De Medicina (Celsus)

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	De Medicina Author: Celsus	Translator: Walter George Spencer
157	Aduersus fistulas quoque , si altius penetrant , ut ad ultimas demitti collyrium non possit , si tortuosae sunt , si multiplices , maius in manu quam in medicamentis praesidium est ; minusque operae est , si sub cute transuersa e feruntur , quam si rectae intus tendunt .— Igitur si sub cute transuersa fistula est , demitti specillum debet , supraque ea incidi . Si flexus reperientur , hi quoque simul specillo et ferro persequendi ; itemque faciendum , si plures se quasi ramuli ostendunt . Vbi ad finis fistulae uentum est , excidendus ex ea totus callus est , superque fibulae dandae et medicamentum quo glutinetur . At si recta subter tendit , ubi , quo maxime ferat , specillo exploratum est , excidi is sinus debet ; dein fibula oris cutis inicienda est ; et aeque glutinantia medicamenta superdanda sunt aut , si corruptius ulcus est , quod interdum osse uitiato fit , ubi id quoque curatum est , pus mouent ia. Solent autem inter costas fistulae subter exire ; quod ubi incidit , eo loco costa ab utraque parte praecidenda et eximenda est , ne quid intus corruptum relinquatur . Solent , ubi costas transierunt , saeptum id , quod transuer sum a superioribus uisceribus intestina discernit , uiolare . Quod intellegi loco et magnitudine doloris potest . Qui * * * nonnumquam spiritus ea cum umore quasi bullante prorumpit , maximeque si hunc ore ille continuit . In eo medicinae locus nullus est . In ceteris uero , quae circa costas sanabilia sunt , pinguia medicamenta inimica sunt ; ceteris , quae ad uulnera adcommodantur , uti licet : optime tamen sicca lin amenta uel , si purgandum aliquid uidetur , in melle tincta inponuntur . Ventri nullum os subest , sed ibi perniciosae admodum fistulae fiunt , adeo ut Sostratus insanabiles esse crediderit . Id non ex toto ita se habere usus ostendit . Et quidem , quod maxime mirum uideri potest , tutior fistula est contra iecur et lienem et uentriculum quam contra intestina , non quo perniciosior ibi sit , sed quo alteri periculo locum faciat . Cuius experimen to moti quidam auctores parum modum rei cognouerunt . Nam uenter saepe etiam telo perforatur , prolapsaque intestina conduntur , et oras uulneris suturae conprehendunt ; quod quemadmodum fiat , mox indicabo . Itaque etiam ubi tenuis fistula abdomen perrumpit , excidere ea m licet suturaque oras coniungere . Si uero ea fistula intus patuit , excissa necesse est latius foramen relinquat , quod nisi magna ui , utique ab interiore parte , sui non potest ; qua quasi membrana quaedam finit abdomen , quam periton aeon Graeci uocant . Ergo ubi aliquis ingredi ac moueri coepit , rumpitur illa sutura , atque intestina soluuntur ; quo fit , ut pereundum homini sit . Sed non omni modo res ea desperationem habet , ideoque tenuioribus fistulis adhibenda curatio est . Propriam etiam num animaduersionem desiderant ea e , quae in ano sunt . In has demisso specillo ad ultimum eius caput incidi cutis debet , dein nouo foramine specillum educi lino sequente , quod in aliam eius partem ob id ipsum perforatam coniectum sit . Ibi linum prehendendum uinciendumque cum altero capite est , ut laxe cutem , quae super fistulam est , teneat ; idque linum debet esse crudum et duplex triplexue , sic tortum , ut unitas facta sit . Interim autem licet negotia gerere , ambulare , lauari , cibum capere perinde atque sanissimo . Tantummodo id linum bis die saluo nodo ducendum est , sic ut subeat fistulam pars quae superior fuit . Neque committendum est , ut id linum putrescat , sed tertio quoque die nodus resoluendus est , et ad caput alterum recens linum alligandum est eductoque uetere id in fistula cum simili nodo relinquendum . Sic enim id paulatim cutem , quae supra fistulam est , incidit ; simulque et id sanescit , quod a lino relictum est et id , quod ab eo mordetur , inciditur . Haec ratio curationis longa sed sine dolore est . Qui festinant , adstringere cutem lino debent , quo celerius secent , noctuque ex penicillo tenuia quaedam intus demittere , ut cutis hoc ipso extenuetur quo extenditur ; sed haec dolorem mouent . Adicitur celeritati sicut tormento quoque , si et linum et id , quod ex penicillo est , aliquo medicamento inlinitur ex is , quibus callum exedi posui . Potest tamen fieri , ut ad scalpelli adcurationem etiam illo loci ueniendum sit , si intus fistula fert , si multiplex est . Igitur in haec genera demisso specillo duabus lineis incidenda cutis est , ut media inter eas habenula tenuis admodum eiciatur ; ne protinus orae coeant , sitque locus aliquis lin amentis , quae quam paucissima superinicienda sunt ; omniaque eodem modo facienda , quae in abscessibus posita sunt . Si uero ab uno ore plures sinus erunt , recta fistula scalpello erit incidenda ; ab eo ceterae , quae iam patebunt , lino excipiendae . Si intus aliqua procedet , quo ferrum tuto peruenire non poterit , collyrium demittendum erit . Cibus autem in eiusmodi omnibus casibus , siue manu siue medicamentis agetur , dari debet umidus , potio liberalis , diuque aqua : ubi iam caro increscit , tum demum et balineis raris utendum erit et cibis corpus inplentibus .	4 Again, for fistulae which penetrate so deeply that a medicated bougie cannot be passed down to the ends, or those which are tortuous or multiple, surgery has the advantage over medicine; and there is less trouble if the fistula runs horizontally under the skin, than when it tends directly inwards. Therefore if it lies horizontally under the skin, a probe should be introduced and cut down upon. When there are bends, these are followed up in the same way with the probe and knife; so also when they present multiple branchings. When the end of the fistula is reached, all the callus should be cut out, then pins are inserted through the skin margin, and agglutinating medicaments spread over all. But if it runs straight inwards, after its chief direction has been explored by means of the probe, that cavity ought to be excised, then a pin is to be inserted through the skin opening, and agglutinating medicaments applied as above; or if there is more corrupt ulceration, which is at time the case when there is disease of bone, after the bone has been treated, suppuratives are put on. Now it is common for fistulae to have their exit between ribs; when this is the case the rib must be cut across on either side at that spot, and the segment removed lest anything diseased be left within. Fistulae which have passed between the ribs often involve the transverse septum separating the viscera above from the intestine. This can be recognized by the position of the fistula and the severity of the pain, and because at times, air with frothy humour escapes from the fistula, especially when the patient has held his breath. In that case there is no opportunity for the medical art. But in the case of other fistulae near the ribs which are curable, greasy medicaments are objectionable but anything else which suits wounds may be used; the best, however, is lint put on dry, or after soaking in honey if anything has to be cleaned. There is no bone in the abdomen, but all the same fistulae there are so dangerous that Sostratus thought them incurable. Experience, however, shows that this is not always the case. Indeed — and this may seem very remarkable — a fistula which forms over the liver, spleen, or stomach, is safer than one right over the intestine, not because a fistula there is more harmful, but because it opens the way to another danger. Some writers who have had experience of this have shown little perception of the true facts. For often the abdomen is actually penetrated by a weapon, and sutures bring the margins of the wound together and how this is done I will presently point out. Therefore also when a fine fistula breaks through the abdominal wall, it is possible to cut it out, and to join its margins by suture. But if such a fistula widens out inside, this excision necessarily leaves a wide gap which cannot be sutured without applying great force especially in the deeper part where the abdomen is enclosed by a kind of membrane which the Greeks call peritoneum. Therefore, when the patient begins to get up and move about, the sutures break, and intestines prolapse; which causes his death. But these cases are not altogether desperate, and so for the finer fistulae, treatment is to be adopted. Special consideration is required in the case of those in the anus. In these, where a probe has been passed up to its end, the skin should be cut through, next through this new orifice the probe is to be drawn out, followed by a linen thread which has been passed through the eye made for the purpose in the other end of the probe. Then the two ends of the linen thread are taken and knotted together so as to grip loosely the skin overlying the fistula. The linen thread should be made up of two or three strands of raw flax, twisted up so as to make one. Meanwhile the patient can do his business, walk, bathe, and take food as if in the best of health. Only this thread is to be moved twice a day, but without undoing the knot, the part of the thread outside being drawn within the fistula, and the thread must not be left until it becomes foul, but every third day the knot is to be undone, and to one end that of another fresh thread is tied, and the old thread being withdrawn the new one is to be left in the fistula after being similarly knotted. For thus the thread cuts through the skin overlying the fistula slowly, and whilst the skin released from the thread undergoes healing, that which is still gripped is being cut through. This method of treatment is lengthy but causes no pain. Those in a hurry should constrict the skin with the thread, so that they may continue through more quickly; and at night they should insert into the fistula some fine pledglets of wool, in order that its overlying skin, being put on the stretch, may be thinned out; but these measures cause pain. More speed may be added, but more pain as well, if both the thread and the pledglets are smeared with some one of the medicaments, which I have noted for the eating away of callus. Even here, however, the knife must be used, if the fistula extends inwards, of is multiple. In these kinds of fistulae, therefore, when the probe has been inserted, the skin is to be cut through along two lines so that between them a very fine strip of skin may be taken out, in order that the margins may not unite at once, and that there may be room for the smallest possible quantity of lint to be inserted; all the rest is done in the way described for abscesses. If, however, from one orifice several sinuses lead off, the straight part of the fistula is to be laid open with the scalpel, and the others branching from it, which are now exposed, are to be gripped by a thread. Should any fistula extend so far inwards that it cannot be safely laid open by the knife, a medicated bougie is to be put in. But in all such cases, whether treated surgically or by medicaments, the food should be moist, the drink abundant, and for a while water: when flesh begins to grow up, then at length the patient is to make use of the bath occasionally, and of flesh-making food.
158	Tela quoque , quae inlata corporibus intus haeserunt , magno negotio saepe eiciuntur . Suntque quaedam difficultates ex generibus eorum : quaedam ex is sedibus , in quas illa penetrarunt . Omne autem telum extrahitur aut ab ea parte , qua uenit , aut ab ea , in quam tetendit . Illic uiam , qua redeat , ipsum sibi fecit , hic a scalpello accipit : nam contra mucronem caro inciditur . Sed si non alte telum insedit , et in summa carne est , aut certe magnas uenas et loca neruosa non transit , nihil melius quam qua uenit id euellere . Si uero plus est , per quod telo reuertendum quam quod perrumpendum est , iamque uenas neruosaque id transit , commodius est aperire quod superest , eaque extrahere : nam et propius petitur , et tutius euellitur ; et in maiore membro , si medius mucro transit , facilius sanescit quod peruium est , quia utrimque medicamento fouetur . Sed si retro telum recipiendum , amplianda scalpello plaga est , quo facilius id sequatur , quoque minor oriatur inflammatio ; quae maior fit , si ab illo ipso telo , dum redit , corpus laniatur . Item si ex alia parte uulnus aperiatur , laxius esse debet , quam ut telo postea transeunte amplietur . Summa autem utraque parte habenda cura est , ne uena , ne maior neruos , ne arteria incidatur . Quorum ubi aliquid detectum est , excipiendum hamo retuso est , abducendumque a scalpello . Vbi autem satis incisum est , telum eximendum est , tum quoque eodem modo et eadem cura habita , ne sub eo , quod eximitur , aliquod eorum laedatur , quae tuenda esse proposui . Haec communia . Sunt propria quaedam in singulis telorum generibus , quae protinus subiciam . Nihil tam facile in corpus quam sagitta conditur , eademque altissime ins idit. Haec autem eueniunt , et quia magna ui fertur illa , et quia ipsa in angusto est . Saepius itaque ab altera parte , quam ex qua uenit , recipienda et praecipue quia fere spiculis cingitur , quae magis laniant , si retrorsus quam si contra eximatur . Sed inde aperta uia , caro diduci debet ferramento ad similitudinem facto Graecae litterae * : deinde , ubi apparuit , si mucro ni harundo inhaeret , propellenda est , donec ab altera adprehendi et extrahi possit ; si iam illa decidit solumque intus ferrum est , mucro uel digitis adprehendi uel forfice atque ita educi debet . Neque alia ratio extrahendi est , ubi ab ea parte , qua uenit , euelli magis placuit : nam ampliato magis uulnere , aut harundo , si inest , euellenda est , aut si ea non est , ferrum ipsum . Quod si spicula apparuerunt eaque breuia et tenuia sunt , forfice ibi comminui debent , uacuumque ab his telum educi : si ea maiora ualentioraque sunt , fissis scriptoris calamis contegenda , ac ne quid lacerent , sic euellenda sunt . In sagittis quidem haec obseruatio est . Latum uero telum si conditum est , ab altera parte educi non expedit , ne ingenti uulneri ipsi quoque ingens uulnus adiciamus . Euellendum est ergo genere quodam ferramenti , quod Diocleum cyathiscum Graeci uocant , quoniam auctorem Dioclen habet ; quem inter priscos maximosque medicos fuisse iam posui . Lammina uel ferrea uel aenea etiam ab altero capite duo utrimque deorsum conuersos uncos habet ; ab altero duplicata lateribus , leuiterque extrema in eam partem inclinata , qua sinuata est , insuper ibi etiam perforata est . Haec iuxta telum transuersa demittitur ; deinde ubi ad imum mucronem uentum est , paulum torquetur , ut telum foramine suo excipiat . Cum in cauo mucro est , ilico digiti subiecti partis alterius uncis simul et ferramentum id extrahunt et telum . Tertium genus telorum est , quod interdum euelli debet ; plumbea glas aut lapis aut simile aliquid , quod perrupta cute integrum intus insedit .— In omnibus his latius uulnus aperiundum , idque quod inest , ea , qua uenit , forfice extrahendum est . Accedit uero aliquid difficultatis sub omni ictu , si telum uel ossi inhaesit uel in articulo se inter duo ossa demersit . In osse usque eo mouendum est , donec laxetur is locus , qui mucronem momordit ; et tunc uel manu uel forfice telum extrahendum est ; quae ratio in dentibus quoque eiciendis est . Vix umquam ita telum non sequitur : sed si morabitur , excuti quoque ictum aliquo ferramento poterit . Vltimum est , ubi non euellitur , terebra iuxta forare , ab eoque foramine ad speciem litterae † uel contra telum os excidere sic , ut lin eae , quae diducuntur , ad telum spectent ; eo facto id necesse est labet et facile auferatur . Inter duo uero ossa si per ipsum articulum perr uperit, circa uolnus duo membra fascis habenisue deliganda et per has in diuersas partes diducenda sunt , ut neruos distendant ; quibus extentis laxius inter ossa spatium est , ut sine difficultate telum recipiatur . Illud uidendum est , sicut in aliis locis posui , ne quis neruus aut uena aut arteria a telo laedatur , dum id extrahit ur, eadem scilicet ratione , quae supra posita est . At si uenenato quoque telo quis ictus est , i sdem omnibus , si fieri potest , etiam festinantius actis , adicienda curatio est , quae uel epoto ueneno , uel a serpente ictis adhibetur . Vulneris autem ipsius extracto telo medicina non alia est , quam quae esset , si corpore icto nihil inhaesisset ; de qua satis alio loco dictum est .	5 Missiles too, which have entered the body and become fixed within, are often very troublesome to extract. And some of the difficulties arise from their shape, some owing to the positions to which they have penetrated. Whatever the missile may be, it is extracted, either by the wound of entry, or through the spot towards which it is pointing. In the former case, the missile has already made a way for its withdrawal; in the latter the way out is made with the scalpel; for the flesh is cut through upon its point. But if the missile is not deeply seated, and lies in superficial tissue, or if it is certain that it has not crossed the line of large blood vessels or sinews, there is nothing better than to pull it out by the way it entered. But if the distance it has to be withdrawn is greater than that which remains to be forced through, or if it has crossed the line of blood vessels and sinews, it is more convenient to lay open the rest of its course and so draw it out. For it will be more easily got at and more safely pulled out. And in the case of one of the larger limbs, if the point has passed beyond the middle, a through and through wound heals more easily because it can be dressed with a medicament at both ends. But if the missile is to be drawn back, the wound should be enlarged with a scalpel, for then the missile comes away more easily, also less inflammation is caused; for this becomes more severe if the missile itself lacerates the tissues while being withdrawn. So also when a counter opening is made, this ought to be too wide for the missile to fill as it is passing out. In either case, the greatest care should be taken that no vein, nor one of the larger sinews, nor an artery, is cut. When any one of these is observed, it is to be caught by a blunt hook and held away from the scalpel. Than the incision has been made large enough, the missile is to be drawn out, proceeding in the same way, and taking the same care, lest that which is being extracted should injure one of those structures which I have said are to be protected. The foregoing are general rules; there are some rules which apply to special missiles, and these I will at once set out. Nothing penetrates so easy into the body as an arrow, and it also becomes very deeply fixed. And this happens both because it is propelled with great force and because it is sharply pointed. Hence it is more often to be extracted through a counter opening than through the wound of entry, and especially so because it is generally furnished with barbs which lacerate more when drawn backwards than if pushed through a counter opening. When a passage out has been laid open, the flesh ought to be stretched apart by an instrument like a Greek letter; next when the point has come into view, if the shaft is still attached, it is to be pushed on until the point can be seized from the counter opening and drawn out: if the shaft has already become detached, and only the arrowhead is within, the point should be seized by the fingers or by forceps, and so drawn out. Nor is the method of extraction different when it is preferred to withdraw the arrow by the wound of entry; the wound having been enlarged, either the shaft, if it is still attached, or, if not, the arrowhead itself, is pulled upon. When the barbs come into view, if they are short and fine, they should be nipped off on the spot by forceps, and the missile drawn out without them. If the barbs are too large and resistant for this, they must be covered by reed pens which have been split, and thus pulled out carefully so as not to tear the flesh. This is what is to be done in the case of arrows. But if it is a broad weapon which has been embedded, it is not expedient to extract it through a counter opening, lest we add a second large wound to one already large. It is therefore to be pulled out by the aid of some such instrument as that which the Greeks call the Dioclean cyathiscus, because invented by Diocles, whom I have said already to have been among the greatest of the ancient medical men. The instrument consists of two iron or even copper blades, one blade has at each angle of its end a hook, turned downwards; the other blade has its sides turned up so that it forms a groove, also its end is turned up somewhat, and perforated by a hole. The latter blade is first passed up to the weapon, and then underneath it, until the point is reached, the blade is then rotated somewhat until the point becomes engaged in the perforation. After the point has entered the perforation, the hooks of the first mentioned blade are fitted by the aid of the fingers over the upturned end of the blade already passed, after which simultaneously the cyathiscus and the weapon are withdrawn. There is a third kind of missile which at times has to be extracted such as a lead ball, or a pebble, or such like, which has penetrated the skin and become fixed within unbroken. In all such cases the wound should be laid open freely, and the retained object pulled out by forceps the way it entered. But some difficulty is added in the case of any injury in which a missile has become fixed in bone, or in a joint between the ends of two bones. When in a bone, the missile is swayed until the place which grips the point yields, after which it is extracted by the hand, or by forceps; this is the method also used in extracting teeth. In this way the missile nearly always comes out, but if it resists, it can be dislodged by striking it with some instrument. The last resort when it cannot be pulled out, is to bore into the bone with a trepan close by the missile, and from that hole to cut away the bone in the shape of the letter V, so that the lines of the letter which diverge to either side face the missile; after that it is necessarily loosened and easily removed. If the missile has forced its way actually into a joint between the ends of two bones, the limbs above and below are encircled by bandages or straps, by means of which they are pulled in opposite directions, so that the sinews are put on the stretch; the space between the ends of the bone is widened by these extensions, so that the missile is without difficulty withdrawn. In doing this care must be taken, as mentioned elsewhere, to avoid injury to a sinew, vein or artery while the weapon is being extracted by the same method which was described above. But if the missile is also poisoned, after doing all the same things, even more promptly, if possible, in addition that treatment is to be applied which is given for one who has drunk poison, or has been bitten by a snake. The care of the wound itself after the extraction of the missile does not differ from that of a wound in which nothing has lodged and on which I have said enough elsewhere.
159	Haec euenire in qualibet parte corporis possunt : reliqua CERTAS SEDES habent , de quibus dicam orsus a capite . In hoc multa uariaque tubercula oriuntur : gang lia, meliceridas , atheromata nominant aliisque etiamnum uocabulis quaedam alii discernunt , quibus ego steatomata quoque adiciam . Quae quamuis et in ceruice et in alis et in lateribus oriri solent , per se tamen non posui , cum omnia ista mediocres differentias habeant , ac neque periculo terreant neque diuerso genere curentur . Omnia uero ista et ex paruulo incipiunt et diu paulatimque increscunt , et tunica sua includuntur . Quaedam ex his dura ac renitentia , quaedam mollia cedentiaque sunt ; quaedam spatio nudantur , quaedam tecta capillo suo permanent ; fereque sine dolore sunt . Quid intus habeant , ut coniectura praesagiri potest , sic ex toto cognosci , nisi cum eiecta sunt , non potest . Maxime tamen in is , quae renituntur , aut lapillis quaedam similia aut concreti confersique pili reperiuntur : in is uero , quae cedunt , aut melli simile aliquid aut tenui pulticulae aut quasi rassae cartilagini aut carni hebeti et cruentae , quibus ali alique colores esse consuerunt . Fereque ganglia renituntur : atheromati subest quasi tenuis pulticula : meliceridi liquidior umor , ideoque pressu s circumfluit : steatomati pingue quiddam . Idque latissime patere consueuit , resoluitque totam cutem superpositam sic , ut e a labet , cum in ceteris sit adstrictior . Omnia derassa ante si capillis conteguntur , per medium oportet incidi : sed steatomatis tunica quoque secanda est , ut effundatur quicquid intus coit , quia non facile a cute et subiecta carne ea separ atur: in ceteris ipsa tunica inuiolata seruanda est . Protinus autem ut alba et intenta se ostendit , tum scalpelli manubriolo deducenda a cute et carne est , eiciendaque cum eo , quod intus tenet . Si quando tamen ab inferiore parte tunicae musculus inhaesit , ne is laedatur , superior pars illius decidenda ; at im a ibi relinquenda est . Vbi tota exempta est , committendae orae , fibulaque his inicienda , et super medicamentum glutinans dandum est . Vbi uel tota tunica uel aliquid ex ea relictum est , pus mouentia adhibenda sunt .	6 Such are lesions which can arise in any part of the body; the remainder occur in special situations, of these I am going to speak, beginning with the head. On the head many kinds of small tumours occur; besides those called ganglia, melicerides and atheromata, different authorities distinguish certain sorts by different names, and to these I myself will add one, steatoma. Although these tend to occur both in the neck and in the armpits and flanks, yet I have not dealt with them separately for there is little difference among them and none of them are dangerous and all are treated in the same way. Now all the above start from a very small beginning and grow slowly for a long time and have a coat of their own to enclose them. Some of them are hard and resistant, some soft and yielding; some become partially bald, others continue to be covered by their proper hair; generally they are painless. What they contain can be surmised, but cannot be fully known until the contents have been turned out. Generally, however, in those which are resistant, we find something like little stones, or balls of compressed hair; and in those which are yielding either some material similar to honey or thin porridge or something like grazed cartilage or bruised and bloody flesh, and the contents generally vary in colour. Ganglia are mostly resistant; atheromata have porridge-like contents; meliceris has a more fluid humour, and so it fluctuates when pressed upon; a steatoma contains a kind of fat. This last spreads most widely and loosens all the skin over it so that it is flaccid, although in the others the skin is more tense. All parts covered by hair should be shaved first and the incision made across the middle; but the coat of a steatoma is also to be cut into in order to let out whatever has collected within, because it is not easy to separate the coat from the skin and underlying flesh; in the other kinds the coating is to be preserved entire. Then as soon as the white and tight coat is seen, it is to be separated from the skin and flesh by the handle of the scalpel, and turned out together with its contents. But if muscle adheres to the deeper part of the tunic, lest it should be injured, only the superficial part of the tunic is to be cut away, and the deeper part left in position. When the whole has been removed the margins of the incision are to be brought together, a pin passed through them and, over this, an agglutinating medicament applied. When the whole, or any part of the coat has been left, suppuratives must be applied.
160	Sed ut haec neque genere uiti neque ratione curationis inter se multum distant , sic in oculis , quae manum postulant , et ipsa diuersa sunt et aliter aliterque curantur . Igitur in superioribus palpebris uesicae nasci solent pingues graues que , quae uix attollere oculos sinunt , leuesque pituitae cursus sed adsiduos in oculis mouent : fere uero in pueris nascuntur . — Oportet conpresso digitis duobus oculo atque ita cute intenta scalpello transuersam lineam incidere , suspensa leuiter manu , ne uesica ipsa uulneretur ; u bi locus ei patefactus est , ipsa prorumpit . Tum digitis ea m adprehendere oportet et euellere ; facile autem sequitur . Dein superinungui collyrio debet ex is aliquo , quo lippientes oculi superinunguntur ; paucissimisque diebus cicatricula inducitur . Molestius est , ubi incisa uesica est : effundit enim umorem , neque postea , quia tenuis admodum est , potest colligi . Si forte id incidit , eorum aliquid inponendum est , quae puri mouendo sunt . In eadem palpebra supra pilorum locum tuberculum paruulum nascitur , quod a similitudine hordei a Graecis crit he nominatur . Tunica quiddam , quod difficulter maturescit , conprehensum est ; id uel calido pane uel cera subinde calfacta foueri oportet sic , ne nimius is calor sit sed facile ea parte sustineatur : hac enim ratione saepe discutitur , interdum concoquitur . Si pus se ostendit , scalpello diuidi debet , et quicquid intus umoris est , exprimi ; eodem deinde uapore postea quoque foueri et superinungui , donec ad sanitatem perueniat . Alia quoque quaedam in palpebris huic non dissimilia oriuntur : sed neque utique figura e eiusdem , et mobilia , simul atque digito uel huc uel illuc inpelluntur ; ideoque ea chalazia Graeci uocant .— Haec incidi debent , si sub cute sunt , ab exteriore parte ; si sub cartilagine , ab interiore ; deinde scalpelli manubriolo deducenda ab integris partibus sunt . Ac , si intus plaga est , inunguendum primum lenibus , deinde acrioribus ; si extra , superdandum emplastrum , quo id glutinetur . Vnguis uero , quod pterygion Graeci uocant , est membranula neruosa oriens ab angulo , quae nonnumquam ad pupillam quoque peruenit , eique officit ; saepius a narium , interdum etiam a temporum parte nascitur . Hunc recentem non difficile est discutere medicamentis , quibus cicatrices in oculis extenuantur : si inueterauit iamque ei crassitudo quoque accessit , excidi debet . Post abstinentiam uero unius diei uel aduersus in sedili contra medicum is homo collocandus est , uel sic auersus , ut in gremium eius caput resupinus effundat . Quidam , si in sinistro oculo uitium est , aduersum ; si in dextro , resupinum collocari uolunt . Alteram autem palpebram a ministro deduci oportet , alteram a medico : sed ab hoc , si ille aduersus est , inferiorem ; si supinus , superiorem . Tum idem medicus hamulum acutum , paululum mucrone intus recuruato , subicere extremo ungui debet , eumque infigere , atque eam quoque palpebram tradere alteri ; ipse hamulo adprehenso leuare unguem , eumque acu traicere linum trahente ; deinde acum ponere , lini duo capita adprehendere , et per ea erecto ungue , si qua parte oculo inhaeret , manubriolo scalpelli deducere , donec ad angulum ueniat ; deinde inuicem modo remittere , modo adtrahere , ut sic et initium eius et finis anguli reperiatur . Duplex enim periculum est , ne uel ex ungue aliquid relinquat ur, quod exulceratum uix ullam recipiat curationem ; uel ex angulo quoque caruncula abscidatur ; quae , si uehementius unguis ducitur , sequitur ideoque decipit : abscisa patefit foramen , per quod postea semper umor descendit : rhy ada Graeci uocant . Verus ergo anguli finis utique noscendus est ; qui ubi satis constitit , non nimium adducto ungue scalpellus adhibendus est , deinde excidenda ea membranula , ne quid ex angulo laedatur . Eodem inde ex melle lin amentum super dandum est supraque linteolum , et aut spongia aut lana sucida ; proximisque diebus deducendus cotidie oculus est , ne cicatrice inter se palpebrae glutinentur , siquidem id quoque tertium periculum accedit ; eodemque modo lin amentum inponendum , ac nouissime inunguendum collyrio , quo ulcera ad cicatricem perducuntur . Sed ea curatio uere esse debet aut certe ante hiemem ; de qua re ad p lura loca pertinente semel dixisse satis erit . Nam duo genera curationum sunt . Alia , in quibus eligere tempus non licet , sed utendum est eo , quod incidit , sicut in uulneribus ; alia , in quibus nullus dies urguet , et expectare tutissimum est , sicut euenit in is , quae et tarde crescunt et dolore non cruciant . In his uer expectandum est , aut si quid magis pressit , melior tamen autumnus est quam aestas aut hiemps , atque is ipse medius , iam fractis aestibus , nondum ortis frigoribus . Quo magis autem necessaria pars erit , quae tractabitur , hoc quoque maiori periculo subiecta est ; et saepe , quo maior plaga facienda , eo magis haec temporis ratio seruabitur . Ex curatione uero unguis , ut dixi , uitia nascuntur , quae ipsa aliis quoque de causis oriri solent . Interdum enim fit in angulo , parum ungue exciso uel aliter , tuberculum , quod palpebras parum deduci patitur : enca nthis Graece nominatur . Exci pi hamulo et circumcidi debet , hic quoque diligenter temperata manu , ne quod ex ipso angulo abscidat . Tum exiguum lin amentum respergendum est uel cadmia uel atramento sutorio , inque eum angulum deductis palpebris inserendum , supraque eodem modo deligandum , proximisque diebus similiter nutriendum , tantum ut primis aqua egelida uel etiam frigida foueatur . Interdum inter se palpebrae coalescunt aperirique non potest oculus . Cui malo solet etiam illud accedere , ut palpebrae cum albo oculi cohaeresca nt, scilicet cum in utroque fuit ulcus neclegenter curatum : sanescendo enim , quod diduci potuit et debuit , glutinauit : ancyloblepharus † sub utroque uitio Graeci uocant . Palpebrae tantum inter se cohaerentes non difficulter diducuntur , sed interdum frustra : nam rursus glutinantur . Experiri tamen oportet , quia bene res saepius cedit . Igitur auersum specillum inserendum , diducendaeque eo palpebrae sunt ; deinde exigua penicilla interponenda , donec exulceratio eius loci finiatur . At ubi albo ipsius oculi palpebra inhaesit , Heraclides Tarentinus auctor est aduerso scalpello subsecare cum magna moderatione , ut neque ex oculo neque ex palpebra quicquam abscidatur ; ac si necesse est , ex palpebra potius . Post haec inunguatur oculus medicamentis , quibus aspritudo curatur ; cottidieque palpebra uert atur, non solum ut ulceri medicamentum inducatur , sed etiam ne rursus inhaereat ; ipsique etiam praecipiatur , ut saepe eam digitis duobus attollat . Ego sic restitutum esse neminem memini . Meges se quoque multa temptasse , neque umquam profuisse , quia semper iterum oculo palpebra inhaeserit , memoriae prodidit . Etiamnum in angulo , qui naribus pro pior est , ex aliquo uitio quasi parua fistula aperitur , per quam pituita adsidue destillat : aegilopa Graeci uocant . Idque adsidue male habet oculum ; nonnumquam etiam exesso osse usque nares penetrat . Atque interdum naturam carcinomatis habet , ubi intentae uenae et a rquatae sunt , color pallet , cutis dura est et leui tactu inritatur , inflammationemque in eas partes , quae coniunctae sunt , euocat . — Ex his eos , qui quasi car cinoma habent , curare periculosum est : nam mortem quoque ea res maturat ; eos uero , quibus ad nares tendit , superuacuum : neque enim sanescunt . A t quibus id in angulo e st , potest adhiberi curatio , cum eo ne ignotum sit esse difficilem : quantoque angulo propius id foramen est , tanto difficilior est , quoniam perangustum est , in quo uersari manus possit . Recenti tamen re mederi facilius est . Sed hamulo summum eius foraminis excipiendum ; deinde totum id cauum , sicut in fistulis dixi , usque ad os excidendum ; oculoque et ceteris iunctis partibus bene obtectis , os ferramento adurendum est ; uehementiusque si iam carie uexatum est , quo crassior squama a bscedat. Quidam adurentia inponunt , ut atramentum sutorium uel chalcitidem uel aeruginem rasam ; quod et tardius et non idem facit . Osse adusto curatio sequitur eadem , quae in ceteris ustis . Pili uero , qui in palpebris sunt , duabus de causis oculum inritare consuerunt : nam modo palpebrae summa cutis relaxatur et procidit ; quo fit , ut eius pili ad ipsum oculum conuertantur , quia non simul cartilago quoque se remisit ; modo sub ordine naturali pilorum alius ordo subcrescit , qui protinus intus ad oculum tendit .— Curationes hae sunt . Si pili nati sunt , qui non debuerunt , tenuis acus ferrea ad similitudinem hastae lata in ignem coicienda est ; deinde candens , sublata palpebra sic , ut eius perniciosi pili in conspectum curantis ueniant , sub ipsis pilorum radicibus ab angulo inmittenda est , ut ea tertiam partem palpebrae trans uat; deinde iterum tertioque usque ad alterum angulum ; quo fit , ut omnes pilorum radices adustae emoriantur . Tum superinponendum medicamentum est , quod inflammationem prohibeat , atque ubi crustae exciderunt , ad cicatricem perducendum . Facillime autem id genus sanescit . Quidam aiunt acu transui iuxta pilos in exteriorem partem palpebrae oportere eamque transmitti duplicem capillum muliebrem ducentem ; atque ubi acus transit , in ipsius capilli sinum , qua duplicatur , pilum esse coiciendum et per eum in superiorem palpebrae partem adtrahendum ; ibique corpori adglutinandum ; et inponendum medicamentum , quo foramen glutinetur : sic enim fore , ut is pilus in exteriorem partem postea spectet . Id primum fieri non potest , nisi in pilo longiore , cum fere breues eo loco nascantur ; deinde si plures pili sunt , necesse est longum tormentum totiens acus traiecta magnamque inflammationem moueat . Nouissime cum umor aliquis ibi subsit , oculo et ante per pilos et tum per palpebrae foramina adfecto uix fieri potest , ut gluten , quo uinctus est pilus , non resoluatur ; eoque fit , ut is eo , unde ui abductus est , redeat . Ea uero curatio , quae ab omnibus frequentatur , nihil habet dubii : siquidem oportet contecto oculo mediam palpebrae cutem , siue ea superior siue inferior est , adprehendere digitis ac sic leuare ; tum considerare , quantulo detracto futurum sit , ut naturaliter se habeat . Siquidem hic quoque duo pericula circumstant : si nimium fuerit excisum , ne contegi oculus non possit ; si parum , ne nihil actum sit , et frustra sectus aliquis sit . Qua deinde incidendum uidebitur , per duas lineas atramento notandum est sic , ut inter oram , quae pilos continet , et pro piorem ei lineam aliquid relinquatur , quod adprehendere acus postea possit . His constitutis scalpellus adhibendus est ; et si superior palpebra , ante ; si inferior , postea propius ipsis pilis incidendum ; initiumque faciendum in sinistro oculo ab eo angulo , qui tempori ; in dextro ab eo , qui naribus propior est ; idque , quod inter duas lineas est , excidendum . Deinde orae uulneris inter se simplici sutura committendae , operiendusque oculus et si parum palpebra descendet , laxanda sut ura; si nimium , aut adstringenda , aut etiam rursus tenuis habenula e st ab ulteriore ora excidenda . Vbi secta est , aliae suturae adiciendae , quae supra tres esse non debent . Praeter haec in superiore palpebra sub pilis ipsis incidenda linea est , ut i ab inferiore parte deducti pili susum spectent ; idque , si leuis inclinatio est , etiam solum satis tuetur ; inferior palpebra eo non eget . His factis , spongia ex aqua frigida expressa super deliganda est . Postero die glutinans emplastrum iniciendum , quarto suturae tollendae , et collyrio , quod inflammationes reprimit , superinunguendum . Nonnumquam autem nimium sub hac curatione excisa cute euenit , ut oculus non tegatur ; idque interdum etiam alia de causa fit : lagopt halmus Graeci appellant . In quo si nimium palpebra e deest , nulla id restituere curatio potest ; si exiguum , mederi licet .— Paulum infra supercilium cutis incidenda est lunata figura cornibus eius deorsum spectantibus . Altitudo esse plagae usque ad cartilaginem debet ipsa illa nihil laesa : nam si ea incisa est , palpebra concidi t , neque attolli postea potest . Cute igitur tantum diducta fit , ut paulum in ima oculi ora descendat hiante scilicet super plag a ; in qua m linamentum coiciendum est , quod et coniungi diductam cutem prohibeat et in medio carunculam citet ; quae ubi eum locum inpleuit , postea recte oculus operitur . Vt superioris autem palpebrae uitium est , quo parum descendit ideoque oculum non contegit , sic inferioris , quo parum susum attollitur , sed pendet et hiat , neque potest cum superiore committi . Atque id quoque euenit interdum ex simili uitio curationis , interdum etiam senectute : ectropion Graeci nominant .— Si ex mala curatione est , eadem ratio medicinae est , quae supra posita est ; plagae tantum cornua ad maxillas , non ad oculum conuertenda sunt : si ex senectute est , tenui ferramento id totum extrinsecus adurendum est , deinde melle inunguendum : a quarto die uapore aquae calidae fouendum , inunguendumque medicamentis ad cicatricem perducentibus . Haec fere circa oculum in angulis palpebrisque incidere consuerunt . In ipso autem oculo nonnumquam summa attollitur tunica , siue ruptis intus membranis aliquibus siue laxatis , et similis figura acino fit : unde id staphyloma Graeci uocant .— Curatio duplex est : altera : ad ipsas radices per medium transuere acu duo lina ducente ; deinde alterius lini duo capita ex superiore parte , alterius ex inferiore astringere inter se ; quae paulatim secando id excidunt . Altera : in summa parte eius ad lenticulae magnitudinem excidere ; deinde spodium aut cadmiam infriare . Vtrolibet autem facto , album oui lana excipiendum et inponendum ; posteaque uapore aquae calidae fouendus oculus et lenibus medicamentis inunguendus est . Claui autem uocantur callosa in albo oculi tubercula , quibus nomen a figurae similitudine est . Hos ad imam radicem perforare acu commodissimum est , infraque eam excidere ; deinde lenibus medicamentis inunguere . Suffusionis iam alias feci mentionem , quia cum recens incidit , medicamentis quoque saepe discutitur : sed ubi uetustior facta est , manus curationem desiderat , quae inter subtilissimas haberi potest . De qua antequam dico , paucis ante ipsius oculi natura indicanda est . Cuius cognitio cum ad plura loca pertineat , tum uel praecipue ad hunc pertinet . Is igitur summas habet duas tunicas , ex quibus superior a Graecis ceratoides uocatur . Ea , qua parte alba est , satis crassa ; pupillae loco extenuatur . Huic inferior adiuncta est , media parte , qua pupilla est , modico foramine concaua ; circa tenuis , ulterioribus partibus ipsa quoque plenior , quae chor ioides a Graecis nominatur . Hae duae tunicae , cum interiora oculi cingant , rursus sub his coeunt , extenuataeque et in unum coactae per foramen , quod inter ossa est , ad membranam cerebri perueniunt eique inhaerescunt . Sub his autem , qua parte pupilla est , locus uacuus est ; deinde infra rursus tenuissima tunica , quam Herophilus arachnoidem nominauit . Ea media subsidit * * * eoque cauo continet quiddam , quod a uitri similitudine hyaloides Graeci uocant . Id neque liquidum neque aridum est , sed quasi concretus umor , ex cuius colore pupillae color uel niger est uel caesius , cum summa tunica tota alba sit : id autem superueniens ab interiore parte membranula * includit . Su per his gutta umoris est , oui albo similis , a qua uidendi facultas proficiscitur : crystalloides a Graecis nominatur . Igitur uel ex morbo uel ex ictu concrescit umor sub duabus tunicis , qua locum esse uacuum proposui ; isque paulatim indurescens interiori * potentiae se opponit . Vitiique eius plures species sunt ; quaedam sanabiles , quae dam quae curationem non admittunt . Nam si exigua suffusio est , si immobilis , colorem uero habet marinae aquae uel ferri nitentis et a latere sensum aliquem fulgoris relinquit , spes superest . Si magna est , si nigra pars oculi , amissa naturali figura , in aliam uertit , si suffusioni color caeruleus est aut auri similis , si labat et hac atque illac mouetur , uix umquam succurritur . Fere uero peior est , quo m ex grauiore morbo , maioribus capitis doloribus uel ictu uehementiore orta est . Neque idonea curation i senilis aetas est , quae sine eo uitio tamen aciem hebetem habet : at ne puerilis quidem , sed inter haec media . Oculus quoque curationi neque exiguus neque concauus satis oportunus est . Atque ipsius suffusionis quaedam maturitas est : expectandum igitur est , donec iam non fluere sed duritie qu adam concreuisse uideatur . Ante curationem autem modico uti cibo , bibere aquam triduo debet , pridie ab omnibus abstinere . Post haec in aduorso collocandus est , loco lucido , lumine a duerso, sic ut contra medicus paulo altius ; a posteriore parte caput eius , qui curabitur , minister contineat , ut inmobile id praestet : nam leui motu eripi acies in perpetuum potest . Quin etiam ipse oculus , qui curabitur , inmobilior faciendus est , super alterum lana inposita : curari uero sinister oculus dextra manu , dexter sinistra debet . Tum acus admouenda est , sic acuta , ut foret , non nimium tenuis ; eaque demittenda sed recta est per summas duas tunicas medio loco inter oculi nigrum et angulum tempori propiorem , e regione mediae suffusionis sic , ne qua uena laedatur . Neque tamen timide d emittenda est , quia inani loco excipitur ; ad quem cum uentum est , ne mediocriter quidem peritus falli potest , quia prementi nihil renititur . Vbi eo uentum est , inclinanda acus ad ipsam suffusionem leuiterque ibi uerti et paulatim eam deducere infra regionem pupillae debet ; ubi deinde eam transit , uehementius inprimi , ut inferiori parti insidat . Si haesit , curatio expleta est : si subinde redit , eadem acu concidenda et in plures partes dissipanda est , quae singulae et facilius conduntur et minus late officiunt . Postea educenda recta acus est ; inponendumque lana molli exceptum oui album , et supra , quod inflammationem coerceat ; atque ita deuinciendum . Post haec opus est quiete , abstinentia , lenium medicamentorum inunctionibus ; cibo , qui postero die satis mature datur , primum liquido , ne maxillae laborent ; deinde inflammatione finita , tali , qualis in uulneribus propositus est ; quibus , ut aqua diutius bibatur , necessario accedit . De pituitae quoque tenuis cursu , qui oculos infestat , quatenus medicamentis agendum e st , iam explicui . Nunc ad ea ueniam , quae curationem manu postulant . Animaduertimus autem quibusdam numquam siccescere oculos , sed semper umore tenui madere ; quae res aspritudinem continuat , ex leuibus momentis inflammationes et lippitudines excita t , totam denique uitam hominis infestat ; idque in quibusdam nulla ope adiuuari potest , in quibusdam sanabile est : quod primum nosse oportet , ut alteris succurratur , alteris manus non iniciatur . Ac primum superuacua curatio est in is , qui ab infantibus id uitium habent , quia necessario mansurum est usque mortis diem ; deinde non necessaria etiam in is , quibus non multa , sed acris pituita est , siquidem manu nihil adiuuantur : medicamentis et uictus ratione , quae crassiorem pituitam reddit , ad sanitatem perueniunt . Lata etiam capita uix medicinae patent . Tum interest uenae pituitam mittant quae inter caluariam et cutem sunt , an quae inter membrana m cerebri et caluariam . Superiores fere per tempora oculos rigant ; inferiores per eas membranas , quae ab oculis ad cerebrum tendunt . Potest autem adhiberi remedium is , quae supra os fluunt ; non potest is , quae sub osse . Ac ne is quidem succurritur , quibus pituita utrimque descendit , quia leuata altera parte nihilo minus altera infestat . Quid sit autem , hac ratione cognoscitur . Raso capite an te ea medicamenta , quibus in lippitudine pituita suspenditur , a superciliis usque ad uerticem inlini debent . Si sicci oculi esse coeperunt , apparet per eas uenas , quae sub cute sunt , inrigari : si nihilo minus madent , manifestum est sub osse descendere : si est umor , sed leuior , duplex uitium est . Plurimi tamen ex laborantibus reperiuntur , quos superiores uenae exerceant ; ideoque pluribus etiam opitulari licet . Idque non in Graecia tantummodo , sed in aliis quoque gentibus celebre est , adeo ut nulla medicinae pars magis per nationes quoque exposita sit . Reperti in Graecia sunt , qui nouem lineis cutem capitis inciderent ; duabus in occipitio rectis , una super eas transuersa ; deinde duabus super aures , una inter eas item transuersa ; tribus inter uerticem et frontem rectis . Reperti sunt , qui a capite recte eas lineas ad tempora deducerent , cognitisque ex motu maxillarum musculorum initiis leuiter super eos cutem inciderent , diductisque per retusos hamos oris insererent linamenta , ut neque inter se cutis antiqui fines committerentur , et in medio caro incresceret ; quae uenas , ex quibus umor ad oculos transiret , adstringeret . Quidam etiam atramento duas lineas duxerunt a media aure ad mediam alteram aurem ; deinde a naribus ad uerticem . Tum ubi lineae committebantur , scalpello inciderunt , et post sanguinem effusum os ibidem ad usserunt . Nihilo minus autem et in temporibus et inter frontem atque caluariam eminentibus uenis idem candens ferrum admouerunt . Frequens curatio est uenas in temporibus adurere , quae fere quidem in eiusmodi malo tument : sed tamen , ut inflentur magisque se ostendant , ceruix ante modice deliganda est , tenuibusque ferramentis et retussis uenae adurendae , donec in oculis pituitae cursus conquiescat . Id enim signum est quasi excaecatorum itinerum , per quae umor ferebatur . Valentior tamen medicina est , ubi tenues conditaeque uenae sunt , ideoque legi non possunt , eodem modo ceruice deligata retentoque ab ipso spiritu quo magis uenae prodeant , atramento notare eas contra tempora et inter uerticem ac frontem ; deinde ceruice resoluta , qua notae sunt uenae , incidere , et sanguinem mittere ; ubi satis fluxit , tenuibus ferramentis adurere : contra tempora quidem timide , ne subiecti musculi qui maxillas tenent sentiant ; inter frontem uero et uerticem uehementer , ut squama ab osse secedat . Efficacior tamen etiamnum est Afrorum curatio , qui uerticem usque ad os adurunt sic , ut squamam remittat . Sed nihil melius est quam quod in Gallia est comata : qui ibi uenas in temporibus et in superiore capitis parte legunt . Adusta quomodo curanda sint , iam explicui . Nunc illud adicio : neque ut crustae decidant , neque ut ulcus inpleatur , adustis uenis esse properandum , ne uel sanguis erumpat uel cito pus subprimatur , cum per hoc siccescere eas partes opus sit , per illud exhauriri opus non sit : si quando tamen sanguis eruperit , infricanda medicamenta esse , quae sic sanguinem supprimant , ne adurant . Quemadmodum autem uenae delegendae sunt , quidque lectis is faciendum sit , cum uenero ad crurum uarices , dicam .	7 But whilst the preceding kinds of lesion do not differ much among themselves or in the mode of treatment, those in the eyes which demand surgical measures are different from each other and differently treated. For instance in the upper eyelid cysts are apt to be formed, fatty and weighty, which hardly allow the eyes to be raised, and they set up a slight but persistent discharge of rheum from the eyes; and these generally occur in children. When the eyeball has been pressed with two fingers so as to render the skin of the upper eyelid tense, a transverse linear incision is to be made with a scalpel, with so light a touch that the cyst itself is not cut into; when the way is opened it protrudes of itself. It should then be seized with the fingers and taken out, for it comes away easily. One of the ointments, with which running eyes are anointed, is then smeared on, and in a very few days a fine scar is induced. There is more trouble when the cyst has been cut into, for it lets out a humour, and afterwards, because it is very thin, it cannot be laid hold of. Should this chance to happen, something to promote suppuration should be applied. A very small tumour forms in the same upper eyelid, above the line of the eyelashes, which from its resemblance to a barleycorn is termed by the Greeks crithê. Its contents are slow to come to a head and contained within a coat; it should be fomented with hot bread or with wax gently heated, but not so hot that it cannot easily be borne by that part; for under this treatment it is often dispersed, but at times it matures. When pus shows itself, it should be cut across with a scalpel and any humour inside squeezed out; then the eyelid is afterwards also to be fomented as above by steam, and ointment applied until it heals. Other tumours also, not unlike these, form on the eyelids; but they are not quite the same shape and are mobile, so that they can be pushed about with the finger; and so the Greeks call them chalazia. They should be cut down upon, from the outside if under the skin, from the inside if under the cartilage, than separated from the sound tissue by the handle of the scalpel. If the cut is on the inner surface, first mild, then more acrid ointment is to be applied; if on the outer, an agglutinating plaster is put on. An unguis too, called pterygium in Greek, is a little fibrous membrane, springing from the angle of the eye which sometimes even spreads so as to block the pupil. Most often it arises from the side of the nose, but sometimes from the temporal angle. When recent it is not difficult to disperse by the medicaments which thin away corneal opacities; if it is of long standing, and thick, it should be excised. After fasting for a day, the patient is either seated facing the surgeon, or turned away, so that he lies on his back, his head in the surgeon's lap. Some want him facing if the disease is in the left eye and lying down if in the right. Now one eyelid must be held open by the assistant, the other by the surgeon; but he holds the lower lid when seated opposite the patient, and the upper when the patient is on his back. Thereupon the surgeon passes a sharp hook, the point of which has been a little incurved, under the edge of the pterygium and fixes the hook in it; next, leaving that eyelid also to the assistant, he draws the hook towards himself thus lifting up the pterygium, and passes through it a needle carrying a thread; then having detached the needle, he takes hold of the two ends of the thread, and raises up the pterygium by means of the thread; he now separates any part of it which adheres to the eyeball by the handle of the scalpel until the angle is reached; next by alternately pulling and slackening the thread, he is able to discover the beginning of the pterygium and the end of the angle. For there is double danger, that either some of the pterygium is left behind and if this ulcerates, it is hardly ever amenable to treatment; or that with it part of the flesh is cut away from the angle; and if the pterygium is pulled too strongly, the flesh follows unnoticed, and when it is cut away a hole is left through which there is afterwards a persistent flow of rheum; the Greeks name it rhyas. Therefore the true edge of the angle must certainly be observed; and when this has been clearly determined, after the pterygium has been drawn forward just enough, the scalpel is to be used, then that little membrane is to be cut away as not to injure the angle in any way. After that, lint soaked in honey is to be put on, and over that a piece of linen, and either a sponge or unscoured wool. And for the next few days the eye must be opened daily to prevent the eyelids uniting by a scar for if that happens a third danger is added; and the lint is to be put on again, and last of all one of the salves applied which help wounds to heal. But this treatment ought to be in the spring, or certainly before winter; this warning applies to many cases, and it will be enough to give it here once for all. For there are two classes of treatment: one in which we cannot choose the time but must make the best of things, as in the case of wounds; the other in which there is no urgency and it is safest to wait, for example when the affection progresses slowly and the patient is not racked by pain. Then we should wait for spring, or if there is more urgency, autumn is better than either summer or winter, and especially mid-autumn when the hot weather has broken and the cold not yet begun. The more essential the part to be treated, the greater the danger; and often the larger the wound to be made, the more regard should thus be paid to the season. In the course of treating pterygium, lesions arise, as I have just said, which are also apt to arise from other causes. Sometimes when the pterygium has not been quite cut away or from some other cause, a small tumour, called by the Greeks encanthis, forms at the angle and this does not allow the eyelids to be completely drawn down. It should be caught up with a hook and cut around, but with so delicate a touch that nothing is cut away from the angle itself. A bit of lint is then besprinkled with oxide of zinc or blacking, and inserted into that angle after separating the lids, and over this the dressing as above is bandaged on. Upon the following days, the eye is dressed in the same way, after having been fomented with tepid, or even with cold water. At times the eyelids adhere together, and the eye cannot be opened. When this happens, the eyelids commonly adhere to the white of the eye, that is to say, when an ulceration upon either has been carelessly treated; for in the course of healing what could and should have been kept apart has been allowed to stick: the Greeks give the name of ancyloblepharus to one who suffers from both lesions. When the eyelids only stick together they are separated without difficulty, but sometimes this is useless for they stick together again. Separation should be tried, however, because it is generally a success. The reverse end of a probe is to be inserted and the eyelids separated by this, then small pledglets of wool are put in until ulceration of the part has ceased. But when an eyelid adheres to the white of the eye itself, Heraclides of Tarentum invented the method of cutting underneath the eyelid with the knife held, but very carefully, so that nothing is cut away, either from the eyeball, or from the eyelid, and if something must be, rather from the eyelid. The eyeball should afterwards be anointed with the medicaments with which trachoma is treated; and the eyelid turned up every day, not only that the medicament may be applied to the ulceration, but also lest the eyelid should adhere again; moreover the patient himself should be told to raise his eyelid frequently with two fingers. I for my part do not remember anyone to have been cured by this method. Meges also has recorded that he tried many times, but was never successful, for the eyelid has always again become adherent to the eyeball. Again, at the angle next to the nostrils, there opens a sort of small fistula, due to some lesion, through which rheum persistently drips; the Greeks call it aigilops. This causes a persistent eye trouble; sometimes it even eats away the bone, and penetrates to the nostril. And at time it has the character of a carcinoma when the veins become distended and look jaundiced, the skin livid, hard and irritable to the slightest touch, and it gives rise to inflammation in the parts near to it. Of these affections it is dangerous to treat those which resemble carcinoma, for that even hastens death. Again, it is useless to treat those which penetrate to the nostrils for they never heal. But when limited to the angle, treatment is possible so long as we do not forget that it is difficult. The nearer the opening to the angle, the greater the deficiency, on account of the very narrow space for handling the lesion. When the trouble is fresh, however, cure is easier. Now the margin of the opening is to be caught up by a hook, then as I have described for fistula in general the whole channel down to the bone is to be excised; and the eye and adjacent parts having been well covered over, the bone is to be cauterized; and more thoroughly when there is already decay, in order that a thicker scale may separate. Some apply caustics, such as cobbler's blacking or bronze or copper filings, which act more slowly, and do not have the same effect. After cauterization of the bone, the same treatment is followed as in other burns. The eyelashes also may irritate the eye from two causes: one is that the skin on the outer surface of the eyelid becomes relaxed and slips downwards, causing its eyelashes to be turned inwards against the eyeball because the cartilage does not simultaneously give way; in the other case, beyond the natural row of eyelashes another row sprouts out, which is directed straight inwards against the eyeball. The following are the modes of treatment. If eyelashes have grown where they ought not, a fine iron needle flattened like a spear point is put into the fire; then when the eyelid is turned up, so that the offending eyelashes can be seen by the operator, the red hot needle is passed along their roots, from the angle, for a third of the length of the eyelid, then for a second and for a third time, until the opposite angle is reached; this causes all the roots of the eyelashes so cauterized to die. A medicament is then applied to check inflammation, and when the crusts have become detached, cicatrization is to be induced. This kind of trouble is very easily cured. Some say that a needle carrying a doubled-up hair from a woman's head should be passed through the eyelid from within outwards close to the eyelashes, and where the needle has passed through, an eyelash is to be inserted into the loop of the said hair where doubled, and the eyelash drawn by the loop through to the outer surface of the eyelid; there it is to be glued down; and a medicament is then applied to agglutinate the puncture; thus it comes about that afterwards that eyelash is directed outwards. But in the first place this cannot be done unless the eyelash is rather long, and in this situation they are generally short; further, when numerous eyelashes are affected, the passing of a needle so many times is necessarily a prolonged torture, and it may set up severe inflammation. Lastly, when there is any rheum subsisting there, and the eye has been irritated previously by the eyelashes, and now by the perforation through the eyelid, it is scarcely possible that the glue binding down the eyelash should not be dissolved; and so it comes to pass that the eyelash returns to the position from which it was forcibly removed. But there is no doubt about the following treatment of too lax an eyelid, which is commonly practised by everybody. It is necessary to close the eye and from the middle, either of the upper or the lower eyelid, to seize a fold of skin between a finger and thumb, and so to raise it; then consider how much must be removed the lid to be in a natural position for the future. In this too there are two dangers; that if too much has been excised the eyeball cannot be covered, if too little nothing has been gained, and a patient has been cut to no purpose. Next where it is seen that incision is to be made, a mark must be made by two lines of ink, but in such a way that between the margin holding the eyelashes, and the marked line adjacent, there remains skin enough for a needle afterwards to take up. When everything is ready the scalpel is to be applied; and the incision nearer the eyelashes themselves is to be made first in the case of the upper lid, but second for the lower one; in the case of the left eye, the incision is made from the outer angle; of the right eye from the inner one; then the skin between the two incisions is to be excised. Next the edges of the wound are to be brought into opposition by one stitch, and the eye is to be closed and if the eyelid descends too little the suture is slackened, if too much, either the suture is tightened, or even an additional fine strip may be excised from the margin furthest from the eyelashes. Where the eyelid has been cut other sutures may be put in but not more than three. Further, in the case of the upper lid, a linear incision is to be made under the row of eyelashes itself, so that these having been drawn away from under are directed upwards, and when there is but a slight drooping of the upper lid, this alone may suffice; the lower lid does not need the additional incision. When these things have been done, a sponge squeezed out of cold water is bandaged on. The next day an agglutinating plaster is applied; on the fourth day the sutures are taken out, and a salve for repressing inflammation smeared on. But in the course of the above treatment it sometimes happens that when too much skin has been excised, the eyeball is not covered; and occasionally this also occurs from some other cause: the Greeks call the condition lagophthalmus. If too much of the eyelid is lost, no treatment can restore it; if a small loss it may be remedied. Just below the eyebrow the skin is to be incised in the figure of a crescent with the horns pointing downwards. The incision should reach as far as the cartilage without injuring it; for should the cartilage be cut into, the eyelid will droop, and cannot afterwards be raised. Therefore if the skin is merely drawn apart, it follows that the bottom of the eyelid droops slightly because of the gap made by the cut above; into this gap lint is to be inserted, both to prevent the separated edges from reuniting, and to help the growth of the flesh between, so that the eyeball comes to be properly covered when the gap has filled up. Whilst a defect in the upper eyelid is that it descends too little and so does not cover the eyeball, sometimes the lower lid is not raised enough but hangs down and gapes open, and cannot reach the upper lid. And this, too, happens sometimes from the defective treatment described above, sometimes from old age: the Greeks call it ectropion. If this is due to bad treatment, the same procedure as that noted above is employed, but the horns of the incision are to be directed now towards the jaws, not towards the eyeball: if from old age, all that extrudes is burnt away with a fine cautery, then honey smeared on; from the fourth day the eye is steamed, and anointed with medicaments to induce a scar. Such as a rule are the lesions which are apt to occur around the eyeball in the angles or eyelids. But in the eyeball itself the outer tunic is sometimes raised, by the rupture or by the relaxation of certain membranes inside, and its shape becomes like a grape: the Greeks therefore call the lesion staphyloma. There are two modes of treatment. In one a needle carrying two threads is passed through the middle of its base, and first the two ends of the upper thread, and then those of the lower, are knotted, and these gradually cut through and so excise the staphyloma. In the other method, a piece about the size of a lentil is cut off from its tip, then oxide or carbonate of zinc is dusted on. After either method, wool soaked in white of egg is applied; subsequently the eye is steamed, and then anointed with soothing medicaments. Again, small hard tumours in the white of the eyeball are called clavi, from a resemblance in shape to nailheads. These it is best to transfix with a needle at their base, and to cut away underneath the needle; then to anoint with soothing medicaments. I have already made mention elsewhere of cataract, because when of recent origin it is also often dispersed by medicaments: when it is more chronic it requires treatment by surgery, and this is one of the most delicate operations. Before I speak of this, the nature of the eyeball itself has to be briefly explained. A knowledge of this is often useful, but especially here. The eyeball, then, has two external tunics, of which the outer is called by the Greeks ceratoides. In that part of the eye which is white it is fairly thick; over the region of the pupil it is thin. To this tunic the under one is joined; in the middle where the pupil is, it is pierced by a small hole: around this it is thin, further out it too is thicker and is called by the Greeks chorioides. These two tunics whilst enclosing the contents of the eyeball, coalesce again behind it, and after becoming thinned out and fused into one, go through the space between the bones, and adhere to the membrane of the brain. Under these two tunics, at the spot where the pupil is, there is an empty space; then underneath again is the thinnest tunic, which Herophilus named arachnoides. At its middle the arachnoides is cupped, and contained in that hollow is what, from its resemblance to glass, the Greeks call hyaloides; it is humour, neither fluid nor thick, but as it were curdled, and upon its colour is dependent the colour of the pupil, whether black or steel-blue, since the outer tunic is quite white: but this humour is enclosed by that thin membrane which comes over it from the interior. In front of these is a drop of humour like white of egg, from which comes the faculty of seeing; it is named by the Greeks crystalloides. Now either from disease or from a blow, a humour forms underneath the two tunics in what I have stated to be an empty space; and this as it gradually hardens is an obstacle to the visual power within. And there are several species of this lesion; some curable, some which do not admit of treatment. For there is hope if the cataract is small, and immobile, if it has also the colour of sea water or of glistening steel, and if at the side there persists some sensation to a flash of light. If large, if the black part of the eye has lost its natural configuration and is changed to another form, if the colour of the suffusion is sky blue or golden, if it shakes and moves this way and that, then it is scarcely ever to be remedied. Generally too the case is worse when the cataract has arisen from a severe disease, from severe pains in the head or from a blow of a violent kind. Old age is not favourable for treatment, since apart from this lesion, sharpness of vision is naturally dulled; neither is childhood favourable, but rather intermediate ages. Neither a small nor a sunken eye is satisfactory for treatment. And in the cataract itself, there is a certain development. Therefore we must wait until it is no longer fluid, but appears to have coalesced to some sort of hardness. Before treatment the patient should eat in moderation and for three days beforehand drink water, for the day before abstain from everything. Then he is to be seated opposite the surgeon in a light room, facing the light, while the surgeon sits on a slightly higher seat; the assistant from behind holds the head so that the patient does not move: for vision can be destroyed permanently by a slight movement. In order also that the eye to be treated may be held more still, wool is put over the opposite eye and bandaged on: further the left eye should be operated on with the right hand, and the right eye with the left hand. Thereupon a needle is to be taken pointed enough to penetrate, yet not too fine; and this is to be inserted straight through the two outer tunics at a point intermediate between the pupil of the eye and the angle adjacent to the temple, away from the middle of the cataract, in such a way that no vein is wounded. The needle should not be, however, entered timidly, for it passes into the empty space; and when this is reached even a man of moderate experience cannot be mistaken, for there is then no resistance to pressure. When the spot is reached, the needle is to be sloped against the suffusion itself and should gently rotate there and little by little guide it below the region of the pupil; when the cataract has passed below the pupil it is pressed upon most firmly in order that it may settle below. If it sticks there the cure is accomplished; if it returns to some extent, it is to be cut up with the same needle and separated into several pieces, which can be the more easily stowed away singly, and form smaller obstacles to vision. After this the needle is drawn straight out; and soft wool soaked in white of egg is to be put on, and above this something to check inflammation; and then bandages. Subsequently the patient must have rest, abstinence, and inunction with soothing medicaments; the day following will be soon enough for food, which at first should be liquid to avoid the use of the jaws; then, when the inflammation is over, such as has been prescribed for wounds, and in addition to these directions it is necessary that water should for some time be the only drink. Also with regard to the discharge of a thin rheum which troubles the eyes, I have already explained what is to be done by means of medicaments. I come now to cases which demand surgical treatment. But we have remarked that in some the eyes never dry up, but are always moistened by a thin rheum; this keeps up trachoma, and upon slight provocation excites inflammations and ophthalmia, so troubling the patient all his life; and sometimes this cannot be remedied at all, but sometimes it is curable. This is the first thing to be decided, that in the latter case the patient may be relieved, in the former no surgical treatment may be applied. And in the first place, the treatment is useless in those who have had the disorder from infancy, of necessity it will continue to their dying day; again, it is not necessary in those cases where the discharge is scanty, though acrid, since they will derive no benefit from surgery; by medicaments and by the regulation of diet which renders the rheum thicker, they come back to health. Further, broad heads are hardly ever adapted to the treatment. Then it makes a difference whether the rheum comes from blood vessels between the skull and the scalp, or from those between the membrane of the brain and the skull. Generally those above the skull irrigate the eyes by way of the temples, those under it by way of membranes connecting the eyes with the brain. Now it is possible to apply a remedy to those blood vessels which lie above the bone — to those below it is not. Neither can patients be relieved in whom rheum is flowing down both ways, because although relieved in one direction, none the less trouble continues by the other. How the matter stands is to be learnt as follows. The head having been first shaved, those medicaments by which the rheum is checked in ophthalmia are smeared on from the eyebrow to the crown of the head. If the eyes begin to dry, it is clear that the moisture comes from those blood vessels which are beneath the scalp; if in spite of the application, they continue moist, it is manifest that the downflow of rheum is from under the skull. If there is humour but in less amount, the lesion is double. In the majority of patients, however, it is found that the superficial blood vessels are involved, and so also the majority can be relieved. This is well known, not in Greece only, but among other races too, so that no portion of the Art of Medicine has become more widespread among the nations of the earth. Some Greek practitioners made nine linear incisions into the scalp, two vertical ones in the occipital region, a transverse one above them; then two above the ears, with a cross-cut uniting them, three vertical ones between the crown and the forehead. Others were found who drew those lines directly from the vertex to the temples and having ascertained where the muscles began from the movements of the jaws, cut through the scalp over them with a light hand, and after the margins of the incisions had been retracted by blunt hooks, inserted lint, in order that the former edges of the skin should not unite, and that flesh should grow up in between so as to constrict the veins carrying humour to the eyes. Some even marked out with ink two lines, from the middle of one ear to the middle of the other, and from the nose to the crown. Then, where the two lines meet, they cut with a scalpel, and after blood has flowed out, they cauterized the bone there. But further, both on the temples and also between the forehead and crown, they likewise applied the red hot cautery to prominent blood vessels. A treatment frequently used is to cauterize the blood vessels on the temples, which indeed in this malady are usually rather swollen, but in order that they may be more distended and show up better, the neck is first bandaged moderately tight and the blood vessels then burnt with fine blunt cautery points until the flow of rheum to the eyes ceases. For that is a sign of the blocking up as it were of the channels by which humor was being carried. There is a more effectual means, however, when the blood vessels are thin and deep-seated, and so cannot be picked out, whereby the neck is bandaged as before, and the patient holds his breath, so as to make the vessels more prominent, and then those on the temples and between the fore- head and vertex are marked out with ink; upon this the neck is released, the blood vessels are cut into where marked and blood let flow; when enough has been let out, the vessels are burnt with fine cauteries; over the temples this is done cautiously lest the underlying muscles controlling the jaws feel it; between the forehead and the crown the cautery is applied firmly in order that a scale may become detached from the skull. Even more efficacious is the African method; they burn the crown of the scalp through down to the bone so that it may cast off a scale. But there is nothing better than the practice in transalpine Gaul; there they pick out blood vessels in the temples and crown of the head. Now I have already explained the treatment after cautery. I here add that there should be no haste, either in detaching crust, or in letting the ulceration heal after cauterization of blood vessels, lest haemorrhage burst out, or pus be too quickly suppressed, for whilst it is the object by the ulceration to dry up these parts, it is not the object to drain them out by bleeding; but if there is bleeding, such medicaments should be sprinkled on as suppress bleeding, but do not cauterize. With regard to the selection of blood vessels, and what is to be done when they are picked out, I will speak when I come to varicose veins in the leg.