pr. The third part of the Art of Medicine is that which cures by the hand, as I have already said, and indeed it is common knowledge. It does not omit medicaments and regulated diets, but does most by hand. The effects of this treatment are more obvious than any other kind; inasmuch as in diseases since luck helps much, and the same things are often salutary, often of no use at all, it may be doubted whether recovery has been due to medicine or a sound body or good luck. Besides, in cases where we depend chiefly upon medicaments, although an improvement is clear enough, yet it is often clear that recovery is sought in vain with them and gained without them: this can be seen for instance in treating the eyes, which after being worried by doctors for a long time sometimes get well without them. But in that part of medicine which cures by hand, it is obvious that all improvement comes chiefly from this, even if it be assisted somewhat in other ways. This branch, although very ancient, was more practised by Hippocrates, the father of all medical art, than by his forerunners. Later it was separated from the rest of medicine, and began to have its own professors; in Egypt it grew especially by the influence of Philoxenus, who wrote a careful and comprehensive work on it in several volumes. Gorgias also and Sostratus and Heron and the two Apollonii and Ammonius, the Alexandrians, and many other celebrated men, each found out something. In Rome also there have been professors of no mean standing, especially the late Tryphon the father and Euelpistus, and Meges, the most learned of them all, as can be understood from his writings; these have made certain changes for the better, and added considerably to this branch of learning. Now a surgeon should be youthful or at any rate nearer youth than age; with a strong and steady hand which never trembles, and ready to use the left hand as well as the right; with vision sharp and clear, and spirit undaunted; filled with pity, so that he wishes to cure his patient, yet is not moved by his cries, to go too fast, or cut less than is necessary; but he does everything just as if the cries of pain cause him no emotion. But it can be asked what is the proper province of this part of my work because surgeons claim for themselves the treatment of wounds as well, and of many of the ulcerations which I have described elsewhere. I for my part deem one and the same man able to undertake all of these; and when divisions are made, I praise him who has undertaken the most. I have myself kept for this part cases in which the practitioner does not find wounds but makes them, and in which I believe wounds and ulcerations to be benefited more by surgery than by medicine; as well as all that which concerns the bones. These cases I shall proceed to discuss in turn, and leaving to another volume the subject of bones I shall deal with the rest in this one; beginning with cases which occur anywhere in the body I shall pass on to those which occur in special situations.
pr. Tertiam esse medicinae partem, quae MANV curet, et uulgo notum et a me propositum est. Ea non quidem medicamenta atque uictus rationem omittit, sed manu tamen plurimum praestat, estque eius effectus inter omnes medicinae partes euidentissimus. Siquidem in morbis, cum multum fortuna conferat, eademque saepe salutaria, saepe uana sint, potest dubitari, secunda ualetudo medicinae an corporis an * beneficio contigerit. In is quoque, in quibus medicamentis maxime nitimur, quamuis profectus euidentior est, tamen sanitatem et per haec frustra quaeri et sine his reddi saepe manifestum est: sicut in oculis quoque deprehendi potest, qui a medicis diu uexati sine his interdum sanescunt. At in ea parte, quae manu curat, euidens omnem profectum, ut aliquid ab aliis adiuuetur, hinc tamen plurimum trahere. Haec autem pars cum sit uetustissima, magis tamen ab illo parente omnis medicinae Hippocrate quam a prioribus exculta est. Deinde posteaquam diducta ab aliis habere professores suos coepit, in Aegypto quoque Philoxeno maxime increuit auctore, qui pluribus uoluminibus hanc partem diligentissime conprehendit. Gorgias quoque et Sostratus et Heron et Apollonii duo et Hammonius Alexandrini multique alii celebres uiri singuli quaedam reperierunt. ⟨Ac⟩ Romae quoque non mediocres professores, maximeque nuper T⟨r⟩yphon pater et Euelpistus et, ut scriptis eius intellegi potest, horum eruditissimus Meges quibusdam in melius mutatis aliquantum ei disciplinae adiecerunt. Esse autem chirurgus debet adulescens aut certe adulescentiae propior; manu strenua, stabili, nec umquam intremescente, eaque non minus sinistra quam dextra promptus; acie oculorum acri claraque; animo intrepidus; misericors sic, ut sanari uelit eum, quem accepit, non ut clamore eius motus uel magis quam res desiderat properet, uel minus quam necesse est secet; sed perinde faciat omnia, ac si nullus ex uagitibus alterius adfectus oriatur. Potest autem requiri, quid huic parti proprie uindicandum sit, quia uulnerum quoque ulcerumque multorum curationes, quas alibi executus sum, chirurgi sibi uindicant. Ego eundem quidem hominem posse omnia ista praestare concipio; atque ubi se diuiserunt, eum laudo qui quam plurimum percepit. ⟨Ip⟩se autem huic parti ea reliqui, in quibus uulnus facit medicus, non accipit, et in quibus uulneribus ulceribusque plus profici manu quam medicamento credo; tum quicquid ad ossa pertinet. Quae deinceps exequi adgrediar, dilatisque in aliud uolumen ossibus, in hoc cetera explicabo; praepositisque is, quae IN QVALIBET CORPORIS PARTE fiunt, ad ea, quae prop⟨r⟩ias sedes habent, transibo.
1. 1 First then the displacements, in whatever part of the body they are, ought to be immediately treated, so that the skin is several times incised with a sharp scalpel where the pain is, and the blood as it issues wiped off with the back of the knife. But if relief is rather slow in coming and there is now redness as well, and if, where the redness is, there is swelling in addition, wherever there is swelling this treatment is best. Repressants are then to be applied, in particular unscoured wool soaked in vinegar and oil. In a slighter case the same applications may afford relief even without the scalpel; and if there is nothing else at hand, wood-ash, preferably of vine twigs, or failing that any other kind, stirred to a paste in vinegar, or even in water.
1. Luxata igitur, in quacumque parte corporis sunt, quam primum sic curari debent, ut, qua dolor est, ea scalpello cutis crebro incidatur, detergeaturque eodem auerso profluens sanguis. Quod si paulo tardius subuenitur iamque etiam rubor est, qua rubet corpus si tumor quoque accessit, quacumque is est, id optimum auxilium est. Tum superdanda reprimentia sunt, maximeque lana sucida ex aceto et oleo. Quod si leuior is casus est, possunt etiam sine scalpello inposita eadem mederi; et si nihil aliud est, cinis quoque maxime ex sarmentis (si is non est, quilibet alius) ex aceto uel etiam ex aqua coactus.
2. 2 There is prompt relief in such cases; but there is more trouble where a lesion has arisen internally of itself which causes swellings and tends to suppuration. I have described elsewhere the various classes of abscession, and I have pointed out the suitable medicaments; it now remains to speak of those which should be treated by surgery. Before the abscession becomes hardened, the overlying skin should be scarified and a cup put on, in order to draw outwards whatever bad and corrupted matter has collected; and it is right to repeat this every third day until every indication of inflammation has gone. It may be, however, that the cupping has no effect; for at times, although seldom, it happens that the abscess is enclosed in a covering of its own, which the ancients named a coat. Meges, because every such coat is sinew-like, said that no sinew could be produced under a lesion by which flesh is eaten away; but that when pus has been there for a long time, a callus forms round it. This has no bearing upon the mode of treatment, for the same thing ought to be done, whether it be a coat, or a callus. There is nothing to prevent a callus being called a coat, since it covers. Moreover at times the coat has formed after the pus has become more matured; so that what is under it cannot be drawn out by cupping. But this is readily recognized when the application of a cup causes no change. Therefore when that happens, or there is already hardening, there is no help from cupping, but as I have said elsewhere it is whilst matter is collecting that it has to be diverted or dispersed, or else matured. In the two former contingencies no further treatment is needed. When pus has matured, if in the armpits or groins it will not often have to be cut into. The same is true when the abscess is of moderate extent, so also when it is in the skin, or even in the flesh, unless the patient's weakness forces us to hurry; it is sufficient to poultice in order to make the pus come out of its own accord. For the place which has not felt the knife may generally escape without a scar. But if the abscess is more deeply seated, we must consider whether the part has sinews or not. For if it is free from sinews, it should be laid open with a red-hot cautery-knife; which has this advantage, that a small wound continues open longer for the withdrawal of the pus, and the resulting scar is small. But if there are sinews near by, the cautery is unsuitable, lest spasm of the sinews ensues or paralysis of the limb; then the scalpel becomes necessary. But although abscesses elsewhere can be opened even whilst immature, where there are sinews, we must wait for them to be fully matured, since the skin then becomes thin, and the pus joins it, and so is nearer to get at. Most abscesses require a linear incision; but in that termed panus, because it generally thins out the skin extremely, all the skin overlying the pus is to be cut away. But when the scalpel is used, care should always be taken that the incisions made are as few and as small as possible, but enough in number and extent to afford the necessary relief. For the larger cavities may at times have to be cut into rather widely even by two or three incisions, and cuts must be so made that the deepest part of the cavity gets a vent, lest any fluid should be left there to eat its way gradually into adjoining tissue, which was previously sound. Also it is natural that the skin should have to be cut away rather widely. For when the whole bodily habit has become vitiated in the course of a prolonged disease and the abscess cavity has extended widely and the skin over it has already become pallid, then we can recognize that the skin is already dead and of no further use; and therefore the excision of overlying skin is better, especially if the suppuration is round about the larger joints, and if the patient, confined to bed, has been exhausted by diarrhoea, and gained nothing from his food. But the skin should be so cut out as to leave a myrtle leaf shaped wound, in order that it may heal more readily: and this should be the constant rule, whenever, or for whatever reason, the practitioner cuts out skin. Where the pus has been let out, for the armpit or groin lint plugging is unsuitable, but a sponge squeezed out of wine must be put on. In other parts, if likewise a lint plug is unnecessary, a little honey will be infused into the cavity to clean it, then agglutinants put on: if lint plugs are needed, over them also should be placed sponges similarly squeezed out of wine. But it has been said elsewhere when plugging is, and is not requisite. In all other ways the same procedure is to be followed after an abscess has been opened by incision, which I have described for one which has ruptured under medicaments.
2. Verum hoc quidem promptum est: in is autem negotium maius est, quae per se uitio intus orto intumescunt et ad suppurationem spectant. Ea omnia genera abscessum esse alias proposui, medicamentaque his idonea executus sum: nunc superest, ut dicam in isdem quae manu fieri debeant. Ergo priusquam indurescant, cutem incidere et cucurbit⟨ul⟩am adcommodare oportet, quae quicquid illuc malae corruptaeque materiae coiit, extrahat; idque iterum tertio die recte fit, donec omne indicium inflammationis excedat. Neque tamen fas non est nihil cucurbitulam agere: interdum enim fit, sed raro, ut, quicquid abscedit, uelamento suo includatur: id antiqui tunicam nominabant. Meges, quia tunica omnis neruosa est, dixit non nasci sub eo uitio neruum, quo caro consumeretur; sed subiecto iam uetustiore pure callum circumdari. Quod ad curationis rationem nullo loco pertinet, quia ⟨quic⟩quid, si tunica est, idem, si callus est, fieri debet. Neque ulla res prohibet, etiamsi callus est, tamen quia cingit, tunicam nominari. Tum pure quoque maturiore haec interdum esse consueuit; ideoque quod sub ea est, extrahi per cucurbitulam non potest. Sed facile ⟨id⟩ intellegitur, ubi nihil admota illa mutauit. Ergo siue id incidit siue iam durities est, in hac auxilii nihil est, ⟨sed⟩, ut alias scripsi, uel auertenda concurrens eo materia uel digerenda uel ad maturitatem perducenda est. Si priora contigerunt, nihil praeterea necessarium est. Si pus maturuit, in alis quidem et inguinibus raro secandum est, item ubicumque mediocris abscessus est, item quotiens in summa cute uel etiam carne uitium est, nisi festinare cu⟨b⟩antis inbecillitas cogit; satisque est cataplasmatis efficere, ut per se pus aperiatur. Nam fere sine cicatrice potest esse is locus, qui expertus ferrum non est. Si autem altius malum est, considerari debet neruosusne is locus sit an non sit. Nam si sine neruis est, candenti ferramento aperiri debet; cuius haec gratia est, quod exigua plaga diutius ad pus euocandum patet, paruaque postea cicatrix fit. At si nerui iuxta sunt, ignis alienus est, ne uel distendantur, uel membrum debilitent: necessaria uero opera scalpelli est. Sed cetera etiam subcruda aperiri possunt: inter neruos ultima expectanda maturitas est, quae cutem extenuet eique pus iungat, quo propius reperiatur. Iamque alia rectam plagam desiderant: in pan⟨o⟩, quia fere vehementer cutem extenuat, tota ea super pus excidenda est. Semper autem ubi scalpellus admouetur, id agendum est, ut et quam minimae et paucissimae plagae sint, cum eo tamen ut necessitati succurramus et in modo et in numero. Nam maiores sinus latius interdum etiam duabus aut tribus lineis incidendi sunt, dandaque opera, ut imus sinus exitum habeat, ne quis umor intus subsidat, qui proxima et adhuc sana ⟨e⟩rodendo sinuet. Est etiam in rerum natura, ut cutis latius excidenda sit. Nam ubi post longis morbis totus corporis habitus uitiatus est lateque se sinus suffudit et in eo iam cutis pallet, scire licet eam iam emortuam esse et inutilem futuram; ideoque excidere commodius est, maxime si circa articulos maiores id euenerit, cubantemque aegrum fluens aluus exhaurit neque per alimenta quicquam corpori accedit. Sed excidi ita debet, ut plaga ad similitudinem myrtei folii fiat, quo facilius sanescat: idque perpetuum est, ubicumque medicus et quacumque causa cutem excidit. Pure effuso, in alis uel inguinibus, linamento opus non est ⟨s⟩ed spongia ex uino inponenda est. In ceteris partibus, si aeque linamenta superuacua sunt, purgationis causa paulum mellis infundendum, deinde glutinantia super danda: si illa necessaria sunt, super ea quoque similiter dari spongia eodem modo ex uino expressa debet. Quando autem linamentis opus sit, quando non sit, alias dictum est. Cetera eadem incisa suppuratione facienda sunt, quae, ubi per medicamenta rupta est, facienda esse proposui.
3. 3 Now how the treatment is succeeding, how much is to be either hoped or feared, can be learnt straightaway from signs which on the whole are the same as have been mentioned already for wounds. Good signs are: ready sleep, easy breathing, no harassing thirst, no aversion to food; for any feverishness to pass off; and for the pus to be white and uniform, not foul. Bad signs are: wakefulness, laboured breathing, thirst, aversion to food, fever, the pus dark or like wine lees, and foul. Again, bad signs in the course of the treatment are: haemorrhage, or if the margins become fleshy before the sinus has been filled up by flesh, and this flesh is insensitive and not firm. But the worst sign of all is a faint, whether during the dressing, or after it. Again there is some reason for anxiety when the illness suddenly subsides, and then suppuration breaks out; or if the illness persists after the pus has been let out. And one cause for anxiety is if the wound is insensible to corrosives. But while it is chance that makes the signs point now one way, now another, it is the practitioner's part to strive to bring about healing. Therefore whenever it is dressed, the abscess cavity should be washed out, with wine mixed with rain water or with a decoction of lentils, when the discharge seems to need checking; with honey wine when cleaning is required; after which it is dressed as before. When the discharge appears to be checked, and the cavity clean, then is the time to help the growth of flesh, both by irrigating with equal parts of wine and honey, and by laying on a sponge soaked in wine and rose oil. Although the growth of flesh is helped by these medicaments, this is better attained, as I have said elsewhere, by a careful regimen; this consists, after the cessation of the fever and a return of appetite, in an occasional bath, gentle rocking daily, food and drink suitable for making flesh. These prescriptions all apply to abscesses which have burst under medicaments; but they have been held over to this place because it is scarcely possible to cure a large abscess without using the knife.
3. Protinus autem quantum curatio efficiat, quantumque aut sperari aut timeri debeat, ex quibusdam signis intellegi potest, fereque isdem, quae ⟨in⟩ uolneribus ⟨exposita sunt⟩. Nam bona signa sunt somnum capere, facile spirare, siti non confici, cibum non fastidire: si febricula fuit, ea uacare; itemque habere pus album, leue, non foedi odoris. Mala sunt uigilia, spiritus grauitas, sitis, cibi fastidium, febris, pus nigrum aut faeculentum et foedi odoris. Item procedente curatione eruptio sanguinis, aut si, antequam sinus carne impleatur, orae carnosae fiunt, illa quoque ipsa carne hebete nec firma. Deficere tamen animam uel ipsa curatione uel postea pessimum omnium est. Quin etiam morbus ipse siue subito solutus est, deinde suppuratio exorta est, siue effuso pure permanet, non iniuste terret. Estque inter causas timoris, si sensus in uulnere rodentium non est. Sed ut haec ipsa fortuna huc illucue discernit, sic medici partium est eniti ad reperiendam sanitatem. Ergo quotiens ulcus resoluerit, eluere id, si reprimendus umor uidebitur, uino ex aqua pluuia[ti]li mixto uel aqua, in qua lenticula cocta sit, debebit; si purgandum erit, mulso; rursusque inponere eadem. Vbi iam repressus uidebitur umor, ulcusque puru⟨m⟩ erit, produci carnem conueniet, et foueri uulnus pari portione uini ac mellis, superque inponi spongiam ex uino et rosa tinctam. Per quae cum caro producatur, plus tamen (ut alias quoque dixi) uictus ratio eo confert; id est solutis iam febribus et cibi cupiditate reddita balneum rarum, cotidiana sed lenis gestatio, cibi potionesque corpori faciundo aptae. Quae omnia per medicamenta quoque suppuratione rupta secuntur: sed quia magno malo uix sine ferro mederi licet, in hunc locum reseruata sunt.
4. 4 Again, for fistulae which penetrate so deeply that a medicated bougie cannot be passed down to the ends, or those which are tortuous or multiple, surgery has the advantage over medicine; and there is less trouble if the fistula runs horizontally under the skin, than when it tends directly inwards. Therefore if it lies horizontally under the skin, a probe should be introduced and cut down upon. When there are bends, these are followed up in the same way with the probe and knife; so also when they present multiple branchings. When the end of the fistula is reached, all the callus should be cut out, then pins are inserted through the skin margin, and agglutinating medicaments spread over all. But if it runs straight inwards, after its chief direction has been explored by means of the probe, that cavity ought to be excised, then a pin is to be inserted through the skin opening, and agglutinating medicaments applied as above; or if there is more corrupt ulceration, which is at time the case when there is disease of bone, after the bone has been treated, suppuratives are put on. Now it is common for fistulae to have their exit between ribs; when this is the case the rib must be cut across on either side at that spot, and the segment removed lest anything diseased be left within. Fistulae which have passed between the ribs often involve the transverse septum separating the viscera above from the intestine. This can be recognized by the position of the fistula and the severity of the pain, and because at times, air with frothy humour escapes from the fistula, especially when the patient has held his breath. In that case there is no opportunity for the medical art. But in the case of other fistulae near the ribs which are curable, greasy medicaments are objectionable but anything else which suits wounds may be used; the best, however, is lint put on dry, or after soaking in honey if anything has to be cleaned. There is no bone in the abdomen, but all the same fistulae there are so dangerous that Sostratus thought them incurable. Experience, however, shows that this is not always the case. Indeed — and this may seem very remarkable — a fistula which forms over the liver, spleen, or stomach, is safer than one right over the intestine, not because a fistula there is more harmful, but because it opens the way to another danger. Some writers who have had experience of this have shown little perception of the true facts. For often the abdomen is actually penetrated by a weapon, and sutures bring the margins of the wound together and how this is done I will presently point out. Therefore also when a fine fistula breaks through the abdominal wall, it is possible to cut it out, and to join its margins by suture. But if such a fistula widens out inside, this excision necessarily leaves a wide gap which cannot be sutured without applying great force especially in the deeper part where the abdomen is enclosed by a kind of membrane which the Greeks call peritoneum. Therefore, when the patient begins to get up and move about, the sutures break, and intestines prolapse; which causes his death. But these cases are not altogether desperate, and so for the finer fistulae, treatment is to be adopted. Special consideration is required in the case of those in the anus. In these, where a probe has been passed up to its end, the skin should be cut through, next through this new orifice the probe is to be drawn out, followed by a linen thread which has been passed through the eye made for the purpose in the other end of the probe. Then the two ends of the linen thread are taken and knotted together so as to grip loosely the skin overlying the fistula. The linen thread should be made up of two or three strands of raw flax, twisted up so as to make one. Meanwhile the patient can do his business, walk, bathe, and take food as if in the best of health. Only this thread is to be moved twice a day, but without undoing the knot, the part of the thread outside being drawn within the fistula, and the thread must not be left until it becomes foul, but every third day the knot is to be undone, and to one end that of another fresh thread is tied, and the old thread being withdrawn the new one is to be left in the fistula after being similarly knotted. For thus the thread cuts through the skin overlying the fistula slowly, and whilst the skin released from the thread undergoes healing, that which is still gripped is being cut through. This method of treatment is lengthy but causes no pain. Those in a hurry should constrict the skin with the thread, so that they may continue through more quickly; and at night they should insert into the fistula some fine pledglets of wool, in order that its overlying skin, being put on the stretch, may be thinned out; but these measures cause pain. More speed may be added, but more pain as well, if both the thread and the pledglets are smeared with some one of the medicaments, which I have noted for the eating away of callus. Even here, however, the knife must be used, if the fistula extends inwards, of is multiple. In these kinds of fistulae, therefore, when the probe has been inserted, the skin is to be cut through along two lines so that between them a very fine strip of skin may be taken out, in order that the margins may not unite at once, and that there may be room for the smallest possible quantity of lint to be inserted; all the rest is done in the way described for abscesses. If, however, from one orifice several sinuses lead off, the straight part of the fistula is to be laid open with the scalpel, and the others branching from it, which are now exposed, are to be gripped by a thread. Should any fistula extend so far inwards that it cannot be safely laid open by the knife, a medicated bougie is to be put in. But in all such cases, whether treated surgically or by medicaments, the food should be moist, the drink abundant, and for a while water: when flesh begins to grow up, then at length the patient is to make use of the bath occasionally, and of flesh-making food.
4. Aduersus fistulas quoque, si altius penetrant, ut ad ultimas demitti collyrium non possit, si tortuosae sunt, si multiplices, maius in manu quam in medicamentis praesidium est; minusque operae est, si sub cute transuersa⟨e⟩ feruntur, quam si rectae intus tendunt.—Igitur si sub cute transuersa fistula est, demitti specillum debet, supraque ea incidi. Si flexus reperientur, hi quoque simul specillo et ferro persequendi; itemque faciendum, si plures se quasi ramuli ostendunt. Vbi ad finis fistulae uentum est, excidendus ex ea totus callus est, superque fibulae dandae et medicamentum quo glutinetur. At si recta subter tendit, ubi, quo maxime ferat, specillo exploratum est, excidi ⟨is⟩ sinus debet; dein fibula oris cutis inicienda est; et aeque glutinantia medicamenta superdanda sunt aut, si corruptius ulcus est, quod interdum osse uitiato fit, ubi id quoque curatum est, pus mouent⟨ia.⟩ Solent autem inter costas fistulae subter exire; quod ubi incidit, eo loco costa ab utraque parte praecidenda et eximenda est, ne quid intus corruptum relinquatur. Solent, ubi costas transierunt, saeptum id, quod transuer⟨s⟩um a superioribus uisceribus intestina discernit, uiolare. Quod intellegi loco et magnitudine doloris potest. Qui * * * nonnumquam spiritus ea cum umore quasi bullante prorumpit, maximeque si hunc ore ille continuit. In eo medicinae locus nullus est. In ceteris uero, quae circa costas sanabilia sunt, pinguia medicamenta inimica sunt; ceteris, quae ad uulnera adcommodantur, uti licet: optime tamen sicca lin⟨a⟩menta uel, si purgandum aliquid uidetur, in melle tincta inponuntur. Ventri nullum os subest, sed ibi perniciosae admodum fistulae fiunt, adeo ut Sostratus insanabiles esse crediderit. Id non ex toto ita se habere usus ostendit. Et quidem, quod maxime mirum uideri potest, tutior fistula est contra iecur et lienem et uentriculum quam contra intestina, non quo perniciosior ibi sit, sed quo alteri periculo locum faciat. Cuius experimen⟨to mo⟩ti quidam auctores parum modum rei cognouerunt. Nam uenter saepe etiam telo perforatur, prolapsaque intestina conduntur, et oras uulneris suturae conprehendunt; quod quemadmodum fiat, mox indicabo. Itaque etiam ubi tenuis fistula abdomen perrumpit, excidere ea⟨m⟩ licet suturaque oras coniungere. Si uero ea fistula intus patuit, excissa necesse est latius foramen relinquat, quod nisi magna ui, utique ab interiore parte, sui non potest; qua quasi membrana quaedam finit abdomen, quam periton⟨a⟩eon Graeci uocant. Ergo ubi aliquis ingredi ac moueri coepit, rumpitur illa sutura, atque intestina soluuntur; quo fit, ut pereundum homini sit. Sed ⟨non⟩ omni modo res ea desperationem habet, ideoque tenuioribus fistulis adhibenda curatio est. Propriam etiam⟨num⟩ animaduersionem desiderant ea⟨e⟩, quae in ano sunt. In has demisso specillo ad ultimum eius caput incidi cutis debet, dein nouo foramine specillum educi lino sequente, quod in aliam eius partem ob id ipsum perforatam coniectum sit. Ibi linum prehendendum uinciendumque cum altero capite est, ut laxe cutem, quae super fistulam est, teneat; idque linum debet esse crudum et duplex triplexue, sic tortum, ut unitas facta sit. Interim autem licet negotia gerere, ambulare, lauari, cibum capere ⟨per⟩inde atque sanissimo. Tantummodo ⟨i⟩d linum bis die saluo nodo ducendum est, sic ut subeat fistulam pars quae superior fuit. Neque committendum est, ut id linum putrescat, sed tertio quoque die nodus resoluendus est, et ad caput alterum recens linum alligandum est eductoque uetere id in fistula cum simili nodo relinquendum. Sic enim id paulatim cutem, quae supra fistulam est, incidit; simulque et id sanescit, quod a lino relictum est et id, quod ab eo mordetur, inciditur. Haec ratio curationis longa ⟨sed⟩ sine dolore est. Qui festinant, adstringere cutem lino debent, quo celerius secent, noctuque ex penicillo tenuia quaedam intus demittere, ut cutis hoc ⟨ipso⟩ extenuetur quo extenditur; sed haec dolorem mouent. Adicitur celeritati sicut tormento quoque, si et linum et id, quod ex penicillo est, aliquo medicamento inlinitur ex is, quibus callum exedi posui. Potest tamen fieri, ut ad scalpelli adcurationem etiam illo loci ueniendum sit, si intus fistula fert, si multiplex est. Igitur in haec genera demisso specillo duabus lineis incidenda cutis est, ut media inter eas habenula tenuis admodum eiciatur; ne protinus orae coeant, sitque locus aliquis lin⟨a⟩mentis, quae quam paucissima superinicienda sunt; omniaque eodem modo facienda, quae in abscessibus posita sunt. Si uero ab uno ore plures sinus erunt, recta fistula scalpello erit incidenda; ab eo ceterae, quae iam patebunt, lino excipiendae. Si intus aliqua procedet, quo ferrum tuto peruenire non poterit, collyrium demittendum erit. Cibus autem in eiusmodi omnibus casibus, siue manu siue medicamentis agetur, dari debet umidus, potio liberalis, diuque aqua: ubi iam caro increscit, tum demum et balineis raris utendum erit et cibis corpus inplentibus.
5. 5 Missiles too, which have entered the body and become fixed within, are often very troublesome to extract. And some of the difficulties arise from their shape, some owing to the positions to which they have penetrated. Whatever the missile may be, it is extracted, either by the wound of entry, or through the spot towards which it is pointing. In the former case, the missile has already made a way for its withdrawal; in the latter the way out is made with the scalpel; for the flesh is cut through upon its point. But if the missile is not deeply seated, and lies in superficial tissue, or if it is certain that it has not crossed the line of large blood vessels or sinews, there is nothing better than to pull it out by the way it entered. But if the distance it has to be withdrawn is greater than that which remains to be forced through, or if it has crossed the line of blood vessels and sinews, it is more convenient to lay open the rest of its course and so draw it out. For it will be more easily got at and more safely pulled out. And in the case of one of the larger limbs, if the point has passed beyond the middle, a through and through wound heals more easily because it can be dressed with a medicament at both ends. But if the missile is to be drawn back, the wound should be enlarged with a scalpel, for then the missile comes away more easily, also less inflammation is caused; for this becomes more severe if the missile itself lacerates the tissues while being withdrawn. So also when a counter opening is made, this ought to be too wide for the missile to fill as it is passing out. In either case, the greatest care should be taken that no vein, nor one of the larger sinews, nor an artery, is cut. When any one of these is observed, it is to be caught by a blunt hook and held away from the scalpel. Than the incision has been made large enough, the missile is to be drawn out, proceeding in the same way, and taking the same care, lest that which is being extracted should injure one of those structures which I have said are to be protected. The foregoing are general rules; there are some rules which apply to special missiles, and these I will at once set out. Nothing penetrates so easy into the body as an arrow, and it also becomes very deeply fixed. And this happens both because it is propelled with great force and because it is sharply pointed. Hence it is more often to be extracted through a counter opening than through the wound of entry, and especially so because it is generally furnished with barbs which lacerate more when drawn backwards than if pushed through a counter opening. When a passage out has been laid open, the flesh ought to be stretched apart by an instrument like a Greek letter; next when the point has come into view, if the shaft is still attached, it is to be pushed on until the point can be seized from the counter opening and drawn out: if the shaft has already become detached, and only the arrowhead is within, the point should be seized by the fingers or by forceps, and so drawn out. Nor is the method of extraction different when it is preferred to withdraw the arrow by the wound of entry; the wound having been enlarged, either the shaft, if it is still attached, or, if not, the arrowhead itself, is pulled upon. When the barbs come into view, if they are short and fine, they should be nipped off on the spot by forceps, and the missile drawn out without them. If the barbs are too large and resistant for this, they must be covered by reed pens which have been split, and thus pulled out carefully so as not to tear the flesh. This is what is to be done in the case of arrows. But if it is a broad weapon which has been embedded, it is not expedient to extract it through a counter opening, lest we add a second large wound to one already large. It is therefore to be pulled out by the aid of some such instrument as that which the Greeks call the Dioclean cyathiscus, because invented by Diocles, whom I have said already to have been among the greatest of the ancient medical men. The instrument consists of two iron or even copper blades, one blade has at each angle of its end a hook, turned downwards; the other blade has its sides turned up so that it forms a groove, also its end is turned up somewhat, and perforated by a hole. The latter blade is first passed up to the weapon, and then underneath it, until the point is reached, the blade is then rotated somewhat until the point becomes engaged in the perforation. After the point has entered the perforation, the hooks of the first mentioned blade are fitted by the aid of the fingers over the upturned end of the blade already passed, after which simultaneously the cyathiscus and the weapon are withdrawn. There is a third kind of missile which at times has to be extracted such as a lead ball, or a pebble, or such like, which has penetrated the skin and become fixed within unbroken. In all such cases the wound should be laid open freely, and the retained object pulled out by forceps the way it entered. But some difficulty is added in the case of any injury in which a missile has become fixed in bone, or in a joint between the ends of two bones. When in a bone, the missile is swayed until the place which grips the point yields, after which it is extracted by the hand, or by forceps; this is the method also used in extracting teeth. In this way the missile nearly always comes out, but if it resists, it can be dislodged by striking it with some instrument. The last resort when it cannot be pulled out, is to bore into the bone with a trepan close by the missile, and from that hole to cut away the bone in the shape of the letter V, so that the lines of the letter which diverge to either side face the missile; after that it is necessarily loosened and easily removed. If the missile has forced its way actually into a joint between the ends of two bones, the limbs above and below are encircled by bandages or straps, by means of which they are pulled in opposite directions, so that the sinews are put on the stretch; the space between the ends of the bone is widened by these extensions, so that the missile is without difficulty withdrawn. In doing this care must be taken, as mentioned elsewhere, to avoid injury to a sinew, vein or artery while the weapon is being extracted by the same method which was described above. But if the missile is also poisoned, after doing all the same things, even more promptly, if possible, in addition that treatment is to be applied which is given for one who has drunk poison, or has been bitten by a snake. The care of the wound itself after the extraction of the missile does not differ from that of a wound in which nothing has lodged and on which I have said enough elsewhere.
5. Tela quoque, quae inlata corporibus intus haeserunt, magno negotio saepe eiciuntur. Suntque quaedam difficultates ex generibus eorum: quaedam ex is sedibus, in quas illa penetrarunt. Omne autem telum extrahitur aut ab ea parte, qua uenit, aut ab ea, in quam ⟨te⟩tendit. Illic uiam, qua redeat, ipsum sibi fecit, hic a scalpello accipit: nam contra mucronem caro inciditur. Sed si non alte telum insedit, et in summa carne est, aut certe magnas uenas et loca neruosa non transit, nihil melius quam qua uenit id euellere. Si uero plus est, per quod telo reuertendum quam quod perrumpendum est, iamque uenas neruosaque id transit, commodius est aperire quod superest, eaque extrahere: nam et propius petitur, ⟨et tutius euellitur;⟩ et in maiore membro, si medius mucro transit, facilius sanescit quod peruium est, quia utrimque medicamento fouetur. Sed si retro telum recipiendum, amplianda scalpello plaga est, quo facilius id sequatur, quoque minor oriatur inflammatio; quae maior fit, si ab illo ipso telo, dum redit, corpus laniatur. Item si ex alia parte uulnus aperiatur, laxius esse debet, quam ut telo postea transeunte amplietur. Summa autem utraque parte habenda cura est, ne uena, ne maior neruos, ne arteria incidatur. Quorum ubi aliquid detectum est, excipiendum hamo retuso est, abducendumque a scalpello. Vbi autem satis incisum est, telum eximendum est, tum quoque eodem modo et eadem cura habita, ne sub eo, quod eximitur, aliquod eorum laedatur, quae tuenda esse proposui. Haec communia. Sunt propria quaedam in singulis telorum generibus, quae protinus subiciam. Nihil tam facile in corpus quam sagitta conditur, eademque altissime ins⟨i⟩dit. Haec autem eueniunt, et quia magna ui fertur illa, et quia ipsa in angusto est. Saepius itaque ab altera parte, quam ex qua uenit, recipienda et praecipue quia fere spiculis cingitur, quae magis laniant, si retrorsus quam si contra eximatur. Sed inde aperta uia, caro diduci debet ferramento ad similitudinem facto Graecae litterae *: deinde, ubi apparuit, si mucro⟨n⟩i harundo inhaeret, propellenda est, donec ab altera adprehendi et extrahi possit; si iam illa decidit solumque intus ferrum est, mucro uel digitis adprehendi uel forfice atque ita educi debet. Neque alia ratio extrahendi est, ubi ab ea parte, qua uenit, euelli magis placuit: nam ampliato magis uulnere, aut harundo, si inest, euellenda est, aut si ea non est, ferrum ipsum. Quod si spicula apparuerunt eaque breuia et tenuia sunt, forfice ibi comminui debent, uacuumque ab his telum educi: si ea maiora ualentioraque sunt, fissis scriptoris calamis contegenda, ac ne quid lacerent, sic euellenda sunt. In sagittis quidem haec obseruatio est. Latum uero telum si conditum est, ab altera parte educi non expedit, ne ingenti uulneri ipsi quoque ingens uulnus adiciamus. Euellendum est ergo genere quodam ferramenti, quod Diocleum cyathiscum Graeci uocant, quoniam auctorem Dioclen habet; quem inter priscos maximosque medicos fuisse iam posui. Lammina uel ferrea uel aenea etiam ab altero capite duo utrimque deorsum conuersos uncos habet; ab altero duplicata lateribus, leuiterque extrema in eam partem inclinata, qua sinuata est, insuper ibi etiam perforata est. Haec iuxta telum transuersa demittitur; deinde ubi ad ⟨imum⟩ mucronem uentum est, paulum torquetur, ut telum foramine suo excipiat. Cum in cauo mucro est, ilico digiti subiecti partis alterius uncis simul et ferramentum id extrahunt et telum. Tertium genus telorum est, quod interdum euelli debet; plumbea glas aut lapis aut simile aliquid, quod perrupta cute integrum intus insedit.—In omnibus his latius uulnus aperiundum, idque quod inest, ea, qua uenit, forfice extrahendum est. Accedit uero aliquid difficultatis sub omni ictu, si telum uel ossi inhaesit uel in articulo se inter duo ossa demersit. In osse usque eo mouendum est, donec laxetur is locus, qui mucronem momordit; et tunc uel manu uel forfice telum extrahendum est; quae ratio in dentibus quoque eiciendis est. Vix umquam ita telum non sequitur: sed si morabitur, excuti quoque ictum aliquo ferramento poterit. Vltimum est, ubi non euellitur, terebra iuxta forare, ab eoque foramine ad speciem litterae †uel contra telum os excidere sic, ut lin⟨e⟩ae, quae diducuntur, ad telum spectent; eo facto id necesse est labet et facile auferatur. Inter duo uero ossa si per ipsum articulum perr⟨u⟩perit, circa uolnus duo membra fascis habenisue deliganda et per has in diuersas partes diducenda sunt, ut neruos distendant; quibus extentis laxius inter ossa spatium est, ut sine difficultate telum recipiatur. Illud uidendum est, sicut in aliis locis posui, ne quis neruus aut uena aut arteria a telo laedatur, dum id extrahit⟨ur,⟩ eadem scilicet ratione, quae supra posita est. At si uenenato quoque telo quis ictus est, i⟨s⟩dem omnibus, si fieri potest, etiam festinantius actis, adicienda curatio est, quae uel epoto ueneno, uel a serpente ictis adhibetur. Vulneris autem ipsius extracto telo medicina non alia est, quam quae esset, si corpore icto nihil inhaesisset; de qua satis alio loco dictum est.
6. 6 Such are lesions which can arise in any part of the body; the remainder occur in special situations, of these I am going to speak, beginning with the head. On the head many kinds of small tumours occur; besides those called ganglia, melicerides and atheromata, different authorities distinguish certain sorts by different names, and to these I myself will add one, steatoma. Although these tend to occur both in the neck and in the armpits and flanks, yet I have not dealt with them separately for there is little difference among them and none of them are dangerous and all are treated in the same way. Now all the above start from a very small beginning and grow slowly for a long time and have a coat of their own to enclose them. Some of them are hard and resistant, some soft and yielding; some become partially bald, others continue to be covered by their proper hair; generally they are painless. What they contain can be surmised, but cannot be fully known until the contents have been turned out. Generally, however, in those which are resistant, we find something like little stones, or balls of compressed hair; and in those which are yielding either some material similar to honey or thin porridge or something like grazed cartilage or bruised and bloody flesh, and the contents generally vary in colour. Ganglia are mostly resistant; atheromata have porridge-like contents; meliceris has a more fluid humour, and so it fluctuates when pressed upon; a steatoma contains a kind of fat. This last spreads most widely and loosens all the skin over it so that it is flaccid, although in the others the skin is more tense. All parts covered by hair should be shaved first and the incision made across the middle; but the coat of a steatoma is also to be cut into in order to let out whatever has collected within, because it is not easy to separate the coat from the skin and underlying flesh; in the other kinds the coating is to be preserved entire. Then as soon as the white and tight coat is seen, it is to be separated from the skin and flesh by the handle of the scalpel, and turned out together with its contents. But if muscle adheres to the deeper part of the tunic, lest it should be injured, only the superficial part of the tunic is to be cut away, and the deeper part left in position. When the whole has been removed the margins of the incision are to be brought together, a pin passed through them and, over this, an agglutinating medicament applied. When the whole, or any part of the coat has been left, suppuratives must be applied.
6. Haec ⟨e⟩uenire in qualibet parte corporis possunt: reliqua CERTAS SEDES habent, de quibus dicam orsus a capite. In hoc multa uariaque tubercula oriuntur: gang⟨lia⟩, meliceridas, atheromata nominant aliisque etiamnum uocabulis quaedam alii discernunt, quibus ego steatomata quoque adiciam. Quae quamuis et in ceruice et in alis et in lateribus oriri solent, per se tamen non posui, cum omnia ista mediocres differentias habeant, ac neque periculo terreant neque diuerso genere curentur. Omnia uero ista et ex paruulo incipiunt et diu paulatimque increscunt, et tunica sua includuntur. Quaedam ex his dura ac renitentia, quaedam mollia cedentiaque sunt; quaedam spatio nudantur, quaedam tecta capillo suo permanent; fereque sine dolore sunt. Quid intus habeant, ut coniectura praesagiri potest, sic ex toto cognosci, nisi cum eiecta sunt, non potest. Maxime tamen in is, quae renituntur, aut lapillis quaedam similia aut concreti confersique pili reperiuntur: in is uero, quae cedunt, aut melli simile aliquid aut tenui pulticulae aut quasi rassae cartilagini aut carni hebeti et cruentae, quibus ⟨ali⟩ alique colores esse consuerunt. Fereque ganglia renituntur: atheromati subest quasi tenuis pulticula: meliceridi liquidior umor, ideoque pressu⟨s⟩ circumfluit: steatomati pingue quiddam. Idque latissime patere consueuit, resoluitque totam cutem superpositam sic, ut e⟨a⟩ labet, cum in ceteris sit adstrictior. Omnia derassa ante si capillis conteguntur, per medium oportet incidi: sed steatomatis tunica quoque secanda est, ut effundatur quicquid intus coit, quia non facile a cute et subiecta carne ea separ⟨a⟩tur: in ceteris ipsa tunica inuiolata seruanda est. Protinus autem ⟨ut⟩ alba et intenta se ostendit, tum scalpelli manubriolo deducenda a cute ⟨et⟩ carne est, eiciendaque cum eo, quod intus tenet. Si quando tamen ab inferiore parte tunicae musculus inhaesit, ne is laedatur, superior pars illius decidenda; at im⟨a⟩ ibi relinquenda est. Vbi tota exempta est, committendae orae, fibulaque his inicienda, et super medicamentum glutinans dandum est. Vbi uel tota tunica uel aliquid ex ea relictum est, pus mouentia adhibenda sunt.
7. 7 But whilst the preceding kinds of lesion do not differ much among themselves or in the mode of treatment, those in the eyes which demand surgical measures are different from each other and differently treated. For instance in the upper eyelid cysts are apt to be formed, fatty and weighty, which hardly allow the eyes to be raised, and they set up a slight but persistent discharge of rheum from the eyes; and these generally occur in children. When the eyeball has been pressed with two fingers so as to render the skin of the upper eyelid tense, a transverse linear incision is to be made with a scalpel, with so light a touch that the cyst itself is not cut into; when the way is opened it protrudes of itself. It should then be seized with the fingers and taken out, for it comes away easily. One of the ointments, with which running eyes are anointed, is then smeared on, and in a very few days a fine scar is induced. There is more trouble when the cyst has been cut into, for it lets out a humour, and afterwards, because it is very thin, it cannot be laid hold of. Should this chance to happen, something to promote suppuration should be applied.
7. Sed ut haec neque genere uiti neque ratione curationis inter se multum distant, sic in oculis, quae manum postulant, et ipsa diuersa sunt et aliter aliterque curantur. Igitur in superioribus palpebris uesicae nasci solent pingues graues⟨que,⟩ quae uix attollere oculos sinunt, leuesque pituitae cursus sed adsiduos in oculis mouent: fere uero in pueris nascuntur. —Oportet conpresso digitis duobus oculo atque ita cute intenta scalpello transuersam lineam incidere, suspensa leuiter manu, ne uesica ipsa uulneretur; u⟨b⟩i locus ei patefactus est, ipsa prorumpit. Tum digitis ea⟨m⟩ adprehendere oportet et euellere; facile autem sequitur. Dein superinungui collyrio debet ex is aliquo, quo lippientes oculi superinunguntur; paucissimisque diebus cicatricula inducitur. Molestius est, ubi incisa uesica est: effundit enim umorem, neque postea, quia tenuis admodum est, potest colligi. Si forte id incidit, eorum aliquid inponendum est, quae puri mouendo sunt.
A very small tumour forms in the same upper eyelid, above the line of the eyelashes, which from its resemblance to a barleycorn is termed by the Greeks crithê. Its contents are slow to come to a head and contained within a coat; it should be fomented with hot bread or with wax gently heated, but not so hot that it cannot easily be borne by that part; for under this treatment it is often dispersed, but at times it matures. When pus shows itself, it should be cut across with a scalpel and any humour inside squeezed out; then the eyelid is afterwards also to be fomented as above by steam, and ointment applied until it heals.
In eadem palpebra supra pilorum locum tuberculum paruulum nascitur, quod a similitudine hordei a Graecis crit⟨h⟩e nominatur. Tunica ⟨quidda⟩m, quod difficulter maturescit, conprehensum ⟨est; id⟩ uel calido pane uel cera subinde calfacta foueri oportet sic, ne nimius is calor sit sed facile ea parte sustineatur: hac enim ratione saepe discutitur, interdum concoquitur. Si pus se ostendit, scalpello diuidi debet, et quicquid intus umoris est, exprimi;
Other tumours also, not unlike these, form on the eyelids; but they are not quite the same shape and are mobile, so that they can be pushed about with the finger; and so the Greeks call them chalazia. They should be cut down upon, from the outside if under the skin, from the inside if under the cartilage, than separated from the sound tissue by the handle of the scalpel. If the cut is on the inner surface, first mild, then more acrid ointment is to be applied; if on the outer, an agglutinating plaster is put on.
eodem deinde uapore postea quoque foueri et superinungui, donec ad sanitatem perueniat. Alia quoque quaedam in palpebris ⟨huic⟩ non dissimilia ⟨ori⟩untur: sed neque utique figura⟨e⟩ eiusdem, et mobilia, simul atque digito uel huc uel illuc inpelluntur; ideoque ea chalazia Graeci uocant.— Haec incidi debent, si sub cute sunt, ab exteriore parte; si sub cartilagine, ab interiore; deinde scalpelli manubriolo deducenda ab integris partibus sunt.
An unguis too, called pterygium in Greek, is a little fibrous membrane, springing from the angle of the eye which sometimes even spreads so as to block the pupil. Most often it arises from the side of the nose, but sometimes from the temporal angle. When recent it is not difficult to disperse by the medicaments which thin away corneal opacities; if it is of long standing, and thick, it should be excised. After fasting for a day, the patient is either seated facing the surgeon, or turned away, so that he lies on his back, his head in the surgeon's lap. Some want him facing if the disease is in the left eye and lying down if in the right. Now one eyelid must be held open by the assistant, the other by the surgeon; but he holds the lower lid when seated opposite the patient, and the upper when the patient is on his back. Thereupon the surgeon passes a sharp hook, the point of which has been a little incurved, under the edge of the pterygium and fixes the hook in it; next, leaving that eyelid also to the assistant, he draws the hook towards himself thus lifting up the pterygium, and passes through it a needle carrying a thread; then having detached the needle, he takes hold of the two ends of the thread, and raises up the pterygium by means of the thread; he now separates any part of it which adheres to the eyeball by the handle of the scalpel until the angle is reached; next by alternately pulling and slackening the thread, he is able to discover the beginning of the pterygium and the end of the angle. For there is double danger, that either some of the pterygium is left behind and if this ulcerates, it is hardly ever amenable to treatment; or that with it part of the flesh is cut away from the angle; and if the pterygium is pulled too strongly, the flesh follows unnoticed, and when it is cut away a hole is left through which there is afterwards a persistent flow of rheum; the Greeks name it rhyas. Therefore the true edge of the angle must certainly be observed; and when this has been clearly determined, after the pterygium has been drawn forward just enough, the scalpel is to be used, then that little membrane is to be cut away as not to injure the angle in any way. After that, lint soaked in honey is to be put on, and over that a piece of linen, and either a sponge or unscoured wool. And for the next few days the eye must be opened daily to prevent the eyelids uniting by a scar for if that happens a third danger is added; and the lint is to be put on again, and last of all one of the salves applied which help wounds to heal. But this treatment ought to be in the spring, or certainly before winter; this warning applies to many cases, and it will be enough to give it here once for all. For there are two classes of treatment: one in which we cannot choose the time but must make the best of things, as in the case of wounds; the other in which there is no urgency and it is safest to wait, for example when the affection progresses slowly and the patient is not racked by pain. Then we should wait for spring, or if there is more urgency, autumn is better than either summer or winter, and especially mid-autumn when the hot weather has broken and the cold not yet begun. The more essential the part to be treated, the greater the danger; and often the larger the wound to be made, the more regard should thus be paid to the season.
Ac, si intus plaga est, inunguendum primum lenibus, deinde acrioribus; si extra, superdandum emplastrum, quo id glutinetur. Vnguis uero, quod pterygion Graeci uocant, est membranula neruosa oriens ab angulo, quae nonnumquam ad pupillam quoque peruenit, eique officit; saepius a narium, interdum etiam a temporum parte nascitur. Hunc recentem non difficile est discutere medicamentis, quibus cicatrices in oculis extenuantur: si inueterauit iamque ei crassitudo quoque accessit, excidi debet. Post abstinentiam uero unius diei uel aduersus in sedili contra medicum is homo collocandus est, uel sic auersus, ut in gremium eius caput resupinus effundat. Quidam, si in sinistro oculo uitium est, aduersum; si in dextro, resupinum collocari uolunt. Alteram autem palpebram a ministro deduci oportet, alteram a medico: sed ab hoc, si ille aduersus est, inferiorem; si supinus, superiorem. Tum idem medicus hamulum acutum, paululum mucrone intus recuruato, subicere extremo ungui debet, eumque infigere, atque eam quoque palpebram tradere alteri; ipse hamulo adprehenso leuare unguem, eumque acu traicere linum trahente; deinde acum ponere, lini duo capita adprehendere, et per ea erecto ungue, si qua parte oculo inhaeret, manubriolo scalpelli deducere, donec ad angulum ueniat; deinde inuicem modo remittere, modo adtrahere, ut sic et initium eius et finis anguli reperiatur. Duplex enim periculum est, ne uel ex ungue aliquid relinquat⟨ur,⟩ quod exulceratum uix ullam recipiat curationem; uel ex angulo quoque caruncula abscidatur; quae, si uehementius unguis ducitur, sequitur ideoque decipit: abscisa patefit foramen, per quod postea semper umor descendit: rhy⟨a⟩da Graeci uocant. Verus ergo anguli finis utique noscendus est; qui ubi satis constitit, non nimium adducto ungue scalpellus adhibendus est, deinde excidenda ea membranula, ne quid ex angulo ⟨l⟩aedatur. Eodem inde ex melle lin⟨a⟩mentum super⟨d⟩andum est supraque linteolum, et aut spongia aut lana sucida; proximisque diebus deducendus cotidie oculus est, ne cicatrice inter se palpebrae glutinentur, siquidem id quoque tertium periculum accedit; eodemque modo lin⟨a⟩mentum inponendum, ac nouissime inunguendum collyrio, quo ulcera ad cicatricem perducuntur. Sed ea curatio uere esse debet aut certe ante hiemem; de qua re ad p⟨l⟩ura loca pertinente semel dixisse satis erit. Nam duo genera curationum sunt. Alia, in quibus eligere tempus non licet, sed utendum est eo, quod incidit, sicut in uulneribus [in fistulis]; alia, in quibus nullus dies urguet, et expectare tutissimum [facile] est, sicut euenit in is, quae et tarde crescunt et dolore non cruciant. In his uer expectandum est, aut si quid magis pressit, melior tamen autumnus est quam aestas aut hiemps, atque is ipse medius, iam fractis aestibus, nondum ortis frigoribus.