Chapter VI: Book 6: ) The incision is to be made long and narrow, and if any putrid (2)

Our author’s description of cancer is abridged from Galen (de Tumor. l. c.) The treatment is derived from the 14th Book of the ‘Meth. Med.’ He recommends melanogogues to remove the material cause of the disease. In external applications he places little confidence, but prefers those prepared from metallic substances which have been burnt and washed. The only chance of a radical cure consists, he says, in making a complete excision of the part; but in doing this he forbids us to secure the arteries with ligatures, as they will occasion a recurrence of the disease. The part, he says, is loaded with a thick, black, or recrementitious blood. When the cancer is ulcerated, he disapproves of cutting and burning.

Celsus describes carcinoma as an immovable and unequal tumour, attended with swelling of the veins, which are pale or livid. His account of the treatment is so important that it deserves to be given in his own words: “Quidam usi sunt medicamentis adurentibus; quidam ferro adusserunt; quidam scalpello exciderunt: neque ulla unquam medicina profuit; sed adusta, protinus concitata sunt, et increverunt donec occiderent; excisa, etiam post inductam cicatricem, tamen reverterunt, et causam mortis attulerunt: cum interim plerique nullam vim adhibendo, qua tollere id malum tentent, sed imponendo tantum lenia medicamenta quæ quasi blandiantur, quo minus ad ultimam senectutem perveniant, non prohibeantur.” In another place, however, he recommends compositions containing arsenic, copperas, cantharides, galls, &c. (v, 22.) He makes a distinction between the _cacoethes_, or malignant tumour, and the true carcinoma, but says that the difference between them is to be recognized only “tempore et experimento.” He marks the gradations of malignant disease with singular precision: first, there is cacoethes; then carcinoma without ulceration; and last, there is the fungated ulcer. (The reading in the edition of Milligan is a great improvement.) In doubtful cases he directs us, first to apply caustics or heating medicines, and, if the disease is alleviated, to proceed to the scalpel or burning, according to circumstances; but if it is exacerbated, we are to conclude that it is of a carcinomatous nature, and must abstain from all acrid and vehement applications.

Scribonius Largus recommends for all malignant ulcers, even such as are cancerous, an application consisting of arsenic, p. vj; of squama æris, p. iij; of elaterium, p. j; of burnt paper, p. iij.

Aëtius gives from Archigenes and Leonidas an interesting account of the disease, which he divides into ulcerated cancer, and cancer without ulceration. He describes the disease in the female breast as consisting of a large tumour which is unequal and resisting, extending its roots far, and being attended with varicose veins: its colour is either cineritious, verging to redness or livid; it appears soft, but is in reality very hard; is accompanied with a pungent pain, and gives rise to malignant phlegmons in the armpits. The pains shoot to the clavicle and scapula. An ulcerated cancer, he says, goes on corroding and spreading deeper, nor can it be stopped; it discharges a sanies of an abominable smell, and is aggravated by medicines and handling. The disease he considers as generally incurable. His surgical treatment will be stated in the Sixth Book. He recommends purging with hiera and the theric, Mithridatic antidote, &c. Apparently, in order to mitigate the violence of the pains, he directs us to make an application containing equal portions of plantain, poppy heads, the seed of the wort, and other things of the like kind. For ulcerated cancer he recommends emollient epithemes, such as the one containing litharge, axunge, white wax, oil, and the yelks of eggs.

Oribasius and Actuarius supply nothing of importance that is not to be found in our author. Nonnus, according to Sprengel, is the only ancient author who attributes cancerous ulcerations to acrimony of the bile. But Nonnus merely copies the words of our author.

The Arabians agree with the Greeks in representing the disease as being produced by black bile. They were, no doubt, led to form this opinion from remarking that the blood in the part is thick and black, which they considered owing to its not being properly purged of its recrementitious sediment. The moderns deride this theory, but they have substituted nothing satisfactory in its stead. Van Swieten thinks more favorably of the ancient doctrines. (Comment. § 485.) Avicenna speaks highly of a milk diet. Serapion likewise approves of milk deprived of its butter, and of a vegetable diet. He speaks of no other treatment as being likely to prove remediable, with the exception of excision and the cautery. Haly Abbas rather approves of excision when the disease is seated in a part which admits of this operation. However, like Galen, he disapproves of tying the arteries. The characteristic symptoms of the disease, he says, are a stony hardness and distension. The account given by Alsaharavius is nothing different. Rhases has little confidence in excision. After ulceration has taken place he approves of using a cooling application, containing ceruse, tutty, rose-oil, the juice of nightshade, and some other such things of a cold nature. He mentions a case of cancer of the breast, in which the whole mamma was extirpated, but the disease returned on the other side. One of his authorities, Antyllus, describes the cancerous sore as having a tendency to spread inwards, its edges being thick, large, and everted, and the discharge thin and acrid. When the disease cannot be got completely extirpated, he forbids us to meddle with it.

Theodoricus and all the earlier modern writers on medicine, call the cancer by the name of apostema melancholicum, and recommend the same treatment for it as the Greeks and Arabians.

SECT. XXVII.—ON ŒDEMA.

Having treated of swellings formed by hot humours, we shall now treat of those from the opposite, beginning with the œdema. For as erysipelas is formed by a bilious humour, so is œdema by a pituitous, being a loose swelling devoid of pain. We are aware also, that œdematous swellings occur in the feet, in dropsical affections, in phthisis, and in cachexia, but in them the œdema is a symptom of the complaint under which the person is labouring, and requires no very particular treatment; for it will be sufficient in general to rub the limbs sometimes with vinegar and rose-oil, and sometimes with oil and salts, or the salts may be added to the vinegar and rose-oil. When the œdema is occasioned by a pituitous humour being determined to the part, a sponge soaked in oxycrate may be properly applied with a bandage loosely put on, beginning below and terminating above. The sponge ought to be new, but if such a one is not at hand, that which is may be cleaned with natron, or more especially with what is called strained lye. If the swelling do not thereby subside, we may mix some alum. And a very convenient application is a tender wick of a lamp, soaked in such a fluid, and applied. A good remedy also is horned poppy. When the œdema has become chronic, having first anointed the part with oil, and then applied a sponge out of lye, bind it firmly, and you will effect a cure. Every kind of earth discusses and represses œdematous swellings, more especially the Ægyptian, and also the matured woad.

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COMMENTARY. See Galen (ad Glauc. ii; de Tumoribus); Aëtius (xv, 1); Oribasius (Morb. Curat. iii, 51); Leo. (vii, 5); Actuarius (Meth. Med. iv, 16); Nonnus (251); Serapion (v, 23); Avicenna (iv, 3, 2); Haly Abbas (Theor. viii, 11; Pract. iii, 30); Alsaharavius (xxix, 13); Rhases (ad Mansor. vii, 12.)

Our author’s account of this disease is taken from Galen, Oribasius, Aëtius, and, in fact, all the Greek, Latin, and Arabian authorities adopt his views, without any material alteration. They all concur in recommending cooling and astringent applications, with suitable bandages; and, in certain cases, friction. Rhases recommends that the limb should be buried in heated sand. He also approves of various cooling and astringent applications with bandages. In the translation of Alsaharavius, the œdema is described by the name of _apostema flegmaticum_; in those of Avicenna, Haly Abbas, and Serapion, by that of _undemia_. The celebrated Paracelsus used the term undemia for œdema. In some late works we have seen it stated that the undemia was a species of erysipelas, but this is evidently a mistake.

SECT. XXVIII.—ON EMPHYSEMA.

Emphysema is formed by a flatulent spirit, collected sometimes under the skin, sometimes under the periosteum, or the membranes which surround the muscles. And it is also sometimes collected in the stomach and intestines, or between them and the peritoneum, in those kinds of dropsy which are called tympanitic; and it differs from œdema in this, that the parts do not pit upon pressure like it, and that it sounds like a drum. The density of the body co-operates in preventing the flatus from being dissipated, at the same time that the flatus also is of a thick nature. Wherefore, the indication of cure is to rarefy the body, and attenuate the thick air; which is to be accomplished by means of attenuant and heating remedies. When the complaint is seated in the stomach and intestines, this is to be brought about by a fine oil, having rue, cumin, or parsley seed boiled in it. And sometimes a large cupping instrument without scarificators, applied two or three times to the navel, will discuss it. When the muscles from contusion are inflated, so as to sound like an emphysema, the parts will not bear very heating and acrid applications. Wherefore, at the commencement, we must use paregorics liberally, and, when the disease is on the decline, discutients. Thus we may use sodden must with a small quantity of oil, applying them warm upon unwashed wool, or mixing the cerate of unwashed wool. And we must take care that the heat be preserved, for it is not expedient that the part be cooled. When the patient has been soothed, we are to mix vinegar and nitre or aphronitrum, and afterwards some lye; and lastly, we may use discutient plasters, for the removal of the complaint such as the following: having boiled the sordes of the oil used in baths, strain it first, so that it may become pure, and again throw it into the pot, and having triturated slaked lime like flour, sprinkle until it become of the consistence of clay, and use. A still more effectual application is the compound medicine from sycomores.

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COMMENTARY. See Galen (Meth. Med. xiv); (Therap. ad Glauc. ii); Aëtius (xv, 2); Oribasius (Synop. vii); Actuarius (Meth. Med. ii, 12); Nonnus (252); Scribonius Largus (§ 119); Avicenna (iv, 3, 2, 20); Serapion (v, 23); Alsaharavius (Pract. xxix, § 1, 14); Rhases (Divis. 127, Cont. xxvii.)

Our author has copied closely from Galen. The great indications of cure, as laid down by him and acknowledged by all subsequent authorities, are to rarefy the containing parts and attenuate the spirit. By _spirit_, as we stated in another place, the ancients meant a thick air or gas. The indications which we have mentioned are best fulfilled by friction with oils, in which calefacient medicines, such as cumin, parsley, anise, and the like, have been boiled. When, however, any inflammation is suspected, he properly forbids us to use acrid or heating medicines. When the pain of the bowels is violent in cases of tympanites, he allows medicines containing opium, which are to be given by the mouth if the small intestines be affected, but are to be administered in a clyster if the large intestines be the seat of the disease. When the disease is in a muscular part, he directs us to use a combination of attenuants and emollients. In certain cases he recommends dry-cupping. Oribasius, Aëtius, Actuarius, and Nonnus, adopt the views of Galen, without any alteration.

For tympanites, Scribonius recommends cumin internally.

Avicenna, like our author, in ordinary cases recommends combinations of attenuants and calefacients, dry-cupping and the like, for dispelling the spirit; but when the disease arises from contusion of the muscles, he directs us to use resolvents and paregorics. Serapion approves of similar treatment. Alsaharavius recommends attenuant and calefacient remedies externally and internally. In the translation of his works, the disease is called inflatio. Rhases recommends friction with calefacient oils; he remarks that the disease occurs most commonly in the stomach and intestines. He calls it by the name of apostema inflatum.

SECT. XXIX.—FOR SPRAINS AND CONTUSIONS.

Sprains of the joints and contusions are remedied by unwashed wool, or a sponge soaked in vinegar and oil, and applied; by the tender parts of boiled bulbous roots with honey, by the leaves of the chaste tree, salts, and roasted nitre, triturated with cerate. The affusion of sweet water, or of hot sea water, may be used. But after the inflammation and pains have subsided, apply rubbing to the sprained parts.

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COMMENTARY. See Aëtius (xiv, 71); Oribasius (Synops. vii, 14); Actuarius (Meth. Med. ii, 35); Scribonius Largus (§ 209); Rhases (Divis. i, 140.)

Aëtius makes mention of all the remedies recommended by our author, with the exception of the affusion of water; which, however, is a method of treatment deserving of attention. Oribasius mentions particularly the affusion of hot sea water. Scribonius Largus recommends a plaster containing litharge, alum, ærugo, ammoniac, &c. Rhases directs us to use attenuant ointments, sedative plasters, and loose bandages, with rest.

SECT. XXX.—ON CONTUSIONS OF THE FLESH AND ECCHYMOSIS.

The flesh being bruised by some weight falling upon it, and the small veins in it being ruptured, blood is poured out from them by exhalation, and collecting under the skin, is called ecchymoma. When the skin is not divided, a soft yielding tumour is the consequence; it is pale, and for the most part unattended with pain. Our object, therefore, is to discuss the contained blood, and that quickly, before it become black; and at first, astringents are to be mixed with the discutients, because the bruised coats of the veins stand in need of condensation. After these things, we must use those applications which are merely discutient without astringency. And by scarifying the ecchymomata at the commencement, we may thus apply the subsequent treatment. For chronic cases of ecchymoma, radish in the form of a cataplasm is a suitable remedy, but it must be taken away when it becomes pungent; or a cataplasm of the juice of radish with crumbs of bread, may be applied. The diseases called hypopion and hyposphagma, are species of ecchymosis, and also the effusion of blood below the nail from a blow; of these, the first two are treated of in their proper places in the Third Book; and the affection of the nail will be handled in the Surgical part of the work.

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COMMENTARY. This is taken almost word for word from Oribasius (Synops. vii, 14); Aëtius directs us to scarify the part affected with ecchymosis, and then to apply to it the inside of citrons (xiv, 68.)

Avicenna approves of scarifications, provided the extravasated blood cannot be got otherwise removed. (iv, 4, 2, 3.)

SECT. XXXI.—ON RUPTURE AND TEARING OF THE FLESH.

Rupture is altogether attended with ecchymosis. It is cured by medicines which are moderately heating, as the acopon from black poplars, and such as resemble it. But when the rupture is deep-seated, we must have recourse to such remedies as are more acrid and cutting. The use of the cupping instrument is likewise beneficial to them. Should therefore the whole ecchymosis be discussed, the separated flesh readily unites; but if it continue a long time, and sordes form under it, the ruptured flesh can no longer unite; and we must only apply the lips together, so that a small occasion may readily separate them, and that the intermediate space may be filled with some moisture, and in a certain manner an ecchymosis may be formed as at the commencement, except that it is sooner discussed, as containing a thin humour, whereas that at the commencement was formed of blood. Vulsion takes place when certain fibres are torn asunder, and it only requires soothing applications until the pain is removed; for they cannot be made to coalesce. Wherefore, the round birthwort, if any, is a convenient application to ruptured and torn parts; and in like manner, the root of the large centaury, and the juice of it, rhubarb, costus, and bdellium, drunk with oxymel.

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COMMENTARY. These remarks are taken from Aëtius (xiv, 69, 70); or Oribasius (Synops. vii, 14); and they are copied by Nonnus (Epit. 254); and Actuarius (Meth. Med. iv, 16.)

The Arabians treat these accidents upon exactly the same principles. See in particular Avicenna, as quoted in the preceding section.

SECT. XXXII.—ON SCIRRHUS.

Genuine scirrhus is a preternatural swelling, hard and devoid of sensibility; but that which is not genuine is only attended with diminished sensibility. That which is wholly insensible, then, is utterly incurable; but that which is attended only with diminished sensibility is not incurable, and yet it is not easily cured, for it is occasioned by a viscid and thick humour, which is fixed in the hardened parts, so as to be difficult to get discharged. Sometimes, then, the scirrhus is the original complaint, and goes on to increase; but for the most part, it is occasioned by the physicians applying too cooling and astringent remedies to erysipelas and phlegmon.

If one, therefore, apply strongly discutient medicines to indurations of the body, one will indeed produce a visible diminution of the scirrhus in a short time, but will leave the remainder of the complaint in an incurable state; for the thin moisture being dissipated, what remains is rendered dry and hard as a stone. The discutient application, then, ought to be in a certain degree emollient, without possessing manifestly heating and desiccant qualities. Such are all kinds of marrow, more especially that of a stag or of a calf, and the grease of a lion, of a panther, or of bears, or of a bull, and among birds, that of geese, of domestic fowls, or of pheasants: but that of bucks and he-goats is drier. And to these may be added, ammoniac perfume, bdellium, more especially the Scythian, the humid and fatty storax, and the Egyptian mastich. To all other parts of the body, when in a scirrhous state, these things may be applied singly, and in composition; but for tendons and ligaments, we are to dissolve in the strongest vinegar some stone that has been heated in the fire. If possible, the one to be used should be pyrites, or if not it, the lapis molaris or millstone. In this, therefore, the affected part is to be moved, so that it may receive the vapour which arises from it; and afterwards, an emollient medicine is to be applied. A thin oil then, and not water, is to be poured on the part, by all means once a day, and sometimes one may boil in the oil the root of marshmallows, or of wild cucumber. The patients ought to abstain from the use of the bath, at least from the frequent use of it. But when the scirrhus is moderately softened, the softest ammoniac is to be dissolved in very strong vinegar, and the part rubbed with it for several days in succession; after which, we must again have recourse to an emollient application, having the fattest galbanum and opoponax added to it. Such are that from bacon, that ascribed to Amythaon, and those which we are about to describe for scrofula.

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COMMENTARY. See Galen (De Tumoribus; Meth. Med. xiv; Therap. ad Glauc. ii); Oribasius (Synops. vii, 34); Aëtius (xv, 3, 4); Leo (vii, 4); Actuarius (Meth. Med. iv, 16); Serapion (v, 23); Avicenna (iv, 3, 2, 12); Haly Abbas (Pract. iii, 31); Alsaharavius (xxix, 1, 15); Rhases (Antid. i, Cont. xxvii, Antidot. i.)

This section is entirely taken from Galen (Ther. ad Glauc. l. c.) Galen’s account, however, is somewhat fuller than our author’s, and contains a case treated upon the principles which he lays down. It was a case of hard swelling in the thigh, arising from an erysipelas which had been improperly treated by astringent and cooling applications. Galen informs us that he began by pouring upon the limb an attenuant oil, namely, the Sabine; after which he caused it to be rubbed with marrows and fats medicated with bdellium, mastich, ammoniac perfume, and the like. After this he bathed the whole limb with a solution of ammoniac in very acrid vinegar. When the swelling had been lessened, but not completely removed by these means, he afterwards applied one of the pitch medicines, and at length effected a cure. In another place he states that scirrhus is sometimes allied to cancer.

Oribasius likewise recommends a combination of emollients with discutients; and Actuarius approves of the same practice.

Aëtius has a valuable chapter upon this subject. Besides the articles mentioned by our author, he recommends various rosins, turpentine, frankincense, and the like. He forbids the use of aluminous, sulphureous, and chalybeate baths. For indurations of tendons he recommends things possessed of attenuant and cutting properties combined with emollients, such as ammoniac dissolved in vinegar with melons.

The Arabians treat of scirrhus in much the same terms as the Greeks. Avicenna properly directs us to bleed when there is congestion of black blood in the part, and afterwards to use applications of a solvent and emollient nature. He and Serapion mention the same identical remedies as those of Paulus. For dissolving hard tumours he recommends an oil containing fenugreek, cyperus, and aromatic reed. Haly Abbas ascribes the formation of scirrhus to the same causes as our author, and recommends relaxant and emollient applications. Alsaharavius directs us to procure evacuations of black bile, and gives prescriptions for various emollient and discutient applications. When the usual remedies do not succeed, he advises recourse to be had to the operation. Rhases divides scirrhus into two varieties, that accompanied with sensibility, and that which is insensible. He mentions that Antyllus approved of extirpation and the actual cautery when the disease is of a corroding and cancerous nature.

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.