But as the foregoing disorders do not differ much either in their nature, or method of cure, so these in the eyes, which require manual operations, are both different in their kinds, and require different methods of cure.

In the upper eye-lids then it is common for fat and heavy vesicles to rise, which scarcely allow the eye to be raised, and occasion gentle, but constant fluxes of gum in the eyes. And they commonly happen to children. In this case, it is necessary to compress the eye with two fingers, and thus stretching the skin, to cut with the knife in a transverse line, with a very light hand, in such a manner as not to wound the vesicle, and so that it may pass out when a way is made for it; then to catch hold of it with the fingers, and pull it out: for it easily separates. After this the part ought to be anointed over with any of these collyriums, that are used in lippitudes; by which means it is covered with a cicatrix in a very few days. It is more troublesome, when the vesicle is cut: for it discharges its humour, and cannot be laid hold of after, because of its smallness. If that accident should happen, one of the medicines that promotes a digestion, may be laid on.

In the eye-lid, likewise, above the lashes, there grows a small tubercle, which from its resemblance to a barley-corn, is, by the Greeks, called crithe[ GU ]. It is contained in a coat, and seldom maturates. Upon this should be applied hot bread, or wax heated now and then, provided the degree of heat be no more, than the part can easily bear: for by this method it is often discussed, sometimes maturated. If pus appear, it ought to be divided by a knife, and the contained humour squeezed out: and to be afterwards treated with the same warmth, and anointed, till it recover a sound state.

Other tubercles not unlike this, grow in the eye-lids; but however not of the same form, and also moveable, when they are impelled this way or that by the finger: which because of their resemblance to hail-stones, the Greeks call chalazia[ GV ]. These ought to be cut on the external side, if they be immediately under the skin; on the internal, if they lie below the cartilage; after that, they must be separated by the handle of the knife from the sound parts. And if the wound be on the internal side, it must be anointed at first with mild, and afterwards more acrid medicines; if, on the external, an agglutinating plaister must be applied over it.

The unguis, called by the Greeks, pterygium[ GW ], is a small nervous membrane, which arising from the angle of the eye, sometimes reaches to the pupil, and obstructs the sight. It oftener begins from the angle, near the nose, sometimes too from that towards the temples. It is no difficult matter to discuss this, when recent, by the medicines, which lessen cicatrices in the eyes. If it be of long standing, and has acquired some thickness, it ought to be cut out. After an abstinence of one day, the patient must be placed in a seat, either with his face opposite to the physician, or with his back to him, in such a manner, that he may recline his head upon his breast. Some, if the disease be in the left eye, chuse to have him set with his face to the physician; if in the right, in the reclined posture. One eye-lid ought to be opened by an assistant, and the other by the physician. If the physician face him, he must take hold of the lower one; if he be reclined, the upper one. Then the physician is to fix under the extremity of the unguis, a small sharp hook, with its point turned a little inward; and to let go the eye-lid, which is then to be held by an assistant, and taking hold of the hook, he is to lift up the unguis, and pass a needle through, drawing a thread after it; then to lay aside the needle, and take hold of the ends of the thread, and by them raising up the unguis, if it adheres any where to the eye, to separate it by the handle of the knife, till he come to the angle; then alternately sometimes to slacken, sometimes to draw it, that so both its origin and the extremity of the angle may be found. For there is a double danger attends it; either lest some part of the unguis be left, which being ulcerated is hardly ever cured, or lest the caruncle be cut away from the angle; for if the unguis be drawn away with too much force, that also follows, and comes away. If it is torn off, an orifice is opened, through which afterwards a humour always descends, which the Greeks call rhyas[ GX ]. The true termination then of the angle must be found out. When that plainly appears, the knife is to be used, the unguis not being too straight drawn; and then this small membrane is to be cut out in such a manner, that no part of the angle be wounded. Afterwards lint covered with honey must be laid on, and over that a linen cloth, and either spunge, or sordid wool. The following days the eye must be opened daily, lest the eye-lids be agglutinated together by a cicatrix (for that is also a third danger) and lint be put on in the same way: lastly, it must be anointed with a collyrium, that cicatrizes ulcers.

But this operation should be performed in the spring, or at least before winter. Which circumstance, though it belongs to several places, it will be sufficient to mention once for all. For there are two kinds of cures; one, in which we are not at liberty to chuse a time, but that must be laid hold of, that offers, as in wounds and fistulas; another, in which we are not pressed for time; but it is quite safe and easy to wait the most convenient season; as is the case in these disorders, which both increase slowly, and are not extremely painful. In such, we must defer it till spring; or if there is any urgent circumstance, the autumn however, is better than the winter or summer; and of that the middle, when the excessive heats are gone, and the colds not yet set in. Now the more necessary the part is, whose cure shall be undertaken, the greater will the danger be it is exposed to. And often by how much larger the wound is to be made, so much the more must the season of the year be regarded.

From the operation for the unguis, as I observed, disorders arise, which may also sometimes proceed from other causes. For sometimes after the imperfect excision of an unguis, or upon some other occasion, a tubercle grows in the angle, which hinders the entire opening of the eye-lids; the Greek name for it is encanthis[ GY ]. It ought to be laid hold of with a hook, and cut round; and here also the operator must be cautious not to cut away any thing from the angle itself. Then a small piece of lint must be sprinkled either with cadmia, or copperas; and the eye-lids being opened it must be introduced into that angle, and bound over in the same manner as the former; and for some following days must be dressed in like manner, first bathing it with water, just warm, or even cold water.

Sometimes the eye-lids grow together, and the eye cannot be opened. Which is often attended with this disorder besides, that the eye-lids adhere to the white of the eye; that is when an ulcer in either of them has been negligently cured. For as it heals, what might, and ought to have been separated, will be agglutinated; both species of the distemper is called by the Greeks ancyloblepharon[ GZ ]. When the eye-lids only cohere, they are separated without difficulty; but sometimes to no purpose: for they are agglutinated again. However trial ought to be made; because the case often turns out well. Therefore the broad end of the probe must be introduced betwixt them, and the eye-lids separated by that; then small penecilla are to be put between them, till the ulceration of the part be cured. But when the eye-lid adheres to the white of the eye itself, Heraclides the Tarentine advises to cut under it gently with a knife with great caution, lest any thing be cut away either from the eye, or the eye-lid; and if that cannot be entirely avoided, rather to take something from the eye-lid. After these let the eye be anointed with such medicines as cure an asperity; and the eye-lid be inverted every day, not only that the medicine may be applied to the ulcer, but also to prevent its adhesion: the patient himself must also be charged to raise it often with two fingers. I do not remember an instance of one person cured by this method. Meges too tells us he tried many ways, and never was successful; for the eye-lid always adhered again to the eye.

Again in that angle, that is next the nose, from some disorder, a kind of small fistula is opened, through which gum(9) perpetually distils; the Greeks call it ægilops[ HA ]. And this gives constant uneasiness to the eye; sometimes also eating through the bone, it penetrates to the nostrils. This sometimes is of a cancerous nature; when the veins are tense and crooked, the colour of it is pale, the skin hard, and irritated by a slight touch, and it raises an inflammation in the contiguous parts. It is dangerous to attempt the cure of those, that are cancerous: for it even hastens death. And it is needless to meddle with such as reach to the nostrils: for neither do they heal. But the cure of these in the angle may be attempted; though it should be known however that it is difficult; and the nearer to the angle the opening is, so much the more difficult, because there is a very little room for the management of the hand; yet it is easier to cure the disorder when recent. The top of the opening must be taken hold of with a small hook; and then all the cavity as I directed in fistulas, must be cut out to the bone; and the eye and other contiguous parts being well covered, the bone must be strongly cauterized with a hot iron. But if it be already affected with a caries, that a thicker scale may cast off, some apply caustic medicines; as copperas, or chalcitis, or rasile verdigrease: which method is both slower, and not so effectual. When the bone is cauterized, the remaining part of the cure is the same as in other burns.

The hairs of the eye-lids sometimes irritate the eye; and that from two causes. For sometimes the skin of the eye-lid is relaxed, and falls down; whence it happens, that the lashes are turned in upon the eye itself, because the cartilage is not also relaxed; at other times, beside the natural row of hairs, another grows under it, which point directly inward upon the eye. The methods of cure are these. If preternatural hairs have grown, an iron needle thin and broad, like a spatha(10), must be put into the fire, and when it is red-hot, the eye-lid being lift up in such a manner, that the offending lashes are in the view of the operator, it must be passed from the angle close to the roots of the hair, till it move over the third part of the eye-lid; then it must be applied a second and third time, as far as the other angle. The consequence of which is, that all the roots of the hairs being burnt, die away. Then a medicine to prevent an inflammation must be applied: and when the eschars have cast off, it must be brought to cicatrize. This kind heals very easily. Some alledge that it is proper to pierce the external part of the eye-lid near the eye-lashes with a needle, which must be passed through with a woman’s hair doubled for a thread; and when the needle has gone through, that the offending hair must be taken up into the loop of the woman’s hair, and by that drawn upward to the superior part of the eye-lid, and there to be glued down to the flesh, and a medicine applied to close up the orifice thus made: for that this will cause the eye-lash to point afterwards externally. This in the first place cannot be practised, but upon a pretty long hair; whereas they generally grow short there. And then if there be several hairs, the patient must suffer a long torture, and the needle passing so often through will raise a great inflammation. Lastly, when any humour is settled there, the eye being irritated both before by the hairs, and afterwards by the perforations of the eye-lids, it is hardly possible to prevent the glutinous matter, which fastens the hair, from being dissolved: and thus of course the hair returns to the place, from whence it was drawn away.

The method of cure for a relaxed eye-lid, which is universally practised, never fails of success. For the eye being closed, one must take hold of the middle part of the skin of the eye-lid, whether it be the upper or the lower, with his fingers, and raise it; then consider how much must be taken away, to reduce it to its natural condition. For there are two dangers attending this case; lest if too much be cut off, the eye cannot be covered; if too little, the end be not obtained, and the patient have suffered to no purpose. The part, which it shall be thought needful to cut, must be marked by two lines with ink in such a manner, that betwixt the range of hairs and the line nearest to it, some space may be left for the needle to lay hold of. These things being determined, the knife is to be used: and if it be the upper eye-lid, the incision next the eye-lashes must be made first; if the inferior one, last: and it must begin in the left eye, at the angle next the temple; in the right, at the angle next the nose; and what lies between the two lines must be cut out. Then the lips of the wound are to be joined together by a single stitch, and the eye must be covered; and if the eye-lid does not descend far enough, it must be relaxed; if too much, it must be either straiter drawn, or a small habenula again cut off from that lip of the wound, which is farthest from the eye-lashes. When it is cut off, other stitches must be added, not above three. Moreover a scarification must be made in the upper eye-lid, under the roots of the eye-lashes, that being raised from the inferior part they may point upwards: and this alone will be sufficient for the cure, if they are but little turned in. The lower eyelid does not need this process. When these are done, a spunge squeezed out of cold water must be bound on: the day following an agglutinating plaister should be applied. On the fourth, the stitches must be taken away, and the wound anointed with a collyrium, to prevent an inflammation.

Sometimes from this operation, when too much of the skin is cut away, it happens, that the eye cannot be covered. And this sometimes proceeds from another cause. The Greeks call the disorder lagophthalmos[ HB ]. When too much of the eye-lid is wanting, there is no remedy for it; if but a small part, it may be cured. An arched incision must be made in the skin a little below the eye-brow, with its horns pointing downward. The wound ought to go as deep as the cartilage, but without injuring it: for if that be cut, the eye-lid falls down, and cannot afterwards be raised. Let the skin then be only divided, so as to allow it to descend a little in the lower part of the eye; which will be the consequence of the wound’s gaping above. Let lint be put into it to prevent the union of the divided skin, and to generate a little flesh in the middle: and when this has filled up the part, the eye is afterwards properly covered by the eye-lid.

As it is a disorder of the upper eye-lid not to descend far enough to cover the eye, so there is a disease of the lower, in which it is not raised high enough, but hangs down, and cannot be brought close to the other. And this also sometimes proceeds from a similar fault in the cure, sometimes even from old age. The Greeks call it ectropium[ HC ]. If it happens from a faulty cure, the treatment is the same as in the foregoing case: only the horns of the wound are turned towards the cheeks, and not to the eye. If it proceed from old age, the whole of it must be cauterized externally with a thin plate of iron; then anointed with honey; and from the fourth day fomented with hot water, and anointed with medicines to bring on a cicatrix.

These then are the general disorders, that commonly occur in the parts about the eye, the angles, and eye-lids. In the eye itself the external coat is sometimes raised, either from the rupture or relaxation of some of the internal membranes; and it resembles a raisin stone in its form, whence the Greeks call it a staphyloma[ HD ]. There are two methods of cure for it. One is to pass through the middle, at the root of it, a needle with a double thread; then to tie tight the ends of one of the threads above, and of the other below; which by cutting it gradually may bring it off. The other is, to cut out from its surface about the bigness of a lentil; then to rub in spodium or cadmia. When either of these is done, the white of an egg must be spread upon wool and applied; and afterwards the eye must be fomented with the steam of hot water, and anointed with mild medicines.

Callous tubercles in the white of the eye are called clavi; which name is given them from their figure. The best method is to pierce them at their very roots with a needle; and below that to cut them off, and then to anoint with mild medicines.

I have already elsewhere mentioned a cataract, because when recent, it is often removed by medicines. But when it is of long standing, it requires a manual operation, and one, which may be reckoned amongst the nicest. Before I treat of this, I shall give a short account of the nature of the eye; the knowledge of which, as it is of importance in several other parts, so it is peculiarly necessary here. The eye then has two external coats; the exterior of which by the Greeks is called ceratoides[ HE ]; and this, where it is white, is pretty thick, but before the pupil is thinner. The interior coat is joined to this, in the middle where the pupil is, and is concave, with a small aperture; round the pupil it is thin, but at a distance from it, something thicker; and by the Greeks is called chorioides[ HF ]. As these two coats surround the internal part of the eye, they again join behind it, and becoming finer, and uniting together, pass through the opening, which is between the bones, to the membrane of the brain, and are fixed to it. Under these, in the part where the pupil is, there is a void space; then again below, is an exceeding fine coat, which Herophilus called arachnoides[ HG ], the middle part of which subsides, and in that cavity is contained somewhat, which from its resemblance to glass the Greeks call hyaloides[ HH ]. This is neither liquid, nor dry; but seems to be a concreted humour; from the colour of which, that of the pupil is either black, or grey, though the external coat be white. This is inclosed by a small membrane, which proceeds from the internal part of the eye. Under these is a drop of humour resembling the white of an egg, from which proceeds the faculty of vision. By the Greeks it is called chrystalloides.

Now a humour concretes under the twoὑαλοειδὴς. coats, where I mentioned the void space to be, either from a disease, or a blow; and being gradually indurated, it obstructs the interior faculty of vision. There are several species of this malady, some of which are curable, and others not. For if the cataract be small, immoveable, of the colour of sea-water, or burnished iron, and leaves some sense of light on its sides, there remains hope. If it is large, if the black part of the eye, losing its natural appearance, is changed into some other, if the cataract be of the colour of wax(11), or gold; if it slides and moves to and fro, it is scarcely ever cured. And for the most part, the more severe the disease, or the greater the pains of the head, or the more violent the blow has been, which gave rise to it, so much the worse it is. Neither is old age a proper time of life for a cure; which without an additional disease causes a dimness of sight: nor even childhood; but the middle age betwixt these. Neither is a very small eye, nor one, that is hollow, fit for this operation. And there is also a certain maturity of the cataract itself: wherefore we must wait till it seems to be no longer fluid, but to have concreted with a certain degree of hardness.

Before the operation, the patient must use a spare diet, drink water for three days, the day immediately preceding take nothing at all. After this preparation he must be set in a light place, in a seat facing the light, and the physician must sit opposite to the patient on a seat a little higher; an assistant behind taking hold of the patient’s head, and keeping it immoveable; for the sight may be lost for ever by a slight motion. Moreover the eye itself, that is to be cured, must be rendered more fixed by laying wool upon the other, and tying it on. The operation must be performed on the left eye by the right hand, and on the right by the left hand. Then the needle sharp pointed(12), but by no means too slender, is to be applied, and must be thrust in, but in a straight direction, through the two coats, in the middle part betwixt the black of the eye and the external angle opposite to the middle of the cataract, care being taken to wound no vein. And it must not be introduced with timidity(13) neither, because it comes into a void space. A person of very moderate skill cannot but know when it arrives there; for there is no resistance to the needle: when we reach it, the needle must be turned upon the cataract, and gently moved up and down there, and by degrees work the cataract downward below the pupil; when it has past the pupil, it must be prest down with a considerable force, that it may settle in the inferior part. If it remain there, the operation is compleated. If it rises again, it must be more cut with the same needle, and divided into several pieces; which when separate, are both more easily lodged, and give less obstruction. After this the needle must be brought out in a straight direction, and the white of an egg spread upon wool must be applied, and over that something to prevent an inflammation, and then the eye be bound up.

Afterwards there is a necessity for rest, abstinence, mild unctuous medicines, and food (which it is soon enough to give on the day following) at first liquid, that the jaws may not be too much employed, then when the inflammation is gone, such as was directed in wounds. To which we must add this rule, that the patient’s drink be water for a pretty long time.

I have already treated of a flux of thin gum, which infests the eyes, so far as the cure depends upon medicines. I now come to these cases, that require manual operation. Now we observe that some people’s eyes never grow dry, but are always moistened with a thin humour; which circumstance occasions a constant asperity, and from slight causes excites inflammations, and lippitudes, and in fine renders a person uneasy all his life. And this disorder in some no remedy can relieve; in others it is curable. Which difference ought first of all to be known, that we may relieve the one, and not meddle with the other.

And in the first place, it is in vain to attempt the operation in those, who have this disorder from their infancy, because it will certainly continue to their dying day. Secondly, it is needless, where the discharge is not great, but acrid; because they are not assisted by a manual operation, but are brought to a sound state by medicines, and a proper diet for generating a thicker phlegm. Broad heads also are hardly susceptible of the remedy. Then it makes a difference whether the gum be discharged by the veins, that lye between the skull and the skin, or by those between the membrane of the brain and the skull: for the former moisten the eyes by the temples; the others by the way of those membranes, that go from the eyes to the brain. Now a remedy may be applied to those veins, that discharge above the bone, but not to those below the bone(14). Neither can relief be given, where the discharge comes from both places; because when one part is relieved, nevertheless the other remains disordered.

The source of the disorder is discovered by this method. After shaving the head, such medicines, as stop the gum in a lippitude, ought to be laid on from the eye-brows as far as the top of the head: if the eyes begin to be dry, it appears that they are moistened by those veins, which are under the skin: if the moisture is not diminished, it is manifest it descends from below the bone: if a humour still flows(15), but in less quantity, the disorder is from both. In most patients however the complaint is found to be derived from the superior veins; and therefore the greater number may be relieved. And this is very well known, not only in Greece, but amongst other nations too: so that no part of medicine has been more clearly explained in any country.

Some practitioners in Greece cut the skin of the head in nine lines; two straight ones in the occiput, one transverse above these; then two above the ears, one also transverse betwixt them; and lastly three straight ones between the top of the head and the forehead. Others drew these incisions in a straight direction from the top of the head to the temples; and discovering from the motion of the jaws the origins of the muscles, made gentle incisions in the skin above these, and separating their lips by means of blunt hooks, they inserted lint in such a manner, as to prevent the edges of the skin from uniting, and to cause flesh to sprout up in the middle, which might bind those veins, from whence the humour passes to the eyes. Others again have drawn a line with ink from the middle of one ear to the middle of the other, and another line from the nose to the crown of the head; and where these lines met, made an incision with a knife; and after the effusion of blood, cauterized the bone in that part. And notwithstanding this, they also applied the actual cautery to the rising veins both in the temples, and betwixt the forehead and crown of the head.

It is a common method of cure to cauterize the veins in the temples, which indeed are generally turgid in this kind of disorder; but that they may be more inflated and show themselves better, the neck must first be tied pretty strait. And the veins must be cauterized with small and blunt irons; till the flux of gum upon the eyes stop: for that is a sign the passages are blocked up, by which the humour was conveyed.

However it is a more effectual method, when the veins are small and lie deep, and therefore cannot be separated(16), to make a ligature about the neck in the same manner, and the patient keeping in his breath, that the veins may rise the more, to mark with ink these in the temples, and between the crown of the head and the forehead; then loosing the neck, to cut the veins, where these marks are, and discharge blood; when a sufficient quantity has flowed, to cauterize them with small irons: in the temples indeed with caution; lest the muscles lying below, which secure the jaws, be hurt; but betwixt the forehead and the crown so strongly, that a scale may cast off from the bone.

But the method of the Africans is still more efficacious, who cauterize the crown of the head to the bone, so as to make it cast off a scale. But nothing is better than what is done in Gallia Comata, where they separate the veins in the temples, and the upper part of the head. The manner of treating cauterized parts I have already explained. At present I shall add this one direction; that when veins are cauterized, we should not endeavour to hasten the separation of the eschars, nor the filling up of the ulcers; lest either an hemorrhage ensue, or the pus be quickly suppressed; since it is fit these parts be dried by the latter, and it is not proper they should be exhausted by the former. If however an hemorrhage should at any time happen, medicines for stopping blood must be rubbed in, but not such as will prove caustic. Now the method of separating veins, and what is to be done, when they are separated, I shall explain, when I come to the varices of the legs.