SECT. XXXIII.—ON STRUMA OR SCROFULA.
Strumæ are indurated glands forming principally in the neck, armpits, and groins. Their general treatment therefore is the same as that for scirrhus, but in particular the flour of bitter lupines is to be boiled in oxymel and applied (this also answers with phyma;) or apply cows’ dung boiled in vinegar. This discusses all indurated swellings. But strumæ may be properly discussed by means of quicklime mixed with honey, the sordes of baths, oil, or axunge; or, equal parts of quicklime and natron, and four times the quantity of cardamom and fenugreek may be boiled with honey for an emollient ointment and applied. This one discusses hard strumæ, and produces the rupture of suppurated swellings; the flour of darnel boiled with pigeon’s dung, or linseed and wine: or, green olives, either wild or cultivated; or, the white cardamus triturated with liquid pitch and made into an emollient ointment may be applied; or, the ashes of the dried root of the wild cucumber, and the burnt dried leaves of the bay, may be mixed with turpentine and applied; or, equal parts of stavesacre and of natron, with double the quantity of rocket may be applied, with rosin; or, goats’ or cows’ dung boiled in vinegar; or, the flour of bitter vetches soaked in the urine of a young person not come to manhood, and added to melted pitch, wax and oil; or, a dead snake may be thrown into a pot, and being covered over with gypsum, it is to be put into a furnace, the ashes of it mixed with equal parts of fenugreek, and then added to honey and used. And the composition from asps is an admirable one, also that from fullers’ herb, that from the wild cucumber and that from cedar rosin. The following one produces suppuration, or resolution of strumæ: Of myrrh, dr. x; of ammoniac perfume, dr. ij; of the mistletoe of oaks, dr. viij; of galbanum, dr. iv; of bee-glue, dr. j; pound in a mortar.
For strumæ and hardness of the breasts. Of wrought birdlime, of dry rosin, of wax, of each lb. j; of galbanum, oz. iij.
For strumæ ulcerated and not ulcerated. Of wax, of pine rosin, of axunge not salted, of horehound, of scraped birdlime, of each oz. vj.
An application for strumæ. Of old oil, lb. ij; of wax, lb. j; of colophonian rosin, oz. iv; of natron, oz. iv; the heads of garlic xij. Take away the cloves (nuclei) of the garlic, macerate in oil for three days, then having boiled until they are softened, throw them away, and melt in the oil those ingredients which are soluble, and after they are taken off the fire sprinkle on it levigated natron. It also breaks apostemes.—Another: Of the ashes of figs, oz. ij; of fissile alum, oz. j; of aphronitrum, oz. j; of liquid pitch, oz. vij.
A septic application for scrofula. Of fissile alum, of realgar, of each, dr. iv; of the flakes of copper, dr. j; of orpiment, dr. j; sprinkle the strumæ with it in a dry state; but if they are of a cancerous nature, mix with rose oil and use twice a day.
Commentary. See Hippocrates (De Glandulis); Galen (Meth. Med. xiv, 11); Oribasius (Synops. vii, 29); Aëtius (xv, 5); Actuarius (Meth. Med. iv, 16); Nonnus (Epit. 124); Celsus (v, 18); Scribonius Largus (153); Myrepsus (56); Marcellus (36); Serapion (v, 25); Avicenna (iv, 3, 2, 10); Albucasis (Chirurg. ii, 42); Alsaharavius (Pract. xxix, 1, 23); Haly Abbas (Pract. iii, 33); Rhases (ad Mansor. vii. 8; Cont. xxvii); Avenzoar (i, 10, 10.)
Hippocrates mentions struma as being one of the worst diseases of the neck, originating in inflammation, and being produced by a pituitous and indolent defluxion.
Galen directs us when scrofulous glands are not situated near large vessels to extract them with the knife, or consume them with septic applications. In another place he relates a case in which an imprudent surgeon, while removing a scrofulous gland of the neck, cut the recurrent nerves, and thereby occasioned loss of speech. (De Loc. Aff. i, 6.) For an account of the operation see the Sixth Book.
Part only of our author’s applications are derived from Oribasius.
A very minute account of these complaints is given by Aëtius. He divides strumæ into the mild and the malignant. The mild are without inflammation or pain, and are attended with a moderate degree of hardness; the malignant are accompanied with inflammation, and a throbbing pain, feel unequal, have enlarged veins, and are exacerbated by handling or medicines. The latter are said to be incurable. He mentions, upon the authority of Leonidas, the accident related by Galen. He approves, however, of the operation in general. Incipient strumæ, he states, may be discussed like scirrhi, by a combination of emollients with discutients. He gives a long list of prescriptions for removing scrofulous tumours. One of them contains arsenic mixed with the fat of a goat or ox. With regard to the general treatment, he recommends laxatives, restricted diet, emetics, and the theriac.
Actuarius and Nonnus, as usual, borrow from our author.
Celsus remarks that strumæ occur most frequently in the neck, armpits, groins, sides, and the female breasts. He represents them as indolent affections of the glands, which come slowly to maturity and prove very troublesome to the physician. Some, he says, give white hellebore in these cases, and use applications for bringing them forward or for discussing them. Others have recourse to caustics, and when the eschar is removed, they heal the ulcer upon general principles. When the sore becomes clean he recommends exercise and a nourishing diet.
Scribonius Largus, Marcellus, and Myrepsus give nearly the same prescriptions as our author. Arsenic is an ingredient in the septic applications of Myrepsus.
Avicenna recommends emetics, phlegmagogues, bleeding in the arm, attenuant food, and avoiding all gross things and repletion. As a discutient he and Serapion commend the diachylon plaster. Haly Abbas likewise mentions this application, and also directs the swellings to be burnt with caustics. Alsaharavius briefly recommends excision or burning. Serapion evidently copies from our author. Avenzoar gives a very full account of scrofulous swellings, which, he says, are formed in general of a gross and viscid phlegm. Except in very particular cases he disapproves of bleeding. He approves in general of discutient applications; but when the swelling tends to suppuration, he directs us to promote it; and when pus is fairly formed he recommends us to let it out, but cautions the surgeon not to attempt this operation unless he has a practical acquaintance with anatomy, lest he wound any of the veins, arteries, or nerves.
Rhases forbids the knife when the scrofula is in the neck or deep seated. In certain cases he approves of destroying the tunic with septic applications.
Brunus, and the other surgical writers of that age, in imitation of the Arabian authorities, direct scrofulous tumours to be treated with discutients, excision, or septics. A discutient ointment recommended by Brunus consists of litharge, common oil, and the juice of melons and fenugreek. His septic medicine is a mixture of arsenic and quicklime, which is to be applied with honey. (Chirurg. Minor. 19.)
SECT. XXXIV.—ON STEATOMA, ATHEROMA, AND MELICERIS.
These things belong to the class of apostemes, as we said when treating of them, and each receives its peculiar appellation from the substance contained in the tumour. Thus one of them is like fat, another like honey, and the third like pap. The indication of cure in them all is to discuss the contents, produce the putrefaction of them, or to cut them out. Some tumours fall under all these three indications of cure, namely, those which contain a thin fluid, as the meliceris; others come under two of them only, as the atheroma, for it can only be cured by excision or putrefaction. But the steotoma admits of no cure except by a surgical operation, for it can neither be discussed nor made to putrefy. The diagnosis of each of these may be found in the Surgical part of the work, while the materials of which the discutients are formed are mentioned under the head of scrofula. This application is peculiarly adapted for discussing meliceris: Twenty raisins without their stones; of squama æris, dr. iij; having first fomented, apply.—Another: Of Cretan cistus, of bdellium, of galbanum, of ammoniæ perfume, of bee-glue, of turpentine, equal parts; to be pounded together in a mortar. It applies to scrofula, parotis, furunculus, and phyma. But Archigenes applies to meliceris aphronitrum, and double the quantity of hellebore, with hard cerate. But septics cannot be applied while the skin remains entire; we must therefore in the first place lay bare the meliceris, atheroma, or strumæ, with caustic medicines, of which the most simple is that consisting of quicklime (calx viva,) soap, and strained lye. The following one is more complex, and admits of being kept: Of calx viva, dr. iv; of red natron toasted, of burnt lees of wine, of each, dr. ij; of vermilion, dr. j; triturate in lye; and having made it of the consistence of liquid honey, boil three times, until it is of the proper thickness, and lay it up in a leaden vessel, pouring in some lye, so that it may not quickly become dry. It applies to acrochordon, myrmecia, pterygium, clavus, callus, and excrescences of the gums. The lees of wine should not be older than two months. Anoint the skin with this, and when it begins to dry clean it away with a sponge, and anoint again; and when the skin becomes black, wash away again, and use escharotics. When the eschars fall off, apply the septic medicines. A septic application which is not irritating: Of squama æris, dr. iv; of realgar, dr. ij; of black hellebore, dr. ij; use with rose oil.—Another: Of squama æris, of realgar, of nettle seeds toasted, equal parts; use with rose oil.—Another: Of burnt sea-urchins, of the shell of the cuttle fish, of arsenic, equal parts; use with rose oil, but rub all the parts around with cerate and oil. This also is a good application: Of quicklime, p. ij; of chalcitis, p. j; of arsenic, p. j.
Commentary. See most of the authorities referred to in the preceding section.
Our author’s definitions seem to be taken from Galen. (De Tumoribus and Meth. Med. xiv.) Galen states that the steatoma is to be cured solely by a surgical operation; that the meliceris may be treated by discutients, septics, or excision with the knife; and that the atheroma admits only of excision, or the application of septics.
Aëtius may be referred to as an interesting authority upon this subject. The steatoma, he says, is a preternatural tumour, free from discoloration, and soft to the touch. He recommends excision for it. The contents of the atheroma consist of a pultaceous substance surrounded by a membranous tunic, within which are also sometimes found hairs; nay, Philoxenus affirms that he had found animals like gnats and flies. The meliceris also has a membranous coat, and its contents resemble honey. He approves also of the surgical operation for the meliceris and atheroma, but permits to attempt their reduction by means of discutients consisting of such ingredients as ammoniac, ceruse, turpentine, galbanum, vinegar, &c. He makes no mention of septics; indeed arsenic does not enter into any of his compositions.
Oribasius and Actuarius lay down the same rules of treatment as our author. Nonnus as usual epitomises him with some slight alterations. The active ingredients in one of his septic applications are sandarach and hellebore. Leo is brief and indistinct.
Celsus marks the differences of these tumours with his characteristic terseness and precision: “Atheromati subest quasi tenuis pulticula: meliceridi liquidior humor; ideoque pressus fluit: steatomati pingue quiddam.” He recommends excision. (vii, 6.)
Avicenna’s plan of treatment is so like our author’s, that we need not give it in detail. The steatoma is to be removed solely by an operation. For the two others he permits the use of septic applications, such as arsenic, quicklime, hellebore, the lees of wine, &c. Haly’s definitions are similar to those of our author, and he recommends either excision or the use of septics, such as vitriol. The treatment laid down by Alsaharavius is quite the same. In the barbarous translation of his works they are called by the names of alsahamia, asalia, and accida. (Pract. xxix, 1, 22.)
Vegetius, the veterinary surgeon, describes these tumours as they appear in cattle. He directs them to be treated by excision. (Mulom. ii, 30.)
It will be remarked from the text, that the ancients were well acquainted with the caustic powers of the calx cum kali. In fact, our author in this section has given a prescription for the paste now commonly used for forming issues.
It appears from the works of Fabricius of Aquapendente, that the practice of treating atheroma and meliceris by septic applications was sufficiently common in his time. Andreas Laurentius approves of removing scrofulous tumours in this way when they are deep-seated and have a broad base. He thus enumerates the septics used in his age: “Secundo extrahi potest struma caustico, nunc affixo in ejus medio candente ferro, nunc admotis erodentibus et putrefacientibus ut sandaraca, arsenico, argento liquido usto, oleo quod ex atramento sutorio igne elicitur, calce non extincta cum sapone, axungia porcina cum argenti sublimati portiuncula, pulvere mercurii, erinaceorum cumbustorum, testæ sæpiæ, auripigmenti.” He also recommends us to tie the base of the tumour with a thread wet in a solution of arsenic (De strum. nat.) The treatment of atheroma by caustics is well described in the ‘Bibliotheca Chirurgica’ of Manget.
SECT. XXXV.—OF FAVI.
The favus is a swelling on the skin, having perforations through which a honey-like fluid is discharged. Wherefore dried grapes with rue are to be applied to it; or, the tender leaves of the fig tree with honey; or, cresses with linseed in honey; or, the root of the garden cucumber with honey; or, sulphur vivum with cerate or turpentine. You may vary the treatment of favi by transferring hither what is said in the Third Book regarding achores.
Commentary. Alexander states that the favus resembles the achores, differing from them solely in magnitude: for the openings of the pores by which the fluid escapes resemble the combs of bees, whence it takes it appellation; but in achores we cannot see the pores by which the fluid issues.
Aëtius gives a similar description of the complaint, which, he says, mostly attacks muscular parts, as the limbs, soles of the feet, over the sixth vertebra of the neck, and the sides. When it attacks the head, he says, it sometimes spreads to the skull. In this case he directs us to treat it with acrid applications, and even the actual cautery. For incipient favus he recommends an application consisting of sulphur, barley flour and meal.
Nonnus recommends the following application: of litharge, dr. ij; of alum, dr. iij; of the leaves of rue, dr. ij; of wine and rose-oil, q. s.
Celsus’s description is so important, that we shall give a considerable part of it in his own language. He mentions two species of the favus, or κήριον. “Alterum est subalbidum, furunculo simile; sed majus, et cum dolore majore: quod ubi maturescit, habet foramina, per quæ fertur humor glutinosus et purulentus; nec tamen ad justam maturitatem pervenit. Si divisum est, multo plus intus corrupti, quam in furunculo, apparet, altiusque descendit. Raro fit nisi in capillis. Alterum est minus, super corpus eminens, durum, latum, subviride, subpallidum, magis exulceratum; siquidem ad singulorum pilorum radices foramina sunt, per quæ fertur humor glutinosus, subpallidus, crassitudinem mellis, aut visci referens, interdum olei: si inciditur, viridis intra caro apparet. Dolor autem, et inflammatio ingens est, adeo ut acutam quoque febrem movere consuerint.” For the second species he recommends as external applications a dried fig, linseed boiled in mulse, and emollient plasters. To the other he also directs us to make applications containing figs, turpentine, rosin, &c. But when these have not the effect, he recommends us to cut the fungous excrescences down to the sound flesh, and then to dress the sore upon general principles. (v. 28.) The above account of an affection of the scalp, which we have often met with in practice, is the most accurate to be found in any author ancient or modern. We are even in doubt whether the complaint be at all noticed in modern works on surgery. It is not to be confounded with the Porrigo favosa, or Porrigo scutulata, of Dr. Bateman.
Avicenna’s description of the achor and favus is far from distinct. (iv, 7, 3, 1.) The favi appear to be the pustulæ capitis quæ dicuntur alsahafa of Alsaharavius. (Pract. i, 11.) His description, however, is by no means distinct. He approves of general evacuants, and local applications of a stimulant nature, such as sulphur, mercury, birthwort, &c. Serapion has not described the favus very accurately, but he has given a full account of the treatment. He properly forbids strong applications at first. (i, 3.) Rhases recommends much the same applications as Serapion. (Ad Mansor. v, 16.)
SECT. XXXVI.—ON THE SIMPLE ULCER.
Since a simple ulcer is merely a division, if one will bring together the parts which are separated, and apply a circular bandage around, the divided parts will adhere together without more ado. It is necessary, however, when at one of its lips the ulcer is everted obliquely, to begin the bandaging there, and turn it to the opposite side. When it is deranged both ways, it will be proper to use a double-headed bandage, and thus to bring the lips together; for when nothing has fallen between the lips, such as a hair, or a sand, or oil, or filth, or the like, the ulcer will adhere completely. When the ulcer is large, so that the separated parts cannot be completely brought together by the aforesaid bandaging, they are to be first united with sutures, and then bandages are to be thus applied, and those remedies used which are called agglutinants, which have the power of drying and consuming the collected moisture, and prevent more from flowing to the part.
Commentary. On ulcers the following ancient authors may be consulted: Hippocrates (De Ulceribus); Galen (Meth. Med. iii, & iv); Oribasius (Synops. vii); Aëtius (xiv); Actuarius (Meth. Med. iv, 16); Nonnus (Epit. 259); Pliny (H. N. xxxii, 44); Celsus (v); Octavius Horatianus (i, 19, 20); Scribonius Largus (94); Avicenna (iv, 4, 1, 2, 3); Serapion (vii, 28); Averrhoes (Collig. vii, 32); Haly Abbas (Pract. iv, 18); Alsaharavius (Tract. xxix, 2, 2); Rhases (Ad Mansor. vii, 3; Divis. i, 138; Contin. xxviii.)
The author of the Hippocratic treatise quoted above particularly praises wine as a lotion for ulcers; and we may mention that Dr. Hosack, an intelligent American writer, states it as his opinion, that the surgeons of the present day might learn from him an important lesson upon its utility in such cases. He condemns the use of oils and fat.
Of all authors, ancient or modern, Galen has laid down the principles upon which ulcers ought to be treated with the greatest precision. He defines an ulcer to be, “a solution of continuity,” a definition evidently very comprehensive, and including wounds as well as cases of spontaneous ulceration. His directions for the treatment of a simple ulcer or fresh wound are similar to those of our author; that is to say, he directs us to bring the lips of it together, and secure them with a bandage, or, if that is not sufficient, by sutures or clasps. Wine he pronounces to be the best of all applications to ulcers, in as far as they are ulcers.
Our author copies very closely from Oribasius.
In applying the bandage, Aëtius directs us to begin above the sore if only one simple bandage is to be used, but if two are necessary, as in fractures, he recommends us to begin at the ulcer and proceed upwards, and in like manner to begin again at the ulcer and roll downwards. He forbids us to loose the bandages oftener than every alternate day; and directs us not to apply water to the ulcer, but to remove the sanies with a soft, dry linen cloth.
Celsus describes very accurately the treatment of a recent wound or simple ulcer. He approves, according to circumstances, of bandages, clasps, or sutures, and his directions respecting the application of them are highly important, but too long for our limits. After the sore is dressed he directs us to apply over it a sponge soaked in vinegar, or, if that cannot be borne, in wine or cold water. This practice is deserving of imitation. He says afterwards: “Optimum etiam medicamentum quies est: moveri et ambulare nisi sanis alienum.”
Octavius Horatianus directs us to avoid the bath, the fire, the sun, cold air, loud cries, intoxication, venery, and passion, lest these should occasion a rupture of the parts which had adhered.
Avicenna with his usual good sense gives judicious directions for the treatment of simple ulcers, but his principles are nearly the same as those laid down by Galen. He defines an ulcer to be “a solution of continuity, attended with a discharge of sanies or pus.” This seems to be an unexceptionable definition. He forbids all oily and watery applications, and recommends us to observe that no body intervene between the lips of the wound when the bandage is applied. Rhases gives similar directions. He condemns the practice of those who put oil into a wound, and who allow the patient to take wine and heating food. Averrhoes lays down similar rules with considerable precision. Haly Abbas and Alsaharavius follow the practice of Galen without the slightest alteration.
Considerable difference of opinion has prevailed respecting the nature of the clasps (Fibulæ ἄγκτηρες) recommended by Celsus and other ancient authorities. Rhodius and Le Clerc maintain that no more was meant than a simple interrupted suture, but to this opinion we cannot subscribe. (See Le Clerc, Hist. de la Méd. iv, 2, 5, and Fabricius of Aquapendente Œuvres Chirurg. ii, 108.) They would appear to have been metallic clasps of a peculiar construction.
SECT. XXXVII.—ON AGGLUTINANTS.
Oak leaves applied, and those of the willow and cabbage; the fruit, leaves, and bark of the mezereon, and the juice of the more austere plantain, papyrus soaked in oxycrate or wine, and wrapped round in a circular manner. The following are agglutinants of fresh wounds: the leaves of the pine and spruce fir, and their fresh bark wrapped round like a bandage, with water, oxycrate, or wine; and new cheese pounded. But we must apply externally the leaves of dock, or of vine, or of beet, or of lettuce. But cheese made of acid milk cures even the larger sores; and the wild pears repress the discharge. The horse-tail (Hippuris) may be applied with advantage, even if the tendons are divided asunder; and the matured woad may be used to indurated bodies even when they occur in the heads of muscles. The leaves and shoots of cypress, and its recent and soft balls (pilulæ) may be applied to indurated parts, but we must mix with it some of the fine dust taken from a wall near a mill. Myrrh rubbed with water, or frankincense and earth worms, agglutinate even the divisions of tendons; also, cinquefoil leaves with honey, and garlic burnt and applied. Old ulcers again are remedied by barley burnt with cerate, and by ceruse with a quadruple quantity of myrtle cerate. For ulcers on the head sprinkle dried myrrh, and do not moisten it, for it will speedily produce adhesion. Or, having triturated dried aloes or birthwort, and having boiled it with honey in wine until it is of a proper consistence, spread upon a pledget and apply it. Of the compound agglutinants are those called the Barbarous, the Golden, that ascribed to Nicolaus, that from willows and dittany, and others of a similar nature, which can produce the adhesion even of very large sores.
Commentary. Celsus gives the following list: glutinant vulnus, myrrha, thus, gummi, præcipueque acanthinum, psyllium, tragacantha, cardamomum, bulbi, lini semen, nasturtium, ovi album, gluten, ichthyocolla, vitis alba, contusæ cum testis suis cochleæ, mel coctum, spongia, vel ex aquâ frigidâ, vel ex vino, vel ex aceto expressa, ex iisdem lana succida: si levis plaga est etiam aranea.
Our author’s list is copied from Oribasius. Aëtius has a long chapter on the composition of applications for agglutinating fresh wounds. The ingredients of them are most various: sumach, litharge, wax, galbanum, bee-glue, turpentine, alum, chalcitis, &c. Actuarius merely extracts a few articles from our author’s list.
Avicenna’s list scarcely differs in any one particular from our author’s, and nearly the same may be said of Haly’s. Isaac (ap. Rhasis Contin. xxviii) particularly commends bdellium and myrrh, with honey and wine.
Galen has explained at considerable length the principles upon which these applications should be used. Agglutinants, he remarks, are austere and astringent medicines, being such as occasion a contraction and condensation of the fleshy fibres; and they must not possess detergent properties. They are principally applicable in the case of plane ulcers, that is to say, ulcers without loss of substance. (See Meth. Med. iii.)
SECT. XXXVIII.—ON PAINFUL AND INFLAMMATORY SORES.
To painful and inflamed wounds desiccant and anti-inflammatory remedies must be applied. Of liquid remedies the best is wine, but oxycrate is also a good remedy. But if the ulcer is foul as well as inflamed, much diluted hydromel may be used. Of dry medicines, those in general will apply which are mentioned for phlegmons, except such as are oily and acrid. This is a particularly excellent one: Having boiled the sweet pomegranate in wine and pounded, apply it. This is an admirable application and much used, for it applies to ulcers of the head, and those of the privy parts, and to very painful sores on all parts of the body, and to inflammations of the eyes. But if the erysipelas or the like attack an ulcer, we must have recourse to the remedies described for them.
Commentary. Hippocrates gives a long list of applications for inflamed sores. We have mentioned above that wine was one of his favorite remedies. If erysipelas come on, he directs us to purge either upwards or downwards.
Galen explains general principles. Our author copies closely from Oribasius.
Avicenna and Rhases agree with Paulus in approving of cooling or desiccative applications, such as a decoction of sweet pomegranate in Pontic wine. This application is recommended by Haly Abbas, who also mentions a cataplasm containing opium.
SECT. XXXIX.—ON UNCONCOCTED ULCERS, AND SUCH AS HAVE NOT SUPPURATED.
Recent ulcers, and such as being in an inflammatory state have not suppurated, may be digested and made to suppurate by these things: of simple things, tepid water poured on them, wheat flour, or chondrus, or bread, or glue for books, applied with turpentine, wax, saffron, frankincense, pitch, rose oil, axunge, or the fat of calves; but the compound application called tetrapharmacon may be applied upon a pledget mixed with rose oil. Old and callous ulcers are concocted by these simple medicines: the dried grape, storax, galbanum, myrrh, Cretan cistus, pitch, rosin, butter, Egyptian mastich and unwashed wool; and by these compound ones: Galen’s plaster without wax, dissolved in oil of ricinus, and applied upon a pledget with old oil, or oleum ricini; and in like manner those called dichromos and basilicon, and the like.
Commentary. Celsus’s list is not very different from our author’s: Concoquunt et movent pus, nardum, myrrha, costum, balsamum, galbanum, propolis, styrax, thuris et fuligo et cortex, bitumen, pix, sulphur, resina, sevum, adeps, oleum. These articles furnish the ingredients of most of our modern applications. For further information respecting each article, the reader is referred to Dioscorides, Galen, and Serapion.
SECT. XL.—ON HOLLOW ULCERS.
The hollow ulcer requires the filling up of the deficient flesh, the materiel of which is a moderate quantity of good blood. Wherefore we procure a moderate supply of it by a sufficiency of food, and produce a proper temperament of the sore by food of wholesome juices, and a suitable temperament of the part in which the sore is seated. With regard to the discharge, that which is thin renders the sore more humid, and that which is thicker makes the sordes adhere to it; on that account it requires applications that are moderately desiccant and detergent; such as frankincense, the flour of barley, that of beans and tares, iris, birthwort, calamine, panax, and pompholyx. When one incarnative remedy does not answer another must be tried. But if the sordes of the ulcer appear greater, and the ulcer more humid, it is to be understood that the medicine has not dried properly, and its powers are to be increased by a mixture of honey. If it is clean, but with less moisture than natural, the medicine has dried more than was proper, and we must apply a cerate mixed with more oil. It sometimes happens when the application is too strong, that the flesh is melted down, so that the ulcer appears foul and moist, like those which have been imperfectly dried; but that from the melting of the flesh becomes more hollow, its lips are callous, and it is red and inflamed; and sometimes the patient has very acute pain. But the other, which arises from the applications being less desiccant than proper, is attended with none of these characters. Wherefore the caries of wood, more especially of such as is possessed of a moderate degree of astringent and detergent qualities, as that of the elm, purges and incarnates clean ulcers; or anemone may be applied for the same purpose. Having shaven down the bark of the pine and pounded it with cerate, and rubbed it upon pledgets, apply it to hollow ulcers, more especially to such as are recent, for it will fill them. The compound medicines for ulcers which are clean, are, that from snails, that ascribed to Manetho from the lees of wine, that from aloes, the dry powder called meletera, that containing equal parts of starch, of manna, of halica, and of tares; and in like manner, the composition from frankincense and that called aphroditarium. But when the ulcers are fouler the powders called cephalic are to be applied, and of those applications that are made upon pledgets, that called trophos, the isis and the athena, and that from distaff-thistle (atractylis,) and moreover that called Italicum, and any others of tried efficacy.
Commentary. The resemblance here pointed out between an ulcer too strongly stimulated and one too little is highly deserving of attention. Our author appears to have borrowed his description from Oribasius, who however abridges it from Galen. Galen and Aëtius give a somewhat fuller account than our author, but their principles of treatment are the same. They remark that frankincense in humid intemperaments engenders flesh, but in dry ones only pus. Pompholyx burnt and washed; calamine and the shells of oysters are said to be incarnant and dissiccant without pungency. Galen inculcates that the greatest difficulty in treating these ulcers, is to find out the nature of the intemperament of the part, and correct it.
Celsus gives the following list of incarnants: Carnem alit et ulcus implet resina pinea, ochra attice, vel asterace, cera, butyrum. He recommends the use of hot water; an application consisting of butter, roses, and a small portion of honey; or the tetrapharmacum with roses. He approves of giving wholesome and nutritious food, such as fowls, venison, pork, and even wine. The list of the Pseudo-Dioscorides contains nearly the same articles as that of Celsus. (Euporist. i, 186.)
Octavius Horatianus recommends a composition of equal parts of honey, turpentine, rosin, and wax, melted in a vessel; or a mixture of powdered rosin, wax, and fat.
Scribonius Largus recommends basilicon, and a composition consisting of calf’s marrow, the fat of geese, butter, stag’s marrow, wax, turpentine, honey, and roses.
Avicenna remarks, that in treating hollow ulcers we must not use very desiccative applications, as they dry up the fluids which are necessary for forming flesh; nor for the same reason, very astringent applications, nor abstergents of any greater strength than to remove the sordes. Rhases recommends a mixture of equal parts of olibanum, aloes, sarcocolla, and dragon’s blood. Camphor is an ingredient in one of his incarnative applications. Alsaharavius makes mention of an application from olibanum, like that of Rhases.
All the ancient authors say that round ulcers are more difficult to heal than those of any other shape; and Cassius Medicus and Alexander Aphrodisiensis assign various reasons for this, the most probable of which seems to be, that in this case the sound parts are further removed than in any other.
Apollonius Dyscolus states that ulcers are prevented from healing by pregnancy, by disease of the spleen, and by varicose veins. (Histor. Mirab. 42.)
SECT. XLI.—MEDICINES FOR CLEANSING FOUL ULCERS.
Foul ulcers, whether hollow or level with the surface, may be properly cleansed by birthwort in honey, turpentine with an equal portion of rose oil and honey, or instead of rose oil butter may be substituted, with Illyrian iris and honey; and by pickled olives applied. To nervous parts, turpentine melted with butter may be applied. When the sores are very foul and spreading, horehound with honey is a good application, which removes the eschars. The following are compound applications: Of boiled lees of oil, of scummed honey, of the species of alum called phormion, equal parts.—Another: Of the dried serapias, called also triorchis, of Illyrian iris, of dried horehound, of birthwort, of each, dr. viij; of the flour of tares, dr. x; use in a powder and with honey. And for foul ulcers the Egyptian cerate is useful, also those from salts when melted, the Indian, that called athena, the green plasters diluted, the powder of dried pumice stone, those from tares, the trochisk called melanchlorus, and in like manner that called criogenes.
Commentary. The following are the most important articles in Celsus’s long list of substances for cleansing ulcers: Purgant, ærugo, auripigmentum, quod ἄρσένικον a Græcis nominatur; (huic autem et sandarachæ in omnia eadem vis, sed validior est) squama æris, thus, resina, et pinea, et terebinthina liquida, misy, chalcitis, galla, sulphur, pix, oleum, ruta, ammoniacum, &c. Hippocrates makes mention of many of these, namely, arsenic, verdigris, flowers of copper, frankincense, myrrh, hellebore, &c.
Scribonius Largus recommends honey, Illyrian iris, and a compound application containing arsenic, scales of copper, elaterium, and burnt paper.
One may find in Galen and Aëtius many compound applications, but as they are all formed from much the same ingredients as those of our author, it will be unnecessary to take further notice of them. Aëtius commends a combination of turpentine and honey.
Avicenna and Haly Abbas recommend the same applications as our author. They make no mention of arsenic. Alsaharavius gives very particular directions for treating these ulcers; when the edges are hard, he directs us to rub them until they become red, or to cut them off and apply to the sore the green ointment; and when the ulcer is covered with much sordes, he recommends us to dress it with the Egyptian ointment. Rhases mentions antimony as an excellent application for cleansing foul ulcers. He properly recommends us to consider whether the foulness of the ulcer be the effect of too much or too little stimulation. He relates a case of the former description, in which the sore got worse under the application of the green ointment. (Cont. xxviii.)
SECT. XLII.—FOR WORMS IN ULCERS.
For worms which form in ulcers, the first thing to be done is to stop the humidity and the putrefaction which occasion them. Worms may be killed by all the things in general which are described for those in the ear. But for those which form in ulcers Archigenes says, mix equal parts of ceruse and poley with liquid pitch, and anoint with it.
Commentary. Aëtius recommends dried plantain, the ashes of the wood of figs, and the juice of calamint. Galen and Avicenna also mention calamint.
Pliny mentions the gall of frogs.
SECT. XLIII.—ON FUNGOUS ULCERS.
The fungous flesh of ulcers is to be removed by medicines which are powerfully desiccant, such as diphryges sprinkled upon it, the squama æris, all the testacea burnt, both the echini (the hedgehog and sea-urchin,) burnt entire. But the following things are moderately cleansing, and repress the fungous flesh: the flower of the Asian stone, and still more powerful than it, the sori and chrysocolla, chalcitis and misy (when burnt they are less caustic,) and the flos æris in like manner; but verdigris is the most powerful of all. Salts, when burnt, consume the foul flesh, and in like manner charpie that has been soaked in strong brine and dried, consumes fungous flesh that is moderately large. But verdigris with the squama æris is powerfully repressing. Of the compound applications the powder called rhodium, and the psarum, and that named yellow, repress fungous growth without being pungent. But the trochisks called phaustiani, when levigated and sprinkled on the sore, and the dry medicine (or powder) called heliocaes, make fungous flesh slough off to the bottom. But the application consisting of equal parts of calx viva, squama æris and manna, answers with fungous flesh; with honey it cleanses such as resemble a mushroom, and with cerate it proves incarnating.
A powder for keeping down fungous flesh: Of litharge, of chalcitis, of verdigris, of plumbago, equal parts.—Another, which represses strongly without being pungent, and applies also to spreading ulcers, and more especially the epulis of the gums, and whitens the teeth: Of quicklime, lb. j; of arsenic, oz. vj; having triturated the dried arsenic with water, add the lime washed like calamine, and, having rubbed them together dry and use. And of the trochisks, that called pantolmios, and those described for polypus, are excellent for repressing fungus in ulcers. But the green plasters, more especially the one from Cappadocian salts, and in like manner the isis, are most effectual in preventing fungous flesh in ulcers.
Commentary. The powerful applications mentioned by our author will be found amply sufficient to fulfil every intention in conducting the treatment of these ulcers. Many of them are mentioned by Hippocrates.
Galen lays it down as a rule that these fungous excrescences are to be repressed by powerfully desiccative substances, such as misy, chalcitis, or more especially verdigris; when burnt and washed they become mild detergents. (Meth. Med. iii.)
Aëtius gives many useful prescriptions for such preparations, but they are entirely formed of the ingredients which enter into those of our author.
Celsus gives a long list of caustics highly applicable in such cases: Adurunt, auripigmentum, atramentum sutorium, chalcitis, misy, ærugo, calx, charta combusta, sal, squama æris, veratrum et album et nigrum, cantharides, sandaracha, alumen scissile, &c. Pliny speaks of a composition of unwashed wool, with barley flour, and verdigris.
Octavius Horatianus recommends the Phrygian stone pulverized, and a powder consisting of the recrementum plumbi, verdigris, aloe, and quicklime.
Rhases and Avicenna copy from our author. Haly Abbas speaks of removing the superfluous flesh with an instrument.
SECT. XLIV.—ON SPREADING ULCERS, PUTRID ULCERS, AND PHAGEDÆNA.
Spreading and putrid ulcers are to be bathed with vinegar and oxycrate, an astringent wine, cold water, sea-water, or the decoction of lentil, of pomegranate rind, of the flowers of the wild pomegranate, of lentisk, of myrtles, of Egyptian thorn, or some other astringent and desiccant medicine. Cataplasms are to be applied to them of the flower of tares and liquid alum, the inner part of bread made of similago, an old goby fish, or some other old pickle, unwashed flesh, and liquid turpentine; these things are to be all pounded together in equal proportions. Or the parts may be anointed with equal proportions of birthwort, and the juice of the leaves of the Palma Christi, and half the quantity of verdigris, made with water to the thickness of honey; but if the eschar is not removed an equal proportion of elaterium is to be mixed with the verdigris. For putrid ulcers sori levigated and sprinkled on them is an effectual remedy, and above is to be put dried charpie; or the round birthwort and galls in equal quantities may be rubbed in with oil; or the root of the wild cucumber, or of cabbage, or of beet, or the leaves of dock are to be bound in a piece of linen, and put into ashes; when they are softened triturate with salt and apply; they will cleanse powerfully. Or apply green olive leaves boiled in wine with honey; or apply chalcitis, or parsley seed levigated, or apply linseed triturated with copperas, or use an application of thyme, dried grapes and boiled figs, or of fig leaves triturated with honey; or of nitre, cumin, and fine flour with honey; or of the root of the wild cucumber, or of squill boiled with honey; or of sori, dr. xij; of chalcitis, dr. x; of misy, dr. iv; triturate with half an hemina of the strongest vinegar until it is dried, and taking it off use by dipping a specillum in it, and rubbing it over the ulcer, and placing above it a double pledget out of wine and oil. But if it is inflamed apply henbane with polenta, or cabbage with honey.
For putrid and spreading ulcers on all parts of the body.—Of quicklime, of chalcitis, of each dr. ij; of arsenic, dr. j. This may be used for pterygia of the fingers, for phagedæna and carbuncle, with honey if on the genital organs, but dry if on any other part of the body. Above apply an oblong pledget with rosin.
An universally applicable powder for all spreading sores, and those of the mouth, for hemorrhages, and for repressing fungous flesh. Of chalcitis, of misy, of both in a crude state, dr. xx; of squama ferri, dr. vj; of immature galls, dr. viij.
For spreading and putrid sores. Of salts, dr. ij; of any species of alum which has been burnt, dr. j; of squama æris, of burnt pumice stone, equal quantities. Scraped verdigris, with burnt misy mixed with liquid pitch; and the flakes of iron with oil also answer well.
For spreading ulcers of the pudendum. These things will apply to them, and also the composition called meliterium, the powder of the wild myrtle, and that from paper; also the composition from oxymel called coracion, the trochisk of Andron and the like, will answer with all spreading ulcers. The same things also apply with phagedæna; for phagedæna is an ulcer that spreads by eating.
For foul and fetid ulcers. The Lemnium sigillum (Lemnian earth) mixed with vinegar, oxymel, oxycrate, or wine, until it is of the consistence of clay, may be rubbed on them with advantage; or the leaves of cypress, its shoots, and tender balls (pilulæ), or the ashes of dried gourd burnt, or of the burnt bark of the plane tree, or of burnt dill in like manner, or of foul wool burnt, or of plaintain; also woad by itself or with polenta, or the dried root of hog’s fennel.
Commentary. It will be remarked that the milder applications mentioned in this section are all powerful desiccants and astringents. Most of them are mentioned by Dioscorides as possessing these properties.
Galen recommends the compound applications mentioned by our author, containing verdigris, squama æris, &c.
For these spreading and putrid sores Aëtius, among other prescriptions, gives one which would no doubt be applicable in the worst cases: “Of crude misy, of crude chalcitis, ā dr. viij; of ochre, dr. iij; of sandarach, dr. iv; of quicklime, dr. ij; of the scales of copper, of alum, ā dr. ij; of diphryges dr. iij; m.” These caustic and escharotic medicines enter into the composition of many of his applications. Some of them contain astringents and desiccants, such as sumach, galls, alum, fossil salts, frankincense, calamine, birthwort, pomegranate rind, &c. In short the ingredients in his applications correspond with Celsus’s list of corrosive substances: Rodunt, alumen liquidum, sed magis rotundum, ærugo, chalcitis, misy, squama æris, sed magis rubri, æs combustum, sandaracha, galla, thus, auripigmentum, calx, nitrum et spuma ejus, alcyonium, resina, squama ferri, atrumentum sutorium, veratrum, &c.
The other authorities give only combinations of these substances; for a full account of which preparations we refer the reader to Galen. (Med. sec. gen. iv.)
Octavius Horatianus recommends lentils boiled and mixed with honey; the leaves of cabbage, coriander, or ivy, all mixed with honey.
The Arabians, although they supply nothing new, add their authority in confirmation of the remedial virtues which the Greeks assigned to the substances mentioned above. Avicenna and Rhases recommend arsenic, copperas, misy, sori, chalcitis, flos æris, quicklime, alum, galls, ammoniac, the trochisk of Andron, &c. When a part becomes black and putrid, Haly Abbas directs us to open a vein leading to it, if the age and state of the patient permit, and afterwards to apply odoriferous things, such as camphor, &c.
SECT. XLV.—ON ULCERS REQUIRING CICATRIZATION.
By drying and constringing the flesh of ulcers requiring cicatrization to such a degree as not only to dissipate the preternatural superfluity, but also to touch upon that which is in its natural state, we may render the surface of the sore like skin, and make the ulcer cicatrize. This is promoted by immature galls, the moderately desiccant bark of pomegranate, and whatever else is desiccant without being possessed of pungent astringency. And such things as these promote cicatrization: myrrh, litharge, and oysters if burnt, for they must be sprinkled on the sore dry. And these things often produce cicatrization: pine bark with myrtle cerate, ivy flowers with cerate, the root of the lily with rose-oil, dried pine-rosin, burnt pumice stone, the flakes of copper; they are to be used in equal proportions dry. The following also repress: mix a small quantity of manna and of diphryges with levigated pumice, and use; or of litharge p. j; of diphryges p. ss, apply on a pledget with cerate. Birdlime with frankincense cicatrizes old ulcers, also verdigris with an equal portion of diphryges and with myrtle cerate, or the small centaury applied fresh. To the more humid apply the root of cypress. To those about the anus and pudendum, more particularly if inflamed, use levigated aloes, either in a dry state or with water, or squama æris; or soften chrysocolla in the sun with wax, and apply.
A dry application for producing cicatrization. Of oysters, dr. xij; of manna, dr. vj; of calamine, dr. iv. It applies also to spreading sores.—Another: Of birthwort, dr. vj; of pine bark, dr. vj; of manna, dr. vj; of pumice, dr. iv; of Colophonian rosin, dr. iv; of iris, dr. iv.—Another: Of hart’s horn burnt, dr. iv; of pine-bark, oz. vj: of ceruse, oz. iv; of scraped verdigris, oz. ix; of calamine, dr. xviij.—Another: Of the flowers of pomegranate, of copperas, of each, dr. xvj; of squama æris, of fissile alum, of each dr. viij; of galls, dr. j.—Another: Of ceruse, of litharge, of each, oz. viij; of the dross of lead, of galls, of dried myrrh, of each, dr. iv.
A cicatrizing application. Take of fissile alum, oz. j; and having levigated it, macerate in a sextarius of water: when dissolved in the water soak pledgets in it, and having dried them apply.
A plaster for cicatrizing the more simple ulcers. Of wax, dr. xl; of litharge, dr. xxxv; of diphryges, dr. viij; of myrtle-oil, half a hemina. The plaster called phœnicinum, that from calamine, the myrsinatum, and the like, are also applicable in such cases. For ulcers of difficult cicatrization: Of wax, of myrtle-oil, of each, dr. vj; of calamine, oz. vj; of lead, of frankincense, of each, dr. ij; of fissile alum, of burnt copper, of each, oz. j; of scraped verdigris, dr. ij; dissolve them singly. For chronic ulcers, and such as are of difficult cicatrization: Of calamine, dr. viij; of chrysocolla, dr. viij; of fissile alum, dr. viij; of verdigris, of the flakes of copper, of each, dr. j; of pine-rosin, dr. xl; of wax, dr. c; of myrtle-oil, q. s.—Another: Of wax, of pine-rosin, of each, oz. vj; of calamine, oz. vj; of crude chalcitis, oz. iij; of myrtle-oil, q. s. The calamine and the chalcitis are to be triturated with wine during the season of the dog-star; use it upon a broad compress, and apply above it a pledget and sponge out of wine.—Another: Of burnt copper, oz. ij; of fissile alum, oz. ij; of sal ammoniac, dr. ij; of wax, oz. vj; of Colophonian rosin, oz. vj; of myrtle-oil, oz. ij; the dry things are to be triturated in the vinegar in the sun for twenty days, and when it becomes of the consistence of honey, having melted the wax, mix it and soften. The medicine from pumice-stone, the isis, and the like, are also applicable in such cases.
Commentary. Celsus gives the following list of the more active articles of this class: Crustas ulceribus tanquam igne adustis inducunt, præcipue, chalcitis, utique si cocta est, flos æris, ærugo, auripigmentum, misy, et id quoque magis coctum.
For a variety of applications suitable to this class of ulcers, we refer the reader to Galen’s 4th book of ‘De Med. sec. gen.’ The ingredients of them are powerfully desiccative, astringent, and escharotic. Many of our author’s prescriptions will be recognized in it. For an account of the isis, and the other compound medicines mentioned towards the end of this section, we refer the reader to Galen (l. c.) and to the Seventh Book of this work. Galen, in another place, and after him Aëtius, give the following important directions for the use of these applications. The ulcers to which this mode of treatment is applicable, being very foul and filled with a vitiated discharge, are first to be wiped clean with a soft linen cloth, and then the cavity of them is to be filled with the medicine, and a splenium (oblong compress) applied externally. Then having put a piece of linen above the splenium and bound it on, we are to place over it a sponge squeezed out of cold water or wine, endeavouring to keep the sponge cold during the whole time of the treatment, which may easily be done by pouring cold water upon it without loosing the bandages. They are not be removed until the third day. Galen states that the articles which answer best in such applications are galls, pomegranate-rind, alum, chalcitis, misy, and the like.
A similar mode of treatment, without any material alteration, is described by the Arabians. Haly Abbas remarks, that cicatrizing medicines are powerfully desiccative with some astringency, such as galls, alum, and the like.
SECT. XLVI.—ON THE MALIGNANT ULCERS CALLED CHIRONIAN AND TELEPHIAN.
Old ulcers which are difficult to get cicatrized are called chironian, as if requiring Chiron himself to cure them; and telephian, from Telephus having long laboured under such a sore. We must attend then whether the whole body being in a state of cacochymy, sends such defluxions to the ulcer, and the prevailing humour is to be evacuated by appropriate remedies. Or if it is a varix which sends these humours to the legs, the ulcer being in it, it is to be cured as will be described in the Surgical part of this work; or the humours are to be evacuated by venesection, taking away blood frequently, and then using topical applications which have the property of extirpating the disease without being pungent. These therefore are simple applications; those from pumice and diphryges, and flakes of copper, verdigris, and lime moderately washed; sprinkle fissile alum levigated, or of unwashed wool, dr. iv; of dried grapes, dr. iv; of natron, dr. ij; having previously anointed with honey, sprinkle of flakes of copper, dr. x; of alum, dr. ij; and having softened in the sun with dr. x of wax, apply.
These are compound medicines. A plaster for chironia. Of ceruse, oz. viij; of fissile alum, oz. ij; of the flakes of copper, dr. ij; of sal ammoniac, of frankincense, of scraped verdigris, of pomegranate rind, of each, oz. ij; of quicklime, oz. j; of wax, lb. j; of myrtle-oil, lb. j. ss; triturate the dry things with wine. At first it removes callus; and it is laid by and kept, and at last when used, being softened with myrtle-oil, it cicatrizes.—Another: Of litharge, lb. j; of oil, lb. ij; of black chamæleon, of the roots of birthwort, of immature galls, of each, oz. j; of galbanum, of ammoniac perfume, of frankincense, of each, oz. ij; prepare, stirring with the roots of green reeds.
From Archigenes, for chironia, and malignant ulcers in the legs and breast, for struma, and parotis. Of the fat of an ox lb. iij; of turpentine, oz. v; of manna, oz. vij: of the earth called sarda which painters use, oz. v: having put the soluble and dry articles together and melted, use.—Another, of Archigenes: Of wax, oz. iv; of oil of unripe olives, of manna of frankincense, of diphryges, of the flakes of copper, of each, dr. iv; having triturated the powder with vinegar, and made of the thickness of honey, mix with the cerate, and use upon a pledget.—Another, for the malignant ulcers of women, and of other persons having a soft skin: Of Tuscan wax, dr. viij; of bulls’ fat, of turpentine, of burnt lead, and of pepper, of each, dr. j; use on a pledget with rose-oil or myrtle-oil.
Commentary. Celsus describes the chironian ulcer as being large, and having hard, callous, and swelled edges, with a copious discharge of thin sanies. It is attended with no inflammation, the pain is moderate, it does not spread, and therefore it is not dangerous, although not readily cured. Sometimes, he says, it becomes covered with a thin cicatrix, and then again the ulcer breaks out. It occurs mostly in the feet and legs. From this description it is evident that by the chironian ulcer Celsus meant merely an ill-conditioned ulcer, and that he distinguished between it and the cacoethes, or malignant ulcer, which last he held to be nearly allied to the carcinoma. However, most of the Greek authors apply the term malignant to the chironian ulcer. For the cure of it Celsus recommends an application consisting of squama æris, lead burnt and washed, calamine, wax, and a small quantity of roses.
Galen furnishes us with an account of the manner in which Thessalus the Methodist proposed to cure all chironian and malignant ulcers. Thessalus lays it down as a rule for the treatment of all sores which are difficult to cure, or which break out again when healed, to remove the exciting cause, whether local or constitutional, by means of proper alteratives. He adds: “In cases of chronic ulcers which cannot be got healed, we must remove the parts which prevent adhesion, and convert the sore into the state of a recent ulcer; and then having allayed the inflammation proceed accordingly. Those sores which heal up and break out again during their exacerbations, and when ulcerated, are to be cured like recent inflammations by soothing applications until the irritation subside, after which cicatrizing applications are to be used, and then the surrounding parts are to be covered with a malagma of mustard, or some other rubefacient and alterative, to remove the indolence. If this is not sufficient, we must attend to the general health, attempting to effect a change of the system by repeated exercise, gestation, a diet increased or diminished according to circumstances, and at the commencement by administering an emetic of radishes, or even the white hellebore.” (Galen, Meth. Med. iv.) Although Galen, who all along displays a strong hostility to the Thessalian asses, (so he calls the Methodists,) has animadverted in severe terms upon the rules here laid down, they would appear to be highly proper and ingenious. Galen in another place (Med. sec. gen. iv) gives from Asclepiades, Andromachus, and others, a great collection of applications for chironian, malignant, and indolent ulcers. One by Asclepiades consists of the scales of copper, scraped verdigris, wax, and larch rosin. Others by Andromachus contain sori, misy, chalcitis, verdigris, alum, turpentine-rosin, and the like, mixed with wax. Hippocrates directs us to treat a callous ulcer by applying to it septic medicines to make the hard parts slough off, after which the edges are to be brought together. (De locis in homine.)
The directions of Aëtius, more especially respecting the constitutional treatment, are highly important. In cases where there is a redundance of blood he recommends venesection, in others both purging and bleeding; and in certain cases he directs us to pay attention to the state of the liver and spleen. He relates a case of an ulcer on the hand, which he cured by opening a vein leading to it. He also directs us to scarify or cut off the callous edges of the ulcer. He gives various prescriptions for sores of this description, containing verdigris, sori, chalcitis, burnt copper, alum, &c.
Octavius Horatianus recommends a plaster consisting of equal parts of chalcitis, wax, and alum. For phagedænæ Pliny mentions an old shad-fish triturated with sandarach. (H. N. xxxii, 44.)
The Arabians treat of these ulcers very fully. Avicenna in particular gives very proper directions for the constitutional treatment. When the state of the ulcer is occasioned by an intemperament, it is to be corrected, and if the blood is deficient in quantity or quality, this is to be remedied by a proper diet; and when on the contrary it is connected with plethora, venesection is to be had recourse to, and if the veins leading to it are varicose, it may be proper to open them. When the sore is kept from healing by a spiculum of bone, we are to cut down and remove it. His applications consist of the same ingredients as those used by the Greeks, namely, the flower of copper, copperas, alum, ceruse, lime, arsenic, &c., mixed with wax and oil. The directions given by Rhases are less circumstantial, but to the same purpose. He particularly directs us to remove the callous edges by friction, scarifications, and septics. He speaks of turpentine as an excellent addition to other ointment. (Contin. xxviii.) He mentions that in case of malignant ulcer on the leg connected with varix, Galen opened the enlarged vein.
The cacoethes of Celsus was evidently the disease called noli me tangere by Theodoricus; a very absurd appellation, which however has been retained to the present day. Celsus has pointed out its resemblance to carcinoma, and recommended the only mode of treatment which ever does any good in these cases, namely, the application of septics, such as arsenic, quicklime, &c., or the actual cautery. As our limits will not permit us to enlarge further on this subject at present, we must be content with referring to No. 108 of the ‘Edinburgh Medical and Surgical Journal,’ where we have given a full exposition of the ancient principles of treatment. (See also the Commentary on s. xxvi of this Book.)
SECT. XLVII.—FOR BLACK CICATRICES.
Let the root of the white and black bryony be boiled in oil until they are reduced to the state of juice, and the oil applied will take away black scars; and so in like manner calamint boiled in wine, and litharge washed with white rose-oil. But the scars from lichen, and all other kinds are made like the other skin by anointing them with the fat of asses; or the seed of rocket triturated with the gall of a goat, of an ox, and of a sheep may be rubbed in with litharge; or a lamb’s foot burnt may be triturated with austere wine for the same purpose; or, ammoniac perfume may be rubbed in with swines’ gall. These are compound applications: Of litharge, of mint, of frankincense, equal parts with honey.—Another: of natron, of ammoniac perfume, of sulphur vivum, of myrrh, equal parts; having triturated with vinegar, white wine, or water, rub in but a very little, so as not to produce an ulcer.—Another: Of Cimolian earth, of pigeons’ dung, of soap, of frankincense, equal parts with vinegar. A detergent ointment for black scars: Of Cimolian earth, dr. xiij; of aphronitrum, dr. v; of white hellebore, dr. v; of the greasy dregs of nut-ben, dr. iv; scrub with it while in the bath.
Commentary. Avicenna condenses all the information contained in the authors who preceded him. He sets out with stating that the class of medicines which are applicable in such cases are the abstergents; of which he enumerates verdigris, stavesacre, the scales of copper, and even arsenic. Among the less active ingredients he mentions, like our author, the fat of asses. We need not give extracts from the other authorities, as no one has treated of this case so fully as Avicenna.
SECT. XLVIII.—ON SINUOUS ULCERS.
When the skin adjacent to an ulcer is not united with the parts below, we call such a complaint a sinus. When, therefore, the sinus extends upwards, the ichor readily flows out from the sore, and adhesion easily takes place; but when it extends downwards the ichor by remaining within corrodes the continuous parts, and unless you first make an incision for its discharge, you will be able to effect nothing; for the sores can neither be incarnated nor the parts made to unite. But if the sinus is in any of the limbs, as the arms or legs, one may produce adhesion without a counter-division by putting the limb in a declining position. Thus when the sinus is in the arm, and the mouth of the sore is near the elbow, by placing the hand in an elevated position, you will render the discharge from the ulcer below easy. And when the sinus is in the thigh, and has its outlet near the knee, you must make the position declining by putting a soft pillow below the back part of the knee, so that the groin may be in a lower position than the knee; and if the sinus does not require incarnation, forthwith by means of a straight and hollow pipe having a bladder attached to it, syringe it with honey so diluted with water that one could drink it, in order to clear away the ichor from the sinus. For promoting adhesion when about to take place, do it with wine, or wine and honey, and then proceed to the agglutinating medicine. But if the sinus being hollow requires incarnation, first inject a little of the composition from dried paper with much rose-oil, then plug up the mouth of it with charpie, and afterwards the plaster of iris, or of Machærion, or of some such, may be melted with liquid rose-cerate, and injected in like manner. If the sinus is moderately incarnated you may apply some of the agglutinating medicines, as if you were curing a case of recent bloody wound. Such are those called the barbarous, dichromos, and gilvus; and more especially that prepared from the oil of palma Christi and the metals without wax which is called the dun plaster of Galen, is applicable. After the application of the medicine, a recent sponge out of wine and honey, or wine alone, is to be put on particularly in a soft manner, and the bandaging is to commence at the bottom of the sinus and end at its orifice. The folds of the bandage should bind the bottom of the sinus firmly, yet so as not to occasion pain, but ought to be gradually relaxed towards its orifice; and the plaster which is put on should be so cut as to leave an opening at the orifice for the escape of the matter, but another small plaster of the same materials should be applied to it in a loose state, so as to favour the discharge. This is to be left on till the bandages are loosed, which is to be done on the third day, when they are to be taken off and changed, but the application along the sinus is to be left. You may judge whether the bottom of the sinus has adhered, from observing if the matter be small and well concocted, or if there be no discharge at all; and moreover if there be no sensible pain along the sinus nor swelling, but the whole part is contracted, dry, and free from pain. But if you see a little well concocted pus at the orifice, you may still more confidently entertain good hopes. If on the second or third day a thin ichor be discharged from the sinus, you need not despair that adhesion has taken place, for often the strength of the medicine squeezes out from the parts below a thin fluid, which being discharged the parts become dry and adhere. But if on the third or fourth day from the commencement the matter appear unconcocted as it runs from the opening, you may be sure that the sinus has not adhered, and you must persevere with the same application. When owing to the moisture of the part it falls off, as is not unlikely, it will not be improper to make some change in the medicine itself.
On sinuous ulcers with a thin covering of skin. When the abscess is too long opened, owing either to the unskilfulness of the surgeon, or the timidity of the patient, the skin which lies over it becomes thin and ragged, and it cannot be removed, then after the syringing which has been described, we must have recourse to an agglutinating application of a humid consistence, but of desiccative properties, such as that from chalcitis called phœnicinum, diluted with old oil, so as neither to be very hard nor of such a consistence as not to stain the finger; and afterwards it is to be mixed with moderately old wine, and applied in a circular form with corresponding bandaging. To skin in this ragged state honey, as was said, is not one of the least proper applications when boiled to the consistence of a plaster and applied. It will be better, however, if after spreading it on the rag you sprinkle over it from a sieve some myrrh finely pulverized, or aloes, or frankincense, or all of these together. I have also found the lesser centaury a wonderful application for the same purpose; next to it is comfrey, after which is the root of the Illyrian iris, and after these is the flour of tares. Sometimes during the process of boiling we sprinkle these upon the honey when the vessel is about to be taken off from the fire. It is better, however, to do so after it is taken off, and then it is to be stirred about, and when it becomes tepid applied to the sinus, and bandaged as aforesaid.
Commentary. Similar directions are given by Galen and Aëtius, but upon the whole those of our author are superior; and as those of the other two supply no additional information, it will be unnecessary to multiply extracts from them. (See Galen, Therap. ad Glauc. ii.)
Actuarius, in like manner, briefly directs that unless the sinus open downwards, it shall be cut open and dressed with an agglutinative application. You may think well of the case, he adds, when the part is dry and free from pain, or when only a little well-concocted pus is discharged from it.
In the translations of the Arabians, the sinus is described by the names of absconsio and caverna. Avicenna states that the sinus differs from the fistula in having a larger cavity, and its edges not being indurated. He lays down very correct rules of treatment, but they are all copied from Galen. Thus he directs, when the orifice of the sore is above the cavity of the sinus, that it should be cut open; or, if this cannot be conveniently accomplished, he recommends us to introduce a tent smeared with some incarnant or detergent application. Upon the authority of Dioscorides he recommends the lesser centaury in such cases. His directions for the application of the bandages are similar to those of our author.
Celsus, and other of the ancient authorities, do not treat of the sinus separately from the fistula.