De Medicina (Celsus)

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	De Medicina Author: Celsus	Translator: Walter George Spencer
177	Vbi uero in ipso inguine ramex est , si tumor modicus est , semel incidi , si maior , duabus lineis debet , ut medium excidatur ; deinde non extracto testiculo , sicut intestinis quoque prolapsis interdum fieri docui , colligendae uenae uinciendaeque , ubi tunicis inhaerebunt , et sub his praecidendae sunt . Neque quicquam noui curatio uulneris eius requirit .	24 But when there is a varix actually situated in the inguinal region, if it forms a moderate swelling, a linear incision is made, if larger two incisions, and the included skin excised. Then without drawing out the testicle, as I directed to be done for cases of prolapse of the intestines, the veins are to be taken up, and ligatured where they are attached to the tunics, then cut away below the ligature knots. The treatment of the wound presents nothing novel.
178	Ab his ad ea transeundum est , quae in cole ipso fiunt . In quo si glans nuda est , uultque aliquis eam decoris causa tegere , fieri potest ; sed expeditius in puero quam in uiro ; in eo , cui id naturale est , quam in eo , qui quarundam gentium more circumcisus est ; in eo , cui glans parua , iuxtaque eam cutis spatiosior , breuior uero ipse coles est , quam in quo contraria his sunt . Curatio autem eorum , quibus id naturale est , eiusmodi est . Cutis circa glandem prehenditur et extenditur , donec illam ipsam condat , ibique deligatur . Deinde iuxta pubem in orbe m tergus inciditur , donec coles nudetur , magnaque cura cauetur , ne uel urinae iter uel uenae , quae ibi sunt , incidantur . Eo facto , cutis ad uinculum inclinatur , nudaturque circa pubem uelut circulus ; eoque linamenta dantur , ut caro increscat et id impleat . * * * satisque uelamenti supra latitudo plagae praestat . Sed donec cicatrix sit , uinctum esse debet , in medio tantum relicto exiguo urinae itinere . At in eo , qui circumcisus est , sub circulo glandis scalpello deducenda cutis ab interiore colest . Non ita dolet , quia summo soluto deduci deorsum usque ad pubem manu potest ; neque ideo sanguis profluet . Resoluta autem cutis rursus extenditur ultra glandem ; tum multa frigida aqua fouetur , emplastrumque circa datur , quod ualentem inflammationem reprimat . Proximisque diebus e i prope a fame uictus sit , ne forte eam partem satietas excitet . Vbi iam si ne inflammatione est , deligari debet a pube usque circulum ; super glandem autem auerso * emplastro inposito induci . Sic enim fit , ut inferior pars glutinetur , superior ita sanescat , ne inhaereat . Contra si glans ita contecta est , ut nudari non possit , quod uitium Graeci phimosin ap pellant , aperienda est ; quod hoc modo fit : subter a summa ora cutis inciditur recta linea usque ad frenum , atque ita superius tergus relaxatum cedere retro potest . Quod si parum sic profectum est , aut propter angustias aut propter duritiem tergoris , protinus triangula forma cutis ab inferiore parte excidenda est sic , ut uertex eius ad frenum , basis in tergo re extremo sit . Tum superdanda lin amenta sunt aliaque medicamenta , quae ad sanitatem perducant . Necessarium autem est , donec cicatrix sit , conquiescere : nam ambulatio adterendo ulcus sordidum reddit . Infibulare quoque adulescentulos , interdum uocis , interdum ualetudinis causa , quidam consueuerunt ; eius haec ratio est : cutis , quae super glandem est , extenditur , notaturque utrimque a l ateribus atramento qua perforetur ; deinde remittitur . Si super glandem notae reuertuntur , nimis adprehensum est et ultra notari debet ; si glans ab is libera est , is locus idoneus fibulae est . Tum qua notae sunt , cutis acu filum ducente transuitur , eiusque fili capita inter se deligantur , cotidieque id mouetur , donec circa foramina cicatriculae fiant . Vbi eae confirmatae sunt , exempto filo fibula additur ; quae quo leuior , eo melior est . Sed hoc quidem saepius inter superuacua quam inter necessaria est .	25 From the above we pass to operations on the penis itself. And, if the glans is bare and the man wishes for the look of the thing to have it covered, that can be done; but more easily in a boy than in a man; in one in whom the defect is natural, than in one who after the custom of certain races has been circumcised; and in one who has the glans small and the adjacent skin rather ample, while the penis itself is shorter, rather than in one in whom the conditions are contrary. Now the treatment for those in whom the defect is natural is as follows. The prepuce around the glans is seized, stretched out until it actually covers the glans, and there tied. Next the skin covering the penis just in front of the pubes is cut through in a circle until the penis is bared, but great care is taken not to cut into the urethra, nor into the blood vessels there. This done the prepuce slides forwards towards the tie, and a sort of small ring is laid bare in front of the pubes, to which lint is applied in order that flesh may grow and fill it up. It is seen that a large enough part of the penis has been bared, if the skin is distended little or not at all, and if the breadth of the wound above supplies sufficient covering. But until the scar has formed it must remain tied, only a small passage being left in the middle for the urine. But in one who has been circumcised the prepuce is to be raised from the underlying penis around the circumference of the glans by means of a scalpel. This is not so very painful, for once the margin has been freed, it can be stripped up by hand as far back as the pubes, nor in so doing is there any bleeding. The prepuce thus freed is again stretched forwards beyond the glans; next cold water affusions are freely used, and a plaster is applied round to repress severe inflammation. And for the following days the patient is to fast until nearly overcome by hunger lest satiety excite that part. When the inflammation has ceased, the penis should be bandaged from the pubes to the corona; over the glans the plaster is applied with the other end of the probe. This is done in order that the lower part may agglutinate, whilst the upper part heals without adhering. On the other hand, if the glans has become so covered that it cannot be bared, a lesion which the Greeks call phimosis, it must be opened out, which is done as follows: underneath the foreskin is to be divided from its free margin in a straight line back as far as the frenum, and thus the skin above is relaxed and can be retracted. But if this is not successful, either on account of constriction or of hardness of the skin, a triangular piece of the foreskin is cut out from underneath, having its apex at the frenum, and its base at the edge of the prepuce. Then lint dressing and other medicaments to induce healing are put on. But it is necessary that the patient should lie up until the wound heals, for walking rubs the wound and makes it foul. Some have been accustomed to pin up the prepuce in adolescents either for the sake of the voice, or for health's sake. This is the method: the foreskin covering the glans is stretched forwards and the point for perforation marked on each side with ink. Then the foreskin is let go. If the marks are drawn back over the glans too much has been included, and the marks should be placed further forward. If the glans is clear of them, their position is suitable for the pinning. Then the foreskin is transfixed at the marks by a threaded needle, and the ends so this thread are knotted together. Each day the thread is moved until the edges of the perforations have cicatrized. When this is assured the thread is withdrawn and a fibula inserted, and the lighter this is the better. But this operation is more often superfluous than necessary.
179	Res uero interdum cogit emoliri manu urinam , cum illa non redditur , aut quia senectute iter eius conlapsum est , aut quia calculus uel concretum aliquid ex sanguine intus se opposuit ; a t mediocris quoque inflammatio saepe eam reddi naturaliter prohibet : idque non in uiris tantummodo sed in feminis quoque interdum necessarium est . Ergo aeneae fistulae fiunt , quae ut omni corpori , amplior i minorique , sufficiant , ad mares tres , ad feminas duae medico habendae sunt : ex uirilibus maxima decem et quinque est digitorum , media duodecim , minima nouem : ex mulie bribus maior nouem , minor sex . Incuruas uero esse eas paulum , sed magis uiriles oportet , leuisque admodum ac neque nimis plenas neque nimis tenues . Homo tum resupinus eo modo , quo in curatione ani figuratur , super subsellium aut lectum conlocandus est . Medicus autem a dextro latere sinistra quidem manu colem masculi continere , dextra uero fistulam demittere in iter urinae debet ; atque ubi ad ceruicem uesicae uentum est , simul cum cole fistulam inclinatam in ipsam uesicam conpellere , eamque urina reddita recipere . Femina breuius urinae iter et rectius habet , quod mammulae simile inter imas oras super naturale positum non minus saepe auxilio eget , aliquanto minus difficultatis exhi bet. Nonnumquam etiam prolapsus in ipsam fistulam calculus , quia subinde ea extenuatur , non longe ab exitu inhaerescit . Eum , si fieri potest , oportet euellere uel oriculario specillo uel eo ferramento , quo in sectione calculus protrahitur . Si id fieri non potuit , cutis extrema quam plurimum adtrahenda et condita glande lino uinc ienda est ; deinde a latere recta plaga col es incidendus , et calculus eximendus est , tum cutis remittenda . Sic enim fit , ut incisum colem integra pars cutis contegat , et urina naturaliter profluat . Cum uesicae uero calculique facta mentio sit , locus ipse exigere uidetur , ut subiciam , quae curatio calculosis , cum aliter succurri non potest , adhibeatur : ad quam festinare cum praeceps sit , nullo modo conuenit . Ac neque omni tempore neque in omni aetate neque in omni uitio id experiundum est , sed solo uere , in eo corpore , quod iam nouem annos , nondum quattuordecim excessit , et si tantum mali est , ut neque medicamentis uinci possit , neque iam trahi posse uideatur , quo minus interposito aliquo spatio interemat . Non quo non interdum etiam temeraria medicina proficiat , sed quo saepius utique in hoc fallat , in quo plura et genera et tempora periculi sunt ; quae simul cum ipsa curatione proponam . Igitur , ubi ultima experiri statutum est , ante aliquot diebus uictu corpus praeparandum est , ut modicos , ut salubres cibos , ut minime glutinosos adsumat ; ut aquam bibat . Ambula ndi uero inter haec exercitatione utatur , quo magis calculus ad uesicae ceruicem descendat . Quod an inciderit , digitis quoque , sicut in curatione docebo , demissis cognoscitur . Vbi eius rei fides est , pridie is puer in ieiunio continendus , et tum loco calido curatio adhibenda ; quae hoc modo ordinatur : homo praeualens et peritus in sedili alto considit ; supinumque eum et auersum , super genua sua coxis eius conlocatis , conprehendit ; reductisque eius cruribus ipsum quoque iubet , manibus ad suos poplites datis , eos quam maxime possit adtrahere , simulque ipse sic eos continet . Quod si robustius corpus eius est , qui curatur , duobus sedilibus iunctis duo ualentes insidunt , quorum et sedilia et interiora crura inter se deligantur , ne diduci possint . Tum is super duorum genua eodem modo collocatur ; atque alter , prout consedit , sinistrum crus eius , alter dextrum , simulque ipse poplites suos adtrahit . Siue autem unus , siue duo continent , super umeros eius suis pectoribus incumbunt . Ex quibus euenit , ut inter ilia sinus super pubem sine ullis rugis sit extentus et in angustum conpulsa uesica e x fac ili calculus capi possit . Praeter haec etiamnum a l ateribus duo ualentes obiciantur , qui circumstantes lab are uel unum uel duos , qui puerum contine nt, non sinunt . Medi cus deinde , diligenter unguibus circumcisis , un cta que sinistra manu duos eius digitos , indicem et medium , leniter prius unum , deinde alterum in anum eius demittit ; dextraeque digitos super imum abdomen leuiter inponit , ne , si utrimque digiti circa calculum uehementer concurrerint , uesicam laedant . Neque uero festinanter in hac re , ut in plerisque , agendum est , sed ita , ut quam maxime id tuto fiat : nam laesa uesica neruorum distentiones cum periculo mortis excitat . A c primum circa ceruicem quaeritur calculus , ubi repertus minore negotio expellitur . Et ideo dixi ne curandum quidem , nisi cum hoc indiciis suis cognitum est . Si uero aut ibi non fuit aut recessit retro , digiti ad ultimam uesicam dantur , paulatimque dextra quoque manus eius ultra translata subsequitur . Atque ubi repertus calculus , qui necesse est in manus incidat , eo curiosius deducitur , quo minor leuiorque est , ne effugiat . [ id est ne saepius agitanda uesica sit . ] Ergo ultra calculum dextra semper manus eius se opponit , sinistrae digiti deorsum eum conpellunt , donec ad ceruicem peruenitur : in quam , si oblongus est , si c compellendus est , ut pronus exeat ; si planus , sic ut transuersus sit ; si quadratus , ut duobus angulis sedeat ; si altera parte plenior , sic ut prius ea , qua tenuior sit , euadat . In rotundo nihil interesse ex ipsa figura patet , nisi si le uior altera parte est , ut ea antecedat . Cum iam eo uenit , t um incidi super uesicae ceruicem iuxta anum cutis plaga lunata usque ad ceruicem uesicae debet , cornibus ad coxas spectantibus : paulum deinde infra ea parte , qua resima plaga est , etiamnum sub cute altera transuersa plaga facienda est , qua ceruix aperi atur, donec urinae iter pateat sic , ut plaga paulo maior quam calculus sit . Nam qui metu fistulae , quam illo loco rhyada Graeci uocant , parum patefaciunt , maiore eodem periculo reuoluuntur , quia calculus iter , cum ui promitur , facit , nisi accipit ; idque etiam perniciosius est , si figura quoque calculi uel aspritudo aliquid eo contulit . Ex quo et sanguinis profusio et distentio neruorum fieri potest . Quae si quis euasit , multo tamen patentiorem fistulam habiturus est rupta ceruice , quam habuisset incisa . Cum uero ea patefacta est , in conspectu m calculus uenit ; in cuius colore nullum discrimen est . Ipse si exiguus est , digitis ab altera parte propelli , ab altera protrahi potest . Si maior , iniciendus a superiore ei parte uncus est eius rei causa factus . Is est ad extremum tenuis , in semicirculi specie m retusae latitudinis , ab exteriore parte leuis , qua corpori iungitur , ab interiore asper , qua calculum adtingit isque longior potius esse debet : nam breuis extrahendi uim non habet . Vbi iniectus est , in utrumque latus inclinandus est , ut appareat calculus si teneatur ; quia , si adprehensus est , ille simul inclinatur . Idque eo nomine opus est , ne , cum adduci uncus coeperit , calculus intus effugiat , hic in oram uulneris incidat eamque conuulneret : in qua re quo d periculum esse t , iam supra posui . Vbi satis teneri calculum patet , eodem paene momento triplex motus adhibendus est : in utrumque latus , deinde extra , sic tamen id leniter ut fiat paulumque primo calculus adtrahatur . Quo facto , attollendus un cus extremus est , uti intus magis maneat faciliusque illum producat . Quod si quando a superiore parte calculus parum commode conprehendetur , a latere erit adprehendendus . Haec est simpli cissima curatio . Sed uarietas rerum quasdam etiamnum animaduersiones desiderat . Sunt enim quidam non asperi tantummodo sed spi nossi quoque calculi , qui per se quidem delapsi in ceruicem sine ullo periculo eximuntur . In uesica uero non tuto uel hi conquiruntur uel adtrahuntur , quoniam ubi illam conuulnerarunt , ex distentione neruorum mortem maturant ; multoque magis , si spina aliqua uesicae inhaeret eamque , cum duceretur , duplicauit . Colligitur autem eo , quod difficilius urina red ditur, in ceruice calculum esse ; eo , quod cruenta destillat , eum esse spinosum ; maximeque sub his digitis quoque experiundum est , neque adhibenda manus , nisi id constitit . Ac tum quoque leniter intus digiti obiciendi , ne ualenter promouend o conuolnerent ; tum incidendum . Multi hic quoque scalpello usi sunt . Meges quoniam is infirmior est potestque in aliqua prominentia incidere , incisoue super illa corpore qua cauum subest , non secare , sed relinquere quod iterum incidi necesse sit , ferramentum fecit rectum , in summa parte labrosum , in ima semicirculatum acutumque . Id receptum inter duos digitos , indicem ac medium , super pollice inposito , sic deprimebat , ut simul cum carne , si quid ex calculo prominebat , incidere t . Quo consequebatur , ut semel quantum satis esset , aperiret . Quocumque autem modo ceruix pa tefacta est , leniter extrahi quod asperum est debet , nulla propter festinationem ui admota . At calculus harenosus et ante manifestus est , quoniam e o urina quoque redditur harenosa , et in ipsa curatione , quoniam inter subiectos digitos neque aeque renititur et insuper dila bitur. Item molles calculos et ex pluribus minutisque sed inter se parum adstrictis compositos indicat urina trahens quasdam quasi squamula s. Hos omnes leniter permutatis subinde digitorum uicibus sic oportet adducere , ne uesicam laedant neue intus aliquae dissipatae reliquiae maneant , quae postmodo curationi difficultatem faciant . Quicquid autem ex his in conspectum uenit , uel digitis uel unco eximendum est . Ac si plures calculi sunt , singuli protrahi debent , sic tamen ut , si quis exiguus supererit , potius relinquatur . Siquidem in uesica difficulter inuenitur , inuentusque celeriter effugit . Ita longa inquisitione uesica laeditur , excitatque inflammationes mortiferas , adeo ut quidam non secti , cum diu frustraque per digitos uesica esset agitata , decesserint . Quibus accedit etiam , quod exiguus calculus ad plagam urina postea promouetur et excidit . Si quando autem is non uidetur nisi rupta ceruice extrahi posse , findendus est : cui us repertor Hammonius ob id litho tomos cognominatus est . Id hoc modo fit : uncus inicitur calculo sic , ut facile eum concussum quoque tene at , ne is retro reuoluatur ; tum ferramentum adhibetur crassitudinis modicae , prima parte tenu i sed retus a ; quod admo tum calculo ex altera parte ictu eum findit , magna cura habita , ne aut ad ipsam uesicam ferramentum perueniat , aut calculi fractura ne quid incidat . Hae uero curationes in feminis quoque similes sunt , de quibus tamen proprie quaedam dicenda sunt . Siquidem in his , ubi paruolus calculus est , scalpellus superuacuus est , quia is urina in ceruicem compellitur , quae et † in breuior quam in maribus et laxior est . Ergo et per se saepe excidit , et si in primo , quod est angustius , inhaeret , eodem tamen unco sine ulla noxa educitur . At in maioribus calculis necessaria eadem curatio est . Sed uirgini subire digiti qua masculo , mulieri per naturale eius debent . Tum uirgini quidem sub ima sinisteri ore ora , mulieri uero inter urinae iter et os pubis incidendum est sic , ut utroque loco plaga ist a transuersa sit ; neque terreri conuenit , si plus ex muliebri corpore sanguinis profluit . Calculo euolso , si ualens corpus est neque magnopere uexatum , sinere oportet sanguinem fluere , quo minor inflammatio oriatur . Atque ingredi quoque eum paulum non alienum est , ut excidat , si quid intus concreti sanguinis mansit . Quod si per se non destitit , rursus , ne uis omnis intereat , subprimi debet ; idque protinus in inbecillioribus ab ipsa curatione faciendum est : siquidem , ut distentione neruorum periclitatur aliquis , dum uesica eius agitatur , sic alter metus excipi t , [ remotis medicaminibus ] ne tantum sanguinis profluat , ut occidat . Quod ne incidat , desidere is debet in acre acetum , cui aliquantum salis sit adiectum ; sub quo et sanguis fere conquiescit , et adstringitur uesica , ideoque minus inflammatur . Quod si parum proficit , adglutinanda cucurbitula est et inguinibus et coxis et super pubem . Vbi iam satis uel euocatus est sanguis uel prohibitus , resupinus is collocandus est sic , ut caput humile sit , coxae paulum excitentur ; ac super ulcus inponendum est duplex aut triplex linteolum aceto madens . Deinde interpositis duabus horis in solium is aquae calidae resupinus d emittendus est sic , ut a genibus ad umbilicum aqua teneat , cetera uestimentis circumdata sint , manibus tantummodo pedibusque nudatis , ut et minus digeratur et ibi diutius maneat : ex quo multus sudor oriri solet . Atqu e os spongia subinde et facie m detergendum est , finisque eius fomenti est , donec infirmando offendat . Tum multo is oleo perunguendus , inducendusque absus lanae mollis tepido oleo repletus , qui pubem et coxas et inguina et plagam ipsam — contectam † eodem ante sed linteolo — protegat ; isque subinde oleo tepido madefaciendus est , ut neque frigus ad uesicam admittat et neruos leniter molliat . Quidam cataplasmatis calfacientibus utuntur ; ea plus pondere nocent , quo uesicam urguendo uulnus inritant , quam c alore proficiunt . Ergo ne uinculum quidem ullum necessarium est . Proximo die , si spiritus difficilius redditur , si urina non excedit , si locus circa pubem mature intumuit , scire licet in uesica sanguinem concretum remansisse : igitur , demissis eodem modo digitis , leuiter pertractanda uesica est , et discutienda , si qua coierunt ; quo fit , ut per uulnus postea procedant . Non alienum est etiam oriculario clystere acetum nitro mixtum per plagam in uesicam conpellere : nam sic quoque discutiuntur , si qua cruenta coierunt ; eaque facere etiam primo die conuenit , si timemus , ne quid intus sit , maximeque ubi ambulando id elicere inbecillitas prohibuit . Cetera eadem facienda sunt , ut demittatur in solio , ut eodem modo panniculus , e odem ulceri lana superiniciatur . Sed neque saepe neque tam diu in aqua calida puer habendus quam adulescens est , infirmus quam ualens , leui quam grauiore inflammatione adfectus , is cuius corpus diger itur quam is cuius astrictum est . Inter haec uero , si somnus est et aequalis spiritus et madens lingua et sitis modica et uenter imus sedet , si mediocris est cum febre modica dolor , scire licet recte curationem procedere . Atque in his inflammatio fere quinto uel septimo die finitur ; qua leuata solium superuacuum est . Supini tantummodo uulnus aqua calida fouendum est , ut , si quid urinae rodit , eluatur . Inponenda autem medicamenta sunt pus mouentia , et si purgandum ulcus uidebitur , melle inlinendum : id si rodet , rosa temperabitur . Huic curationi aptissimum uidebitur enneapharmacum emplastrum : nam et sebum habet ad pus mouendum et mel ad ulcus repurgandum , medulla m etiam maximeque uitulina m ; quod in id , ne fistula relinquatur , praecipue proficit . Linamenta uero tum super ulcus non sunt necessaria : super medicamentum ad id continendum recte inponuntur . At ubi ulcus purgatum est , puro linamento ad cicatricem perducendum est . Quibus temporibus tamen , si felix curatio non fuit , uaria pericula oriuntur . Quae praesagire protinus licet : si continua uigilia est , si spiritus difficultas ; si lingua arida est , si sitis uehemens ; si uenter imus tumet ; si uulnus hiat , si transfluens urina id non rodit , * * * similiter ante tertium diem quaedam liuida excedunt ; si is aut nihil aut tarde respondet ; si uehementes dolores , si post diem quintum magnae febres urguent et fastidium cibi permanet , si cuba re in uentrem iucundius est . Nihil tamen peius est distentione neruorum et ante diem nonum uomitu bilis . Sed cum inflammation is sit metus , succurri abstinentia , modicis et tempestiuis cibis , inter haec fomentis , et quibus supra scripsimus , oportet .	26 Sometimes we are compelled to draw off the urine by hand when it is not passed naturally; either because in an old man the passage has collapsed, or because a stone, or a blood-clot of some sort has formed an obstruction within it; but even a slight inflammation often prevents natural evacuation; and this treatment is needed not only for men but sometimes also for women. For this purpose bronze tubes are made, and the surgeon must have three ready for males and two for females, in order that they may be suitable for every body, large and small: those for males should be the longest, fifteen finger-breadths in length, the medium twelve, the shortest nine; females, the longer nine, the shorter six. They ought to be a little curved, but more so for men, and they should be very smooth and neither too large nor too small. Then the man must be placed on his back, in the way described for anal treatment, on a low seat or couch; while the practitioner stands on his right side, and taking the penis of the male patient in his left hand, with his right hand passes the pipe into the urethra; and when it has reached the neck of the bladder, the pipe together with the penis is inclined and pushed on right into the bladder; and when the urine has been evacuated, it is taken out again. The woman's urethra is both shorter and straighter, like a nipple placed between the inner labia over the vagina, and this requires assistance no less often though it is attended by somewhat less difficulty. Sometimes too a stone slips into the urethra itself, and lodges not far from its orifice, because this becomes narrower further down. The stone should if possible be extracted either by an earscoop or by the instrument with which a stone is drawn out in the course of lithotomy. If this cannot be done, the foreskin is drawn as far forwards as possible over the glans and tied there by a thread. Then to one side of the penis a longitudinal incision is to be made and the stone taken out, after which the prepuce is released. This is done in this way so that an intact portion of skin covers the incision into the penis, and urine flows out naturally. Now that mention has been made of the bladder and of stone, this seems the proper place to describe what treatment is to be adopted in cases of calculus, when it is impossible otherwise to afford relief; but it is most inadvisable to undertake it hastily, since it is very dangerous. This operation is not suitable for every season or at any age or for every lesion, but it must be used in the spring alone, in a boy who is not less than nine years of age and not more than fourteen, and if the disease is so bad that it cannot be relieved by medicaments, or endured by the patient without shortly bringing his life to a close. Sometimes even a rash line of treatment is successful, but it generally disappoints, especially in this sort of case, where the types and seasons of danger are very numerous, and these I will describe along with the treatment itself. Therefore when it has been decided to make trial of this last resource, for some days beforehand the patient's body is to be prepared by dieting, so that he takes a moderate amount of food which is wholesome, and not glutinous, and drinks water. Meanwhile he should also take walking-exercise to encourage the stone to descend to the neck of the bladder. Whether this has happened is recognized by the insertion of the finger, as I shall point out in the course of the treatment. When that is assured and the boy has been kept fasting from the previous day, then the operation is carried out in a warm room, and in the following manner. A strong and well-trained man, seated on a high stool, seizes the boy from behind and draws him backwards until his buttocks rest on the man's knees. When the boys' legs have been drawn up, the man orders him to put his hands behind his knees, and to pull upon them as much as he can, and at the same time the man keeps them in this position. But if a stronger person is to be treated, two strong men are seated on stools, side by side, and both the stools and the adjacent legs of the men are lashed together, so that they cannot be separated. Then the patient is seated in the same way as above upon the knees of the two men; and according to their position, one man takes hold of the patient's left leg, the other of the right, whilst at the same time the patient pulls upon his own hams. Whether one or two men hold the patient, they press downwards with their chests upon the patient's shoulders. Hence it results that the hollow between the iliac regions above the pubes is outstretched without any folds, and as the bladder is crammed into a narrow space the calculus can easily be seized hold of. In addition, moreover, two strong men should be put to stand at the sides, and they by standing there prevent the man or men who holding the boy from slipping. Then the surgeon having carefully pared his nails and anointed his left hand, gently introduces two fingers, the index and the middle, first one and then the other, into the anus; next he places the fingers of his right hand upon the hypogastrium, but lightly, lest if the two sets of fingers should press around the calculus with any force, the bladder may be injured. And in this procedure we must not act with haste, as in most cases, but so that safety is the first consideration; for an injury to the bladder causes spasm with danger of death. And the stone is first sought for about the neck of the bladder; when found there it is expelled with less trouble. And this is why I said there should be no operation except when the stone has been recognized by its special signs. But if the stone is not found at the neck of the bladder, or if it has slipped backwards, the fingers are placed against the base of the bladder, while the surgeon's right hand too is placed above the stone and gradually follows it downwards. When the stone has been found, and it must fall between his hands, it is guided downwards with special care the smaller and the smoother it is, lest it escape. This is that the bladder may not be too often disturbed. Therefore the right hand of the surgeon is always kept above the stone whilst the fingers of the left press it downwards until it arrives at the neck of the bladder: and it must be pressed towards this so that if oblong, it comes out end on; if flat it lies crossways; if cubical, it rests on two of its angles; if any part is larger, the smaller part comes out first. In the case of a spherical stone, it is clear that the shape makes no difference, except that if any part is the smoother this should be in front. When the stone has now got there, then the skin over the neck of the bladder next the anus should be incised by a semilunar cut, the horns of which point towards the hips; then a little lower down in that part of the incision which is concave, a second cut is to be made under the skin, at a right angle to the first, to open up the neck of the bladder until the urinary passage is opened so that the wound is a little larger than the stone. For those who make a small opening for fear of a fistula, which in this situation the Greeks call rhyas, incur this same danger to a greater degree, because the stone, when it is pressed down with force, makes a way out for itself unless it is given one. And this is even more harmful if the shape of the stone or its roughness has caused any additional trouble. As a consequence bleeding and spasm may be set up. And even if the patient survives he will have, nevertheless, a much wider fistula if the neck of the bladder has been torn, than he would have had if it had been cut. Now when the urethra has been laid open, the stone comes into view; its colour is of no importance. If it is small, it can be pushed outwards with the fingers on one side, and extracted by those on the other. If large, we must put over the upper part of it the scoop made for the purpose. This is thin at the end, beaten out into a semicircular shape, smooth on the outer side, where it comes into contact with the body, rough on the inner where it touches the stone. The scoop must be rather long, for a short one has not the strength to extract. When the scoop has been put in, it should be moved to each side to see whether the stone is held, because if it has been well grasped, it is moved with the scoop. This is required lest when the scoop begins to be drawn forward, the stone should slip inwards and the scoop cut into and lacerate the wound opening, and I have noted above how dangerous this is. When it is certain that the stone is sufficiently held, almost simultaneously a triple movement is to be made; first towards each side, then outwards, this in such a way that the movement is gentle and the stone is at first drawn outwards but little; this done the one end is to be raised so that the scoop may stay further in, and more easily draw out the stone. But if at any time the stone cannot be properly caught from above, it will have to be taken hold of from one side. This is the simplest method of operation. But various contingencies call for some further observations. There are some stones which are not merely rough but also spinous, which if they have come down to the neck of the bladder of their own accord may be extracted without any danger. But it is not safe to search for these within the bladder and draw them out, for when they have wounded the bladder they cause a speedy death from spasm, and much more so if a spinous stone sticks to the bladder, and when being drawn down has folded it over. Now it may be inferred that the stone is at the neck of the bladder, when the patient has difficulty in passing water: or that the stone is spinous, when he passes bloody urine in drops. And it is most important that the calculus should be felt under the fingers, and that the operation should not be proceeded with unless this is assured. And then too the fingers must be applied gently, lest they wound by pressing forcibly: the incision is then made. Many use a scalpel here also. Since this is rather weak, and may meet some projecting part of the stone, and while cutting the flesh over the projection fail to divide what is in the hollow beneath, but leave something which necessitates a second operation. Meges made a straight blade, with a wide border on its upper part, semicircular and sharp below. This knife, with its handle grasped between the two fingers, index and middle, and the thumb put into the back of the blade, was so pressed down that any projection upon the stone might be cut through along with the flesh. By this means it followed that he made one opening of a sufficient size. But in whatever way the neck of the bladder is laid open, any rough stone should be extracted gently, and no force used to hasten matters. A sandy stone is made evident before the operation by the sandy urine which is passed, and in the course of it, since it does not present a uniform resistance to the fingers in the rectum, and in addition it breaks up. Again soft stones and those composed of numerous small ones which only lightly adhere together, are indicated when the urine shows scalelike particles. All these should be brought out gently by changing as before the position of the fingers in turn, without injury to the bladder, yet so as not to leave behind in it any scattered remnants which will render the after-treatment difficult. When anything of this kind comes into view it is to be extracted by the fingers or scoop. And if there are several stones they are to be extracted one by one, but if a very small stone remains over it had better be left. For it is difficult to find it in the bladder, or when found it easily escapes again. In such a prolonged search the bladder is injured and fatal inflammations set up; so that some who have not been operated on have died after the bladder has been for a long while and in vain pushed about by the fingers. There is the additional reason that a small stone is later moved forward with the urine into the wound and so removed. If, however, at any time the stone appears too large to extract without tearing the neck of the bladder, it is to be split up; hence Ammonius the inventor of this process was surnamed lithotomus. This is done as follows: the scoop is passed over the stone, so that it easily keeps hold of the stone, even when it is struck; next an instrument is used of moderate thickness, its front end tapering yet blunt, and when this is put against the calculus, and its other end struck, it splits up the stone, great care being taken that the instrument does not come into contact with the bladder itself, and that no fragment from the broken calculus cuts into it. Now these operations are similar in females too, yet there are some particulars to be mentioned about them. Since in women when the stone is small, the use of the knife is unnecessary because the stone is forced by the urine into the neck of the bladder which is shorter and more yielding in females than in males. Therefore the stone often escapes of itself, and if it sticks in the first part, which is narrower, yet it may be extracted by the scoop described above without any harm. But for larger stones the treatment is the same. Except that in the case of a virgin the fingers are passed as in males, in the case of a woman into the vagina. Then the incision is to be made in a virgin just under the left labium, in a woman between the urethra and pubic bone, and in both instances by a transverse wound. There is no need to be frightened if there is freer bleeding from a woman. When the stone has been extracted, if the patient is strong and has not suffered excessively, it is well to let the bleeding go on, so that less inflammation may follow. Besides it is not unfitting for him to move about a little, in order that any blood clot still inside may drop out. But if again the bleeding does not cease of its own accord, it must be stopped lest all his strength be used up; and in weaker patients this is to be done immediately after the operation; since just as there is the risk of spasm from pushing about the bladder, so there is a second danger that in the absence of medicaments so much blood may be lost as to prove fatal. To prevent this the patient should be seated in a bath of strong vinegar to which a little salt has been added; under this treatment the bleeding generally stops, and it also has an astringent effect on the bladder so that the inflammation there is lessened. But if this is not successful, cups are to be applied on groins and hips and above the pubes. As soon as sufficient blood has been drawn away or the bleeding checked, the patient should be so placed on his back that his head is low, his hips a little raised; and two or three layers of linen soaked in vinegar are to be applied over the wound. Then after two hours he should be put into a hip bath and lean back in the hot water, so that the water covers him from his knees to his navel, while the rest of his body is wrapped up, except that his hands and feet are exposed, in order that he may be less exhausted and remain in the bath longer: the usual result is free sweating. And his mouth and face must be wiped with a sponge from time to time, and an end put to this hot bath whenever it becomes harmful by weakening the patient. Afterwards the patient is freely rubbed with oil, and a dressing of soft wool applied, soaked in warm oil, covering the pubes and hips and groins as well as the wound itself, which had previously been covered with a similar dressing, but of lint. From time to time this dressing is to be saturated with the warm oil in order that cold may not reach the bladder, and that the sinews may be gently softened. Some make use of heating plasters; these do more harm by their weight pressing upon the bladder, and by irritating the wound, than they do good by their heating. For the same reason not even a bandage is required. On the next day if there is difficulty in breathing, if urine is not passed, if the region about the pubes swells prematurely it may be recognized that a blood clot has collected in the bladder; for this the fingers are introduced into the rectum as before and the bladder stroked gently so as to break up clots; thus they subsequently escape by the wound. It is not inappropriate to inject vinegar mixed with soda into the bladder through the wound by means of an ear syringe, for in this way also clotted blood is broken up; and it is proper to do this even on the first day if we are afraid that there is a clot inside, especially when weakness prevents the patient from moving about to eliminate it. The treatment afterwards is the same, sitting in a hot bath, a pad and wool prepared as before as dressings. But a boy should not be put so often into the hot water nor kept in so long as an adolescent; a weak patient as a robust one; one with a slight inflammation as one severely inflamed; a patient with a relaxed body as one in good tone. Meanwhile, if the patient sleeps and breathes regularly and his tongue is moist and there is only moderate thirst and the hypogastrium is flat, if there is not much pain and but moderate fever, we may assume that the treatment is doing well. In such cases the inflammation generally ends on the fifth or seventh day; when it has passed off, the hip bath becomes unnecessary; whilst the patient is on his back the wound is just to be fomented enough with hot water to wash away any urine that irritates. Now the medicaments to be applied should be suppuratives, and if the wound seems to need cleaning, it is to be smeared with honey, or if that irritates it can be tempered with rose oil. The nine-drug plaster seems the most suitable at this stage of the treatment for it contains both suet as a suppurative, and honey to clean the wound, also marrow, best from a calf; its contents are particularly efficient in preventing the establishment of a fistula. But lint at this period is not to be applied directly to the wound, but it may be properly put on over medicaments to keep them in place. When, however, the wound is clean, it is to be healed by applying plain lint. During this period, however, when the course of the treatment has not gone well, various dangers arise. These may be expected: if there is persistent insomnia, laboured breathing, a dry tongue, great thirst, a distended hypogastrium; if the wound gapes; if the urine as it escapes does not irritate the wound; if there is some livid discharge by night and day alike before the third day; if the patient does not answer or replies slowly; if there are severe pains; if after the fifth day high fever oppresses the patient and a distaste for food persists; if he finds more ease by lying on his stomach. But the worst complication is spasm of the sinews and bilious vomiting before the ninth day. But when there is danger of inflammation the best treatment is by abstinence, food in small quantities and at stated intervals, and at the same time fomentations and the other things described above.
180	Proximus cancri metus est . Is cognoscitur , si et per uulnus et per ipsum colem fluit sanies mali odoris , cumque eo quaedam a concreto sanguine non abhorrentia tenu esque carunculae lanulis similes ; praeter haec , si orae uulneris aridae sunt , si dolent inguina ; si febris non def it , eaque in noctem augetur , si inordinati horrores accedunt . Considerandum autem est , in quam partem cancer is tendat . Si ad colem , indurescit is locus et rubet et tactu dolorem excitat , testiculique intumescunt : si in ipsam uesicam , ani dolor sequitur , coxae durant , non facile crura extendi possunt . A t si in alterutrum latus , oculis id expositum est , paresque utrimque easdem notas sed minores habet .— Primum autem ad rem pertinet corpus recte iacere , ut superior pars eadem semper sit * * in quam uitium fertur . Ita si ad colem it , supinus is collocari debet ; si ad uesicam , in uentrem ; si in latus , in id , quod integrius est . Deinde ubi uentum fuerit ad curationem , homo in aquam demittetur , in qua marrubium decoctum sit aut cupressus aut myrtus ; idemque umor * clystere intus a getur; tum superponetur lenticula cum malicorio mixta , quae utraque ex uino decocta sint ; uel rubus aut oleae folia eodem modo decocta , aliaue medicamenta , quae ad cohibendos purgandosque cancros proposuimus . Ex quibus si qua erunt arida , per scriptorium calamum inspirabuntur . Vbi stare coeperit cancer , mulso u olnus eluetur , uitabiturque eo tempore ceratum , quod ad recipiendum id malum corpus emollit : potius plumbum elotum cum uino inunguetur , superque idem linteolo inlitum inponetur . Sub quibus perueniri ad sanitatem potest , cum eo tamen quod non ignoremus orto cancro saepe adfici stomachum , cui cum uesica quaedam consortio est ; exque eo fieri , ut neque retineatur cibus neque , si quis retentus est , coquatur , neque corpus alatur , ideoque ne uulnus quidem aut purgari aut ali possit ; quae necessario mortem maturant . Sed ut his succurri nullo modo potest , sic a primo tamen diu tenenda ratio curationis est ; in qua quaedam obseruatio ad cibum quoque potionemque pertinens necessaria est . Nam cibus inter principia non nisi umidus dari debet : ubi ulcus purgatum est , ex media materia : holera et salsamenta semper aliena sunt . Potione opus est modica : nam si parum bibitur , accenditur uulnus , et uigilia urguet et uis corporis minuitur : si plus aequo adsumitur , subinde uesica impletur eo que inritatur . Non nisi aqua m autem bibendam esse manifestius est , quam ut subinde dicendum sit . Solet uero sub eiusmodi uictu euenire , ut al uos non reddatur . Haec aqua ducenda est , in qua uel faenum Graecum uel malua decocta sit . Idem umor rosa mixtus in ipsum uulnus oriculario clystere agendus est , ubi id rodit urina neque purgari patitur . Fere uero primo per uulnus exit hae c ; deinde eo sanescente diuiditur , et pars per colem descendere incipit , donec ex toto plaga claudatur ; quod interdum tertio mense , interdum non ante sextum , nonnumquam exacto quoque anno fit . Neque desperari debet solida glutinatio uulneris , nisi ubi aut uehementer rupta ceruix est , aut ex cancro multae magnaeque carunculae simulque neruosa aliqua exciderunt . Sed ut uel nulla ibi fistula uel exigua admodum relinquatur , summa cura prouidendum est . Ergo cum iam ad cicatricem uulnus intendit , extentis iacere feminibus et cruribus oportet , nisi tamen molles harenosiue calculi fuerunt : sub his enim tardius uesica purgatur ; ideoque diutius plagam patere necessarium est et tum demum , ubi iam nihil tale extra fertur , ad cicatricem perduci . Quod si antequam uesica purgata est , orae se glutinarunt , dolorque et inflammatio redierunt , uulnus digitis uel auerso specillo diducendum est , ut torquentibus detur exitus ; iisque effusis cum diutius pura urina descendat , tum demum quae cicatricem inducant ponenda sunt ; extend endique , ut supra posui , pedes quam maxime iuncti . Quod si fistulae metus ex is causis , quas proposui , subesse uidebitur , quo facilius cludatur ea u el certe coangustetur , in anum quoque danda plumbea fistula est ; extentisque cruribus femina talique inter se deligandi sunt , donec , qualis futura est , cicatrix sit .	27 The nearest danger is canker. This is recognized if the discharge, whether from the wound, or through the penis, is a malodorous sanies, also something of the nature of blood-clot, and thin bits of flesh like flocks of wool; and in addition to this if the margins of the wound become dry; if there is pain in the groins; if the fever does not subside and it increases at night, if there are irregular shivering-fits as well. We must examine in what direction the canker is spreading. If to the penis, that part becomes hard and red and is painful to the touch, and the testicles swell; if into the bladder itself, anal pain follows, the hips harden, the legs cannot be easily stretched. But if to either side, this fact is clear to the eyes, and the gangrene shows the same marks on both sides, but smaller on that less affected.— But first it is important that the patient shall lie properly, that is, that the same part should always be uppermost and that that should be the part where the disease is spreading. Thus if the direction is into the penis, the patient is laid on his back; if into the bladder, on his belly; if into one side, then he lies on the more sound one. Coming to the treatment, the man should be placed in a bath containing a decoction of horehound or of cyprus or of myrtle; and the same fluid boiled is injected into the wound with a syringe; then is put on a plaster of lentils with pomegranate rind, both of which have been boiled in wine, or a similar decoction of blackberry, or of olive leaves, or of other material which I have set out as suitable for arresting and cleaning wounds affected by canker. Dry medicaments of this sort may be blown in through a quill. When the gangrene begins to come to a standstill, the wound is washed with honey wine, but at this stage a cerate should be avoided, for by softening the tissues it predisposes to that very malady: we must rather smear on washed lead with wine, over that the same spread on linen. By such measures it is possible to effect a cure, but we must not ignore the fact that when canker has once started, the stomach is often affected, since the bladder is closely associated with it; hence, it happens that food is not kept down, or when it is retained, not digested, nor is the body nourished; and thus the wound cannot clean, nor gain flesh: and these facts necessarily hasten death. But while it is in no way possible to save such cases as these, yet a method of treatment should be observed from the very first for a long while, in which of course due regard must be had to food and drink. For at first only fluid food should be given; when the wound has cleaned food of the middle class; greens and salted fish are always unsuitable. The amount of drink should be moderate, for if too little is drunk, the wound becomes inflamed, the patient suffers from insomnia and gets weaker; if too much is drunk, the bladder fills frequently and so is irritated. It is too obvious to need repetition that nothing except water is to be drunk. Now it generally happens under such a diet that the bowels do not act. They are to be moved by a clyster containing either fenugreek or mallow. The same decoction mixed with rose oil is to be injected into the wound itself through an ear syringe whenever the urine causes irritation and stops the wound from cleaning. General all the urine escapes at first through the wound; then in the course of healing it divides, and part begins to pass through the penis until the wound has completely closed; and this occurs at times in the third month, at times not before the sixth month, and occasionally not for a year. And we need not despair of the firm healing of the wound, unless the neck of the bladder has been roughly ruptured, or when owing to gangrene many large portions of the flesh have sloughed away and some fibrous tissue too. But the greatest care must be taken that no fistula, or only a very small one, is left there. With this object as the wound tends to form a scar, the patient should lie with his thighs and legs stretched out, except only when the stones have been soft and sandy: for then the bladder is slower in cleaning itself: and so it is necessary to keep the wound open longer, and only when there is nothing more to come out of the bladder is the wound allowed to heal. If the margins of the wound stick together, before the bladder has been cleaned, and pain and inflammation recur, the wound should be reopened, either by the finger, or by the reversed end of a probe, in order that what is causing the pain may be let out; and after such evacuation, when for some time clear urine has passed, then at length cicatrizing applications are put on; and as prescribed above, the legs are kept extended with the feet close together as much as possible. But if there seems to be danger of a fistula, from the causes mentioned above, a leaden tube should be put into the anus to make the closing of the fistula easier, or at any rate to narrow it, whilst the legs are kept extended and the thighs and ankles tied together until the scar has assumed its final form.