De Medicina

Celsus, Aulus Cornelius

Celsus, Aulus Cornelius. De Medicina. Spencer, Walter George, translator. Cambridge, MA: Harvard University; London, England: W. Heinemann Ltd, 1935-1938.

12 Ulcerations of the tongue need no other treatment than that noted in the first part of the previous chapter. But those which arise at the side of the tongue last the longest; and it should be looked to, whether some tooth opposite the ulcer is too pointed, which often keeps an ulceration in that position from healing, in which case the tooth must be smoothed down.

13 There often occur on the gums adjacent to the teeth certain painful swellings: the Greeks call them parulides. These at first should be gently rubbed over with powdered slat; or with a mixture of powdered rock-salt, cyprus oil and catmint; then the mouth is washed out with lentil gruel, and the mouth is held open at intervals until there has been a sufficient flow of phlegm.

When there is still more severe inflammation, the same medicaments are to be used as noted above for ulcerations of the mouth: and between the tooth and gum should be inserted a little roll of soft lint soaked in one of the compositions which I said are called antherae. If the hardness of the gum prevents this, then hot steam by means of a sponge

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is to be applied outside, followed by a cerate. If suppuration shows itself, the steaming is continued longer, and hot honey wine in which a fig has been boiled down is held in the mouth; and before the abscess is quite mature it should be cut into, for fear that the bone may suffer if the pus should be retained longer. But if there is greater swelling, it is better to cut all away so as to free the tooth on both sides. When the pus is let out, if the incision is small it will suffice to hold hot water in the mouth and to foment externally with its steam; if it is larger, lentil gruel should be used, and the same medicaments as for the treatment of ulcerations of the mouth in general. There are also other ulcerations, mostly arising in the gums, for which the same remedies are beneficial; in particular, however, privet should be chewed and the juice held in the mouth. It happens now and then, whether following a gumboil or not, that a discharge of pus persists from an ulcer on the gum; this is due to either a decayed tooth or to bone that is broken or injured and diseased in some other way, and it most commonly occurs through a fissure in the bone. When this is the case, the place must be laid open, the tooth extracted; any projecting scale of bone is to be removed; and any carious bone scraped away. What ought to be done after this has been included in the treatment of other ulcerations. If the gums have retracted from the teeth, the same antherae are of service. It is also useful to chew pears and apples which are not too ripe, and to hold their juice in the mouth. Vinegar that is not too sharp can also be held in the mouth with similar advantage.

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14 Inflammation of the uvula should also cause anxiety when severe. In this case, as before, abstinence is necessary, and it is right to let blood; and if anything prevents this, it is useful to clyster the bowel; and also the head must be kept covered and raised; and the patient must gargle with a decoction of blackberries and lentils. But the uvula its is to be smeared either with omphacium or oak-galls or split alum to any one of which honey has been added; it is also good to smear the uvula with chelidonium juice by means of a spoon, and especially with honey. For this purpose also the composition called Andronium is suitable; it consists of: split alum, red copper scales, blacking, oak-galls, myrrh and antimony sulphide; these are pounded separately and again pounded when mixed together, a dry wine being gradually added till the ingredients have the consistency of honey. After the uvula has been smeared with one of these compounds there is, as a rule, a free flow of phlegm; when this has subsided, hot wine should be gargled. But if there is less severe inflammation, it is sufficient to pound up assafoetida and add cold water to it, and to put the fluid into a spoon and apply it under the uvula itself. When there is only moderate swelling, even cold water held in the same way under the uvula subdues it. Also the same cold water is to be used as a gargle which, with or without the addition of assafoetida, has been applied in this manner to the uvula.

15 If at any time gangrene has attacked ulcers of the mouth, the first thing to consider is whether the general health is bad, and if so to obviate it; next the actual ulcers are to be treated. But if the

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disease is superficial, it is sufficient to use a powdered anthera to dust on the ulcer if moist; if the ulcer is rather dry, to smear it on mixed with a little honey: for somewhat deeper ulcerations, apply burnt papyrus two parts, and orpiment one part; if the mischief penetrates very deeply, burnt papyrus three parts, orpiment one part, or equal parts of rock salt and roasted iris, or copper ore, quick-lime and orpiment, likewise equal parts. But in order that neighbouring spots may not be injured, it is necessary to apply lint dipped in rose oil over these caustic medicaments. Some also put the roasted salt into 250 cc. of strong vinegar until it ceases to dissolve; then the vinegar is boiled to dryness, and the salt pounded up and dusted on. But whenever this medicament is applied, the mouth should be washed out both before and after, either with lentil gruel, or with a decoction of vetches or of olives or of vervains, to any one of which a little honey is added.

Also vinegar of squills held sufficiently long in the mouth is beneficial for such ulceration, so too the salt after evaporation as described above dissolved again in vinegar. But whilst the affection continues to be severe it is necessary both to hold one or other of the remedies in the mouth for some time and to use them two or three times a day, If it is a child who is attacked, a probe wrapped round with wool is dipped in the medicament and held to the ulcer, lest by accident he should swallow the caustic. If it is the gums which are involved, and some teeth are loose, they should be extracted, for they greatly hinder treatment. If these medicaments do no good, the ulcers are to be cauterized. But this procedure is not necessary for any ulcer on

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the lips since excision is more convenient. Indeed such an ulcer, except by adopting surgical measures, whether cauterizing or excising, cannot be replenished with new flesh. But the bones of the bums, which are inert, continue bare after the cauterization; for no flesh grows up afterwards. A lentil dressing, however, is to be applied to the parts cauterized until it is rendered as healthy as possible.

16 Such are the disorders in the head which generally require medicaments. But just below the ears parotid swellings are inclined to occur, sometimes during health when inflammation occurs there, some after prolonged fevers when the force of the disease has been turned in that direction. It is of the nature of an abscession; and so no novel treatment is called for, only what follows must be attended to: if there is swelling without previous disease, repressants are to be tried first; if there has been illness, repressives are objectionable, and it is more convenient that the abscess should mature and be opened as soon as may be.

17 For prominent navels, in order that surgical measures need not be used, abstinence should first be tried, a clyster to induce a motion, and the following applications to the umbilicus: hemlock and soot 4 grams each; washed white lead 24 grams; washed lead 32 grams; 2 eggs; to these nightshade juice also is added. This ought to be kept on for a long time, the patient meanwhile lying up, and taking food in such moderation that all flatulence

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is avoided.

18 Next come subjects relating to the privy parts, for which the terms employed by the Greeks are the most tolerable, and are now accepted for use, since they are met with in almost every medical book and discourse. Not even the common use has commended our coarser words for those who would speak with modesty. Hence it is more difficult to set forth these matters and at the same time to observe both propriety and the precepts of the art. Nevertheless, this ought not to deter me from writing, firstly in order that I may include everything which I have heard of as salutary, secondly because their treatment ought above all things to be generally understood, since every one is most unwilling to show such a complaint to another person.

So then when the penis swells up owing to inflammation, and the foreskin cannot be drawn back, or conversely drawn forwards, the place should be fomented freely with hot water. But when the glans is covered up, hot water should be injected, between it and the foreskin, by means of an ear syringe. If the foreskin is thus softened and rendered thinner, and yields when drawn upon, the rest of the treatment is more speedy. If the swelling goes on, either lentil meal or horehound or olive leaves, boiled in wine, is to be laid on, to each of which, whilst being pounded up, a little honey is to be added; and the penis is to be bandaged upwards to the belly. That is required in the treatment of all its disorders; and the patient ought to keep quiet and abstain from food, and drink water just so much as is justified by thirst. On the next day fomentations with water must again be applied in the same way, and even force should be tried as to

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whether the foreskin will yield; if it does not give way, the foreskin is to be notched at its margin with a scalpel. For when sanies has flowed out this part will become thinner, and the foreskin the more easily drawn upon. But whether the foreskin is made to yield by this procedure, or whether it has at no time proved resistant, ulcerations will be found, either in the ulterior part of the foreskin, or in the glans, or behind this in the penis, and these ulcerations must of necessity be either clean or dry or moist and purulent. If they are dry, they must in the first place be fomented with hot water; then apply either buckthorn in wine, or olive lees in the same, or butter with rose oil. If there is a thin humour, the ulcerations should be bathed with wine, and then to butter and rose oil a little honey and a fourth part of turpentine resin is to be added and this dressing put on. But when pus runs from the ulcers, first they are to be bathed with hot honey wine; than there is put on: pepper 4 grams; myrrh 0.66 gram; saffron and boiled antimony sulphide 8 grams each; these are heated in dry wine to the consistency of honey. Moreover, the same composition is suitable for the tonsils, a dripping uvula, and ulcerations of the mouth and nostrils. Another for the same purpose consists of pepper and myrrh 0.66 gram each; saffron 1.33 gram; cooked antimony sulphide 4 grams; roasted copper 8 grams; these are first pounded together in dry wine, then, when they are dry, are again pounded up in 125 cc. of raisin wine and heated to the consistency of birdlime. Verdigris too mixed with boiled honey, also those compositions noted above for ulcerations of the mouth, or the compositions of Erasistratus or of
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Craton are suitable for applying to suppurating genitals. Also . . . olive leaves are boiled in 375 cc. of wine, to which is added split alum 16 grams, lycium 32 grams; and 250 cc. of honey; and if there is more pus, this medicament is made up with honey; if less, with wine. After treatment, the general procedure, so lon as the inflammation persists, is to apply a poultice such as was mentioned above, and to dress the ulcers daily in the same way. If a free discharge of foul pus begins, the ulcers should be bathed with lentil gruel to c a little honey has been added. Or a decoction is made of olive or of mastich leaves, or of horehound, and the liquid used with honey in the same way; and the same remedies are to be laid on of even omphacium with honey, or that prescription used for the ears containing verdigris and honey, or Andron's composition, or an anthera, as long as a little honey is added to it. Some treat all ulcerations of the kind here spoken of with lycium and wine. If the ulceration spreads more widely and deeply, it should be bathed in the same way, and then there should be applied either verdigris or omphacium with honey or Andron's composition or that containing horehound, myrrh or saffron, split alum boiled, dried rose leaves and oak-galls, 4 grams each; Sinopic minium 8 grams. These are pounded up first separately, then together again, with honey added, until of the consistency of a liquid cerate; then gently heated in a bronze pot but not allowed to boil over. When drops from it begin to solidify, the pot is taken off the fire; and this composition when it is to be
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used is dissolved in honey or wine. But the same by itself is also good for fistulae. The ulceration at times even penetrates to fibrous tissues; there is a running discharge, then sanies, thin and foul, coloured or like water in which fresh meat has been soaked; and the place is painful and has a pricking sensation. This kind, although purulent, is none the less to be treated by bland applications, such as the tetrapharmacum plaster dissolved in rose oil with the addition of a little frankincense; or the composition made of butter, rose oil, resin and honey noted by me above. In particular this ulcer should be fomented freely with hot water, and should be kept covered, not exposed to cold. Sometimes through such an ulceration the penis is so eaten away underneath the foreskin that the glans falls off; in which case the foreskin itself must be cut away all round. It is the rule, whenever the glans of any part of the penis has fallen off, or has been cut away, that the foreskin should not be preserved, lest it come into contact, and adhere to the ulceration, so that afterwards it cannot be drawn back, and further perhaps may choke the urethra. Again, little tumours, which the Greeks call phymata, spring up around the glans; they are burnt away by caustic or the cautery; when the crusts fall off, copper scales are dusted that no more may grow there.

The foregoing ulcerations stop short of canker, which in other parts, but here the more especially, attacks ulcerations. It begins in a black patch. If it invades the foreskin, at once a probe should be passed underneath, upon which the foreskin is to be incised and the margins seized with forceps; then

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what is corrupted is cut away, a little of the sound tissue being also removed; this is followed by cauterization. Whenever there is any cauterization, it follows too that here lentil meal is to be applied; next when the crusts have separated the ulcers are treated like others. But if the canker invades the penis itself, some one of the caustics is dusted on, and especially that composed of quick-lime, copper ore and orpiment. If medicaments fail, in this case also whatever is corrupted should be cut away with a scalpel, so far that some sound tissue is also removed. It is likewise the rule here that after the canker has been cut out, the wound is to be cauterized. But if hard scabs form, whether after caustics or the cautery, there is a great danger that haemorrhage from the penis will follow upon their separation. Therefore there is need for prolonged rest with the body almost immobile until the scabs gently separate from the penis. But if the patient, either purposely or accidentally, from moving about too soon, has detached the scabs and haemorrhage has occurred, cold water should be applied. If this has little effect, recourse must be had to medicaments which suppress haemorrhage. If these do not succeed either, the spot should be carefully and cautiously cauterized, and no opportunity afterwards given for the same risk by any sort of movement.

Occasionally on this part there arises that kind of canker which the Greeks call phagedaena. In such a case there must be no delay whatever: the treatment is immediate cauterization, whether with medicaments as above, or, if these have little effect, with the cautery. There is also a sort of blackness, which is insensitive, but spreads and, if we leave it

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alone, extends even to the bladder, after which nothing can avail If it is situated at the lip of the glans around the urethra, a fine probe should be inserted into the urethra first that it may not be closed up; then the black patch burnt with the cautery. If it has gone deep, whatever is involved is to be cut away. The rest of the treatment is the same as for other kinds of canker.

Again, now and then a callosity forms in the penis; and it is almost entirely without feeling; this also should be excised. But if a carbuncle occurs here, it is first to be irrigated with water through an ear syringe; next the growth is to be cauterized with medicaments, especially copper ore with honey or verdigris with boiled honey, or fried sheep's dung pounded up similarly with honey. When the carbuncle falls off, use the fluid medicaments prepared for ulcers of the mouth.

But if any inflammation occurs in the testicles, not due to injury, blood is to be let from the ankle; there must be abstinence from food and bean meal boiled in honey wine must be applied, always cumin rubbed up in boiled honey; of pounded cumin with the rose oil cerate; or parched linseed, pounded up and boiled in honey wine; or wheat flour in honey wine boiled with cyprus shoots; or pounded lily root. If the testicles have become indurated, apply linseed or fenugreek seed boiled in honey wine; or the cyprus oil cerate; or fine wheat flour pounded up in wine to which a little saffron has been added. If the induration is already of long standing, the most efficacious something is wild cucumber root boiled in honey wine, then pounded up. If the testicles swell as the result of an injury, it is necessary

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to let blood, especially if they are livid as well. Then one of the compositions containing cumin mentioned above should be put on; or the composition which contains: fused soda 4 grams; pine resin and cumin, 8 grams each; black bryony berries without the seeds 16 grams; along with sufficient honey to combine them. If, as the result of an injury, the testicle lacks nutrition, generally pus develops; then the only thing to be done is of cut into the scrotum, and let out the pus, and to excise the testicle itself.

The anus also is subject to many most tedious maladies, which do not require much variation in their treatment. In the first place, the skin of the anus is often fissured at several places; the Greeks call these ragadia. If this is recent, the patient should keep quiet and sit in hot water. Further, pigeon's eggs are to be boiled until hard, shelled, and then one should be covered completely in very hot water, the other is applied hot to the place, the eggs being used thus turn and turn about. Then the tetrapharmacum or the rhypodes is to be diluted for use with rose oil; or fresh wool-grease is mixed with the liquid cerate made up with rose oil; or washed lead with the same cerate; or a little myrrh to turpentine resin; or old oil to litharge; with any one of which the anus is smeared. If the lesion is external, not hidden inside, lint may be soaked in the same medicament and applied; whatever is put on is to be covered by a cerate. In such a case also neither acrid nor coarse food is to be taken nor such as constipates; dry food is not satisfactory

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unless in very small amount; liquid, mild, fatty and glutinous nutriment is better. There is nothing to prevent the use of mild wine.

A condyloma is a small tumour due to inflammation of some kind. When it appears the same prescriptions apply regarding rest, food and drink as have just been set out. Also the tumour itself may be properly treated by fomenting similarly with eggs. But the patient should first sit in a repressant decoction of vervains. Then we may properly apply lentil meal with a little honey, also mellilot boiled in wine, bramble leaves pounded up with the rose oil cerate or a quince, or the inner rind of a pomegranate boiled in wine, pounded up in the same cerate; or copper ore boiled and pounded, then taken up in wool-grease and rose oil; and the composition containing: frankincense 4 grams, split alum 8 grams, white lead 12 grams, litharge 20 grams, into which whilst it is being pounded up rose oil and wine are dropped by turns. But the binder for this part is a square of linen or woollen cloth, which has a loop at each of two adjacent angles and a tape at each of the two opposite ones. The square having been applied underneath with the two loops upon the abdominal wall, the pes are brought round from behind and passed through the loop on its corresponding side. Each tape being drawn tight, that on the right side is carried round the back to the left, and the left tape back and round to the right side. Finally, the ends of the tapes are tied together in front of the abdomen. But if a long-standing condyloma is already indurated and does not yield to the foregoing measures, it can be burnt with a caustic consisting of: verdigris 4

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 grams; myrrh 16 grams; cumin 32 grams; frankincense 48 grams; antimony sulphide, poppy juice, and acacia juice, 64 grams each, and by this medicament some also produce a fresh surface on the ulcers, which I have described above. If this has little effect upon the condyloma it is possible to apply strong caustics. When the tumour has been eaten away, a change is made to mild medicaments.

There is also a third lesion, in which vein mouths rise up as from little heads, which at frequent intervals pour out blood: the Greeks call them haemorrhoids. In women they may even appear at the vulvar orifice. There are some in whom it is hardly safe to suppress such a flux of blood, those who are not the weaker for it; for to these it is a purgation, not a disease. Hence some, after being cured, since the blood had no way out, and diseased matter was diverted towards the praecordia and viscera, have been carried off by sudden diseases of the gravest kind. But if the bleeding is doing harm to anyone, he should sit in a decoction of vervains, and the best thing to apply is pomegranate rind pounded up with dried rose leaves, or anything else that stops bleeding. But inflammation especially tends to occur when first a rather violent evacuation of the bowels has ruptured the epidermis, and later a hard stool has injured this spot. Then the patient should sit in soft water and foment with eggs; yolk of egg which has been stirred up with rose leaves and boiled in raisin wine is to be applied; if the haemorrhoids are internal, by the finger, if external, spread upon linen. The medicaments described above for recent fissures are suitable here also. In this case the diet

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should be the same as in the preceding one. But if the above treatment has little effect, it is usual to apply caustics to destroy these small heads. If they are already of long standing, then, on the authority of Dionysius, sandarach should be dusted on, and after that the composition should be applied containing copper scales and orpiment 20 grams, limestone 32 grams; the next day the haemorrhoids are to be punctured with a needle. The small heads having been cauterized, a scab is produced which prevents blood from running out. But whenever haemorrhage is thus suppressed, the diseased matter is to be dispersed by free exercise that no danger may ensue. And besides, in men and in women who are not menstruating, blood should be let from the arm now and then.

If the anus itself, or, as sometimes happens, the mouth of the womb, prolapses, examination should be made to see whether what is protruding is clean, or is covered with a mucous humour. If it is clean, the patient should sit in water; either in salt water or in water boiled with vervains or pomegranate rind. If it is moist, it should be bathed with dry wine and smeared with roasted wine lees. After being treated in one of these ways, it is to be replaced, and pounded plantain or willow leaves boiled in vinegar applied, next lint, and wool over it: and these must be bandaged on, whilst the legs are kept tied together.

In the same place an ulceration like a fungus may arise, which must be bathed with lukewarm water in winter, at other seasons in cold water; then copper scales are dusted on, and over that is applied a cerate made with myrtle oil to which has been

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added a little of copper scales, soot, and lime. If this treatment gives no relief, it is to be cauterized, either with more active medicaments or with the cautery.

19 Old-standing ulcerations of the fingers are most suitably treated by buckthorn juice, or by boiled olive lees, in either case with the addition of wine. In the same parts a small piece of flesh sometimes grows out from the nail, causing great pain; the Greeks call it pterygium. Round alum from Melos should be dissolved in water to the consistency of honey; the same quantity of honey as there was of dry alum is then poured in, and the mixture is stirred with a rod until it is of a saffron colour, and then smeared on. Some prefer to boil up the same ingredients together for the same purpose after mixing equal quantities of dry alum and honey. If the whitlow is not removed by this treatment, it should be cut away; next the finger is bathed in a decoction of vervains, and over it is then put the following composition: copper ore, pomegranate rind, and copper scales, mixed with ripe figs, lightly boiled in honey; or burnt papyrus, orpiment, and crude sulphur in equal parts may be mixed with a cerate containing myrtle oil; or scraped verdigris 4 grams, copper scales 8 grams, mixed together in 42 cc. of honey; or equal parts of limestone, copper ore and orpiment are mixed together. Whichever of these is applied, it is covered over by linen wetted with water. On the third day the finger is dressed again, any dried part is

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removed, and similar treatment continued. When this does not succeed, the whitlow is cleaned by means of a scalpel, and the place burnt with a fine cautery, followed by the dressing usual after cauterization.

And when nails are scabrous, they must be loosened all round, where they are in contact with the flesh; next some of the following composition is put on them: sandarach and sulphur 8 grams each; soda and orpiment 16 grams each; liquid resin 32 grams. The finger is dressed again on the third day. Under this medicament, diseased nails fall off and in their stead better ones grow.

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The third part of the Art of Medicine is that which cures by the hand, as I have already said, and indeed it is common knowledge. It does not omit medicaments and regulated diets, but does most by hand. The effects of this treatment are more obvious than any other kind; inasmuch as in diseases since luck helps much, and the same things are often salutary, often of no use at all, it may be doubted whether recovery has been due to medicine or a sound body or good luck. Besides, in cases where we depend chiefly upon medicaments, although an improvement is clear enough, yet it is often clear that recovery is sought in vain with them and gained without them: this can be seen for instance in treating the eyes, which after being worried by doctors for a long time sometimes get well without them. But in that part of medicine which cures by hand, it is obvious that all improvement comes chiefly from this, even if it be assisted somewhat in other ways. This branch, although very ancient, was more practised by Hippocrates, the father of all medical art, than by his forerunners. Later it was separated from the rest of medicine, and began to have its own professors; in Egypt it grew especially by the influence of Philoxenus, who wrote a careful and comprehensive work on it in

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several volumes. Gorgias also and Sostratus and Heron and the two Apollonii and Ammonius, the Alexandrians, and many other celebrated men, each found out something. In Rome also there have been professors of no mean standing, especially the late Tryphon the father and Euelpistus, and Meges, the most learned of them all, as can be understood from his writings; these have made certain changes for the better, and added considerably to this branch of learning.

Now a surgeon should be youthful or at any rate nearer youth than age; with a strong and steady hand which never trembles, and ready to use the left hand as well as the right; with vision sharp and clear, and spirit undaunted; filled with pity, so that he wishes to cure his patient, yet is not moved by his cries, to go too fast, or cut less than is necessary; but he does everything just as if the cries of pain cause him no emotion.

But it can be asked what is the proper province of this part of my work because surgeons claim for themselves the treatment of wounds as well, and of many of the ulcerations which I have described elsewhere. I for my part deem one and the same man able to undertake all of these; and when divisions are made, I praise him who has undertaken the most. I have myself kept for this part cases in which the practitioner does not find wounds but makes them, and in which I believe wounds and ulcerations to be benefited more by surgery than by medicine; as well as all that which concerns the bones. These cases I shall proceed to discuss in turn, and leaving to another volume the subject of bones I shall deal with the rest in this one; beginning

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with cases which occur anywhere in the body I shall pass on to those which occur in special situations.

1 First then the displacements, in whatever part of the body they are, ought to be immediately treated, so that the skin is several times incised with a sharp scalpel where the pain is, and the blood as it issues wiped off with the back of the knife. But if relief is rather slow in coming and there is now redness as well, and if, where the redness is, there is swelling in addition, wherever there is swelling this treatment is best. Repressants are then to be applied, in particular unscoured wool soaked in vinegar and oil. In a slighter case the same applications may afford relief even without the scalpel; and if there is nothing else at hand, wood-ash, preferably of vine twigs, or failing that any other kind, stirred to a paste in vinegar, or even in water.

2 There is prompt relief in such cases; but there is more trouble where a lesion has arisen internally of itself which causes swellings and tends to suppuration. I have described elsewhere the various classes of abscession, and I have pointed out the suitable medicaments; it now remains to speak of those which should be treated by surgery. Before the abscession becomes hardened, the overlying skin should be scarified and a cup put on, in order to draw outwards whatever bad and corrupted matter has collected; and it is right to repeat this every

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third day until every indication of inflammation has gone. It may be, however, that the cupping has no effect; for at times, although seldom, it happens that the abscess is enclosed in a covering of its own, which the ancients named a coat. Meges, because every such coat is sinew-like, said that no sinew could be produced under a lesion by which flesh is eaten away; but that when pus has been there for a long time, a callus forms round it. This has no bearing upon the mode of treatment, for the same thing ought to be done, whether it be a coat, or a callus. There is nothing to prevent a callus being called a coat, since it covers. Moreover at times the coat has formed after the pus has become more matured; so that what is under it cannot be drawn out by cupping. But this is readily recognized when the application of a cup causes no change. Therefore when that happens, or there is already hardening, there is no help from cupping, but as I have said elsewhere it is whilst matter is collecting that it has to be diverted or dispersed, or else matured. In the two former contingencies no further treatment is needed. When pus has matured, if in the armpits or groins it will not often have to be cut into. The same is true when the abscess is of moderate extent, so also when it is in the skin, or even in the flesh, unless the patient's weakness forces us to hurry; it is sufficient to poultice in order to make the pus come out of its own accord. For the place which has not felt the knife may generally escape without a scar. But if the abscess is more deeply seated, we must consider whether the part has sinews or not. For if it is free from sinews, it should be laid open with a red-hot cautery-knife;
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which has this advantage, that a small wound continues open longer for the withdrawal of the pus, and the resulting scar is small. But if there are sinews near by, the cautery is unsuitable, lest spasm of the sinews ensues or paralysis of the limb; then the scalpel becomes necessary. But although abscesses elsewhere can be opened even whilst immature, where there are sinews, we must wait for them to be fully matured, since the skin then becomes thin, and the pus joins it, and so is nearer to get at. Most abscesses require a linear incision; but in that termed panus, because it generally thins out the skin extremely, all the skin overlying the pus is to be cut away. But when the scalpel is used, care should always be taken that the incisions made are as few and as small as possible, but enough in number and extent to afford the necessary relief. For the larger cavities may at times have to be cut into rather widely even by two or three incisions, and cuts must be so made that the deepest part of the cavity gets a vent, lest any fluid should be left there to eat its way gradually into adjoining tissue, which was previously sound. Also it is natural that the skin should have to be cut away rather widely. For when the whole bodily habit has become vitiated in the course of a prolonged disease and the abscess cavity has extended widely and the skin over it has already become pallid, then we can recognize that the skin is already dead and of no further use; and therefore the excision of overlying skin is better, especially if the suppuration is round about the larger joints, and if the patient, confined to bed, has been exhausted by diarrhoea, and gained nothing from his food. But the skin should be so cut out as to
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leave a myrtle leaf shaped wound, in order that it may heal more readily: and this should be the constant rule, whenever, or for whatever reason, the practitioner cuts out skin. Where the pus has been let out, for the armpit or groin lint plugging is unsuitable, but a sponge squeezed out of wine must be put on. In other parts, if likewise a lint plug is unnecessary, a little honey will be infused into the cavity to clean it, then agglutinants put on: if lint plugs are needed, over them also should be placed sponges similarly squeezed out of wine. But it has been said elsewhere when plugging is, and is not requisite. In all other ways the same procedure is to be followed after an abscess has been opened by incision, which I have described for one which has ruptured under medicaments.

3 Now how the treatment is succeeding, how much is to be either hoped or feared, can be learnt straightaway from signs which on the whole are the same as have been mentioned already for wounds. Good signs are: ready sleep, easy breathing, no harassing thirst, no aversion to food; for any feverishness to pass off; and for the pus to be white and uniform, not foul. Bad signs are: wakefulness, laboured breathing, thirst, aversion to food, fever, the pus dark or like wine lees, and foul. Again, bad signs in the course of the treatment are: haemorrhage, or if the margins become fleshy before the sinus has been filled up by flesh, and this flesh is insensitive and not firm. But the worst sign of all is a faint, whether during the dressing, or after it. Again there is some reason for anxiety when the illness suddenly subsides, and then suppuration breaks out; or if the illness persists after the pus

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has been let out. And one cause for anxiety is if the wound is insensible to corrosives. But while it is chance that makes the signs point now one way, now another, it is the practitioner's part to strive to bring about healing. Therefore whenever it is dressed, the abscess cavity should be washed out, with wine mixed with rain water or with a decoction of lentils, when the discharge seems to need checking; with honey wine when cleaning is required; after which it is dressed as before. When the discharge appears to be checked, and the cavity clean, then is the time to help the growth of flesh, both by irrigating with equal parts of wine and honey, and by laying on a sponge soaked in wine and rose oil. Although the growth of flesh is helped by these medicaments, this is better attained, as I have said elsewhere, by a careful regimen; this consists, after the cessation of the fever and a return of appetite, in an occasional bath, gentle rocking daily, food and drink suitable for making flesh. These prescriptions all apply to abscesses which have burst under medicaments; but they have been held over to this place because it is scarcely possible to cure a large abscess without using the knife.

4 Again, for fistulae which penetrate so deeply that a medicated bougie cannot be passed down to the ends, or those which are tortuous or multiple, surgery has the advantage over medicine; and there is less trouble if the fistula runs horizontally under the skin, than when it tends directly inwards. Therefore if it lies horizontally under the skin, a probe should be introduced and cut down upon. When there are bends, these are followed up in

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the same way with the probe and knife; so also when they present multiple branchings. When the end of the fistula is reached, all the callus should be cut out, then pins are inserted through the skin margin, and agglutinating medicaments spread over all. But if it runs straight inwards, after its chief direction has been explored by means of the probe, that cavity ought to be excised, then a pin is to be inserted through the skin opening, and agglutinating medicaments applied as above; or if there is more corrupt ulceration, which is at time the case when there is disease of bone, after the bone has been treated, suppuratives are put on.

Now it is common for fistulae to have their exit between ribs; when this is the case the rib must be cut across on either side at that spot, and the segment removed lest anything diseased be left within. Fistulae which have passed between the ribs often involve the transverse septum separating the viscera above from the intestine. This can be recognized by the position of the fistula and the severity of the pain, and because at times, air with frothy humour escapes from the fistula, especially when the patient has held his breath. In that case there is no opportunity for the medical art. But in the case of other fistulae near the ribs which are curable, greasy medicaments are objectionable but anything else which suits wounds may be used; the best, however, is lint put on dry, or after soaking in honey if anything has to be cleaned.

There is no bone in the abdomen, but all the same fistulae there are so dangerous that Sostratus thought them incurable. Experience, however, shows that this is not always the case. Indeed — and this may

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seem very remarkable — a fistula which forms over the liver, spleen, or stomach, is safer than one right over the intestine, not because a fistula there is more harmful, but because it opens the way to another danger. Some writers who have had experience of this have shown little perception of the true facts. For often the abdomen is actually penetrated by a weapon, and sutures bring the margins of the wound together and how this is done I will presently point out. Therefore also when a fine fistula breaks through the abdominal wall, it is possible to cut it out, and to join its margins by suture. But if such a fistula widens out inside, this excision necessarily leaves a wide gap which cannot be sutured without applying great force especially in the deeper part where the abdomen is enclosed by a kind of membrane which the Greeks call peritoneum. Therefore, when the patient begins to get up and move about, the sutures break, and intestines prolapse; which causes his death. But these cases are not altogether desperate, and so for the finer fistulae, treatment is to be adopted.

Special consideration is required in the case of those in the anus. In these, where a probe has been passed up to its end, the skin should be cut through, next through this new orifice the probe is to be drawn out, followed by a linen thread which has been passed through the eye made for the purpose in the other end of the probe. Then the two ends of the linen thread are taken and knotted together so as to grip loosely the skin overlying the fistula. The linen thread should be made up of two or three strands of raw flax, twisted up so as to

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make one. Meanwhile the patient can do his business, walk, bathe, and take food as if in the best of health. Only this thread is to be moved twice a day, but without undoing the knot, the part of the thread outside being drawn within the fistula, and the thread must not be left until it becomes foul, but every third day the knot is to be undone, and to one end that of another fresh thread is tied, and the old thread being withdrawn the new one is to be left in the fistula after being similarly knotted. For thus the thread cuts through the skin overlying the fistula slowly, and whilst the skin released from the thread undergoes healing, that which is still gripped is being cut through. This method of treatment is lengthy but causes no pain. Those in a hurry should constrict the skin with the thread, so that they may continue through more quickly; and at night they should insert into the fistula some fine pledglets of wool, in order that its overlying skin, being put on the stretch, may be thinned out; but these measures cause pain. More speed may be added, but more pain as well, if both the thread and the pledglets are smeared with some one of the medicaments, which I have noted for the eating away of callus. Even here, however, the knife must be used, if the fistula extends inwards, of is multiple. In these kinds of fistulae, therefore, when the probe has been inserted, the skin is to be cut through along two lines so that between them a very fine strip of skin may be taken out, in order that the margins may not unite at once, and that there may be room for the smallest possible quantity of lint to be inserted; all the rest is done in the way described for abscesses. If, however, from one
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orifice several sinuses lead off, the straight part of the fistula is to be laid open with the scalpel, and the others branching from it, which are now exposed, are to be gripped by a thread. Should any fistula extend so far inwards that it cannot be safely laid open by the knife, a medicated bougie is to be put in. But in all such cases, whether treated surgically or by medicaments, the food should be moist, the drink abundant, and for a while water: when flesh begins to grow up, then at length the patient is to make use of the bath occasionally, and of flesh-making food.

5 Missiles too, which have entered the body and become fixed within, are often very troublesome to extract. And some of the difficulties arise from their shape, some owing to the positions to which they have penetrated. Whatever the missile may be, it is extracted, either by the wound of entry, or through the spot towards which it is pointing. In the former case, the missile has already made a way for its withdrawal; in the latter the way out is made with the scalpel; for the flesh is cut through upon its point. But if the missile is not deeply seated, and lies in superficial tissue, or if it is certain that it has not crossed the line of large blood vessels or sinews, there is nothing better than to pull it out by the way it entered. But if the distance it has to be withdrawn is greater than that which remains to be forced through, or if it has crossed the line of blood vessels and sinews, it is more convenient to lay open the rest of its course and so draw it out. For it will be more easily got at and more safely pulled out. And in the case of one of the larger limbs, if the point has passed beyond the middle, a through and through wound

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heals more easily because it can be dressed with a medicament at both ends. But if the missile is to be drawn back, the wound should be enlarged with a scalpel, for then the missile comes away more easily, also less inflammation is caused; for this becomes more severe if the missile itself lacerates the tissues while being withdrawn. So also when a counter opening is made, this ought to be too wide for the missile to fill as it is passing out. In either case, the greatest care should be taken that no vein, nor one of the larger sinews, nor an artery, is cut. When any one of these is observed, it is to be caught by a blunt hook and held away from the scalpel. Than the incision has been made large enough, the missile is to be drawn out, proceeding in the same way, and taking the same care, lest that which is being extracted should injure one of those structures which I have said are to be protected.

The foregoing are general rules; there are some rules which apply to special missiles, and these I will at once set out. Nothing penetrates so easy into the body as an arrow, and it also becomes very deeply fixed. And this happens both because it is propelled with great force and because it is sharply pointed. Hence it is more often to be extracted through a counter opening than through the wound of entry, and especially so because it is generally furnished with barbs which lacerate more when drawn backwards than if pushed through a counter opening. When a passage out has been laid open, the flesh ought to be stretched apart by an instrument like a Greek letter; next when the point has come into view, if the shaft is still attached, it is to be pushed on until the point can be seized from

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the counter opening and drawn out: if the shaft has already become detached, and only the arrowhead is within, the point should be seized by the fingers or by forceps, and so drawn out. Nor is the method of extraction different when it is preferred to withdraw the arrow by the wound of entry; the wound having been enlarged, either the shaft, if it is still attached, or, if not, the arrowhead itself, is pulled upon. When the barbs come into view, if they are short and fine, they should be nipped off on the spot by forceps, and the missile drawn out without them. If the barbs are too large and resistant for this, they must be covered by reed pens which have been split, and thus pulled out carefully so as not to tear the flesh. This is what is to be done in the case of arrows.

But if it is a broad weapon which has been embedded, it is not expedient to extract it through a counter opening, lest we add a second large wound to one already large. It is therefore to be pulled out by the aid of some such instrument as that which the Greeks call the Dioclean cyathiscus, because invented by Diocles, whom I have said already to have been among the greatest of the ancient medical men. The instrument consists of two iron or even copper blades, one blade has at each angle of its end a hook, turned downwards; the other blade has its sides turned up so that it forms a groove, also its end is turned up somewhat, and perforated by a hole. The latter blade is first passed up to the weapon, and then underneath it, until the point is reached, the blade is then rotated somewhat until the point becomes engaged in the perforation. After the point has entered the perforation, the

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hooks of the first mentioned blade are fitted by the aid of the fingers over the upturned end of the blade already passed, after which simultaneously the cyathiscus and the weapon are withdrawn.

There is a third kind of missile which at times has to be extracted such as a lead ball, or a pebble, or such like, which has penetrated the skin and become fixed within unbroken. In all such cases the wound should be laid open freely, and the retained object pulled out by forceps the way it entered. But some difficulty is added in the case of any injury in which a missile has become fixed in bone, or in a joint between the ends of two bones. When in a bone, the missile is swayed until the place which grips the point yields, after which it is extracted by the hand, or by forceps; this is the method also used in extracting teeth. In this way the missile nearly always comes out, but if it resists, it can be dislodged by striking it with some instrument. The last resort when it cannot be pulled out, is to bore into the bone with a trepan close by the missile, and from that hole to cut away the bone in the shape of the letter V, so that the lines of the letter which diverge to either side face the missile; after that it is necessarily loosened and easily removed. If the missile has forced its way actually into a joint between the ends of two bones, the limbs above and below are encircled by bandages or straps, by means of which they are pulled in opposite directions, so that the sinews are put on the stretch; the space between the ends of the bone is widened by these extensions, so that the missile is without difficulty withdrawn. In doing this care must be taken, as mentioned elsewhere, to avoid injury to a sinew, vein or artery

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while the weapon is being extracted by the same method which was described above.

But if the missile is also poisoned, after doing all the same things, even more promptly, if possible, in addition that treatment is to be applied which is given for one who has drunk poison, or has been bitten by a snake. The care of the wound itself after the extraction of the missile does not differ from that of a wound in which nothing has lodged and on which I have said enough elsewhere.