In the course of treating pterygium, lesions arise, as I have just said, which are also apt to arise from other causes. Sometimes when the pterygium has not been quite cut away or from some other cause, a small tumour, called by the Greeks encanthis, forms at the angle and this does not allow the eyelids to be completely drawn down. It should be caught up with a hook and cut around, but with so delicate a touch that nothing is cut away from the angle itself. A bit of lint is then besprinkled with oxide of zinc or blacking, and inserted into that angle after separating the lids, and over this the dressing as above is bandaged on. Upon the following days, the eye is dressed in the same way, after having been fomented with tepid, or even with cold water.
Quo magis autem necessaria pars erit, quae tractabitur, hoc quoque maiori periculo subiecta est; et saepe, quo maior plaga facienda, eo magis haec temporis ratio seruabitur. Ex curatione uero unguis, ut dixi, uitia nascuntur, quae ipsa aliis quoque de causis oriri solent. Interdum enim fit in angulo, parum ungue exciso uel aliter, tuberculum, quod palpebras parum deduci patitur: enca⟨nth⟩is Graece nominatur. Exci⟨p⟩i hamulo et circumcidi debet, hic quoque diligenter temperata manu, ne quod ex ipso angulo abscidat.
At times the eyelids adhere together, and the eye cannot be opened. When this happens, the eyelids commonly adhere to the white of the eye, that is to say, when an ulceration upon either has been carelessly treated; for in the course of healing what could and should have been kept apart has been allowed to stick: the Greeks give the name of ancyloblepharus to one who suffers from both lesions. When the eyelids only stick together they are separated without difficulty, but sometimes this is useless for they stick together again. Separation should be tried, however, because it is generally a success. The reverse end of a probe is to be inserted and the eyelids separated by this, then small pledglets of wool are put in until ulceration of the part has ceased. But when an eyelid adheres to the white of the eye itself, Heraclides of Tarentum invented the method of cutting underneath the eyelid with the knife held, but very carefully, so that nothing is cut away, either from the eyeball, or from the eyelid, and if something must be, rather from the eyelid. The eyeball should afterwards be anointed with the medicaments with which trachoma is treated; and the eyelid turned up every day, not only that the medicament may be applied to the ulceration, but also lest the eyelid should adhere again; moreover the patient himself should be told to raise his eyelid frequently with two fingers. I for my part do not remember anyone to have been cured by this method. Meges also has recorded that he tried many times, but was never successful, for the eyelid has always again become adherent to the eyeball.
Tum exiguum lin⟨a⟩mentum respergendum est uel cadmia uel atramento sutorio, inque eum angulum deductis palpebris inserendum, supraque eodem modo deligandum, proximisque diebus similiter nutriendum, tantum ut primis aqua egelida uel etiam frigida foueatur. Interdum inter se palpebrae coalescunt aperirique non potest oculus. Cui malo solet etiam illud accedere, ut palpebrae cum albo oculi cohaeresca⟨nt, s⟩cilicet cum ⟨in⟩ utroque fuit ulcus neclegenter curatum: sanescendo enim, quod diduci potuit et debuit, glutinauit: ancyloblepharus †sub utroque uitio Graeci uocant. Palpebrae tantum inter se cohaerentes non difficulter diducuntur, sed interdum frustra: nam rursus glutinantur. Experiri tamen oportet, quia bene res saepius cedit. Igitur auersum specillum inserendum, ⟨di⟩ducendaeque ⟨eo⟩ palpebrae sunt; deinde exigua penicilla interponenda, donec exulceratio eius loci finiatur. At ubi albo ipsius oculi palpebra inhaesit, Heraclides Tarentinus auctor est aduerso scalpello subsecare cum magna moderatione, ut neque ex oculo neque ex palpebra quicquam abscidatur; ac si necesse est, ex palpebra potius. Post haec inunguatur oculus medicamentis, quibus aspritudo curatur; cottidieque palpebra uert⟨a⟩tur, non solum ut ulceri medicamentum inducatur, sed etiam ⟨ne rursus inhaereat; ipsique etiam⟩ praecipiatur, ut saepe eam digitis duobus attollat. Ego sic restitutum esse neminem memini.
Again, at the angle next to the nostrils, there opens a sort of small fistula, due to some lesion, through which rheum persistently drips; the Greeks call it aigilops. This causes a persistent eye trouble; sometimes it even eats away the bone, and penetrates to the nostril. And at time it has the character of a carcinoma when the veins become distended and look jaundiced, the skin livid, hard and irritable to the slightest touch, and it gives rise to inflammation in the parts near to it. Of these affections it is dangerous to treat those which resemble carcinoma, for that even hastens death. Again, it is useless to treat those which penetrate to the nostrils for they never heal. But when limited to the angle, treatment is possible so long as we do not forget that it is difficult. The nearer the opening to the angle, the greater the deficiency, on account of the very narrow space for handling the lesion. When the trouble is fresh, however, cure is easier. Now the margin of the opening is to be caught up by a hook, then as I have described for fistula in general the whole channel down to the bone is to be excised; and the eye and adjacent parts having been well covered over, the bone is to be cauterized; and more thoroughly when there is already decay, in order that a thicker scale may separate. Some apply caustics, such as cobbler's blacking or bronze or copper filings, which act more slowly, and do not have the same effect. After cauterization of the bone, the same treatment is followed as in other burns.
Meges se quoque multa temptasse, neque umquam profuisse, quia semper iterum oculo palpebra inhaeserit, memoriae prodidit. Etiamnum in angulo, qui naribus pro⟨p⟩ior est, ex aliquo uitio quasi parua fistula aperitur, per quam pituita adsidue destillat: aegilopa Graeci uocant. Idque adsidue male habet oculum; nonnumquam etiam exesso osse usque nares penetrat. Atque interdum naturam carcinomatis habet, ubi intentae uenae et a⟨r⟩quatae sunt, color pallet, cutis dura est et leui tactu inritatur, inflammationemque in eas partes, ⟨quae⟩ coniunctae sunt, euocat. —Ex his eos, qui quasi car⟨ci⟩noma habent, curare periculosum est: nam mortem quoque ea res maturat; eos uero, quibus ad nares tendit, superuacuum: neque enim sanescunt. A⟨t⟩ quibus ⟨id⟩ in angulo e⟨s⟩t, potest adhiberi curatio, cum eo ne ignotum sit esse difficilem: quantoque angulo propius id foramen est, tanto difficilior est, quoniam perangustum est, in quo uersari manus possit. Recenti tamen re mederi facilius est. Sed hamulo summum eius foraminis excipiendum; deinde totum id cauum, sicut in fistulis dixi, usque ad os excidendum; oculoque et ceteris iunctis partibus bene obtectis, os ferramento adurendum est; uehementiusque si iam carie uexatum est, quo crassior squama a⟨bs⟩cedat.
The eyelashes also may irritate the eye from two causes: one is that the skin on the outer surface of the eyelid becomes relaxed and slips downwards, causing its eyelashes to be turned inwards against the eyeball because the cartilage does not simultaneously give way; in the other case, beyond the natural row of eyelashes another row sprouts out, which is directed straight inwards against the eyeball. The following are the modes of treatment. If eyelashes have grown where they ought not, a fine iron needle flattened like a spear point is put into the fire; then when the eyelid is turned up, so that the offending eyelashes can be seen by the operator, the red hot needle is passed along their roots, from the angle, for a third of the length of the eyelid, then for a second and for a third time, until the opposite angle is reached; this causes all the roots of the eyelashes so cauterized to die. A medicament is then applied to check inflammation, and when the crusts have become detached, cicatrization is to be induced. This kind of trouble is very easily cured. Some say that a needle carrying a doubled-up hair from a woman's head should be passed through the eyelid from within outwards close to the eyelashes, and where the needle has passed through, an eyelash is to be inserted into the loop of the said hair where doubled, and the eyelash drawn by the loop through to the outer surface of the eyelid; there it is to be glued down; and a medicament is then applied to agglutinate the puncture; thus it comes about that afterwards that eyelash is directed outwards. But in the first place this cannot be done unless the eyelash is rather long, and in this situation they are generally short; further, when numerous eyelashes are affected, the passing of a needle so many times is necessarily a prolonged torture, and it may set up severe inflammation. Lastly, when there is any rheum subsisting there, and the eye has been irritated previously by the eyelashes, and now by the perforation through the eyelid, it is scarcely possible that the glue binding down the eyelash should not be dissolved; and so it comes to pass that the eyelash returns to the position from which it was forcibly removed. But there is no doubt about the following treatment of too lax an eyelid, which is commonly practised by everybody. It is necessary to close the eye and from the middle, either of the upper or the lower eyelid, to seize a fold of skin between a finger and thumb, and so to raise it; then consider how much must be removed the lid to be in a natural position for the future. In this too there are two dangers; that if too much has been excised the eyeball cannot be covered, if too little nothing has been gained, and a patient has been cut to no purpose. Next where it is seen that incision is to be made, a mark must be made by two lines of ink, but in such a way that between the margin holding the eyelashes, and the marked line adjacent, there remains skin enough for a needle afterwards to take up. When everything is ready the scalpel is to be applied; and the incision nearer the eyelashes themselves is to be made first in the case of the upper lid, but second for the lower one; in the case of the left eye, the incision is made from the outer angle; of the right eye from the inner one; then the skin between the two incisions is to be excised. Next the edges of the wound are to be brought into opposition by one stitch, and the eye is to be closed and if the eyelid descends too little the suture is slackened, if too much, either the suture is tightened, or even an additional fine strip may be excised from the margin furthest from the eyelashes. Where the eyelid has been cut other sutures may be put in but not more than three. Further, in the case of the upper lid, a linear incision is to be made under the row of eyelashes itself, so that these having been drawn away from under are directed upwards, and when there is but a slight drooping of the upper lid, this alone may suffice; the lower lid does not need the additional incision. When these things have been done, a sponge squeezed out of cold water is bandaged on. The next day an agglutinating plaster is applied; on the fourth day the sutures are taken out, and a salve for repressing inflammation smeared on.
Quidam adurentia inponunt, ⟨ut⟩ atramentum sutorium uel chalcitidem uel aeruginem rasam; quod et tardius et non idem facit. Osse adusto curatio sequitur eadem, quae in ceteris ustis. Pili uero, qui in palpebris sunt, duabus de causis oculum inritare consuerunt: nam modo palpebrae [superioris] summa cutis relaxatur et procidit; quo fit, ut eius pili ad ipsum oculum conuertantur, quia non simul cartilago quoque se remisit; modo sub ordine naturali pilorum alius ordo subcrescit, qui protinus intus ad oculum tendit.— Curationes hae sunt. Si ⟨pili nati sunt,⟩ qui non debuerunt, tenuis acus ferrea ad similitudinem hastae lata in ignem coicienda est; deinde candens, sublata palpebra sic, ut eius perniciosi pili in conspectum curantis ueniant, sub ipsis pilorum radicibus ab angulo inmittenda est, ut ea tertiam partem palpebrae trans⟨u⟩at; deinde iterum tertioque usque ad alterum angulum; quo fit, ut omnes pilorum radices adustae ⟨e⟩moriantur. Tum superinponendum medicamentum est, quod inflammationem prohibeat, ⟨at⟩que ubi crustae exciderunt, ad cicatricem perducendum. Facillime autem id genus sanescit. Quidam aiunt acu transui iuxta pilos in exteriorem partem palpebrae oportere eamque transmitti duplicem capillum muliebrem ducentem; atque ubi acus transit, in ipsius capilli sinum, qua duplicatur, pilum esse coiciendum et per eum in superiorem palpebrae partem adtrahendum; ibique corpori adglutinandum; et inponendum medicamentum, quo foramen glutinetur: sic enim fore, ut is pilus in exteriorem partem postea spectet. Id primum fieri non potest, nisi in pilo longiore, cum fere breues eo loco nascantur; deinde si plures pili sunt, necesse est longum tormentum totiens acus traiecta magnamque inflammationem moueat. Nouissime cum umor aliquis ibi subsit, oculo ⟨et⟩ ante per pilos et tum per palpebrae foramina adfecto uix fieri potest, ut gluten, quo uinctus est pilus, non resoluatur; eoque fit, ut is eo, unde ui abductus est, redeat. Ea uero curatio, quae [palpebrae laxioris] ab omnibus frequentatur, nihil habet dubii: siquidem oportet contecto oculo mediam palpebrae cutem, siue ea superior siue inferior est, adprehendere digitis ac sic leuare; tum considerare, quantulo detracto futurum sit, ut naturaliter se habeat. Siquidem hic quoque duo pericula circumstant: si nimium fuerit excisum, ne contegi oculus non possit; si parum, ne nihil actum sit, et frustra sectus aliquis sit. Qua deinde incidendum uidebitur, per duas lineas atramento notandum est sic, ut inter oram, quae pilos continet, et pro⟨p⟩iorem ei lineam aliquid relinquatur, quod adprehendere acus postea possit. His constitutis scalpellus adhibendus est; et si superior palpebra, ante; si inferior, postea propius ipsis pilis incidendum; initiumque faciendum in sinistro oculo ab eo angulo, qui tempori; in dextro ab eo, qui naribus propior est; idque, quod inter duas lineas est, excidendum. Deinde orae uulneris inter se simplici sutura committendae, operiendusque oculus et si parum palpebra descendet, laxanda sut⟨ura⟩; si nimium, aut adstringenda, aut etiam rursus tenuis habenula e⟨st⟩ ab ulteriore ora excidenda. Vbi secta est, aliae suturae adiciendae, quae supra tres esse non debent. Praeter haec in superiore palpebra sub pilis ipsis incidenda linea est, ut⟨i⟩ ab inferiore parte deducti pili susum spectent; idque, si leuis inclinatio est, etiam solum satis tuetur; inferior palpebra eo non eget. His factis, spongia ex aqua frigida expressa super deliganda est.
But in the course of the above treatment it sometimes happens that when too much skin has been excised, the eyeball is not covered; and occasionally this also occurs from some other cause: the Greeks call the condition lagophthalmus. If too much of the eyelid is lost, no treatment can restore it; if a small loss it may be remedied. Just below the eyebrow the skin is to be incised in the figure of a crescent with the horns pointing downwards. The incision should reach as far as the cartilage without injuring it; for should the cartilage be cut into, the eyelid will droop, and cannot afterwards be raised. Therefore if the skin is merely drawn apart, it follows that the bottom of the eyelid droops slightly because of the gap made by the cut above; into this gap lint is to be inserted, both to prevent the separated edges from reuniting, and to help the growth of the flesh between, so that the eyeball comes to be properly covered when the gap has filled up.
Postero die glutinans emplastrum iniciendum, quarto suturae tollendae, et collyrio, quod inflammationes reprimit, superinunguendum. Nonnumquam autem nimium sub hac curatione excisa cute euenit, ut oculus non tegatur; idque interdum etiam alia de causa fit: lagopt⟨h⟩almus Graeci appellant. In quo si nimium palpebra⟨e⟩ deest, nulla id restituere curatio potest; si exiguum, mederi licet.— Paulum infra supercilium cutis incidenda est lunata figura cornibus eius deorsum spectantibus. Altitudo esse plagae usque ad cartilaginem debet ipsa illa nihil laesa: nam si ea incisa est, palpebra concidi⟨t⟩, neque attolli postea potest. Cute igitur tantum diducta fit, ut paulum ⟨in⟩ ima oculi ora descendat hiante scilicet super plag⟨a⟩; in qua⟨m⟩ linamentum coiciendum est, quod et coniungi diductam cutem prohibeat et in medio carunculam citet;
Whilst a defect in the upper eyelid is that it descends too little and so does not cover the eyeball, sometimes the lower lid is not raised enough but hangs down and gapes open, and cannot reach the upper lid. And this, too, happens sometimes from the defective treatment described above, sometimes from old age: the Greeks call it ectropion. If this is due to bad treatment, the same procedure as that noted above is employed, but the horns of the incision are to be directed now towards the jaws, not towards the eyeball: if from old age, all that extrudes is burnt away with a fine cautery, then honey smeared on; from the fourth day the eye is steamed, and anointed with medicaments to induce a scar.
quae ubi eum locum inpleuit, postea recte oculus operitur. Vt superioris autem palpebrae uitium est, quo parum descendit ideoque oculum non contegit, sic inferioris, quo parum susum attollitur, sed pendet et hiat, neque potest cum superiore committi. Atque id quoque euenit interdum ex simili uitio curationis, interdum etiam senectute: ectropion Graeci nominant.—Si ex mala curatione est, eadem ratio medicinae est, quae supra posita est;
Such as a rule are the lesions which are apt to occur around the eyeball in the angles or eyelids. But in the eyeball itself the outer tunic is sometimes raised, by the rupture or by the relaxation of certain membranes inside, and its shape becomes like a grape: the Greeks therefore call the lesion staphyloma. There are two modes of treatment. In one a needle carrying two threads is passed through the middle of its base, and first the two ends of the upper thread, and then those of the lower, are knotted, and these gradually cut through and so excise the staphyloma. In the other method, a piece about the size of a lentil is cut off from its tip, then oxide or carbonate of zinc is dusted on. After either method, wool soaked in white of egg is applied; subsequently the eye is steamed, and then anointed with soothing medicaments.
plagae tantum cornua ad maxillas, non ad oculum conuertenda sunt: si ex senectute est, tenui ferramento id totum extrinsecus adurendum est, deinde melle inunguendum: a quarto die uapore aquae calidae fouendum, inunguendumque medicamentis ad cicatricem perducentibus. Haec fere circa oculum in angulis palpebrisque incidere consuerunt. In ipso autem oculo nonnumquam summa attollitur tunica, siue ruptis intus membranis aliquibus siue laxatis, et similis figura acino fit: unde id staphyloma Graeci uocant.—Curatio duplex est: altera: ad ipsas radices per medium transuere acu duo lina ducente; deinde alterius lini duo capita ex superiore parte, alterius ex inferiore astringere inter se; quae paulatim secando id excidunt. Altera: in summa parte eius ad lenticulae magnitudinem excidere;
Again, small hard tumours in the white of the eyeball are called clavi, from a resemblance in shape to nailheads. These it is best to transfix with a needle at their base, and to cut away underneath the needle; then to anoint with soothing medicaments.
deinde spodium aut cadmiam infriare. Vtrolibet autem facto, album oui lana excipiendum et inponendum; posteaque uapore aquae calidae fouendus oculus et lenibus medicamentis inunguendus est.
I have already made mention elsewhere of cataract, because when of recent origin it is also often dispersed by medicaments: when it is more chronic it requires treatment by surgery, and this is one of the most delicate operations. Before I speak of this, the nature of the eyeball itself has to be briefly explained. A knowledge of this is often useful, but especially here. The eyeball, then, has two external tunics, of which the outer is called by the Greeks ceratoides. In that part of the eye which is white it is fairly thick; over the region of the pupil it is thin. To this tunic the under one is joined; in the middle where the pupil is, it is pierced by a small hole: around this it is thin, further out it too is thicker and is called by the Greeks chorioides. These two tunics whilst enclosing the contents of the eyeball, coalesce again behind it, and after becoming thinned out and fused into one, go through the space between the bones, and adhere to the membrane of the brain. Under these two tunics, at the spot where the pupil is, there is an empty space; then underneath again is the thinnest tunic, which Herophilus named arachnoides. At its middle the arachnoides is cupped, and contained in that hollow is what, from its resemblance to glass, the Greeks call hyaloides; it is humour, neither fluid nor thick, but as it were curdled, and upon its colour is dependent the colour of the pupil, whether black or steel-blue, since the outer tunic is quite white: but this humour is enclosed by that thin membrane which comes over it from the interior. In front of these is a drop of humour like white of egg, from which comes the faculty of seeing; it is named by the Greeks crystalloides.
Claui autem uocantur callosa in ⟨albo⟩ oculi tubercula, quibus nomen a figurae similitudine est. Hos ad imam radicem perforare acu commodissimum est, infraque eam excidere; deinde lenibus medicamentis inunguere. Suffusionis iam alias feci mentionem, quia cum recens incidit, medicamentis quoque saepe discutitur: sed ubi uetustior facta est, manus curationem desiderat, quae inter subtilissimas haberi potest. ⟨De⟩ qua antequam dico, paucis ante ipsius oculi natura indicanda est. Cuius cognitio cum ad plura loca pertineat, tum uel praecipue ad hunc pertinet. Is igitur summas habet duas tunicas, ex quibus superior a Graecis ceratoides uocatur. Ea, qua parte alba est, satis crassa; pupillae loco extenuatur. Huic inferior adiuncta est, media parte, qua pupilla est, modico foramine concaua; circa tenuis, ulterioribus partibus ipsa quoque plenior, quae chor⟨i⟩oides a Graecis nominatur. Hae duae tunicae, cum interiora oculi cingant, rursus sub his coeunt, extenuataeque et in unum coactae ⟨per⟩ foramen, quod inter ossa est, ad membranam cerebri perueniunt eique inhaerescunt. Sub his autem, qua parte pupilla est, locus uacuus est; deinde infra rursus tenuissima tunica, quam Herophilus arachnoidem nominauit. Ea media subsidit * * * eoque cauo continet quiddam, quod a uitri similitudine hyaloides Graeci uocant.
Now either from disease or from a blow, a humour forms underneath the two tunics in what I have stated to be an empty space; and this as it gradually hardens is an obstacle to the visual power within. And there are several species of this lesion; some curable, some which do not admit of treatment. For there is hope if the cataract is small, and immobile, if it has also the colour of sea water or of glistening steel, and if at the side there persists some sensation to a flash of light. If large, if the black part of the eye has lost its natural configuration and is changed to another form, if the colour of the suffusion is sky blue or golden, if it shakes and moves this way and that, then it is scarcely ever to be remedied. Generally too the case is worse when the cataract has arisen from a severe disease, from severe pains in the head or from a blow of a violent kind. Old age is not favourable for treatment, since apart from this lesion, sharpness of vision is naturally dulled; neither is childhood favourable, but rather intermediate ages. Neither a small nor a sunken eye is satisfactory for treatment. And in the cataract itself, there is a certain development. Therefore we must wait until it is no longer fluid, but appears to have coalesced to some sort of hardness. Before treatment the patient should eat in moderation and for three days beforehand drink water, for the day before abstain from everything. Then he is to be seated opposite the surgeon in a light room, facing the light, while the surgeon sits on a slightly higher seat; the assistant from behind holds the head so that the patient does not move: for vision can be destroyed permanently by a slight movement. In order also that the eye to be treated may be held more still, wool is put over the opposite eye and bandaged on: further the left eye should be operated on with the right hand, and the right eye with the left hand. Thereupon a needle is to be taken pointed enough to penetrate, yet not too fine; and this is to be inserted straight through the two outer tunics at a point intermediate between the pupil of the eye and the angle adjacent to the temple, away from the middle of the cataract, in such a way that no vein is wounded. The needle should not be, however, entered timidly, for it passes into the empty space; and when this is reached even a man of moderate experience cannot be mistaken, for there is then no resistance to pressure. When the spot is reached, the needle is to be sloped against the suffusion itself and should gently rotate there and little by little guide it below the region of the pupil; when the cataract has passed below the pupil it is pressed upon most firmly in order that it may settle below. If it sticks there the cure is accomplished; if it returns to some extent, it is to be cut up with the same needle and separated into several pieces, which can be the more easily stowed away singly, and form smaller obstacles to vision. After this the needle is drawn straight out; and soft wool soaked in white of egg is to be put on, and above this something to check inflammation; and then bandages. Subsequently the patient must have rest, abstinence, and inunction with soothing medicaments; the day following will be soon enough for food, which at first should be liquid to avoid the use of the jaws; then, when the inflammation is over, such as has been prescribed for wounds, and in addition to these directions it is necessary that water should for some time be the only drink.
Id neque ⟨liquidum neque⟩ aridum est, sed quasi concretus umor, ex cuius colore pupillae color uel niger est uel caesius, cum summa tunica tota alba sit: id autem superueniens ab interiore parte membranula * includit. Su⟨per⟩ his gutta umoris est, oui albo similis, a qua uidendi facultas proficiscitur: crystalloides a Graecis nominatur. Igitur uel ex morbo uel ex ictu concrescit umor sub duabus tunicis, qua locum esse uacuum proposui; isque paulatim indurescens interiori * potentiae se opponit. Vitiique eius plures species sunt; quaedam sanabiles, quae⟨dam quae⟩ curationem ⟨non⟩ admittunt. Nam si exigua suffusio est, si immobilis, colorem uero habet marinae aquae uel ferri nitentis et a latere sensum aliquem fulgoris relinquit, spes superest. Si magna est, si nigra pars oculi, amissa naturali figura, in aliam uertit, si suffusioni color caeruleus est aut auri similis, si labat et hac atque illac mouetur, uix umquam succurritur. Fere uero peior est, quo⟨m⟩ ex grauiore morbo, maioribus capitis doloribus uel ictu uehementiore orta est. Neque idonea curation⟨i⟩ senilis aetas est, quae sine ⟨e⟩o uitio tamen aciem ⟨hebetem⟩ habet: at ne puerilis quidem, sed inter haec media. Oculus quoque curationi neque ⟨exiguus neque⟩ concauus satis oportunus est. Atque ipsius suffusionis quaedam maturitas est: expectandum igitur est, donec iam non fluere sed duritie qu⟨a⟩dam concreuisse uideatur. Ante curationem autem modico uti cibo, bibere aquam triduo debet, pridie ab omnibus abstinere. Post haec in aduorso collocandus est, loco lucido, lumine a⟨d⟩uerso, sic ut contra medicus paulo altius; a posteriore parte caput eius, qui curabitur, minister contineat, ut inmobile id praestet: nam leui motu eripi acies in perpetuum potest. Quin etiam ipse oculus, qui curabitur, inmobilior faciendus est, super alterum lana inposita [deligata]: curari uero sinister oculus dextra manu, dexter sinistra debet. Tum acus admouenda est, sic ⟨ac⟩uta, ut foret, non nimium tenuis; eaque demittenda sed recta est per summas duas tunicas medio loco inter oculi nigrum et angulum tempori propiorem, e regione mediae suffusionis sic, ne qua uena laedatur. Neque tamen ⟨timide⟩ d⟨e⟩mittenda est, quia inani loco excipitur; ad quem cum uentum est, ne mediocriter quidem peritus falli potest, quia prementi nihil renititur. Vbi eo uentum est, inclinanda acus ad ipsam suffusionem leuiterque ibi uerti et paulatim eam deducere infra regionem pupillae debet; ubi deinde eam transit, uehementius inprimi, ut inferiori parti insidat. Si haesit, curatio expleta est: si subinde redit, eadem acu concidenda et in plures partes dissipanda est, quae singulae et facilius conduntur et minus late officiunt. Postea educenda recta acus est; inponendumque lana molli exceptum oui album, et supra, quod inflammationem coerceat; atque ita deuinciendum. Post haec opus est quiete, abstinentia, lenium medicamentorum inunctionibus;
Also with regard to the discharge of a thin rheum which troubles the eyes, I have already explained what is to be done by means of medicaments. I come now to cases which demand surgical treatment. But we have remarked that in some the eyes never dry up, but are always moistened by a thin rheum; this keeps up trachoma, and upon slight provocation excites inflammations and ophthalmia, so troubling the patient all his life; and sometimes this cannot be remedied at all, but sometimes it is curable. This is the first thing to be decided, that in the latter case the patient may be relieved, in the former no surgical treatment may be applied. And in the first place, the treatment is useless in those who have had the disorder from infancy, of necessity it will continue to their dying day; again, it is not necessary in those cases where the discharge is scanty, though acrid, since they will derive no benefit from surgery; by medicaments and by the regulation of diet which renders the rheum thicker, they come back to health. Further, broad heads are hardly ever adapted to the treatment. Then it makes a difference whether the rheum comes from blood vessels between the skull and the scalp, or from those between the membrane of the brain and the skull. Generally those above the skull irrigate the eyes by way of the temples, those under it by way of membranes connecting the eyes with the brain. Now it is possible to apply a remedy to those blood vessels which lie above the bone — to those below it is not. Neither can patients be relieved in whom rheum is flowing down both ways, because although relieved in one direction, none the less trouble continues by the other. How the matter stands is to be learnt as follows. The head having been first shaved, those medicaments by which the rheum is checked in ophthalmia are smeared on from the eyebrow to the crown of the head. If the eyes begin to dry, it is clear that the moisture comes from those blood vessels which are beneath the scalp; if in spite of the application, they continue moist, it is manifest that the downflow of rheum is from under the skull. If there is humour but in less amount, the lesion is double. In the majority of patients, however, it is found that the superficial blood vessels are involved, and so also the majority can be relieved. This is well known, not in Greece only, but among other races too, so that no portion of the Art of Medicine has become more widespread among the nations of the earth. Some Greek practitioners made nine linear incisions into the scalp, two vertical ones in the occipital region, a transverse one above them; then two above the ears, with a cross-cut uniting them, three vertical ones between the crown and the forehead. Others were found who drew those lines directly from the vertex to the temples and having ascertained where the muscles began from the movements of the jaws, cut through the scalp over them with a light hand, and after the margins of the incisions had been retracted by blunt hooks, inserted lint, in order that the former edges of the skin should not unite, and that flesh should grow up in between so as to constrict the veins carrying humour to the eyes. Some even marked out with ink two lines, from the middle of one ear to the middle of the other, and from the nose to the crown. Then, where the two lines meet, they cut with a scalpel, and after blood has flowed out, they cauterized the bone there. But further, both on the temples and also between the forehead and crown, they likewise applied the red hot cautery to prominent blood vessels. A treatment frequently used is to cauterize the blood vessels on the temples, which indeed in this malady are usually rather swollen, but in order that they may be more distended and show up better, the neck is first bandaged moderately tight and the blood vessels then burnt with fine blunt cautery points until the flow of rheum to the eyes ceases. For that is a sign of the blocking up as it were of the channels by which humor was being carried. There is a more effectual means, however, when the blood vessels are thin and deep-seated, and so cannot be picked out, whereby the neck is bandaged as before, and the patient holds his breath, so as to make the vessels more prominent, and then those on the temples and between the fore-head and vertex are marked out with ink; upon this the neck is released, the blood vessels are cut into where marked and blood let flow; when enough has been let out, the vessels are burnt with fine cauteries; over the temples this is done cautiously lest the underlying muscles controlling the jaws feel it; between the forehead and the crown the cautery is applied firmly in order that a scale may become detached from the skull. Even more efficacious is the African method; they burn the crown of the scalp through down to the bone so that it may cast off a scale. But there is nothing better than the practice in transalpine Gaul; there they pick out blood vessels in the temples and crown of the head. Now I have already explained the treatment after cautery. I here add that there should be no haste, either in detaching crust, or in letting the ulceration heal after cauterization of blood vessels, lest haemorrhage burst out, or pus be too quickly suppressed, for whilst it is the object by the ulceration to dry up these parts, it is not the object to drain them out by bleeding; but if there is bleeding, such medicaments should be sprinkled on as suppress bleeding, but do not cauterize. With regard to the selection of blood vessels, and what is to be done when they are picked out, I will speak when I come to varicose veins in the leg.
cibo, qui postero die satis mature datur, primum liquido, ne maxillae laborent; deinde inflammatione finita, tali, qualis in uulneribus propositus est; quibus, ut aqua diutius bibatur, necessario accedit. De pituitae quoque tenuis cursu, qui oculos infestat, quatenus medicamentis agendum e⟨s⟩t, iam explicui. Nunc ad ea ueniam, quae curationem manu postulant. Animaduertimus autem quibusdam numquam siccescere oculos, ⟨sed⟩ semper umore tenui madere; quae res aspritudinem continuat, ex leuibus momentis inflammationes et lippitudines excita⟨t,⟩ totam denique uitam hominis infestat; idque in quibusdam nulla ope adiuuari potest, in quibusdam sanabile est: quod primum [discrimen est] nosse oportet, ut alteris succurratur, alteris manus non iniciatur. Ac primum superuacua curatio est in is, qui ab infantibus id uitium habent, quia necessario mansurum est usque mortis diem; deinde non necessaria etiam in is, quibus non multa, ⟨sed⟩ acris pituita est, siquidem manu nihil adiuuantur: medicamentis et uictus ratione, quae crassiorem pituitam reddit, ad sanitatem perueniunt. Lata etiam capita uix medicinae patent. Tum interest uenae pituitam mittant quae inter caluariam et cutem sunt, an quae inter membrana⟨m⟩ cerebri et caluariam. Superiores fere per tempora oculos rigant; inferiores per eas membranas, quae ab oculis ad cerebrum tendunt. Potest autem adhiberi remedium is, quae supra os fluunt; non potest is, quae sub osse. Ac ne is quidem succurritur, quibus pituita utrimque descendit, quia leuata altera parte nihilo minus altera infestat. Quid sit autem, hac ratione cognoscitur. Raso capite an⟨te⟩ ea medicamenta, quibus in lippitudine pituita suspenditur, a superciliis usque ad uerticem inlini debent. Si sicci oculi esse coeperunt, apparet per eas uenas, quae sub cute sunt, inrigari: si nihilo minus madent, manifestum est sub osse descendere: si est umor, sed leuior, duplex uitium est. Plurimi tamen ex laborantibus reperiuntur, quos superiores uenae exerceant; ideoque pluribus etiam opitulari licet. Idque non in Graecia tantummodo, sed in aliis quoque gentibus celebre est, adeo ut nulla medicinae pars magis per nationes quoque exposita sit. Reperti in Graecia sunt, qui nouem lineis cutem capitis inciderent; duabus in occipitio rectis, una super eas transuersa; deinde ⟨duabus⟩ super aures, una inter eas item transuersa; tribus inter uerticem et frontem rectis. Reperti sunt, qui a capite recte eas lineas ad tempora deducerent, cognitisque ex motu maxillarum musculorum initiis leuiter super eos cutem inciderent, ⟨di⟩ductisque per retusos hamos oris insererent linamenta, ut neque inter se cutis antiqui fines committerentur, et in medio caro incresceret; quae uenas, ex quibus umor ad oculos transiret, adstringeret. Quidam etiam atramento duas lineas duxerunt a media aure ad mediam alteram aurem; deinde a naribus ad uerticem. Tum ubi lineae committebantur, scalpello inciderunt, et post sanguinem effusum ⟨o⟩s ibidem ad⟨us⟩serunt. Nihilo minus autem et in temporibus et inter frontem atque caluariam eminentibus uenis idem candens ferrum admouerunt. Frequens curatio est uenas in temporibus adurere, quae fere quidem in eiusmodi malo tument: sed tamen, ut inflentur magisque se ostendant, ceruix ante modice deliganda est, tenuibusque ferramentis et retussis uenae adurendae, donec in oculis pituitae cursus conquiescat. Id enim signum est quasi excaecatorum itinerum, per quae umor ferebatur. Valentior tamen medicina est, ubi tenues conditaeque uenae sunt, ideoque legi non possunt, eodem modo ceruice deligata retentoque ab ipso spiritu quo magis uenae prodeant, atramento notare eas contra tempora et inter uerticem ac frontem; deinde ceruice resoluta, qua notae sunt uenae, incidere, et sanguinem mittere; ubi satis fluxit, tenuibus ferramentis adurere: contra tempora quidem timide, ne subiecti musculi qui maxillas tenent sentiant; inter frontem uero et uerticem uehementer, ut squama ab osse secedat. Efficacior tamen etiamnum est Afrorum curatio, qui uerticem usque ad os adurunt sic, ut squamam remittat. Sed nihil melius est quam quod in Gallia est comata: qui ibi uenas in temporibus et in superiore capitis parte legunt. Adusta quomodo curanda sint, iam explicui. Nunc illud adicio: neque ut crustae decidant, neque ut ulcus inpleatur, adustis uenis esse properandum, ne uel sanguis erumpat uel cito pus subprimatur, cum per hoc siccescere eas partes opus sit, per illud exhauriri opus non sit: si quando tamen sanguis eruperit, infricanda medicamenta esse, quae sic sanguinem supprimant, ne adurant. Quemadmodum autem ⟨uenae⟩ delegendae sunt, quidque lectis is faciendum sit, cum uenero ad crurum uarices, dicam.
8. 8 Whilst the eyes demand many kinds of surgical treatment, there are but few affections of the ears which are dealt with by this branch of medicine. It does happen, however, whether from birth, or later when there has been ulceration and the ear becomes filled up by scarring, that there is no passage in the ear and so it cannot hear. When this is the case, we must try with a probe whether the part is filled up deeply, or whether there is merely a superficial agglutination. For if deeply, there is no yielding to pressure made on the probe; if superficial, the probe enters freely. The former should not be touched, lest, where there is no hope of success, a spasm may be set up, and from that may follow danger of death. The latter is easily treated. For where the passage should be, either one of the caustic medicaments is to be applied, or an opening made with the cautery, or the place may even be cut through with a scalpel. After it has been laid open, and the ulceration has been cleaned, a quill is to be inserted, smeared with a medicament to induce a scar, and the same medicament applied around, until the skin has healed round the quill; by this means when the quill has been removed, the faculty of hearing follows. But where the ears, in a man for instance, have been pierced and have become offensive, it is enough to pass a red hot needle quickly though the hole in order to blister its margins superficially or even to produce the same effect by a caustic; then afterwards to put on applications to clean the place and later what will make the flesh grow there and induce a scar. But if the hole is enlarged, as is usually the case with those who have worn heavy ear-rings, the rest of the lobule should be cut through; then the edges above made raw with a scalpel, and the wound sutured, and agglutinating medicaments put on. A third method, where there has been some mutilation, is to patch, and since this can be done in the case of the lips and nostrils as well, and the procedure is the same, the description too should be given at the same time.
8. Verum ut oculi multiplicem curationem etiam manus exigunt, sic in auribus admodum pauca sunt, quae in hac medicinae parte tractentur. Solet tamen euenire, uel a primo die protinus, uel postea facta exulceratione, dein per cicatricem aure repleta, ut foramen in ea nullum sit, ideoque audiendi usu careat. Quod ubi incidit, specillo temptandum est, altene id repletum, an in summo tantum glutinatum sit. Nam si alte est, prementi non cedit; si in summo, specillum protinus recipit. Illud attingi non oportet, ne ⟨sine⟩ effectus spe distentio oriatur neruorum, et ex ea mortis periculum sit: hoc facile curatur. Nam qua cauom esse debet, uel medicamentum aliquod inponendum est ex adurentibus, uel candenti ferro aperiendum, uel etiam scalpello incidendum. Cumque id patefactum et iam ulcus purum est, coicienda eo pinna est, inlita medicamento cicatricem inducente, circaque id⟨em⟩ medicamentum dandum, ut cutis circa pinnam sanescat; quo fit, ut ea remota postea facultas audiendi sit. At ubi aures, in uiro puta, perforatae sunt et offendunt, traicere id cauum celeriter candente acu ⟨sa⟩tis est, ut leuiter eius orae ulcerentur; aut etiam adurente medicamento idem exulcerare, postea deinde inponere id, quod purget, tum quod eo loc⟨o⟩ repleat et cicatricem inducat. Quod si magnum id foramen est, sicut solet esse in is, qui maiora pondera auribus gesserunt, incidere quod superest ad extremum oportet; supra deinde oras scalpello exulcerare, et postea suere, ac medicamentum, qu⟨o⟩ glutinetur, inponere. Tertium est, si quid ibi curti est, sarcire. Quae res cum in labris quoque et naribus fieri possit, eandem etiam rationem habeat, simul explicanda est.
9. 9 Mutilations then occur in these three parts and can be treated if they are small; if they are large, either they are not susceptible of treatment, or else may be so deformed by it as to be more unsightly than before. And indeed in the ear and nostrils the deformity is the only trouble; but in the case of the lips, if these have become too much contracted, there is also loss of a necessary function, because it becomes less easy both to take food and to speak plainly. Now new substance is not produced at the place itself, but it is drawn from the neighbourhood; and when the change is small this hardly robs any other part and may pass unnoticed, but when large, it cannot do so. And again, this procedure in unsuited to the aged, to those in bad bodily condition, and to those whose wounds heal with difficulty; because there are no cases in which canker sets in more quickly, or is more difficult to get rid of. The method of treatment is as follows: the mutilation is enclosed in a square; from the inner angles of this incisions are made across, so that the part on one side of the quadrilateral is completely separated from that on the opposite side. Then the two flaps, which we have freed, are brought together. If they cannot be sufficiently brought together, at each end beyond the original incisions semilunar cuts which only divide the skin are made with the horns pointing towards the incisions. This enables the edges to be brought together more easily. No force should be used, but the traction should be such that the edges easily approximate and, when left free, do not recoil much. At times, however, if the skin has been drawn across from one side to a considerable extent, or even at all, it makes the part which it has left unsightly. In a case of that sort, leaving that side untouched, an incision should be made only on the other side. For instance we should not attempt to make traction upon the lobules of the ears, the bridge of the nose, the margins of the nostrils, or the corners of the lips. But we shall try traction from either side if anything is required for the upper part of the ears, the tip of the nose, the bridge of the nose, the skin between the nostrils, and the middle of the lips. At times the mutilation is in two places, but the method of treatment is the same. Cartilage if it projects into the incision is to be cut away; for it does not agglutinate nor is it safely transfixed by a needle. But it should not be much cut away lest pus collect on each side between the two margins of loose skin. Then the margins after being brought together are to be sutured by taking up from each skin only, and the earlier incisions are also to be sutured. In dry parts such as the nostrils, it is sufficient to spread on litharge. But into the more distance semilunar wounds lint is to be placed in order that flesh may grow and fill the wound; and it is clear that the greatest attention should be paid to what is thus sutured, from what I mentioned above about canker. Consequently every third day the part should be steamed, then dressed as before; and generally the wound has adhered by the seventh day. Then the sutures should be removed, and the wound allowed to heal.
9. Curta igitur in his tribus * * ac si qua parua sunt, curari possunt; ⟨si qua maiora sunt, aut⟩ non recipiunt curationem, aut ita per hanc ⟨ipsam⟩ deformantur, ut minus indecora ante fuerint. Atque in aure quidem et naribus deformitas sola timeri potest: in labris uero, si nimium contracta sunt, usui quoque necessario iactura fit, quia minus facile et cibus adsumitur et sermo explicatur. Neque enim creatur ibi corpus, sed ex uicino adducitur; quod in leui mutatione et nihil †eripere et fallere oculum potest, in magna non potest. Neque senile autem corpus, neque quod mali habitus est, neque in quo difficulter ulcera sanescunt, huic medicinae idoneum est, quia nusquam celerius cancer occupat aut difficilius tollitur. Ratio curationis eiusmodi est: id, quod cu⟨rt⟩um est, in quadratum derigere; ab interioribus eius angulis lineas transuersas incidere, quae citeriorem partem ab ulteriore ex toto deducant; deinde ea, quae sic resoluimus, in unum adducere. Si non satis iunguntur, ultra lineas, quas ante fecimus, alias duas lunatas et ad plagas conuersas immittere, quibus summa tantum cutis diducatur: sic enim fit, ut facilius quod adducitur sequi possit; quod non est cogendum, sed ita ⟨ad⟩ducendum, ut ex facili subsequatur et dimissum non multum recedat. Interdum tamen ab altera parte cutis * aut omnino adducta deformem, quem reliquit, locum reddit. Eiusmodi loci altera pars incidenda, altera intacta habenda est. Ergo neque ex imis auribus neque ex medio naso imisue narum partibus neque ex angulis labrorum quicquam adtrahere temptabimus: utri⟨m⟩que autem petemus, si quid summis auribus, si quid imis, si quid aut medio naso aut mediis naribus aut mediis labris deerit. Quae tamen inter⟨dum⟩ etiam duobus locis cu⟨rt⟩a esse consuerunt: sed eadem ratio curandi est. Si cartilago in eo, quod incisum est, eminet, excidenda est: neque enim aut glutinatur aut acu tuto traicitur. Neque longe tamen excidi debet, ne inter duas oras liberae cutis utrimque coitus puris fieri possit. Tum iunctae orae inter se suendae sunt utrimque cute adprehensa, et qua priores lineae sunt, ea quoque suturae iniciendae sunt. Siccis locis ut in naribus inlita spuma argenti satis proficit. In ulteriores uero lunatasque plagas li⟨n⟩amentum dandum est, ut caro increscens uulnus impleat; summaque cura quod ita sutum est, tuendum esse apparere ex eo potest, quod de cancro supra posui. Ergo ⟨etiam⟩ tertio quoque die fouendum erit uapore aquae calidae, rursusque idem medicamentum iniciendum; fereque septimo die glutinatum est. Tum suturae eximi, et ulcus ad sanitatem perduci debet.
10. 10 As for the polypus which grows in the nostrils, I have already laid down elsewhere that the best treatment is with the knife. Therefore this too should be loosened from the bone by a sharp instrument, shaped like a spear head, care being taken not to injure the cartilage under it, which is difficult to treat. When detached it is to be extracted by an iron hook; then the nostril is gently filled with lint folded or in a roll, soaked in something to stop the bleeding; when the bleeding has stopped, the ulceration is to be cleaned with a lint plug. When it is clean, insert a quill (as described above in the case of the ear), smeared with the medicament which causes a scar to form until healing is completed.
10. Polypum uero, qui in naribus nascitur, ferro praecipue curari iam alias posui. Ergo ⟨etiam⟩ hunc ferramento acuto in modum spathae facto resoluere ab osse oportet, adhibita diligentia, ne infra cartilago laedatur, in qua difficilis curatio est. Vbi abscis⟨s⟩us est, unco ferramento extrahendus est; tum inplicitum linamentum uel aliquid ex penicillo respergendum est medicamento, quo sanguis supprimitur, eoque naris leuiter inplenda. Sanguine suppresso linamento ulcus purgandum est. Vbi purum est, eo pinna, eodem modo quo in aure supra positum est, medicamento inlita, quo cicatrix inducitur, intus demittenda, donec in tot⟨um⟩ id sanescat.