(1). The other sutures are exactly fitted to each other upon the same level. But the transverse ones above the ears, grow gradually thinner to their edges; and thus the inferior bones slightly overtop the superior ones. The bone behind the ear is the thickest in the head; for which reason, probably hair does not grow there. Over these muscles too(2), that cover the temples, a bone is situated in the middle, which is inclined to the external part. But the face has the largest suture; which beginning from the one temple runs transversely through the middle of the eyes, and the nose, to the other temple; from which two short ones point downward under the internal angles. The cheek-bones also have each of them a transverse suture in the upper part. And from the middle of the nose, or the sockets of the upper teeth, proceeds one through the middle of the palate; and another also divides the palate transversely. These then are the sutures found in most people.

The largest foramina of the head are those of the eyes; next the foramina of the nose; then those we have at the ears. The foramina of the eyes run straight and undivided to the brain. Two foramina are observed in the nose, divided by a bone in the middle: for these about the eye-brows and angles of the eyes begin osseous, and so proceed near the third part of the way; then turning cartilaginous, the nearer they approach to the mouth, so much the softer and more fleshy they become. But these foramina, which from the beginning of the nostrils to the internal part are simple, are there again divided each into two courses; the branches opening into the fauces both emit and receive the breath; the others go to the brain; in the end they are branched into many small openings, which afford the sense of smelling. In the ear too the passage at first is straight, and simple, but farther in, it becomes winding; the part next the brain is separated into many and small openings, from which we have the faculty of hearing. Near these there are as it were two small sinuses; and above them, that bone terminates, which going in a transverse direction from the cheeks is sustained by the inferior bones. It may be called jugale from the same resemblance, which gave it the Greek name of Zygodes[HW]. The maxilla is a soft bone(3), and only one in number: the middle and lowest part of which compose the chin; from whence it proceeds on both sides to the temples; and this only moves: for the malæ with the whole bone, that contains the upper teeth, are immoveable: but the extremities of the maxilla shoot as it were into two horns. One of these processes is broader below(4), and is narrowed at the vertex, and being extended forward enters below the os jugale, and over that is tied down by the muscles of the temples. The other is shorter and rounder, and is lodged like a hinge in that cavity, which is near the foramina of the ear; and there turning itself different ways, gives the maxilla a power of moving.

[HW] ζυγὼδες.

The teeth are harder than bone; part of them are fixed in the lower jaw-bone, and part in the upper. The four first from their cutting are by the Greeks called tomici[HX]. On each side of these _above and below_ stand the four canine teeth; beyond which there are commonly five maxillary teeth, except in those, in whom the genuine (_dentes sapientiae_) which generally grow late, have not come out. The fore teeth adhere each by one root, the maxillary by two at least, some by three or four. And a longer root commonly emits a shorter tooth; and the root of a straight tooth is straight, that of a crooked one bent. From this root in children, a new tooth springs, which most frequently forces out the former; sometimes however it appears above or below it.

[HX] τομικοὶ.

Next to the head is the spine, which consists of twenty-four Vertebræ. There are seven in the neck, twelve by the ribs, and the other five are below the ribs. These are round and short, and send out two processes on each side; in the middle they are perforated, where the spinal marrow, connected with the brain, descends. The sides also between the two processes are perforated by small holes, through which, from the membrane of the brain similar small membranes proceed. And all the Vertebræ(5) (except the three uppermost) at the superior part in the processes themselves have small depressions; at the lower, on the contrary, they send out processes pointing downwards. The first then immediately sustains the head, by receiving small processes of it into two depressions; which is the reason that the surface of the head below is rendered unequal by two prominences. The second is inserted into the under part of the first, and the superior part of the second is round and narrow (_processus dentatus_) in order to admit of a circular motion, so that the first surrounding the second allows the head to move towards each side. The third receives the second in the same manner; whence the neck has great facility of motion. And indeed it would not be able to sustain the head, if straight and strong nerves on each side did not secure the neck; these the Greeks call Carotæ. For one of them in every flexure, being always stretched, prevents the upper parts from slipping further. The third Vertebra has prominences, which are inserted into that below it. All the rest are inserted each into its inferior one by processes pointing downwards; and by depressions, which they have on each side, they receive the superior, and are secured by many ligaments, and a great quantity of cartilage. And thus one moderate flexure forward being allowed, a man both stands erect for some kinds of employment, and at other times bends himself as the actions he is engaged in require.

Below the neck, the first rib is situated opposite to the shoulders. After that the six inferior ones(6) reach the bottom of the breast: and these at their origin being round, and furnished with something like small heads, are fixed to the transverse processes of the vertebræ, which are in that part a little depressed; then they grow broader, and bending outward, degenerate gradually into cartilage; and in that part being again turned gently inward, are joined to the pectoral bone: which begins strong and hard at the fauces, being excavated on each side, and terminates at the præcordia, where it is softened into a cartilage. And under the superior ribs there are five, which the Greeks call Nothæ (_spurious_) shorter, and thinner, which also gradually turn to cartilage, and adhere to the external parts of the abdomen; the lowest of these in the greatest part of it is nothing else but a cartilage.

From the neck two broad bones, one on either side, go to the shoulders, by us called scutula operta, by the Greeks Omoplatæ. These have cavities at their vertices; from the vertices they become triangular, and growing gradually broader tend to the spine; and the broader they are in any part, so much the duller is their sensation. These too at their extremity are cartilaginous, and in their back part lie as it were loose, because, unless at the top, they are fixed to no bone, but are there tied down by strong muscles and nerves.

But at the first rib(7) a little within the middle of it, a bone grows out, in that part indeed slender; but going forward, the nearer it comes to the broad bone of the scapula, it becomes thicker, and broader, bending a little inwards, which being a little enlarged at its other vertex, sustains the clavicle. This bone is crooked, and is to be reckoned amongst the hardest bones; the one end of it is joined to the bone I just mentioned before, and by the other it is fixed in a small depression of the pectoral bone, and is moved a little in the motion of the arm; and its lower head is connected by ligaments and a cartilage with the broad bone of the shoulders.

Here the humerus begins, which at both its ends is enlarged, soft, without marrow, and cartilaginous; in the middle round and hard, and containing marrow; is a little concave(8) in its fore and internal part; and convex in its posterior and external part. Now the fore part is next the breast; the posterior is toward the scapulæ; the internal next the side; and the external at the greatest distance from the side: which distinctions will afterwards appear applicable to all joints in the extremities. The upper end of the humerus is rounder than the other bones, which I have yet mentioned, and _a small part of it_ is inserted into the vertex of the broad bone of the shoulder; the greatest part, standing out of it, is secured by ligaments. But the inferior head has two processes; the intermediate space between which, is even more depressed than its extremities.

This affords a reception to the fore-arm; which consists of two bones. The Radius, which the Greeks call cercis[HY], is the superior one and shorter, and at first being more slender, with its ends round, and a little concave, receives the small tubercle of the humerus, which is secured there by ligaments and a cartilage. The cubitus is the inferior and longer; it is at first larger in its upper end, and by two vertices, as it were, standing out, fixes itself into the sinus of the humerus, which I mentioned, betwixt its two processes. The two bones of the fore arm at first(9) are close together, then separate by degrees, and meet again at the hand, their former proportions being reversed: for there the radius is pretty large, and the cubitus very small. After that the radius rising to a cartilaginous head is inserted into its neck. The cubitus is round at its extremity, and projects a little on one part. And to save frequent repetition, this ought to be known, that most bones end in a cartilage, and that every articulation is thus terminated: for it could neither be moved, unless it pressed upon something smooth, nor be joined with flesh and ligaments, unless these were connected by some matter of a middle nature.

[HY] κερκὶς.

In the hand, the first part of the palm consists of many and small bones, the number of which is uncertain. But all of them are oblong and triangular, and connected together by a peculiar kind of structure, the plain of each one being higher than another alternately; whence it happens, that the whole makes up the appearance of one bone a little concave on the internal part. But from the hand two small processes are lodged in the cavity of the radius. Then at the other end five straight bones going to the fingers, compleat the palm; from which the fingers themselves have their origin. These consist each of three bones. The conformation of them all is the same. The more internal bone has a depression in its vertex, and receives the small tubercle of the external, and these are secured by ligaments. From them arise the nails, which grow hard: and thus they adhere by their roots, not to bone, but rather to flesh. This then is the construction of the superior parts.

But the lower part of the spine ends in the hip-bone, which is transverse, and far the strongest, and defends the womb, bladder, and intestine Rectum. And this in the external part is convex; at the spine inclined backward; on the sides, that is, at the hips themselves, it has round cavities; from whence arises the bone, which is called pecten; and that being situated transversely over the intestines under the pubes, strengthens the belly; it is straighter in men, but in women more bent externally, that it may not prevent the birth.

From these proceed the thigh bones; the heads of which are still rounder than those of the humeri; though the latter have more rotundity, than is found in any of the rest. A little lower they have two processes on the fore and posterior part. From that they descend hard and full of marrow, externally convex, and are again enlarged at the inferior heads. The superior ones are inserted into the cavities of the hip-bone, as the humeri into the bones of the scapulæ; then, lower down, they slope gently inward, that they may more equally sustain the superior parts. And their inferior heads have also depressions between them, that they may be the more easily received by the bones of the leg: which articulation is covered by a small, soft, and cartilaginous bone, which is called Patella. This floating above, and not being fixed to any bone, but bound down by flesh and tendons, and a little more inclined to the thigh bone, defends the joint in all flexures of the legs.

The leg consists of two bones; for in every thing the thigh resembles the arm, and the leg the fore-arm; so that the shape and elegance of the one may be known from the other; which beginning with the bones, answers also in the flesh. One of these bones is situated on the external part of the calf of the leg, and from that properly enough takes the name of Sura(10). This is shorter and more slender above, but is enlarged at the ancles. The other, which is placed in the fore part, and has the name of Tibia, is longer and larger in the upper part, and is alone connected with the lower end of the thigh-bone, as the cubitus is with the humerus: and these bones too, being joined both below and above, separate in the middle, as those of the fore arm.

The leg bones are received below by a transverse bone in the ancle; and that is situated above the heel bone; which in one part has a depression and in another prominences, and it both receives the processes from the ancle-bone, and is inserted into its cavity. And this is hard, without marrow, and projecting more to the posterior part makes a round figure there. The other bones of the foot are constructed in a similar manner to those of the hand. The soles answer to the palms, the toes to the fingers, and the nails to the nails.

CHAP. II.

GENERAL DIVISION OF DISORDERS IN THE BONES. OF A BLACKNESS AND CARIES, AND THEIR TREATMENT.

Whenever a bone is injured, it is either corrupted, or fissured, or fractured, or perforated, or contused, or dislocated. A corrupted bone generally turns first oily, and afterwards either black or carious. These cases happen from large ulcers, or fistulas over them, when they have either grown antient, or have been seized with a gangrene. First of all it is necessary to lay bare the bone, cutting out the ulcer, and if the disorder extends farther than the ulcer was, to pare away the flesh below, till the sound part of the bone be exposed all round; then it is sufficient to cauterize the part that is oily, once or twice, by the application of an iron instrument, that so a scale may cast off; or to scrape it, till some blood appear, which is the mark of a sound bone: for whatever is vitiated must necessarily be dry. The same method must also be pursued in a cartilage that is injured; for that too must be scraped by a knife, till what remains be sound. And then what is thus scraped, whether bone or cartilage, must be sprinkled with nitre well powdered. And nothing else is to be done, where a caries or blackness is in the surface of the bone: for in that case, the cautery or the scraping must only be continued a little longer. A person, that scrapes these, ought to press the instrument boldly, that he may both do it effectually, and have the sooner done. The operation is finished, when we come to the white or firm bone. It is evident, that when the defect is a blackness, it ends in the white, and that where there is a certain degree of solidity, there the caries terminates. We have already observed, that there is also some blood in a sound bone: But when either of these happen to go in pretty deep, it is uncertain where they end.

It is easy to form a judgment in a caries, if a small probe is introduced into the foramina, which by penetrating more or less, shews that the caries is either in the surface, or of greater depth. The same may be collected(11) even from the pain and fever; for when these are moderate, it cannot have penetrated deep. A greater certainty is obtained however by the application of the perforator: for the disease ends, where the dust of the bone ceases to be black. Therefore if the caries has gone deep, several holes must be made in it by the perforator, as deep as the disease goes; then into these holes must be put hot irons, till the bone become entirely dry. For the consequences of this operation will be, that whatever is spoilt will be separated from the bone below; and the cavity will be filled up with flesh; and afterwards either no humour at all, or a small quantity will be discharged.

But if the blackness goes through(12) to the other side of the bone, it ought to be cut out. The same may be done also in a caries, that penetrates to the other side of the bone. But where the whole is spoilt, the whole must be taken away. If the inferior part is sound, so far as is corrupted, ought to be cut out. Likewise if the skull or pectoral bone, or a rib be carious, the actual cautery is needless, but there is a necessity for excision. Neither does the opinion of these people deserve our attention, who defer the excision to the third day after the bone is laid bare, before they cut it out; for in all cases it is safer to perform an operation, before an inflammation come on. Therefore both the skin is to be cut, and the bone laid bare, and freed from every fault, as far as possible, in the same moment. Now a disease in the pectoral bone is far the most pernicious of any; because though the operation have succeeded well, it hardly ever restores a perfect soundness.

CHAP. III.

OF THE USE OF THE MODIOLUS AND PERFORATOR, AND OTHER INSTRUMENTS, ESPECIALLY FOR THE BONES OF THE HEAD.

There are two ways of cutting out a bone; if the part injured be very small, by a modiolus, which the Greeks call chœnicion[HZ], if larger by terebræ. I shall explain the method of each. The modiolus is a concave and round iron instrument with serrated edges in its lowest extremity; through the middle of which is put a pin, surrounded also by an interior circle. Of perforators there are two kinds: one of them resembling that, which carpenters use; the other with a longer head, which begins from a sharp point, and then turns quickly broader; and again from another beginning goes upward with thickness pretty near equal.

[HZ] χοινίκιον. This was the name of a measure among the Greeks, and from its resemblance in shape, they have probably used the same word for this chirurgical instrument; for the same reason, I suppose the Romans have named it _modiolus_. Though I have chosen to retain our author’s term, yet the reader will see the difference is not material betwixt that, and the trepan of our surgeons; the terebra comes so near to the perforator, that I have used the modern term for it.

If the disease be confined to a small space, so that the modiolus can cover it, that must be used preferably. But if a caries appear below, the pin in the middle is put into the opening. If there be a blackness, a small hole is made by the angle of a chisel(13) to receive the pin, that the modiolus resting upon that, by being turned round may not slip, and then it is turned like the perforator by a strap. And there is a certain degree of pressure required, that both a perforation may be made, and it may go round; because if it be lightly impressed, it does not produce the effect; if too much, it has no motion. And it is not improper to drop in a little rose oil or milk, the smoothness of which may make it turn with the greater ease; yet too much of the liquid blunts the edge of the instrument. But when the modiolus has marked out a way for itself, the middle pin is taken out, and it is worked about by itself. And then, when the soundness of the inferior part is discovered by the dust, the modiolus is taken away.

But if the disease is more extended than to be covered by that, we must make use of the perforator. By this a hole is made in the limit, that divides the injured from the sound part of the bone; and not far from that a second, and a third, till the part, that is to be cut out, be surrounded with these holes. And in this case too the dust indicates how deep the perforator is to go. Then a chisel being drove by a mallet from one hole to another, cuts out the intermediate space between them; and thus a circumference is formed like to that, which is imprinted in a smaller circle by the modiolus. In whichever way the circle has been made, let the same chisel, laid flat on the corrupted bone, smooth each superior lamina, till the bone be left entirely sound.

A blackness hardly ever goes quite through a bone, but a caries does, especially where the skull is faulty. There also the disorder is discovered by the probe, which being introduced into the hole, that terminates at the sound part of the bone, both finds some resistance, and comes out moist. If it prove pervious, the probe going in deeper between the bone and the membrane, meets with no resistance, and comes out dry: not because there is no corrupt sanies within, but because it is there diffused, as being in a larger cavity.

Now whether a blackness, which the perforator has discovered, or a caries, which the probe has shewn, pass through the bone, the use of the modiolus is generally fruitless: because, where the disease has penetrated so deep, it must also necessarily be largely extended in breadth. Here then we must use the second kind of perforator above described; and to prevent its growing too hot, it must be dipped now and then in cold water. But then we must proceed with greater caution, when we have perforated either half through in a simple bone, or the superior lamina in a double one. The space itself guides us in the first case; and in the other, the blood. Therefore at that time the strap must be drawn slower, the left hand should press more gently, and be taken off pretty frequently: also the depth of the perforation is to be considered, that we may be sensible whenever the bone is broke through, and run no risque of wounding the membrane of the brain by its point, from which proceed violent inflammations, with danger of death.

When the holes are made, the intermediate spaces must be cut out in the same manner, but with much more circumspection; lest the angle of the chisel chance to wound the same membrane; till a passage be made, through which the instrument to protect the membrane may be introduced. The Greeks call it meningo-phylax[IA]. It is a copper plate, firm, bent a little upward towards the end, and externally smooth: which being introduced in such a manner, that its external surface be next the brain, is put under that part, which is to be separated by the chisel; and if it receives its angles, it stops its progress; and upon this account the physician repeats his strokes upon the chisel both more boldly, and more safely, till the bone being cut out all round is raised by this plate, and may be taken away without any hurt to the brain. When the whole bone is taken out, the edges must be scraped round and smoothed, and if any dust has fallen upon the membrane, it must be gathered up. When the superior part is taken away, and the inferior left, not only the edges, but the whole bone must be smoothed, that the skin may afterwards generate upon it without being hurt, which growing upon a rough bone, does not immediately become sound, but produces new pains.

[IA] Μηνιγγοφύλαξ: the etymology of this word answers exactly to its use: it is delineated by Scultet. tab. 2. fig. 9.

The steps to be taken after the brain is uncovered, I shall mention, when I come to fractured bones. If any base is preserved, medicines not greasy, that are calculated for recent wounds, must be applied, and over them must be laid sordid wool moistened with oil and vinegar. In process of time flesh grows from the bone itself, which fills up the cavity made by the operation. And when any bone is cauterized, it separates from the sound part, and granulations sprout up between the sound and mortified part, which expel what has separated. And this, because it is a thin and small lamina, by the Greeks is called lepis[IB], that is, a scale.

[IB] λεπὶς.

It may happen too, that from a blow, a bone may be neither fissured, nor broke through, but the surface of it only contused, and rendered rough. When this occurs, it is sufficient to scrape and smooth it. Though these methods are most commonly practised in the head, yet they are common to the other bones too; so that wherever the like case shall occur, the same remedy must be used. But as they are fractured, fissured, perforated, and contused, they require some particular methods of cure in each kind, and in most of them, some general ones also. Of these I shall proceed to treat, beginning with the head.

CHAP. IV.

OF FRACTURES OF THE SKULL.

When a blow has been received upon the skull, we must immediately enquire, whether the person has vomited bile; whether he have lost his sight, or his speech; whether blood has issued by his nostrils, or ears; whether he has immediately fallen down; whether he has lain insensible, as if asleep: for these do not happen without a fracture of the bone. And when they occur, we may be assured, that an operation is necessary, but of uncertain success. If besides, a torpor has come on; if he is delirious, if either a palsy, or a convulsion has followed, it is probable that the membrane of the brane too is wounded; and of such patients there is still less hope. But if none of these have ensued, and it may be doubted, whether the bone be fractured, it is first to be considered, whether the blow was given by a stone or a stick, or iron, or any other weapon, and whether _the instrument_ was smooth, or rough, small or large, whether struck with force, or more lightly; because the more gentle the stroke was, so much the more easily we may suppose the bone to have resisted it. But it is best to examine that by a more certain mark. Therefore a probe ought to be introduced where the wound is, neither too small nor sharp, lest if it should light upon any of the natural sinuses, it mislead us into an opinion of a fracture, where there is none; and not too thick, lest small fissures escape it. When the probe comes to the bone, if nothing but what is smooth and slippery occur, one may judge it to be sound; if there is an asperity, especially where there are no sutures, that is an evidence the bone is fractured.

Hippocrates has recorded, that he was himself deceived by the sutures. This is the custom of great men, who have a just consciousness of their own superior abilities: for little minds, because they are deficient in every thing, never allow themselves to be deficient in any. An ingenuous confession of an error is worthy of a great genius, who will have enough besides to entitle him to esteem; and it is especially _laudable_ in a practical art, which is handed down to posterity for their benefit; that they may not be deceived in the same way another was deceived before them. A regard to the memory of a professor, in other respects so great a man, led us into this digression.

Now a suture may deceive for this reason, because it is equal in asperity to the other; so that though there be a fissure, one may readily take it for a suture, in a place, where it is likely one lies below. Therefore it is not fit to be thus deceived; but the safest method is to lay bare the bone: for, as I observed before, the place of the sutures is not certain; and the same part may both have this natural junction, and be fissured by a blow, or may have some fissure near it. Nay sometimes, when the blow has been violent, though nothing be found by the probe, yet it is better to open it. And if even then the fissure is not manifest, writing ink must be drawn over the bone, and then scraped off with a chisel, for if there be any fissure it retains the blackness.

Sometimes it even happens, that the blow has been given on one side, and the bone fissured on the other. For that reason, if upon receiving a violent blow, bad symptoms have followed, and no fissure be found in that part, where the skin is lacerated; it is not improper to consider, whether any part on the opposite side be softer, and swelled; and to open that; for there a fissure in the bone will be found. Nor is it very troublesome to heal the skin again, though nothing has been discovered by the incision. A fractured bone, unless help be seasonably administered, brings on violent inflammations, and is treated with more difficulty afterwards.

Rarely, but sometimes it happens, that the whole bone remains sound; but from the blow some internal vein in the membrane of the brain is broke, and discharges blood, which being coagulated there, raises violent pains, and deprives some people of their sight. But there is generally a pain in the part that covers it, and an incision being made in the skin there, the bone is found pale; and therefore this must also be cut out. Upon whatever account this operation is necessary, if the opening of the skin is too small, it must be enlarged, till all the injured part be in view. In this great care must be taken to leave upon the bone no part of that fine membrane that covers the skull below the skin; because when this is lacerated by the chisel, or perforators, it excites violent fevers with inflammations. Therefore it is better to separate it entirely from the bone. If the external wound be made by the blow, we cannot alter the form of it. If we are to make one, the best is that made by two transverse lines in the shape of the letter X, that afterwards the skin may be cut below, beginning at each of the prominent angles.

If blood is discharged in the time of doing this, it must be frequently restrained by a spunge dipped in vinegar, and taken up by lint applied upon it, and the head raised high. This accident is attended with no danger except among the muscles, which secure the temples; but even in that place there is no safer method.

In almost every fissure, or fracture of the bone, the ancient physicians had immediate recourse to instruments to cut it. But it is far the best method, first to try plaisters that are composed for the skull. Some one of these, it is proper to soften with vinegar, and apply alone upon the fissured or fractured bone; then over that, somewhat broader than the wound, a piece of linen spread with the same medicine, and besides that, sordid wool dipped in vinegar; then to bind up the wound, and open it again every day; and dress it in this manner for five days; from the sixth, to foment it also with the vapour of hot water by a spunge, continuing all the former treatment. And if granulations begin to grow, if the febricula is either gone, or abated, if the appetite has returned, and the patient gets sufficient sleep, we must continue the same dressings. Some time after, the plaister must be softened, with the addition of a cerate made of rose oil, to promote the growth of flesh: for, by itself, it has a repellent quality. By this method often the fissures are filled with a kind of callus, which is as it were a cicatrix in a bone. And in large fractures, if the bones do not cohere together in any part, they are united by the same callus; and this is a far better covering to the brain, than the flesh that grows, when the bone is cut out. If, under the first treatment, the fever increases, the sleeps are short and disturbed by dreams, the ulcer is moist and does not fill, small glandular swellings rise in the neck; the pains are violent; and with all these the loathing of food increases; then, and only in that case, recourse must be had to the hand and the chisel.

There are two dangers attending a blow upon the skull; that it be either split, or depressed in the middle. If it is fissured, the lips of it may be compressed; either because one of them rises above the other, or even because they have run together again with force: whence it happens, that a humour descends upon the membrane, and has no vent, and thus irritates it, and brings on violent inflammations.

When the bone is depressed in the middle, it presses upon that same membrane of the brain; and sometimes also some sharp points from the fracture, prick it. In the cure of these cases as little as possible must be taken off the bone. Therefore, if one edge rests upon the other, it is sufficient to cut off the prominence with a plain chisel. After that is removed, if the fissure gapes a little, it is enough for the cure. But if the edges are compressed together, an opening must be made with the perforator, at a finger’s breadth distance on one side, and from that the chisel must be carried in two lines, to the fissure, in the form of the letter Λ: so that the vertex of it may be at the opening, and the base at the fissure.

But if the fissure extends to a great length, it will be proper to repeat the operation from another foramen; and thus nothing that is broke off can be concealed under the bone, and a large opening is procured for whatever is hurtful within. Nor is it necessary to cut out the whole of a fractured bone, though it be depressed; but if it be either entirely broke through, and has separated wholly from the cranium, or if it adhere to _the surrounding skull_ in a small part, it must be divided from the sound bone by the chisel. Then in the depressed bone, near the fissure we have made, holes must be bored; if the injured part be small, two; if larger, three; and the spaces betwixt these must be cut out; and then the chisel must be drove on both sides to the fissure, in such a manner as to make a semicircular cavity, and let the middle part be toward the fracture, and the horns point to the sound bone. Then if any pieces be loose, and can be easily taken away, they must be removed by the forceps, which is made for that purpose, especially those sharp pieces, which irritate the membrane. If this cannot be easily done, the plate, which I called meningo-phylax, must be put below it; and above that whatever is prickly, and stands inward, must be cut off; and whatever is depressed inward must be raised by the same plate. The effect of such treatment is, that the fractured bones, if they adhere together in any part, may be consolidated; and wherever they are broke away, in time they may be separated by medicines without any pain; and at the same time a space may be left sufficiently large between them, to evacuate the sanies; and the brain may have a better protection from the bone than it would have had, if that were cut out.

After these things are done, the membrane must be sprinkled with sharp vinegar; that, if there be a discharge of blood from it, it may be restrained, or if any blood remain coagulated within, it may be discussed; then the same medicine must be applied, softened in the manner above prescribed, to the membrane itself; the other directions, which relate to the linen spread, and the sordid wool, must be observed in the same manner, and the patient must be kept in a warm place, and the wound dressed every day; and in summer even twice.

But if, by reason of an inflammation, the membrane has swelled, warm rose oil must be infused upon it. If it shall swell to such a height as to rise above the bones, it will be restrained by lentils well powdered, or vine leaves powdered, and mixed with either fresh butter, or recent goose fat; and the neck will require to be mollified by liquid cerate made of iris ointment. But if the membrane shall appear not to be clean, equal quantities of the plaister and honey must be mixed; which must be infused upon it; and to keep that on, a piece of lint or two must be clapped on, and that again covered with a linen cloth spread with a plaister. When the membrane is sufficiently clean, cerate must be added in the same manner to the plaister to promote the growth of flesh.

As to abstinence, and the food, and drink, in the first and more advanced stages of the cure, the same rules must be observed which I prescribed in wounds, and with the greater exactness, by how much a hurt in this part is more dangerous. Nay even when it shall be fit to allow such a quantity of food as not barely to sustain the patient, but to nourish him, yet every thing that requires chewing must be avoided; also smoke, and whatever excites sneezing. The membrane being moveable, and of its natural colour, granulations of ruddy flesh, and an easy motion of the lower jaw and neck, afford certain hopes of recovery. The bad signs are, the membrane immoveable, black, livid, or of any other vitiated colour; a delirium, acrid vomiting, a palsy, or convulsion, livid flesh, or rigor of the jaws and neck. The other symptoms that relate to sleep, appetite, fever, and the colour of the pus, are either salutary or mortal, as in other wounds.

When the case succeeds well, the growth of flesh begins from the membrane itself; or if the bone in that part be double, it sprouts from thence too, and fills up the void space between the bones; sometimes it even rises higher than the surface of the skull. If that happens, copper scales must be sprinkled on to keep it down; and medicines applied to bring a cicatrix over it, which is easily obtained in every place, except the part of the forehead, which is a little above the space that lies between the eyebrows (_sinus frontalis_): for there, an ulceration for the whole life after, can hardly be prevented; this must be covered with a linen cloth spread with a medicine. And the following directions must be always observed in a fractured skull, that till the cicatrix be strong, the sun, wind, frequent bathing, and excess in wine be avoided.

CHAP. V.

OF FRACTURES OF THE NOSE.

In the nose, both the bone and the cartilage are liable to be fractured; and that sometimes happens in the fore part, sometimes on one side. If either both, or one of them be fractured in the fore part, the nostrils fall in, and the breath is drawn with difficulty. If the bone is fractured on one side, that part is hollow; if the cartilage, the nostrils are turned to the opposite side.

Any part of the cartilage, that has given way, must be gently raised, either by a probe put under it, or two fingers compressing it on both sides; then lint platted of a due length, sewed up in soft leather, must be put within; or some part of a dry penecillum composed in the same manner; or a large quill dipped in gum or joiner’s glue, and covered with soft leather, which prevent the cartilage from sinking in. But if the fracture be in the fore part, both nostrils are to be equally filled. If on one side, what is put in ought to be thicker in that part where the nose falls in, and smaller on the other; and externally, a soft strap must be carried round, the middle of which is spread with fine flour and soot of frankincense mixed together; and this must be drawn beyond the ears, and the two ends being crossed there and returned, are to be glued to the forehead: for it sticks to the skin like glue, and when it has grown hard, it keeps the nostrils firm. But if what is put within gives pain, which happens chiefly where the interior part of the cartilage is broke through, the nostrils being raised in the same(14) manner, must be only held firm by the strap abovementioned; then, after fourteen days, that must be removed; it is to be separated by hot water, with which also the swelled part(15) must be fomented every day.

But if the bone be fractured, that must also be reduced into its place by the fingers; and when the fracture is in the fore part, both nostrils must be filled; when on the side, that to which the bone has been forced; cerate also must be applied, and it is to be bound down a little more tightly; because in that part, there not only grows callus enough to make it sound, but even to form an eminence. From the third day, it must be fomented with hot water, and the more so, the nearer it may be expected to approach a sound state. And if there be several small pieces in the fracture, nevertheless each of them _that are beat in_, must be forced into its place by the fingers: also the strap must be applied externally, as before directed; and over that a cerate, without any other bandage.

But if any fragment be separated all round, and will not be united with the rest, as may be known from the humour, which will be discharged in great quantity from the wound, it must be extracted by a vulsella; and when the inflammation is gone, some one of those medicines that are gently repellent, must be applied. The case is worse, when besides a fracture of the bone, or cartilage, there is also a wound in the skin. This very seldom occurs. When it does happen, they must nevertheless be raised to their place in the same manner; and upon the skin must be laid some one of these plaisters, that are adapted to recent wounds: but no bandage must be applied over it.

CHAP. VI.

OF FRACTURES OF THE EARS.

Sometimes the cartilage of the ear is broke. When this happens, an agglutinating medicine must be applied, before a suppuration begins; for that often prevents it, and heals the ear. Both here and in the nose, it should be understood, that the cartilage itself is not re-united, but that the flesh growing round it consolidates the part; and therefore, if, together with the skin the cartilage is broke, the skin is sewed on both sides; but I now speak of the cartilage fractured, when the skin is entire. If pus then is already formed, the skin must be opened on one side, and over against the incision, the cartilage itself must be cut in a lunated form; then a gentle styptic must be used; such as lycium diluted with water, till the bleeding be stopped; after that a plaister that is not greasy, spread upon linen, must be laid on, and soft wool put behind the ear, to fill up the space between that and the head; then it must be fastened by a gentle bandage; and from the third day fomented with warm water, as I directed for the nostrils; and in these kinds of accidents, at first abstinence is necessary, till the inflammation be gone.

CHAP. VII.

OF A FRACTURED MAXILLA, TOGETHER WITH SOME GENERAL OBSERVATIONS RELATING TO FRACTURES.

As I am to proceed from these parts to the lower jaw, I think it proper to insert some observations relating to all the bones in general, to prevent a frequent repetition of them. Every bone then is sometimes split longitudinally, like wood, sometimes is fractured transversely, sometimes obliquely; and in this last species the ends are sometimes blunt, sometimes acute, which last is of the worst kind; because they are not easily united, where they do not rest upon something obtuse, then they also wound the flesh, and sometimes a nerve or a muscle: moreover, one fragment sometimes happens to be divided into several. In fractures of the other bones, one end often recedes entirely from the other; but the broken ends of a jaw-bone remain always in contact in some one part.

Therefore, first the bones are to be forced into their place, by two fingers pressing on each side, both within the mouth and upon the chin; then if the fracture of the jaw-bone be transverse, (in which case one tooth generally stands out beyond that next to it) when it is reduced, the two contiguous teeth, or if they are loose, those next to them, must be tied together by a horse-hair. In a different kind of fracture this is needless. All the other steps are the same _as in the above-described fractures_; for a double linen cloth dipped in wine and oil must be laid upon it, and with that fine flour, and the soot of frankincense; then a roller or soft strap, with a longitudinal opening in the middle, that it may take in the chin both above and below; and lastly, the ends of it must be brought over the head and tied there.

With regard to the bones in general, it may further be remarked once for all, that fasting at first is necessary; then from the third day moist food; when the inflammation is removed a little fuller diet and such as promotes the growth of flesh; wine is hurtful through the whole time. On the third day, they ought to be opened, and fomented with the vapour of hot water by a spunge, and the same dressings, as at first, are to be put on; this to be repeated on the fifth day, and so on, till the inflammation is gone, which ceases, either on the ninth day, or generally on the seventh: when that is removed, the bones must be examined again, that if any fragment is not in its place, it may be reduced, and the bandage must not be taken away, till two thirds of the time have elapsed, in which the several bones unite.

Now, generally between the fourteenth and twenty-first day, the following bones heal: the lower jaw, cheek-bone, clavicle, breast-bone, scapula, ribs, the spine at the hips, the ancle-bone, heel, hand, and foot; between the twentieth and thirtieth, the bones of the leg and fore arm; between the twenty-seventh and fortieth, the arm and thigh bones.

But concerning the lower jaw-bone I must add, that the case requires the long use of a liquid diet. Also far a considerable time pancakes and such like must be continued, and nothing be chewed, till the callus has perfectly restored the strength of the bone: and for some days, at first, the patient must not speak at all.

CHAP. VIII.

OF A FRACTURED CLAVICLE.

The clavicle, if it be fractured transversely, sometimes unites very well of itself, and if it be not moved, may do well without a bandage; but sometimes, and especially when it is moved, it slides away; and generally the part next the breast lies over, and behind that next the humerus. The reason of which is, that it does not move by itself; but complies with the motion of the humerus: therefore, this standing still, the humerus is moved upon it. That part of the clavicle, next the breast, very seldom lies on the forepart; insomuch that men of great character in the profession have told us they never met with it; but the authority of Hippocrates is sufficient to put the fact beyond dispute.

However, as these cases are dissimilar, so each requires a treatment somewhat different from the other. When the clavicle flies back towards the scapulæ, the humerus must be pushed backward by the palm of the right hand, and at the same time the clavicle itself be brought forward. When turned to the breast, this must be forced backward, and the humerus brought forward; and if the humerus fall below the other, that part of the bone next the breast must not be depressed, because it is immoveable; but the humerus itself must be raised; but if it rise higher, the part next the breast must be filled with wool, and the arm bound down to the breast. If there be sharp pieces in the fracture, an incision must be made in the skin over it; and any parts of the bone, that wound the flesh, must be cut off; then the blunted bones must be brought together; and if there be a prominence any where, it must be kept down by a linen cloth, three times folded, dipped in wine and oil: if there be several fragments, they are to be covered with a splint, the inside of which is to be smeared with wax, lest the roller should slip on one side. The roller must be bound over the clavicle, when reduced, rather often than tight: and this rule holds in all fractures. In a fracture of the right clavicle, the bandage ought to pass from it to the left arm-pit; if, of the left _clavicle_, to the right; and again under the arm-pit of the affected bone: this done, if the clavicle be inclined toward the scapula, the fore-arm must be tied to the side; if forward, to the neck; and the patient laid on his back. All the other directions given before must be observed.

Now there are several bones that have very little motion, and are either hard, or cartilaginous, which are liable to be fractured, or pierced, or bruised, or fissured, as the malae, the breast-bone, scapula, ribs, spine of the hips, ancle-bone, heel, hand, and foot. The method of cure is the same in all these. If there is an external wound, that must be dressed with the medicines proper for it. While the wound is healing, a callus also fills up the fissures of the bone, or any vacuity that may be in it. If the skin is entire, and from the pain we infer that the bone is injured, there is nothing else to do but rest; and cerate must be applied, and tied on gently, till the pain is removed by the bone becoming sound.

CHAP. IX.

OF FRACTURES OF THE RIBS AND SPINE.

But there are some peculiarities to be observed relating to the ribs; because they are near the viscera, and that part is exposed to great dangers. A rib then is sometimes fissured in such a manner, that not the exterior surface of the bone, but the interior part of it, which is thin, is hurt; sometimes it is broke entirely through. If the whole is not fractured, there rarely follows either a spitting of blood, or a febricula, or any suppuration; and the pain is not great; however the place is slightly pained upon being touched. But this case requires no more than to do what is above directed; and in binding it up to begin at the middle of the roller (_a double-headed roller_) lest it draw the skin to either side. After the twenty-first day, when the bone ought to be united, we must endeavour, by a more plentiful diet, to render the body as plump as possible, that it may cover the bone the better; which being yet tender is in that part exposed to injuries under a thin skin. And through the whole time of the cure, vociferation must be avoided, and even speaking, hurrying, anger, all violence of motion, smoke, dust, and whatever excites either coughing or sneezing; and it is not even proper to hold in the breath much.

But if a rib be entirely broke through, the case is more troublesome: for both violent inflammations, and a fever and suppuration, and often a danger of death ensue; and a spitting of blood. Therefore, if the strength admits, blood must be taken from the arm of the same side with the rib; if it does not allow this, a clyster must be given, but without any thing acrid; and the patient must fast a considerable time. He must not eat bread before the seventh day, but live upon gruel alone; and upon the part must be applied cerate made of lycium, with an addition of boiled resin; or the malagma of Polyarchus; or cloths squeezed out of wine, rose oil, and common oil; and over these soft sordid wool, and two double-headed rollers, but not tight. What I mentioned before as hurtful, are in this case to be avoided with greater caution; so that even the breath must not be too often fetched. But if a cough be troublesome, a potion must be taken for it, either of germander, or rue, or the herb staechas, or of cummin and pepper. When there are severe pains, it is proper to lay on a cataplasm either of darnel or barley, with an addition of a third part of mellow figs. And this must lie on in the day time; but in the night, either cerate, or a malagma, or cloths; because the cataplasm may drop off. Therefore it must be opened every day, till such time as we may be content with the cerate or malagma. And for ten days the body must be reduced by fasting; from the eleventh we must begin to nourish it; and therefore the bandage about it must be more lax than at first; and generally this method is continued to the fortieth day.

In the course of which, if there be any fear of a suppuration, the malagma will be more effectual to discuss it than cerate. If, notwithstanding, the suppuration take place, and cannot be discussed by the medicines prescribed before, no time must be lost, lest the bone below be affected; but in the part where it shall swell most, a hot iron must be introduced, till it reach the pus, which must be evacuated. If a tumour does not appear any where, we may discover where the pus is principally lodged in this manner. We must rub all the part with Cimolian chalk, and suffer it to dry; and wherever the moisture shall penetrate deepest, there the pus is nearest to the skin; and here the actual cautery is to be used. If there shall be a pretty large abscess, it will require two or three perforations; and lint to be put into them, or some part of a penecillum; which may be tied by a thread at the top, that it may be easily drawn out. What remains to be done is the same as in other burns. When the ulcer shall be clean, the body must be nourished, lest a consumption follow, which would be fatal. Sometimes too, when the bone is more slightly affected, and neglected at first, not pus, but a certain humour like mucus is collected within, and the skin over it grows soft; in which case, we must use the cautery in the same manner.

[Sidenote: _Fracture of the spine._]

There is also something peculiar to be noted in the spine: for if any part has separated from a vertebra, or is any way broken(16), the part becomes hollow; prickings are felt there, because these fragments must necessarily be jagged: whence it happens, that the patient now and then leans forward. These are indications of the case; and the same medicines are necessary, which have been mentioned in the first part of this chapter.

CHAP. X.

OF FRACTURES OF THE HUMERUS, FORE-ARM, THIGH, LEG, FINGERS, AND TOES.

The cases which occur in the arms and thighs, and their methods of cure, are in a great measure similar. There are also some general things that belong equally to the arms, fore-arms, thighs, legs, fingers, and toes; for a fracture in the middle of these is least dangerous; but the nearer the fracture is, either to the superior or inferior head, so much the worse: for it both creates greater pain, and is more difficult to cure. Of fractures, the most innocent is a simple transverse one; worse, where it is oblique, and where there are fragments; worst of all, when these are sharp. Sometimes the bones in these parts being fractured, continue in their places: but they much more frequently give way, and one part lies over the other. This circumstance ought to be first of all considered; and there are certain marks for knowing it. If they are displaced, they are bent, and cause the sensation of pricking, and are unequal to the touch. But if they meet one another, not directly, but obliquely (which happens, when they are not in their place) that limb is shorter than the other, and the muscles of it swell.

Therefore, if this is found to be the case, it is proper to extend the limb immediately: for the tendons and muscles being _in a natural state kept_ stretched by the bones, are _in this case_ contracted; neither do they return to their place, unless they be extended by force. Again, if that is neglected for some days at first, an inflammation comes on, during which, it is both difficult and dangerous to use violence to the tendons; for there follows a convulsion or gangrene; or at least, which is the mildest of the bad consequences, a suppuration; therefore, if the bones have not been replaced before _the inflammation_, they must not be reduced till after it is gone. Now one person alone may extend a finger, also any other member, if it be of a child, by taking hold of one part with his right hand, and the other with his left. A stronger limb requires two to pull different ways. If the tendons are very firm, as is the case in robust men, and chiefly in their thighs and legs, the ends of the joints on both sides must be tied with straps, or linen rollers, and pulled contrary ways by several persons; and when this force has stretched the limb a little beyond its natural length, then the bones must be pressed by the hands into their place; and the sign of a bone’s being reduced, is the removal of the pain. The limb being made equal with the other, must be wrapt up in cloths two or three times doubled, dipped in wine and oil; for which purpose linen is best.

Six bandages are generally required. The first to be applied is the shortest; which should be rolled about the fracture(17), and ascend spirally like a screw; and it is sufficient for it to go round in this manner thrice. The second is one half longer than this; which, if the bone project in any part, must begin there; if it be every where equal, it may begin any where upon the fracture, and go in an opposite direction to the former, tending downwards, and returning again to the fracture, end in the upper part beyond the former bandage. Over these must be laid cerate, upon a broad piece of linen, to keep them on. And if the bone is prominent in any part, a cloth, three times doubled, moistened in the wine and oil before mentioned, must be laid upon it. These are to be secured by a third and a fourth bandage, in such a manner, that the following move always in a contrary direction to the former, the third alone must end in the lower part, and the other three in the superior; because it is better to make several convolutions, than to bind it tight; for a strict bandage disorders a part, and makes it liable to a gangrene. We ought to bind an articulation as little as possible; but if the fracture of the bone is near the joint, there is a necessity for it.

When the limb is bound up, it must be kept so to the third day, and the bandage should be such, as on the first day not to hurt _by its stricture_, and yet not to seem lax; on the second it should be a little laxer; the third almost loosened. Therefore, the limb must then be bound up again, and a fifth roller must be added to the former; after which it must be again opened on the fifth day, and then secured by six rollers, in such a manner, that the third and fifth may end below, and the rest above. As often as the limb is opened, it must be fomented with hot water. But if the fracture be near a joint, wine, with the addition of a small proportion of oil, must be dropped upon it for a long time, and all the other directions observed, till the inflammation leave it, or the limb become smaller than ordinary: which, if it does not happen on the seventh day, will certainly be effected by the ninth. Then the bones are handled with great ease.

Therefore, if they are not well joined to each other, they must be set again; and if any fragments rise above the rest, they must be reduced into their places, and then the limb must be rolled up in the same manner, and splints be fitted round it, to keep the bones in their places. And on that side, to which the fracture inclines, a broader and stronger splint must be applied. About a joint all these should turn outward, that they may not hurt it, and be bound no tighter than is necessary to secure the bone: as they grow laxer in time, they must be a little tightened every third day by their straps; and if there be no itching nor pain, continue so, till two-thirds of the time be compleated, in which each of these bones unites; afterwards, it is to be bathed more gently with hot water; for at first it is necessary to dissipate the humours, and afterwards to make them transpire. Therefore it must also be anointed lightly with liquid cerate, and the surface of the skin rubbed; and the fracture be bound up more loosely. It must be opened every third day, and all the applications be repeated, except the hot water; only one of the rollers, as often as it is loosed, must be withdrawn.

[Sidenote: _Of a fractured humerus._]

The foregoing rules are general; the following peculiar to each bone. If the humerus be fractured, the extension must not be made as in another limb; but the patient is placed in a high seat, and the physician in a lower one opposite to him. Then the patient’s fore-arm is to be supported by a bandage passed round it, and fastened behind the neck. _This done_, a second bandage, _with two heads_, is to be rolled round the upper part of the humerus, and have its two ends tied into a knot above the head. Lastly, a third bandage of the like kind is to be fastened to the lower part of the humerus, and carried downwards, its two ends being also tied together. Then, from behind the patient’s head, an assistant stretching his own arm _through the loop of_ the second mentioned roller, his right, if the right humerus is to be extended, his left, if the left _humerus_, takes hold of a stick placed between the patient’s thighs; the physician also sets his right foot, if he be to operate upon the left humerus, his left, if upon the right, on the third of these rollers; and at the same time the assistant raises the one roller, and the physician depresses the other; by which means, the humerus is gently extended. If the fracture be in the middle or lower part of the bone, shorter rollers are required; if in the superior, longer; so that they may be extended from thence over the breast, under the other arm-pit to the shoulders. In binding it up, the fore-arm must be so inclined, and the affected part put into such a position by the bandages, that the suspending of the forearm afterwards, do not turn the humerus any other way, than when it was bound up. And the fore-arm being hung, the humerus is to be also gently tied down to the side; by which means it will be prevented from moving, and therefore the bones continue as they have been set. When we come to the application of splints, these ought to be longest on the external side, shorter on the fore-part, but shortest of all under the arm-pit. And when the humerus is fractured near the cubitus, they must be pretty often removed, lest the tendons there grow rigid, and the fore-arm be rendered useless. Whenever they are removed, the fracture must be held in the hand; and the cubitus fomented with hot water, and rubbed over with soft cerate; and splints must either not be put upon the processes of the cubitus at all, or they must be somewhat shorter _than the others_.

[Sidenote: _Of a fracture of the fore-arm._]

But if there is a fracture in the fore-arm, it must be first of all considered, whether one bone or both be broken: not that there is any different method of cure to be used; but first that the extension may be the stronger, if both bones be fractured, because the tendons must necessarily be less contracted, when one of the bones is entire, and keeps them upon the stretch; in the next place, that every thing which relates to securing the bones, may be done with the greater accuracy, if one of them does not help the other: for where one is unhurt, it helps more than rollers and splints. The fore-arm ought to be tied up with the thumb turned a little toward the breast; for that is the most natural posture of the fore-arm: and after the bandages are put on, it is best held in a scarf, the full breadth of which is under the fore-arm, with its ends, which are very narrow, fixed over the neck; thus the arm is conveniently suspended from the neck, and ought to hang a little higher than the other elbow.

But if any part of the top of the cubitus be fractured, it is improper to secure it by bandages, because the fore-arm becomes immoveable. And if means only are found(18) to remove the pain, it remains as useful as before.

[Sidenote: _Fractures of the thighs and legs._]

It is of equal importance in the leg for one of the bones to continue entire. Both in this and the thigh it is fit after binding it up to put it in a box. This box ought to have holes below, through which any humour that is discharged, may descend; and at the foot a prop, which may both sustain, and not suffer it to slip; and holes in the sides, through which straps being past, some bars[IC] may keep the leg and thigh in their position. If it be a fracture of the leg, this ought to reach from the foot to the ham; if of the thigh, as far as the hip; if near the head of the thigh-bone, so as that the hip likewise may be within it. We ought not to be ignorant, however, that a fractured thigh becomes shorter, because it never entirely returns to its former state; and that the person ever after supports himself upon his toes in that foot, which occasions great weakness; however it is much worse, where the misfortune has been encreased by neglect.

[IC] morae.

[Sidenote: _Fractures of the fingers._]

It is sufficient to bind a finger to one small twig, after the inflammation is gone.

[Sidenote: _General rules._]

The foregoing directions are confined to the cases relating to particular limbs; the following are general: fasting for some days at first; then when the callus is growing, a pretty full diet; long abstinence from wine; plentiful fomentations of hot water, while the inflammation continues; when that has ceased, they must be more sparing; lastly, a pretty long but gentle rubbing of liquid cerate into the more remote parts. Nor must the limb be immediately put upon exercise, but by degrees returned to its former motions.

The case is a good deal worse, when, besides the fracture of the bone, there is also a wound in the flesh; and particularly if that happen in the muscles of the thigh or arm: for the inflammations there are much greater, and they are more liable to gangrenes. And generally, where the bones of the thigh have slipped past each other, it is necessary to cut it off. The arm is also endangered in the same circumstances, but is more easily preserved. And these dangers are still more to be apprehended, if the fracture be near the joints: therefore, such a case must be treated with more care, and the muscle must be cut through transversely over the middle of the wound; and if the hæmorrhage has been but small, the patient must be bled, and extenuated by fasting for ten days. And though the other limbs may be extended slowly, and the bones reduced gently to their place; yet in these it is not quite expedient either to extend the tendons, or handle the bones. And the patient must be allowed to keep them in the position that is easiest to him. To all such wounds must be applied, at first, lint dipped in wine, with an addition of a very little rose oil: the other management is the same as above recommended. They are to be bound up with rollers broader(19) than the wound; which must be applied looser, than if there was not a wound there; and as the wound is more liable to corruption and a gangrene, we are by a number of rollers to manage it so, that though they are slack, they may keep the bones firm.

This method may be followed in the thigh or arm, provided the bones have chanced to return to their proper place; but if they be in any different situation, they must only have such a bandage, as will keep on the medicine that is applied. The other directions I gave before must be observed: except that neither splints nor boxes be used, with which the wound cannot heal; but only more and broader rollers are necessary; and both hot oil and wine must be poured upon them now and then; more frequently the latter. At the beginning the patient must fast; the wound must be bathed with hot water; he must avoid the cold; and recourse must be had to medicines for promoting digestion of the wound, and more care must be taken of the wound than the bone: for that reason it must be opened every day and dressed.

In the mean time, should any small fragment of the bone project, if it be blunt, it must be reduced into its place; if sharp, its point, when long, must first be cut off, when short, filed, and in either case smoothed with a chisel; and then it must be returned in again. And if that cannot be done by the hand, a vulsella, such as workmen make use of, must be applied with that part(20) which turns inward to the sharp point of the bone, that by its convex part the prominent bone may be thrust into its place. If it be too large, and covered by small membranes, we should allow these to be dissolved by medicines, and when the bone is laid bare, cut it off; which is to be done pretty early, and afterwards, in this method we may let the bone unite and the wound heal; the first in its proper time, and the other as the circumstances admit.

Sometimes too it happens in a large wound, that some fragments as it were mortify, and do not unite with the rest. This may be discovered from the quantity of discharge; which makes it necessary to open the ulcer oftener than it is dressed; and the consequence generally is, that this bone, after some days, of itself falls off; otherwise, though the condition of the wound is miserable enough before, that often encreases it, and makes it more tedious of cure. The bone too is often broken away, when the skin is entire, and immediately an itching and pain come on. Wherefore, if that happens it is proper to open it the sooner, and bathe it in the summer time with cold water; and in the winter with water just warm; and then apply myrtle cerate.

Sometimes, the fracture, by some points like prickles, irritates the flesh: which being discovered by the itching and prickings, the physician must open it, and cut off these points. The other part of the cure is the same in both these cases as in a recent wound. When the ulcer is clean, nourishing food must be taken. If the limb is still too short, and the bones are not in their places, a wedge of the smallest and smoothest kind must be put in between them with its head standing out a little, and the thick part of it must be driven farther in every day, till that limb be equal to the other. Then the wedge must be taken out, and the wound healed up. When a cicatrix is brought on, it must be bathed with a decoction of myrtle, ivy, and other like vervains, cold, and a drying medicine applied upon it; and in this case, there is a greater necessity for rest, till the limb recover its strength.

When the bones happen not to unite, because they have been often opened, and often moved, the method of cure is obvious; for they may unite. If the fracture be of long standing, the limb must be extended, to create a fresh injury; the bones must be separated from one another by the hand, that their surfaces may be roughened by rubbing against each other, and if there be any fat substance, it may be abraded, and the whole of it become as it were recent: great care, however, must be taken not to wound tendons or muscles. Then it must be bathed with a decoction of pomegranate bark in wine; and the same mixed with the white of eggs, must be applied to it; on the third day it must be opened, and bathed with a decoction of the vervains abovementioned: which must be repeated on the fifth day, and splints put round it; the other steps, both before and after, which I directed already, must be taken in the same manner. However, sometimes the bones unite obliquely(21); and thus the limb becomes both shorter and deformed, and if the ends are pretty sharp, continual prickings are felt: for this reason the bones ought to be fractured again, and put in a proper direction. It is done in this manner. The limb is fomented with plenty of hot water, and rubbed over with liquid cerate and extended; in the mean time, the physician handling the bones, the callus being yet tended, separates them by his hands, and forces the part that projects, into its place: and if that is not effectual, on that side, to which the bone inclines, he puts a regula wrapped up in wool; and by thus binding it up brings it to a habit of lodging in its former place.

Sometimes also, though the bones have united as they should do, too large a callus grows upon them; and therefore the part is swelled. When this happens, the limb must be rubbed gently for a long time, with oil, salt and nitre, and bathed with plenty of salt water; a discutient malagma must be applied; and a tight bandage put on; and the patient must eat herbage, and take vomits; by which course, the callus is reduced together with the flesh. Some good is done by an application of mustard and a fig upon another limb, till it corrode a little, and derive the matter to that part. When the tumour is lessened by these means, the person may return to his ordinary course of life.

CHAP. XI.

OF LUXATIONS.

Thus far then we have treated of fractures. Now the bones are dislocated in two ways. For sometimes those that are joined together, separate from each other, as when the broad bone of the scapula recedes from the humerus(22), and in the fore-arm the radius from the cubitus, and in the leg, the tibia from the fibula, and sometimes in leaping the heel-bone from the ancle; which last, however, seldom happens. Sometimes the articulations are displaced. I shall speak first of the former.

When such an accident happens, the part is immediately hollow, and by pressing upon it with the finger one feels a cavity. After that, a violent inflammation comes on; and particularly in the ancle; for generally it occasions fevers and gangrenes, and either convulsions, or contractions, which draw the head down upon the shoulders. To avoid which, the same method must be followed here, as in injuries of the moveable bones. And whenever it happens, the medicines prescribed before must be laid on these parts to remove the pain and tumour: for bones once separated in this manner never come together again; and though some degree of comeliness be attainable in the part, yet it is of no use(23).

But the lower jaw and the vertebræ, and all the joints, though they be secured by strong ligaments, are luxated by the force of a blow, or when the ligaments are either ruptured, or some way weakened; and more easily in children or lads, than in those that are more robust. And they slip out forward and backward, and inward and outward; some of them in all these ways, others in particular ways. And there are some general signs belonging to all, others peculiar to each one: for there is always a tumour in that part, to which the bone is propelled, and a cavity in that from whence it recedes. Now these marks are common to them all; the others peculiar to the several bones will be mentioned, when I speak of each case distinctly.

But though all the articulations may be dislocated, they cannot be all replaced; for the head is never reduced, nor a vertebra in the spine, nor a jaw-bone, which being out on both sides, has raised an inflammation before it could be returned. Again, those that slip out from the fault of the ligaments, when they are forced into their places, give way again. And those that have been dislocated in childhood, and have not been reduced, grow less than the rest: and the flesh of all these that are not in their place, is decayed, and more so in the member nearest to it, than in one beyond it. For instance, if the humerus is not in its place, the arm wastes more than the fore-arm, and that more than the hand. Then according to the situations, and the nature of the accidents, there is left either more or less use of the limb; and the more use remains of it, the less it is wasted.

Now whatever is dislocated should be reduced before an inflammation begin. If that has already seized it, till it cease, it must not be meddled with; after its removal, trial must be made in such limbs as are reducible. A great deal depends upon the habit both of the body and the ligaments: for if the body be slender, or humid, or if the ligaments be weak, the bone is more quickly reduced; but it is both more liable to dislocation, and is less firmly held after it is reduced(24). Bodies of the contrary qualities hold it faster in its place; but when once forced out, admit of its return with difficulty. It is proper to alleviate the inflammation by applying sordid wool squeezed out of vinegar; and if the misfortune be in a strong articulation, to abstain from food for three, and sometimes even five days; to drink warm water till the thirst be gone; to observe these rules more strictly in luxations of those bones, that are held by strong large muscles; and much more so if a fever has ensued; on the fifth day to foment with hot water; and taking away the wool, to apply cerate made of Cyprine oil, with the addition of nitre, till the inflammation be entirely removed. Then it is proper to use friction to the limb; to take food of good juices, wine in moderate quantity; and by this time, to make some use of the limb: because motion, as it is extremely hurtful in pain, so it is very salutary when the pain is removed. These observations are general; I shall now treat of the particular cases.

CHAP. XII.

OF A LUXATED MAXILLA.

In a dislocation of the lower jaw it is pushed forward, but sometimes on one side, sometimes on both. If on one side, it inclines together with the chin to the contrary side, the teeth do not answer to each other, but the canine teeth below are opposite to the incisores: if on both sides, the chin leaves its place, and is protruded to the external part; and the lower teeth come farther out than the upper; and the muscles of the temples appear tense. The patient, as soon as possible, must be placed in a seat in such a manner, that an assistant may secure his head behind; or he may be seated near a wall, putting a hard leather cushion between the wall and his head, and let his head be pressed upon the cushion by an assistant, that it may be kept the steadier; then the thumbs of the physician being wrapped up with linen cloths, or rollers, that they may not slip, must be introduced into his mouth; and the fingers must be applied externally. When the maxilla is firmly grasped, if the luxation be on one side, the chin must be shaken, and brought towards the throat; then at the same time his head must be held, and the chin being raised, the maxilla forced into its place, and the mouth shut; and all this must be done almost in the same instant. But if the luxation be on both sides, the same method must be taken; but the jaw-bone must be forced back equally on both sides. When the bone is replaced, if the case was attended with a pain of the eyes and neck, blood must be taken from the arm. And as liquid food at first is proper for all persons, whose bones have been dislocated, so particularly in this circumstance; where even frequent speaking, by the motion of the mouth, hurts the nerves of the temples(25).

CHAP. XIII.

OF A LUXATION OF THE HEAD.

In the first part of this book, I have already observed, that the head is secured upon the neck by two processes received into two depressions of the upper vertebra. These processes are sometimes dislocated toward the posterior part; the consequence of which is, that the nerves below the occiput are extended, the chin is fixed upon the breast, and the patient can neither drink, nor speak, and sometimes discharges his semen involuntarily. Such patients die very quickly. I judged it necessary to mention this case, not because there is any cure for it; but that it might be known by its symptoms, and if any should lose a friend in this way, they might not think it was for want of a physician.

CHAP. XIV.

OF A LUXATION IN THE SPINE.

The same misfortune attends those, whose vertebræ of the spine are luxated. For this cannot happen, unless both the medulla, which passes through the middle, and the two membranes, that go through the two processes on the sides, as also the ligaments, that secure them, be ruptured. They are dislocated both backward, and forward; both above and below the transverse septum. As they slip the one way or the other, there will be either a swelling or a cavity behind. If this happens above the septum, the hands become paralytick, a vomiting or convulsions follow, the breath is oppressed, and a violent pain and deafness ensue. If below the septum, the thighs are paralytick, the urine is suppressed, and sometimes it even flows involuntarily. Though a person does not in such cases die so quickly as where the head is luxated, yet it commonly happens within three days; for what Hippocrates has directed in a vertebra luxated externally, that the patient must be laid prone, and extended, and then a person ought to stand upon him with his heel and force it in, must be understood of those, that are but partially displaced, not of these, that are entirely luxated; for sometimes a weakness of the ligaments causes a vertebra to protuberate forwards, though it be not dislocated: this is not mortal. But it is not possible to force it back from the internal part. If any vertebra be reduced from the external side, it generally returns again, unless, which is very rare, the tone of the nerves be restored(26).

CHAP. XV.

OF A LUXATION OF THE HUMERUS.

The humerus slips sometimes into the axilla, sometimes forward. If it has fallen into the arm-pit, the cubitus recedes from the body, and cannot be brought upward with the humerus to the ear of the same side; also that arm is longer than the other: if forward, the upper part of the fore-arm is extended, but not to its full length; and the cubitus is moved with more difficulty forward than backward.

Therefore if the humerus has fallen into the arm-pit, and the patient be young, or of a lax habit, so that the ligaments are weak, it is sufficient to place him in a seat; and to order one assistant to draw back gently the head of the broad bone of the scapula, and another to extend the fore-arm; while the physician himself sitting behind, with his knee under the patient’s arm-pit, forces the humerus upwards, and at the same time presses the scapula with one hand, while he pushes the cubit to the side with the other.

But if the patient be of a large stature, or the ligaments more robust, a wooden spatha is necessary of the thickness of two fingers, and so long as to reach from the arm-pit to the fingers. In the top of it, is a small round head a little hollowed; that it may receive some part of the head of the humerus; and in three places at due distances there are two holes made for the admission of soft straps. This spatha being wrapt up in a roller, that it may hurt the less, is applied from the fore-arm to the arm pit, in such a manner, that the head of it is put under the axilla; then it is tied to the arm by its straps, in one place a little below the head of the humerus, another a little above the elbow, and the third above the hand; to which purpose the distances of the holes are then also to be adapted. The arm being thus tied up is put over a step of a ladder, so high, that the patient cannot stand upon the ground; and at the same time his body is suffered to sink on one side, and his arm kept extended on the other; the effect is, that the head of the humerus, being impelled by the head of the spatha, is forced into its place, sometimes with a crack, sometimes without it. It appears from Hippocrates alone, that there are many other methods; but none of them has been more approved by experience than this.

But if the humerus is luxated forward, the patient must be laid on his back, and a roller, or strap put round the middle of the arm-pit, and the ends of it delivered to one assistant behind the patient’s head, and his fore-arm to another; then the first must be ordered to extend the strap, and the other the fore-arm; and the physician must thrust back the patient’s head with his left hand, and with his right raise the cubitus together with the humerus, and force the bone into its place; which in this case is more easily reduced than in the former.

When the humerus is replaced, wool must be put under the arm-pit; that if the bone was in the interior part, it may prevent its returning; if forward, that it may however be more conveniently rolled up. Then the roller being first carried under the arm-pit, ought to surround the head of the bone, and passing over the breast to the other arm-pit, and from that to the scapulæ, and back again to the head of the _luxated_ humerus, it must be carried round in this manner several times, till the head of the humerus be well secured. The humerus being thus bound up is better fixed, if it be drawn close to the side, and tied down to it with a roller.

CHAP. XVI.

OF A LUXATION OF THE CUBITUS.

From what has been said in the first part of this book, it may be understood, that three bones meet together at the elbow, the humerus, radius, and cubitus. If the cubitus, which is fixed to the humerus, separates from it, the radius, which is contiguous to it, is sometimes dislocated, and sometimes remains firm. Now the cubitus may be luxated in all the four different ways. If it be displaced forward, the fore-arm is extended, and cannot be bent; if backward, the fore-arm is bent, cannot be extended, and is shorter than the other; sometimes it brings on a fever and bilious vomiting; if externally, or internally, the fore-arm is stretched, but is a little bent to that part, from whence the bone has receded.

Whatever species it be, the method of reduction is the same (and not only in the cubitus, but in all the larger limbs, which are joined in the articulation by a long process) to extend both limbs different ways, till there be a void space between the bones; and then to thrust the luxated bone from that side, into which it has prolapsed, to the contrary. However the methods of extension are various according to the strength of the ligaments, and the position of the luxated bones. And sometimes the hands alone are used, sometimes other means.

Therefore if the cubitus is displaced forward, it is sufficient for it to be extended by two hands, sometimes assisted by two straps; then some round body must be put into the bend of the elbow, and upon that, the cubitus is to be suddenly forced towards the humerus. But in the other cases the best method is so extend the fore-arm in the same manner, as was directed in a fractured humerus, and then to reduce the bones.

The remaining part of the cure is the same as in the other luxations; only this must be sooner, and more frequently opened, also more plentifully fomented with hot water, and rubbed longer with oil, and nitre, and salt. For the cubitus, whether it remain displaced, or be reduced, is more quickly surrounded by a callus than another joint, and if this grows, while the arm is at rest, it afterwards prevents its flexure.

CHAP. XVII.

OF A LUXATED HAND.

The hand too may be displaced in all the four directions. If it slips backward, the fingers cannot be extended; if forward, they cannot be bent; if on either side, the hand is turned to the opposite, that is, either toward the thumb, or the little finger, and may be replaced without much difficulty. The hand and fore-arm should be extended on something, that is hard and will not give way, the hand being prone, if the luxation was to the posterior part; and supine, if forward; if internally, or externally, it should be laid on one side. When the ligaments are sufficiently stretched, if the luxation was lateral, it must be repelled to the contrary side by the hands: but where it was forward, or backward, some hard body is to be put upon it, and pressed upon the prominent bone by the hand, which additional force pushes it more easily into its place.

CHAP. XVIII.

OF LUXATIONS IN THE PALM.

The bones also in the palm are sometimes dislocated, and that either forward, or backward. For they cannot be luxated laterally by reason of the resistance from the parallel bones on each side. There is only one indication of it, which is common to them all: a tumour in that part, to which the bone comes, and a cavity in the other, from which it recedes. But the bone being well pressed by a finger, returns without extension to its place.

CHAP. XIX.

OF LUXATED FINGERS.

In the fingers there are as many different cases, and the same signs, as in the hands. But an equal degree of force is not necessary in their extension; because the _several_ bones are shorter, and the ligaments less strong. They ought only to be extended upon a table, when the luxation is forward or backward; and then compressed with the palm of the hand that thus the finger may be(27) restored to the place from whence it slipped.

CHAP. XX.

OF A LUXATION OF THE FEMUR.

Having treated of the humerus(28), what I said there may seem to suffice for the lower extremities; for there is some similitude in this case between the femur, and humerus, the tibia, and cubitus, the foot and hand. However something must be said in particular about these.

The femur is protruded in all the four ways; most frequently to the internal part, next externally, very rarely forward, or backward. If it be luxated internally, the leg is longer and turned round externally more than the other; for the toes point outward. If to the external part, it is shorter and bowed inward, and the foot turns the same way; the heel in walking does not touch the ground, but the person rests upon the extremity of the sole of the foot; and in this case, the leg sustains the superior part of the body better than in the former, and less needs the help of a staff. If forward, the leg cannot be bent, and being extended is as long at the heel as the other: but the toes are turned less inward; also the pain is most violent in this case; and the urine very liable to be suppressed: when the inflammation together with the pain have ceased, such patients walk pretty well, and their foot is straight. If the luxation be backward, the leg cannot be extended; and is shorter; also in standing, the heel does not reach the ground.

But there is a great danger attending the femur, that it be either difficult to reduce, or slip out again after it is replaced: some affirm it always comes out again; but Hippocrates, and Diocles, and Philotimus, and Nileus, and Heraclides the Tarentine, very celebrated authors, have affirmed, that they have made a perfect cure. Neither would Hippocrates, Andreas, Nileus, Nymphodorus, Protarchus, Heraclides, and a certain artificer too, have contrived so great a variety of machines for extending the femur in this case, if it were to no purpose. But as this is a false opinion, so on the other hand it is true, that the ligaments and muscles there being very strong, if they retain their natural firmness, they will hardly admit of a reduction; if they do not, they do not hold it fast, when reduced.

Therefore trial must be made, and if the limb be but tender, it is sufficient to make an extension by one strap at the groin, and another at the knee; if it be muscular, the extension will be better made by tying these straps to strong sticks; and then putting the lower ends of the sticks against a fulcrum, and pulling the upper ends with both hands. The extension of the limb is still more strong upon a bench, that has axes at both ends, to which these straps are tied; which being turned as in a wine-press, by persevering, they will not only extend, but even break the ligaments and muscles. Now the patient must be laid upon this bench, either prone or supine, or on one side, so that the part, into which the bone has slipped, be always uppermost, and that, from which it has receded, lowermost. When the ligaments are extended, if the bone is luxated forward, some round body must be put upon the groin; and the knee must suddenly be drawn towards the body, in the same manner, and for the same reason, as is done in the arm; and if the femur gives way to the flexion, it is reduced.

But in the other cases, where the bones have receded a little from each other, the physician ought to force back the prominent part; and an assistant to push the hip in a contrary direction. When the bone is reduced, there is nothing different required in the treatment, except confining the patient longer to his bed; lest if the femur be moved, while the ligaments are too lax, it may slip out again. However it may be secured by keeping the middle or upper part of the joint in some canaliculus(29).

CHAP. XXI.

OF A LUXATION OF THE KNEE.

It is very well known, that the knee slips inward, outward, and backward. Most authors have written, that it is not displaced forward. And that may appear very probable; as in that place the patella is opposed to it, and likewise keeps in the head of the tibia. But Meges has given an instance of a person cured by him, where the luxation was forward.

In these cases the ligaments may be extended by the same means, which I recited in the femur. And where the bone is luxated backward, it is reduced in the same manner, by some round body applied to the ham, and drawing up the leg. In the other cases the hands are only to be used, and then the bones are at the same time forced different ways.

CHAP. XXII.

OF A LUXATED ANCLE.

The ancle is luxated in all directions. When it is inward, the sole of the foot is turned outward. When the contrary case to this happens, there is also the contrary symptom. But if it be luxated forward, the broad tendon behind is hard, and tense; and the foot turns downward. If backward, the heel is almost hid, and the sole of the foot is enlarged. This luxation is reduced by the hands; the foot and leg being first extended different ways. And in this case also the patient must be kept longer in bed; lest the ancle, which sustains the whole body, yield beneath its load, and be forced out again before the ligaments have recovered their strength. And at first low shoes must be used, lest the binding hurt the ancle.

CHAP. XXIII.

OF LUXATIONS IN THE SOLES OF THE FEET.

The bones in the soles of the feet are luxated in the same manner as those in the hands; and are reduced by the same methods; only it is necessary to put a roller round the heel; lest as the middle part and extremity of the sole require to be bound, the ancle being left free, may receive the redundant matter, and thus come to suppuration.

CHAP. XXIV.

OF LUXATED TOES.

In the toes there is nothing else required, than what has been directed before in the fingers.

CHAP. XXV.

OF LUXATIONS ATTENDED WITH A WOUND.

These are the methods to be taken, when the bones have been displaced without a wound; but they are often dislocated, and the part wounded at the same time; and here the danger is great, and so much the greater, as the limb is larger, and the ligaments, or muscles that hold it, stronger; and therefore, from the arm and thigh bones there is danger of death: and if the bones are reduced, there is no hope; and yet when they are not replaced, there is also some danger. In both, the event is the more to be feared, the nearer the wound is to the articulation. For Hippocrates has asserted, that no bone could in this case be safely reduced, except the fingers and toes, and the bones of the feet and hands; and that even here great caution must be used, lest it suddenly destroy the patient. Some have reduced both arms and legs; and to prevent gangrenes and convulsions (which in such cases often terminate in speedy death) they let blood from the arm. But not even a finger (where, as the malady, so also the danger is least) ought to be reduced, either while there is an inflammation, or afterwards, when the bones have continued long luxated. And farther, if after the reduction of the bone, convulsions come on, it must be immediately put out again.

Now every member that is at once wounded and dislocated, and continues unreduced, ought to lie in the posture easiest to the patient; provided it neither be moved nor hang down. In every case of this kind the cure is much promoted by long fasting; and then the use of those methods prescribed before. In fractured bones, where there is a wound, if the naked bone project, it will always prevent its healing; therefore, the prominent part must be cut away, and dry lint applied, and medicines not greasy; till the greatest degree of soundness attainable in such a case be restored; for it both leaves a weakness behind it, and the part is covered with a thin cicatrix, which must of necessity be ever after greatly exposed to injuries.

NOTES

TO