10 As for the polypus which grows in the nostrils, I have already laid down elsewhere that the best treatment is with the knife. Therefore this too should be loosened from the bone by a sharp instru
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ment, shaped like a spear head, care being taken not to injure the cartilage under it, which is difficult to treat. When detached it is to be extracted by an iron hook; then the nostril is gently filled with lint folded or in a roll, soaked in something to stop the bleeding; when the bleeding has stopped, the ulceration is to be cleaned with a lint plug. When it is clean, insert a quill (as described above in the case of the ear), smeared with the medicament which causes a scar to form until healing is completed.
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.
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
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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
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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
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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
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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.
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
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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.
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
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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
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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
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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.
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
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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.
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
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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
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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.