11. 11 Now as to the lesion called by the Greeks ozaena, I have found nothing in the writings of great surgeons about surgical treatment if it did not yield to medicaments. I believe this is because it seldom heals quite completely, though the treatment its involves considerable pain. Some, however, lay down that either an earthenware tube, or a smooth quill, is to be inserted into the nostril until it reaches the bone, and then a fine cautery point is passed down that tube right to the bone. The cauterized spot is afterwards dressed with verdigris and honey, and when clean is healed by applying lycium. Or the nostril may be laid open from its base as far as the bone, so that the place can be seen, and the cautery more easily applied; then the nostril must be sewn up, and the cauterized ulceration treated as above; the fine suture is dressed with litharge or other agglutinant.
11. Id autem uitium, quod ozena Graece uocatur, si medicamentis non cederet, quemadmodum manu curandum esset, apud magnos chirurgos non rep⟨p⟩eri. Credo quia res raro ad sanitatem satis proficit, cum aliquid in ipsa curatione torment⟨i⟩ habeat. Apud quosdam tamen positum est uel fictilem fistulam uel enodem scriptorium calamum in narem esse coiciendum, donec susum ad os perueniat; tum per id tenue ferramentum candens dandum esse ad ipsum os; deinde adustum locum purgandum esse aerugine et melle: ubi purus est, Lycio ad sanitatem perducendum. Vel narem incidendam esse ab ima parte ad os, ut et conspici locus possit, et facilius candens ferramentum admoueri; tum sui narem debere, et adustum quidem ulcus eadem ratione curari: suturam uero inlini uel spuma argenti uel alio glutinante.
12. 12 In the mouth too some conditions are treated by surgery. In the first place, teeth sometimes become loose, either from weakness of the roots, or from disease drying up the gums. In either case the cautery should be applied so as to touch the gums lightly without pressure. The gums so cauterized are smeared with honey, and swilled with honey wine. When the ulcerations have begun to clean, dry medicaments, acting as repressants, are dusted on. But if a tooth gives pain and it is decided to extract it because medicaments afford no relief, the tooth should be scraped round in order that the gum may become separated from it; then the tooth is to be shaken. And this is to be done until it is quite moveable: for it is very dangerous to extract a tooth that is tight, and sometimes the jaw is dislocated. With the upper teeth there is even greater danger, for the temples or eyes may be concussed. Then the tooth is to be extracted, by hand, if possible, failing that with the forceps. But if the tooth is decayed, the cavity should be neatly filled first, whether with lint or with lead, so that the tooth does not break in pieces under the forceps. The forceps is to be pulled straight upwards, lest if the roots are bent, the thin bone to which the tooth is attached should break at some part. And this procedure is not altogether free from danger, especially in the case of the short teeth, which generally have shorter roots, for often when the forceps cannot grip the tooth, or does not do so properly, it grips and breaks the bone under the gum. But as soon as there is a large flow of blood it is clear that something has been broken off the bone. It is necessary therefore to search with a probe for the scale of bone which has been separated, and to extract it with a small forceps. If this does not succeed the gum must be cut into until the loose scale is found. And if this has been done at once, the jaw outside the tooth hardens, so that the patient cannot open his mouth. But a hot poultice made of flour and a fig is then to be put on until pus is formed there: then the gum should be cut into. A free flow of pus also indicates a fragment of bone; so then too it is proper to extract the fragment; sometimes also when the bone is injured a fistula is formed which has to be scraped out. But a rough tooth is to be scraped in the part which has co black, and smeared with crushed rose-petals to which a fourth part of ox-galls and the same amount of myrrh has been added; and at frequent intervals undiluted wine is to be held in the mouth; and in this case the head is to be wrapped up, and the patient should have much walking exercise, massage of his head and food which is not too bitter. But if teeth become loosened by a blow, or any other accident, they are to be tied by gold wire to firmly fixed teeth, and repressants must be held in the mouth, such as wine in which some pomegranate rind has been cooked, or into which burning oak galls have been thrown. In children too if a second tooth is growing up before the first one has fallen out, the tooth which ought to come out must be freed all round and extracted; the tooth which has grown up in place of the former one is to be pressed upwards with a finger every day until it has reached its proper height. And whenever, after extraction, a root has been left behind, this too must be at once removed by the forceps made for the purpose which the Greeks call rhizagra. Now tonsils which have become hardened after inflammation (they are called by the Greeks antiades) since they are enclosed in a thin tunic, should be scratched round with a finger and drawn out. But if they cannot be so detached they should be seized with a hook and excised with a scalpel; and the hollow then swilled out with vinegar and the wound smeared with something to check the blood. If the uvula, owing to inflammation is elongated downwards, and is painful and dusky red in colour, it cannot be cut away without danger; for usually much blood flows: and so it is better to employ the treatment described elsewhere. But if, though there is no inflammation, it has become drawn so far downwards owing to phlegm, and is thin, pointed and white, it should be cut away; so also when the tip is bluish black and thick, but the base thin. There is no better way than to seize it with a small forceps and below this to cut off as much as we wish. And there is no danger of cutting off too much or too little since we can leave below the forceps only that part which is clearly useless; and cut away what is in excess of the natural length of the uvula. After the operation the same treatment should be carried out as I have just described for the tonsils. Again the tongue in some persons is tied down from birth to the part underlying it, and on this account they cannot even speak. In such cases the extremity of the tongue is to be seized with a forceps, and the membrane under it incised, great care being taken lest the blood vessels close by are injured and bleeding causes harm. The treatment of the wound afterwards has been described above. And indeed many when the wound has healed have spoken; I have, however, known a case when, though the tongue has been undercut so that it could be protruded well beyond the teeth, nevertheless the power of speech has not followed. So it is that in the Art of Medicine even where there is a rule as to what ought to be done, yet there is no rule as to what result ensues. Sometimes also under the tongue an abscess occurs which is generally enclosed in a coat and causes much pain. If it is small, one cut is enough; if large, the skin over it is to be excised down to the coating; then the two margins are laid hold of with hooks, and the coating is to be freed from what it surrounds and completely extracted, taking great care throughout the operation that no large blood vessel is cut into. The lips often split, and this not only is painful but has the inconvenience that speech is hindered; as this is apt to enlarge the cracks painfully and so causes them to bleed. If the cracks are superficial they are better treated by the medicaments used for ulcerations of the mouth. But if the fissures have penetrated deeper, it is necessary to burn them with a fine cautery, spearhead shaped, which should as it were skim over them without being pressed down. Afterwards the same is to be done as for cauterization of the ears.
12. In ore quoque quaedam manu curantur. Vbi in primis dentes nonnumquam mouentur, modo propter radicum inbecillitatem, modo propter gingiuarum arescentium uitium.—Oportet in utrolibet candens ferramentum gingiuis admoueri, ut attingat leuiter, non insidat. Adustae gingiuae melle inlinendae ⟨et mulso eluendae⟩ sunt. Vt pura ulcera esse coeperunt, arida medicamenta inf⟨ri⟩anda sunt ex is, quae reprimunt. Si uero dens dolores mouet eximique eum, quia medicamenta nihil adiuuant, placuerit, circumradi debet, ut gingiuae ab eo resoluantur; tum is concutiendus est. Eaque facienda, donec bene moueatur: nam dens haerens cum summo periculo euellitur, ac nonnumquam maxilla loco mouetur; idque etiam maiore periculo in superioribus dentibus fit, quia potest tempora oculosue concutere. Tum, si fieri potest, manu; si minus, forfice, dens excipiendus est. Ac si ex⟨e⟩ssus est, ante [id foramen] uel linamento uel bene adcommodato plumbo replendus est, ne sub forfice confringatur. Recta uero forfex ⟨d⟩ucenda est, ne inflexis radicibus os rarum, cui dens inhaeret, parte aliqua frangat. Neque ideo nullum eius rei periculum est utique in dentibus breuibus, qui fere longiores radices non habent: saepe enim forfex cum dentem conprehendere non possit aut frustra conprehendat, os gingiuae prehendit et frangit. Protinus autem ubi plus sangu⟨in⟩is profluit, sci⟨re⟩ licet, aliquid ex osse fractum esse. Ergo specillo conquirenda est ⟨test⟩a, quae recessit, et uolsella protrahenda est. ⟨Si⟩ non sequitur, incidi gingiua debet, donec labans ossis testa recipiatur. Quod si factum statim non est, indurescit extrinsecus maxilla, ut is hiare non possit. ⟨Sed⟩ inponendum ⟨calidum⟩ ex farina et fico cataplasma est, donec ibi pus moueatur; tum incidi gingiua debet. Pus quoque multum profluens ossis fracti nota est: itaque etiam tum id extrahi convenit; nonnumquam etiam eo laeso fistula fit, quae eradi debet. Dens autem scaber, qua parte niger, radendus inlinendusque rosae flore contrito, cui gallae quarta pars et altera murrae sit adiecta; continendumque ore crebro uinum meracum; atque in eo casu uelandum caput, ambulatione multa, frictione capitis, cibo non acri utendum. At si ex ictu uel alio casu aliquid labant dentes, auro cum is, qui bene haerent, uinciendi sunt; continendaque ore reprimentia, ut uinum, in quo malicorium decoctum, ⟨aut⟩ in quo galla candens coniecta sit. Si quando etiam in pueris ante alter dens nascitur quam prior excidat, is qui cadere debuit circumpurgandus et euellendus est: is qui natus est in locum prioris cotidie digito adur⟨g⟩endus, donec ad iustam magnitudinem perueniat. Quotienscumque dente exempto radix relicta est, protinus ea quoque ad id facta forfice, quam riza⟨gran⟩ Graeci uocant, eximenda est. Tonsillas autem, quae post inflammationes indu⟨ru⟩erunt, antiades autem a Graecis appellantur, cum sub leui tunica sint, oportet digito circumradere et euellere: si ne si⟨c⟩ quidem resoluuntur, hamulo excipere ⟨et⟩ scalpello excidere; tum ulcus aceto eluere et inlin⟨e⟩re uulnus medicamento, quo sanguis supprimitur. Vua si cum inflammatione descendit, dolorique est et subrubicundi coloris, praecidi sine periculo non potest: solet enim multum sanguinem effundere: ita⟨que⟩ melius est is uti, quae alias proposita sunt. Si uero inflammatio quidem nulla est, nihilo minus autem ultra iustum modum a pituita deducta sit, et est tenuis, acuta, alba, praecidi debet; itemque si ima liuida et crassa, summa tenuis est. Neque quicquam commodius est quam uolsella prehendere, sub e⟨a⟩que quod uolumus excidere. Neque enim ullum periculum est, ⟨ne⟩ plus minusue praecidatur, cum liceat tantum infra uolsella⟨m⟩ relinque⟨re,⟩ quantum [in]utile esse manifestum est; idque praecidere, quo longior uua est quam esse naturaliter debet. Post curationem eadem facienda sunt, quae in tonsilla his proxime posui. Lingua uero quibusdam cum subiecta parte a primo [natali] die uincta est, qui ob id ⟨n⟩e loqui quidem possunt.—Horum extrema lingua uolsella prehendenda est, sub eaque membrana incidenda, magna cura habita, ne uenae quae iuxta sunt uiolent⟨ur⟩ et profusio[ne] sanguinis noceat. Reliqua curatio uulneris in prioribus posita est. Et plerique quidem ubi consanuerunt, locuntur: ego autem cognoui, qui succisa lingua cum abunde super dentes eam promeret, non tamen loquendi facultatem consecutus est. Adeo in medicina, etiam ubi perpetuum est, quod fieri debet, non tamen perpetuum est id, quod sequi conuenit. Sub lingua quoque interdum aliquid abscedit, quod fere consistit in tunica doloresque magnos mouet.—Quo, si exiguum est, incidi semel satis est; si maius, summa cutis usque ad tunicam excidenda est; deinde utrimque orae hamulis excipienda⟨e⟩ et tunica undique circumdato liberanda * * * est, magna diligentia per omnem curationem habita, ne qua maior uena incidatur. Labra autem saepe finduntur eaque res habet cum dolore etiam hanc molestiam, quod sermo prohibetur; qui subinde eas rimas cum dolore diducendo sanguinem citat. Sed has, ⟨si⟩ in summo sunt, medicamentis curare commodius est, quae ad ulcera oris fiunt. Si uero altius descenderunt, necessarium est tenui ferramento adurere; quod spathae simile quasi transcurrere, non inprimi debet. Postea facienda eadem sunt, quae in auribus adustis exposita sunt.
13. 13 Now in the neck between the skin and the trachea, a tumour occurs which the Greeks call bronchocele, it contains now soft flesh, now a humour somewhat like honey or water, sometimes also hairs mixed up with minute bones; whatever the contents, they are enclosed in a coat. Treatment is possible by caustics which eat away the skin together with the underlying tunic. When this has been done, if there is humour inside, it flows out; if anything solid, it is turned out with the finger; the wound then heals under lint dressings. But treatment by the knife is shorter. A linear incision is made over the middle of the tumour down to the tunic; then the morbid pouch is separated by the finger from the sound tissue, and the whole is removed along with its covering. Next the wound is washed out with vinegar to which either salt or soda has been added, and the margins brought together by one suture; the rest of the applications are the same as in other cases of sutured wounds and after that it is lightly bandaged so as not to trouble the throat by pressure. But if it is impossible to take out the tunic, caustics are to be dusted into its interior, and it is then dressed with lint and other suppuratives.
13. At in ceruice inter cutem et asperam arteriam tumor increscit: bronchocelen Graeci uocant; quo modo caro hebes, modo umor aliquis melli aquaeue similis includitur, interdum etiam minutis ossibus pili inmixti. Ex quibus quicquid est, tunica continetur.—Potest autem adurentibus medicamentis curari, quibus summa cutis cum subiecta tunica exestur. Quo facto, siue umor est, profluit; siue quid densius, digitis educitur; tum ulcus sub lin⟨a⟩mentis sanescit. Sed scalpelli curatio brevior est. Medio tumore una linea inciditur usque ad tunicam; deinde uitiosus sinus ab integro corpore separatur digito, totusque cum uelamento suo eximitur. Tum aceto, cui uel salem uel nitrum aliquis adiecit, * eluitur, oraeque una sutura iunguntur; ceteraque eadem quae in aliis suturis superiniciuntur leuiterque inde, ⟨ne⟩ fauces * * urgeatque, deligatur. Si quando autem tunica eximi non potu⟨er⟩it, intus inspergenda adurentia; lin⟨a⟩mentisque id curandum est et ceteris pus mouentibus.
14. 14 There are also around the navel many lesions about which, owing to their rarity, there is little agreement among authorities. But it is probable that each has passed over what was unknown to himself; while no one has depicted what he had not seen. Common to all cases is an ugly prominence of the umbilicus, and the causes are sought for. Meges gave three; rupture into it of the intestine, of the omentum, or of humour. Sostratus said nothing about the omentum; in addition to the other two he said that at times there was increase of flesh in that part, sometimes sound, sometimes cancerous. Gorgias himself also omitted mention of the omentum; but he gave the same number of causes, three, and said that occasionally wind also ruptured into it. Heron having given all these four causes, made mention of both the omentum and of that form which was caused simultaneously by the omentum and intestine. But which of these causes it is, may be recognized by the following indications. When intestine has prolapsed the swelling is neither hard nor soft; it is reduced by anything cold; and it increases not only under heat of all kinds but also when the breath is held. At intervals it rumbles, and if the patient lies down on his back the swelling subsides, as the intestine has slipped back. But when it is the omentum, whilst other signs are similar, the swelling is softer, broad at its base, thinned out towards its apex; if any one grasps it, it slips away. When both intestine and omentum have prolapsed, the signs are mingled, and the softness is intermediate between the two; but the flesh is harder, and even when the patient lies on his back there is always swelling, and it does not yield to pressure, to which the preceding forms yield readily. If it is malignant the signs are the same as I have stated for cancer. Humour fluctuates when pressed upon; wind, on the other hand yields under pressure, but returns at once, also the swelling retains the same shape when the patient lies down on his back. Of these varieties, the disorder due to wind does not admit of treatment; also cancerous flesh is dangerous to treat, so should be left alone. Sound flesh ought to be cut away and the wound dressed with lint. Some let out humour, either by perforating with a needle, or by cutting into the apex of the tumour, and then similarly dressing the wound with lint. As to the rest of the treatment opinions vary. Of course the patient must be laid on his back, in order that the swelling, whether it be intestine or omentum, may slip back into the abdomen. But when the navel sac was then empty, some caught it between two little rods, and fastened the ends of the rods tightly together, so that it mortified there; some passed a needle doubly threaded through the base of the sac, then knotted the two ends of each thread on opposite sides, as is done also in staphyloma of the eye; from in this way that part beyond the ligatures mortifies. Some, in addition, before tying the ends also cut into the protrusion along a marked line and excised it: in order that they might more easily insert a finger and push back whatever had ruptured into the sac; then at length they tied the ligatures. But it is quite enough to order the patient to hold his breath so that the tumour shows itself at its largest; then to mark its base with ink; next with the patient on his back, to compress the tumour with the fingers, so that whatever has not slipped back of itself is forced back by the hand. After this the umbilicus is drawn forwards, and tightly constricted with flaxen thread along the marks of the ink; next the part beyond the ligature is either burnt with caustics or with the cautery, until it mortifies, after which the wound is dressed like other burns. This method answers best, not only when it is intestine or omentum or both, but even when it is humour. But first precautions must be taken against any danger from the ligature. For neither an infant nor a robust adult nor an old man is suited to this treatment, but a child between seven and fourteen years of age. Secondly a suitable body for it is one that is sound, but where there is general ill-health, or pustules or eruptions, and such like, it is not suitable. The smaller tumours also are readily curable, but there is danger in the treatment of those which are excessively large. Moreover the autumn and winter seasons should be avoided, the spring is the best season, early summer is not unfavourable. The patient should also fast on the day before the operation, and that is not enough, but the bowels also are to be moved by a clyster, in order that all that has extruded may more readily return into the abdomen.
14. Sunt etiam circa umbilicum plura uitia, de quibus propter raritatem inter auctores parum constet. Verisimile est autem id a quoque praetermissum, quod ipse non cognouerat; a nullo id, quod non uiderat, fictum. Commune omnibus est umbilicum indecore prominere: causae requiruntur. Meges tres has posuit: modo intestinum eo inrumpere; modo omentum; modo umorem. Sostratus nihil de omento dixit: duobus isdem adiecit carnem ibi interdum increscere, eamque modo integram esse, modo carcinomati similem. Gorgias ipse quoque omenti mentionem omisit: sed eadem tria causatus, spiritus quoque interdum eo dixit inrumpere. Heron omnibus his quattuor positis, et omenti mentionem habuit et eius, quod * * simul et omentum et intestinum habuerit. Quid autem horum sit, his indiciis cognoscitur. Vbi intestinum prolapsum est, tumor neque durus neque mollis est, omni frigore minuitur: non solum sub omni calore sed etiam retento spiritu crescit. Sonat interdum, atque ubi resupinatus est aliquis, delapso intestino ipse desidit. Vbi uero omentum est, cetera similia sunt; tumor mollior et, ab ima parte latus, extenuatus in uertice est; si quis adprehendit, elabitur. Vbi utrumque est, indicia quoque mixta sunt, et inter utrumque mollities: at caro durior est, semperque etiam resupinato corpore tumet, prementique non cedit, prioribus facile cedentibus. Si uitiosa est, easdem notas habet, quas in carcinomate exposui. Vmor autem si premitur, circumfluit: at spiritus pressus cedit, sed protinus redit, resupinato quoque corpore tumorem in eadem figura tenet. Ex his id, quod ex spiritu uitium est, medicinam non admittit; caro quoque carcinomati similis cum periculo tractatur; itaque omittenda est. Sana excidi debet idque uulnus lin⟨a⟩mentis curari. Vmorem quidem * * uel inciso summo tumore effundunt, et uulnus isdem linamentis curant. In reliquis uariae sententiae sunt. Ac resupinandum quidem corpus esse res ipsa testatur, ut in uterum, siue intestinum siue omentum est, delabatur. Sinus uero umbilici tum uacus ⟨a⟩ quibusdam duabus regulis exceptus est, uehementerque earum capitibus deligatis ibi emortus: a quibusdam, ad imum acu traiecta duo lina ducente, deinde utriusque lini duobus capitibus diuersae partes adstrictae; quod in uua quoque oculi fit: nam sic id, quod supra uinculum est, moritur. Adiecerunt quidam, ut antequam uincirent, summum una linea inciderent exciderentque: quo facilius digito demisso quod illuc inrupisset depellerent; tum deinde uinxerunt. Sed abunde est iubere spiritum continere, ut tumor quantus maximus esse potest, se ostendat; tum imam basem eius atramento notare, resupinatoque homine digitis tumorem eum premere, ut, si quid delapsum non est, manu cogatur. Post haec umbilicum adtrahere, et qua nota atramenti est, lino uehementer adstringere; deinde partem superiorem aut medicamentis aut ferro adurere, donec emoriatur, atque ut cetera usta ulcus nutrire. Idque non solum ubi intestinum uel omentum uel utrumque est, sed etiam ubi umor est, optime proficit. Sed ante quaedam uisenda sunt, ne quod ex uinculo periculum sit. Nam curationi neque infans neque aut robustus annis aut senex aptus est, sed * a septimo fere anno ad quartum decimum. Deinde ei corpus idoneum est id, quod integrum est: at quod mali habitus est, quo⟨d⟩ue papulas, inpetigine⟨m⟩, similiaque habet, idoneum non est. Leuibus quoque tumoribus facile subuenitur: at in eorum, qui nimis magni sunt, curatione periculum est. Tempus autem anni autumnale et hibernum uitandum; uer est idoneum maxime ac prima ae⟨s⟩tas non aliena est. Praeter haec abstinere pridie debet; neque id satis est, sed aluus quoque ei ducenda est, quo facilius omnia, quae excesserunt, intra uterum considant.
15. 15 I have said elsewhere that in those who are dropsical the water ought to be let out: here I must describe how this should be done. Now some make the perforation about four fingers breadth below the navel, and to the left; some make it by perforating the navel itself; some first burn through the skin and then cut into the abdominal cavity, because flesh which has been divided by cautery heals less quickly. Now when entering the knife great care should be taken that no blood vessel is cut into. The knife must be such that its point should be about the third of a finger's breadth, and it should be so entered as to penetrate the membrane separating the flesh from the interior; then a lead or bronze tube should be inserted, either with lips curved back at its outer end, or with a collar round the middle so that the whole of it cannot slip inside. The part of the tube within the abdominal cavity should be a little longer than the part outside, in order that it may project inwards beyond the deeper membrane. Through this tube the humour is let out; and when the greater part has escaped, the tube is to be closed by a lint plug, and left in the wound if it was not burnt with a cautery; then on each of the following days about one hemina is let out, until there appears no trace of fluid. Some, however, even when the skin has not been cauterized, take out the tube forthwith, and then bandage on the wound a squeezed-out sponge; then on the next day they pass in a tube again (which the recent wound admits if it is slightly stretched) in order that any remaining fluid may be let out. They are satisfied when this has been done twice in this manner.
15. Aquam is, qui hydropici sunt, emitti oportere alias dixi: nunc quemadmodum fiat, dicendum est. Quidam autem sub umbilico, fere quattuor interpositis digitis, in sinistra parte; quidam ipso umbilico perforato id facere consuerunt: quidam cute primum adusta, deinde interiore abdomine inciso, quia, quod per ignem diuisum est, minus celeriter coit. Ferramentum autem d⟨e⟩mittitur, magna cura habita, ne qua uena incidatur. Id tale esse debet, ut fere tertiam digiti partem latitudo mucronis impleat; demittendumque ita est, ut membranam quoque transeat, qua caro ab interiore parte finitur; eo tum plumbea aut aenea fistula coicienda est, uel recuruatis in exteriorem partem labris, uel in media circumsurgente quadam mora, ne tota intus delabi possit. Huius ea pars, quae intrat, paulo longior esse debet quam ⟨quae extra,⟩ ut ultra ulteriorem membranam procedat. Per hanc effundendus umor est; atque ubi maior pars eius euocata est, cludenda demisso linteolo fistula est, et in uulnere, si ustum non est, relinquenda; deinde per insequentes dies circa singulas heminas emittendum, donec nullum aquae uestigium appareat. Quidam tamen etiam non usta cute protinus fistulam recipiunt, et super uulnus spongiam expressam deligant; deinde postero die rursus fistulam demittunt (quod recens uulnus paulum diductum patitur), ut, si quid umoris superest, emittatur; idque bis ita fecisse contenti sunt.
16. 16 Sometimes the abdomen is penetrated by a stab of some sort, and it follows that intestines roll out. When this happens we must first examine whether they are uninjured, and then whether their proper colour persists. If the smaller intestine has been penetrated, no good can be done, as I have already said. The larger intestine can be sutured, not with any certain assurance, but because a doubtful hope is preferable to certain despair; for occasionally it heals up. Then if either intestine is livid or pallid or black, in which case there is necessarily no sensation, all medical aid is vain. But if intestines have still their proper colour, aid should be given with all speed, for they undergo change from moment to moment when exposed to the external air, to which they are unaccustomed. The patient is to be laid on his back with his hips raised; and if the wound is too narrow for the intestines to be easily replaced, it is to be cut until sufficiently wide. If the intestines have already become too dry, they are to be bathed with water to which a small quantity of oil has been added. Next the assistant should gently separate the margins of the wound by means of his hands, or even by two hooks inserted into the inner membrane: the surgeon always returns first the intestines which have prolapsed the later, in such a way as to preserve the order of the several coils. When all have been returned, the patient is to be shaken gently: so that of their own accord the various coils are brought into their proper places and settle there. This done, the omentum too must be examined, and any part that is black dead is to be cut away with shears; what is sound is returned gently into place in front of the intestines. Now stitching of the surface skin only or of the inner membrane only is not enough, but both must be stitched. And there must be two rows of stitches, set closer together than in other places, partly because they can be broken here more easily by the abdominal movement, partly because that part of the body is not specially liable to severe inflammations. Therefore two needles are to be threaded and one is to be held in each hand; and the stitches are to be inserted, first through the inner membrane, so that the surgeon's left hand pushes the needle from within outwards through the right margin of the wound, and his right hand through the left margin, beginning from one end of the wound. The result is that it is the blunt end of the needle which is always being pushed away from the intestines. When each margin has been once traversed, the hands interchange needles, so that into the right hand comes the needles which was in the left, and into the left the needle which was in the right; and again, after the same method they are to be passed through the margins; and when for the third and fourth time, the needles have changed hands the wound is to be closed. Afterwards the same thread and the same needles are now transferred to the skin, and stitches are to be inserted by a like method into this as well, always directing the needles from within outwards, and with the same change, between the hands. It is too obvious to need constantly repeating that agglutinants are then to be put on with the addition either of a sponge or of greasy wool, squeezed out of vinegar. Over this application the abdomen should be lightly bandaged.
16. Nonnumquam autem uenter ictu aliquo perforatur, sequiturque ut intestina euoluantur. Quod ubi incidit, protinus considerandum est, an ea integra sint, deinde an is color suus maneat. Si ten⟨ui⟩us intestinum perforatum est, nihil profici posse iam rettuli. Latius intestinum sui po⟨te⟩st, non quo certa fiducia sit, sed quo[d] dubia spe⟨s⟩ certa desperatione sit potior: interdum enim glutinatur. Tum si utrumlibet intestinum liuidum aut pallidum aut nigrum est, quibus illud quoque necessario accedit, ut sensu careat, medicina omnis inanis est. Si uero adhuc ea sui coloris sunt, cum magna festinatione succurrendum est: momento enim alienantur, externo et insueto spiritu circumdato. Resupinandus autem homo est coxis erectioribus; et si angustius uulnus est, quam ut intestina commode refundantur, incidendum est, donec satis pateat. Ac si iam sicciora sunt intestina, perluenda aqua sunt, cui paulum admodum olei sit adiectum. Tum minister oras ulceris leuiter diducere manibus suis uel etiam duobus hamis interiori membranae iniectis debet: medicus priora semper intestina, quae posteriora prolapsa sunt, condere sic, ut orbium singulorum locum seruet. Repositis omnibus, leuiter homo concutiendus est; quo fit, ut per se singula intestina in suas sedes deducantur et in his considant. His conditis, omentum quoque considerandum est, ex quo, si quid iam nigri [emortui] est, forfice excidi debet; si quid integrum est, leuiter super intestina deduci. Sutura autem neque summae cutis neque interioris membranae per se satis proficit, sed utri⟨us⟩que. E⟨t⟩ quidem duobus linis inicienda est, spissior quam alibi, quia et rumpi facilius motu uentris potest, et non aeque magnis inflammationibus ⟨pars ea⟩ exposita est. Igitur in duas acus fila coicienda, ⟨e⟩aeque duabus manibus tenendae; et prius interiori membranae sutura inicienda est sic, ut sinistra manus in dexteriore ora, in sinisteriore dextra a principio uulneris orsa ab interiore parte in exteriorem acum mittat. Quo fit, ut ab intestinis ea qu⟨idem⟩ pars semper acuum ⟨sit,⟩ quae retusa est. ⟨Se⟩mel utraque parte traiecta, permutandae acus inter manus sunt, ut ea sit in dextra, quae f⟨u⟩it in sinistra; ea ueniat in sinistram, quam dextra continuit; iterumque eodem modo per oras immittenda⟨e⟩ sunt; atque ita tertio et quarto deincepsque permutatis inter manus acubus, plaga includenda. Post haec eadem fila, eaedemque acus ad cutem transferendae, similique ratione ei quoque parti sutura inicienda, semper ab interiore parte acubus uenientibus, semper inter manus traiectis. Dein glutinantia inicienda, quibus aut spongia⟨m⟩ aut sucidam lanam ex aceto expressam accedere debere manifestius est, quam ut semper dicendum sit. Inpositis his, leuiter deligari uenter debet.
17. 17 Sometimes, however, whether from some blow, or from holding the breath too long, or from carrying a heavy weight, the inner membrane of the abdomen is ruptured, whilst the skin over it is entire. This often occurs too in the case of women from childbearing, and it particularly takes place in the iliac regions. But it follows since the overlying flesh is soft, that it does not hold the intestines properly in place and that the skin is stretched by them and forms an ugly swelling. And this too is treated differently by different surgeons. For some pass two threads through the base by means of a needle, and then tie on each side, as has been described for the navel and for staphyloma, in order that what is beyond the ligature may mortify; some excise the middle of the swelling by a myrtle-leaf shaped incision, which as I said is the method which should always be adopted, and then they unite the edges by stitching. But the best way is with the patient on the back, to try with the hand in which part the swelling is most yielding, for of necessity it is at that part that the inner membrane is ruptured, and where it is entire the swelling is more resistant. Where the rupture is seen to be, two linear incisions are made with a scalpel, so that when what lies between has been excised, the inner membrane has a wound freshly made on each side, because stitching will not unite a lesion of long standing. When on exposure any part of the membrane presents not a recent but an old rupture, a thin strip is to be pared away, which only just makes the margins raw. All the directions for stitching and further treatment have been given above. Besides the above there are sometimes varicose veins upon the abdominal wall, and because there is no other treatment for these than what is usual for the legs since I shall treat of that part later, I will defer this too till then.
17. Interdum tamen uel ex ictu aliquo uel retento diutius spiritu uel sub graui fasce interior abdominis membrana superiore cute integra rumpitur. Quo⟨d⟩ feminis quoque ex utero saepe euenire consueuit; fitque praecipue circa ilia. Sequitur autem, cum superior caro mollis sit, ut non satis intestina contineat, isque intenta cutis indecore intumescat.—Atque id quoque aliter ab aliis curatur. Quidam enim per acum duobus linis ad imam basem inmissis sic utrimque deuinciunt, quemadmodum et ⟨in⟩ umbilico et in uua positum est, ut quicquid super uinculum est emoriatur: quidam medium tumorem excidunt ad similitudinem myrtei foli, quod semper eodem modo seruandum esse iam posui, et tum oras sutura iungunt. Commodissimum est autem resupinato corpore experiri manu, qua parte ⟨is⟩ tumor maxime cedat, quia necesse est ea parte ⟨rupta⟩ membrana sit; quaque integra est, ea magis obnitatur; tum qua rupta uidebitur, immittendae scalpello duae lineae sunt, ut excisso medio interior membrana utrimque recente⟨m⟩ plagam habeat, quia quod uetus est, sutura non coit. Loco patefacto, si qua parte membrana non nouam plagam sed ueterem habet, tenuis excidenda habena est, quae tantum ora⟨s⟩ eius exulceret. Cetera, quae ad suturam reliquamque curationem pertineant, supra conprehensa sunt. Praeter haec euenit, ut in quorundam uentribus uarices sint; quarum quia nulla alia curatio est, quam quae in cruribus esse consueuit, †tum eam partem explanaturus, hanc quoque eo differo.
18. 18 Now I come to those lesions which are apt to arise in the genital parts around the testicles; and to explain them more easily, the nature of the said region must briefly be described first. The testicles then are somewhat like marrow, for they do not bleed and they lack all feeling; but the coverings by which they are enclosed give pain both when injured and inflamed. Now the testicles hang from the groins, each by a cord which the Greeks call the cremaster with each of which descend a pair of veins and a pair of arteries. And these are ensheathed in a tunic, thin, fibrous, bloodless, white, which is called by the Greeks elytroides. Outside this is stronger tunic, which at its lowest part is closely adherent to the inner one; the Greeks call it dartos. Further, many fine membranes hold together the veins, and the arteries, and the cords aforesaid, and also in between the two tunics there are some fine and very small membranes, descending from the parts above. Thus far the coverings and supports belong to each testicle separately; next common to both and to all within is the pouch which is now visible to us; the Greeks call it oscheon, we the scrotum; and at its lowest part this is slightly connected with the middle coverings, higher up it is only surrounded by them. Now, underneath the scrotal covering many lesions are apt to occur, sometimes after the rupture of the coverings which, as I have said, begin from the groins, sometimes when they are uninjured. Since at times either owing to disease there is first inflammation, then afterwards a rupture from the weight; or after some blow there, there is a direct rupture of the covering which ought to separate the intestines from the parts below; then either omentum, or it may be intestine, rolls down by its own weight; this having found a way gradually from the groins into the parts below as well, there separates by its pressure the coverings which are fibrous and therefore give way. The Greeks call the condition enterocele and epiplocele, with us the ugly but usual name for it is hernia. Now if omentum has come down, the tumour in the scrotum never disappears, either if the patient fasts, or if his body is turned from side to side, or lies in some special position; again, if the breath is held, it does not increase to any extent; to the touch it seems uneven and soft and slippery. But if intestine has also come down this tumour is with-out inflammation, sometimes it diminishes, sometimes increases, and it is generally painless and soft. When the patient is quiescent or lying down, it disappears, at times altogether; sometimes it becomes divided so that very small remnants stay in the scrotum. But after shouting or over-eating, or if the patient has been strained by a weight of any sort, it increases; under all kinds of cold it shrinks, under heat it enlarges; then the scrotum becomes globular and smooth to the touch; and within the scrotum the intestine slips about, when pressed upon it reverts towards the groin, when released it rolls down again with a sort of murmur. That is what happens in slight cases; but at times, when faeces have been taken in, it swells more largely, it cannot be forced back, and it then brings on pain both in the scrotum and in groins and abdomen. At times the stomach also becomes affected, and there is an issue from the mouth, first of red, then of green, and even in some of black bile. At times too, whilst the membranes remain entire, fluid distends the scrotum. There are two forms of this affection: for the fluid collects either between the coverings or in the membranes surrounding the veins and arteries, and then these membranes become thickened and weighted down. And even if the fluid lies between the membranes it is not confined to one place; it may lie between the superficial and middle membrane, or between the middle and inner membranes. The Greeks have one general name, they call it hydrocele, whichever kind it is; our people, not knowing enough perchance to make distinctions, call it by the same name as the preceding disorder. Now there are signs, some common to all cases, some particular: the common one is the existence of the fluid; the particular, the situation of it. We learn that there is fluid underneath, if the swelling never disappears entirely although it is at times less, whether from fasting or feverishness, and especially in boys; the tumour is soft when the fluid contained is only small in amount; but if it increases to a great extent, the tumour becomes tense like a wineskin which has been filled and tightly tied. Also veins in the wall of the scrotum are distended; and upon pressure with the finger the fluid recedes, and as it flows round raises up the part where there is no pressure and is seen through the scrotal wall as if it were contained in a glass or horn vessel; and however much is there is no pain. But the situation of the fluid is recognized as follows: if it is between the scrotal wall and the middle membrane, when we press with two fingers, the humour gradually comes up, returning as the fingers are withdrawn; the scrotal wall is whiter than natural; if it is drawn upon, it stretches either not at all, or very little; the testicle on that side cannot be seen or felt. But if it is under the middle membrane, the scrotum is stretched and more raised up, so that the root of the penis is concealed under the swelling. Besides the above a varicose affection which the Greeks call cirsocele occurs, in which also the membranes are intact. The veins become swollen, and when twisted, and massed together at the upper part, they distend the scrotum generally, or the middle or the inner covering; sometimes they grow even beneath the inner covering around the actual testicle and its cord. Of these the veins in the scrotal wall can be seen; but those situated in the middle or inner coverings, being more deeply placed, are not indeed equally visible but even these can be seen, especially because there is a certain amount of swelling in proportion to the size and form of the veins, and this is more resistant to pressure, and also is rendered irregular owing to the bulgings of the veins, whilst the testicle on that side hangs lower down than it ought. But when the disease has spread also over the testicle and its cord, the testicle sinks a little lower, and becomes smaller than its fellow, in as much as its nutrition has become defective. Sometimes, though rarely, flesh also grows between the tunics; the Greeks call this sarcocele. At times also the testicle itself swells owing to inflammation and this causes fever as well. And unless this inflammation quickly subsides, pain spreads to the inguinal and iliac regions, and these parts swell; the cord from which the testicle hangs becomes fuller, and at the same time it hardens. Besides this it happens sometimes that the groin is occupied by a rupture; they call it bubonocele.
18. Venio autem ad ea, quae in naturalibus partibus circa testiculos oriri solent; quae quo facilius explicem, prius ipsius loci natura paucis proponenda est. Igitur testiculi simile quiddam medullis habent: ⟨nam⟩ sanguinem non emittunt et omni sensu carent: dolent autem in ictibus et inflammationibus tunicae, quibus i continentur. Dependent uero ab inguinibus per singulos neruos, quos cremasteras Graeci uocant, cum quorum utroque binae descendunt et uenae et arteriae. Haec autem tunica conteguntur tenui, neruosa, sine sanguine, alba, quae ely⟨t⟩roides a Graecis nominatur. Super ea ualentior tunica est, quae interiori uehementer ima parte inhaeret: darton Graeci uocant. Multae deinde membranulae uenas et arterias eosque neruos conprehendunt; atque inter duas quoque tunicas a superioribus partibus leues paruulaeque sunt. Hactenus propria utrique testiculo uelamenta et auxilia sunt: communis deinde utrique omnibusque interioribus sinus est, qui iam conspicitur a nobis: ⟨os⟩cheon Graeci, scrotum nostri uocant; isque ab ima parte mediis tunicis leuiter innexus est, a superiore tantum circumdatus. Sub hoc igitur plura uitia esse consuerunt; quae modo ruptis tunicis, quas ab inguinibus incipere proposui, modo his integris fiunt. Siquidem interdum uel ex morbo primum inflammatur, deinde postea pondere abrumpitur; uel ex ictu aliquo protinus rumpitur tunica, quae diducere ab inferioribus partibus intestina debuit; tum pondere eo deuoluitur aut omentum aut etiam intestinum; idque ibi reperta uia paulatim ab inguinibus in inferiores quoque partes nissum subinde neruosas tunicas et ob id eius rei patientes diducit: enterocelen et epiplocelen Graeci uocant: apud nos indecorum sed commune his hirneae nomen est. Deinde, si descendit omentum, numquam in scroto tumor tollitur, siue inedia fuit, si⟨ue⟩ corpus huc illucue conuersum aut aliquo modo conlocatum est; itemque, si ⟨re⟩tentus est spiritus, non magnopere increscit; tactu uero inaequalis est et mollis et lubricus. At si intestinum quoque descendit, tumor is sine ⟨in⟩flammatione modo minuitur, modo increscit estque fere sine dolore et cum mollitie. ⟨Cum⟩ quiescit aliquis aut iacet, interdum ex toto desidit; interdum sic diuiditur, ut in scroto exiguae reliquiae maneant. At clamore et satietate, et si sub aliquo pondere is homo nisus est, crescit: frigore omni contrahitur, calore diffunditur; estque tum scrotum et rotundum et tactu leue: idque, quod subest, lubricum est; si pressum est, ad inguina reuertitur, dimissumque iterum cum quodam quasi murmure deuoluitur. Et id quidem in leuioribus malis euenit: nonnumquam autem stercore accepto uastius tumet, retroque compelli non potest, adfertque tum dolorem et scroto et inguinibus et abdomini. Nonnumquam stomachus quoque adfectus primum rufam bilem per os reddit, deinde uiridem, quibusdam etiam nigram. Integris uero membranis interdum eam partem umor distringit. Atque eius quoque species duae sunt: nam uel inter tunicas ⟨is⟩ increscit uel in membranis, quae ibi circa uenas et arteria⟨s⟩ sunt, ubi eae grauatae occal⟨l⟩uerunt. Ac ne ei quidem umori, qui inter tunicas est, una sed⟨es⟩ est: nam modo inter summam et mediam, modo inter mediam et imam consistit. Graeci ⟨communi⟩ nomine, quicquid est, hydrocelen appellant: nostri, ut scilicet nullis discriminibus satis cognitis, haec quoque sub eodem nomine quo priora habent. Signa autem quaedam communia sunt, quaedam propria: communia, quibus umor deprehenditur; propria, quibus loc⟨u⟩s. Vmorem subesse discimus, si tumor est numquam ex toto se remittens, sed interdum leuior aut propter famem aut propter febriculam, maximeque in pueris; isque mollis est, si non nimius umor subest: at si is uehementer increuit, renititur sicut uter repletus et arte adstrictus. Venae quoque in scroto inflantur, est, si digito pressimus, cedit umor circumfluens⟨que⟩ id, quod non premitur, attollit et tamquam in uitro cornuue per scrotum apparet, estque, quantum in ipso est, sine dolore. Sedes autem eius sic deprehenditur. Si inter summam mediamque tunicam est, cum digitis duobus pressimus, paulatim umor inter eos * reuertens subit; scrotum †ipsius albidius: si ducitur, aut nihil aut paruulum intenditur; testiculus ea parte neque uisu neque tactu sentitur. At si sub media tunica est, intentum scrotum magis se attollit, adeo ut superior coles sub tumore eo delitescat. Praeter haec aeque integris tunicis ramex innascitur: cirso⟨ce⟩len Graeci appellant. Venae intumescunt, ⟨e⟩aeque intortae conglomerataeque a superiore parte uel ipsum scrotum inplent uel mediam tunicam uel imam: interdum etiam sub ima tunica circa ipsum testiculum neruumque eius increscunt. Ex his ea⟨e⟩, quae in ipso scroto sunt, oculis patent: eae uero, quae mediae imaeue tunicae insident, ut magis conditae non aeque quidem cernuntur, sed tamen etiam uisui subiectae sunt, praeterquam quod et tumoris aliquid est pro uenarum magnitudine ac modo, et id prementi magis renititur ac per ipsos uenarum toros inaequale est et, qua parte id est, testiculus magis iusto dependet. Cum uero etiam super ipsum testiculum neruumque eius id malum increuit, aliquanto long⟨i⟩us testiculus ipse descendit, minorque altero fit, ut pote alimento amisso. Raro sed aliquando caro quoque inter tunicas increscit: sarcocelen Graeci uocant. Interdum etiam ex inflammatione tumet ipse testiculus, ac febres quoque adfert; et nisi celeriter ea inflammatio conquieuit, dolor ad inguina atque ilia peruenit, partesque eae intumescunt; neruus, ex quo testiculus dependet, plenior fit simulque indurescit. Super haec inguen quoque nonnumquam †uarice inplicetur: bubonocelen appellant.
19. 19 When these lesions have been recognized their treatment must be discussed; in this some methods are common to all, some peculiar to particular kinds. I shall discuss first what is common to all. But I shall now speak of those cases demanding the knife: for those which are incurable, or should be cared for otherwise, will be mentioned as I come to the separate kinds. Now sometimes the inguinal region has to be cut into, sometimes the scrotum. In either case the man for three days before should drink water, and for the day before abstain also from food: on the day itself he must lie on his back; next if the groin has to be cut into, and if the pubes is already covered by hair, this is to be shaved off beforehand: and then after stretching the scrotum, so that the skin of the groin is rendered tense, the cut is made below the abdominal cavity, where the membranes below are continuous with the abdominal wall. Now the laying open is to be done boldly, until the outer tunic, that of the scrotum itself, is cut through, and the middle tunic reached. When an incision has been made, an opening presents leading deeper. Into this the index finger of the right hand is introduced, in order that by the separation of the intervening little membranes the hernial sac may be freed. Next the assistant grasping the scrotum with his left hand should stretch it upwards, and draw it away as far as possible from the groins, at first including the testicle itself until the surgeon cuts away with the scalpel all the fine membranes which are above the middle tunic if he is unable to separate it with his finger; then the testicle is let go in order that it may slip downwards, and show in the wound and then be pushed out by the surgeon's finger, and laid along with its two tunics upon the abdominal wall. There whatever is diseased is cut round and away, in the course of which many blood vessels are met with; the smaller ones can be summarily divided; but larger ones, to avoid dangerous bleeding, must be first tied with rather long flax thread. If the middle tunic be affected, or the disease has grown beneath it, it will have to be cut away even as high as the actual groin. Lower down, however, not all is to be removed: for at the base of the testicle there is an intimate connexion with the inner tunic, where excision is not possible without extreme danger; and so there it is to be left. The same is to be done if the inner tunic is the seat of the disease. But the cutting away cannot be done quite completely at the inguinal end of the wound, but only somewhat lower down, lest the abdominal membrane be injured and set up inflammation. On the other hand too much of its upper part should not be left behind, lest subsequently there forms a pouch which continues to be the seat of the same malady. The testicle having been thus cleared is to be gently returned through the incision, along with the veins and arteries and its cord; and it must be seen that blood does not drop down into the scrotum, or a clot remain anywhere. This will be accomplished if the surgeon takes the precaution of tying the blood vessels; the threads with which the ends of these are tied should hang out of the wound; following upon suppuration they will fall off painlessly. Through the margins of the wound itself two pins are then passed, and over this an agglutinating dressing. But it becomes necessary sometimes to cut away a little from one or other of the edges of the skin-incisions in order to make a broader and thicker scar. When this occurs the lint dressing must not be pressed on but must be applied lightly, and over it such things as repel inflammation, unscoured wool or sponge soaked in vinegar; all the other treatment is the same as when suppuratives have to be applied.
19. His cognitis, de curatione dicendum est, in qua quaedam communia omnium sunt, quaedam propria singulorum. Prius de communibus dicam. Loquar autem nunc de is, quae scalpellum desiderant: nam uel quae sanari non possunt, uel aliter nutriri debeant, dicendum erit, simul ad species singulas uenero. Inciditur autem interdum inguen, interdum scrotum. In utraque curatione homo ante triduum bibere aquam, pridie abstinere etiam a cibo debet: ipso autem die collocari supinus; deinde si inguen incidendum est, idque iam pube contegitur, ante radendum est; et tunc extenso ⟨s⟩croto, ut cutis inguinis intenta sit, id incidendum sub imo uentre, qua cum abdomine tunicae inferiores committuntur. Aperiendum autem audacter est, donec summa tunica, quae ipsius ⟨s⟩croti est, incidatur, perueniaturque ad eam, quae media. Plaga facta foramen deorsum uersus subest. In id demittendus est sinistrae manus digitus index, ut deductis interuenientibus membranulis sinum laxet. Minister autem sinistra manu conprehendens scrotu⟨m⟩ susum uersum [eum] debet extendere, et quam maxime ab inguinibus abducere, primum cum ipso testiculo, dum medicus omnes membranulas, quae supra mediam tunicam sunt, si digito deducere non potest, scalpello abscidat; deinde sine eo, ut is delapsus ipsi plagae iungatur digitoque inde promatur, et super uentrem cum duabus suis tunicis collocetur. Inde si qua uitiosa sunt, ⟨circumcidenda sunt;⟩ in quibus cum multae uenae discurrant, tenuiores quidem protinus praecidi possunt; maiores uero ante longiore lino deligandae sunt, ne periculose sanguinem fundant. Si media tunica uexata erit aut sub ea malum increuerit, excidenda erit sic, ut alte ad ipsum inguen praecidatur. Infra tamen non tota demenda est: nam quod ad basin testiculi uehementer cum ima tunica conexu⟨m⟩ est, excidi sine summo periculo non potest; itaque ibi relinquendum est. Idem in ima quoque tunica, si laesa est, faciendum est. Sed non a summa inguinis plaga uerum infra paulum ea abscidenda, ne laesa abdominis membrana inflammationes moueat. Neque tamen nimium ex ea susum relinquendum est, ne postea sinuetur et sedem eidem malo praestet. Purgatus ita testiculus per ipsam plagam cum uenis et arteriis et neruo suo leuiter demittendus est, uidendumque, ne sanguis in scrotum descendat neue concretus aliquo loco maneat. Quae ita fient, si uenis uinciendo medicus prospexerit: lina, quibus capita earum continebuntur, extra plagam dependere debebunt; quae pure orto sine ullo dolore excident. Ipsi autem plagae iniciendae duae fibulae sunt, et insuper medicamentum, quo glutinetur. Solet autem interdum ab altera ora necessarium esse aliquid excidi, ut cicatrix maior et latior fiat. Quod ubi incidit, lin⟨a⟩menta super ⟨non⟩ fulcienda sed leuiter tantum ponenda sunt, supraque ea, quae inflammationem repellant, id est ex aceto uel lana sucida uel spongia: cetera eadem, quae, ubi pus moueri debet, adhibenda sunt. At cum infra incidi oportet, resupinato homine subicienda sub scroto sinistra manus est; deinde id uehementer adprehendendum et incidendum.