Chapter XXIII: Preface (1)

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

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

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

CHAP. I.

OF CONTUSIONS.

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

CHAP. II.

OF THE OPERATIONS NECESSARY IN SUPPURATED TUMOURS.

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

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

CHAP. III.

OF THE GOOD OR BAD SYMPTOMS OF SUPPURATIONS.

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

CHAP. IV.

OF FISTULAS.

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

[Sidenote: _Of fistulas amongst the ribs._]

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

[Sidenote: _Of fistulas in the belly._]

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

[Sidenote: _Of fistulas in the anus._]

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

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

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

CHAP. V.

OF EXTRACTING WEAPONS OUT OF THE BODY.

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

[Sidenote: _Of arrows._]

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

[Sidenote: _Of broad weapons._]

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

[GP] γραφίσκος Διοκλέους.

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

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

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

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

[Sidenote: _Of poisonous weapons._]

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

CHAP. VI.

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

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

[GQ] γάγγλια.

[GR] μελικηρίδες.

[GS] ἀθερώματα.

[GT] στεατώματα.

CHAP. VII.

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

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

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

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

[Sidenote: _Of a crithe._]

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

[GU] κριθὴ.

[Sidenote: _Of chalazia._]

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

[GV] χαλάζια.

[Sidenote: _Of the unguis._]

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

[GW] πτερύγιον.

[GX] ῥυὰς.

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

[Sidenote: _Of an encanthis._]

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

[GY] ἐγκανθὶς.

[Sidenote: _Of the ancyloblepharon._]

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

[GZ] ἀγκυλοβλέθαρον.

[Sidenote: _Of the aegilops._]

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

[HA] αἰγίλωψ.

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

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

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

[Sidenote: _Of the lagophthalmus._]

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

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

[Sidenote: _Of an ectropium._]

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

[HC] ἐκτρόπιον, from turning.

[Sidenote: _Of the staphyloma._]

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

[HD] σταφύλωμα.

[Sidenote: _Of clavi._]

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

[Sidenote: _Description of the eye._]

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

[HE] κερατοειδὴς.

[HF] χοριοειδὴς.

[HG] ἀραχνοειδὴς.

[HH] ὑαλοειδὴς.

[Sidenote: _Of a cataract._]

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