Chapter XXX: Part 30

It is a common direction, applicable both to the man and the woman, to preserve the whole body in a proper temperament, by exercise, food, baths, and everything else in moderation. What is most especially to be attended to is, not to allow them to get into a fat habit of body; for fat persons are unfit for the propagation of children, owing to the want of agreement in their genital organs, and because they do not emit much semen. Nor are those who are much emaciated more so. All things which are heating and moderately flatulent assist, such as taking heating wine in moderation; and of pot-herbs, the rocket, clary (_horminum_), hedge-mustard, and the like; but they must, by all means, abstain from calamint and rue. When conception will not take place, owing to some cacochymy, we must purge it away, or dilute it by a proper diet. But women must attend particularly to the state of the uterus, and that the menstrual evacuation be not obstructed. When, therefore, the monthly purgation is near, the woman must attend particularly to take food and drink in moderation, and also some of those things which promote the discharge, such as the fragrant and acrid pot-herbs, as scandix, samphire, fennel, parsley, and alsander. And the intemperaments of the womb must be rectified. Wherefore the cold intemperaments of the uterus are indicated by retention of the menses, a cold and incrassating diet, and some torpor about the pubes, loins, and legs; and these persons, if they become perfectly congealed in habit, have no venereal desires at all. Wherefore we must endeavour, in every other way, but particularly by all kinds of fomentations, and by fumigation with aromatics, to recall the natural heat. And it will not be at all improper to drink of castor and of some of the aromatic seeds, such as cumin, anise, the flowers of pennyroyal, and the fruit of junipers, mixing some pepper with each. Fumigations of the womb may be applied either by sitting on a proper chair, and receiving the vapours which arise, or by injections of hot water in which sage, mugwort, rue, cumin, pennyroyal, sweet flag, and the aromatic seeds have been boiled. A cataplasm of any of them may also be applied to the lower part of the belly. The epitheme of Polyarchus is also appropriate. Frictions of the lower part of the belly and nates are no less proper. The woman may also use pessaries of myrrh, rue, galbanum, and castor, having previously fomented with honied water or salt water. The pessary called Goné is also an excellent one. Warmer intemperaments of the uterus are indicated by the whole body being hotter than usual, by the menses being voided in small quantity and with pain, and by the privy parts of the woman being ulcerated. They are to be remedied by such things as are moderately moistening and cooling, such as the pot-herbs, lettuces, mallows, blite, gourd, cucumber, pompion, orach, and purslain, and by the other articles of food of a like nature; and we must apply to the bladder, abdomen and loins, all cooling things, such as cataplasms and liniments made of the juices of herbs. If the woman cannot conceive owing to humidity of the uterus, it is indicated by there being much moisture of the parts during the venereal act, and by the menses being thin and in great quantity. A desiccative diet, therefore, suits with these cases; also exercises and frictions of the upper parts; emetics and dry food in moderate quantities. It will likewise answer well to strengthen the uterus by austere medicines, such as the decoction of lentisk, of myrtles, of roses, and of sumach; or also by that of pomegranate flowers, of the tender shoots of bramble, and of galls. When the uterus is drier than common, it is to be cured by the opposite remedies, I mean by baths and unguents, a moistening diet of pot-herbs, wine in moderation, and that not very old. But if conception be prevented by thick humours, and if they be of a pungent nature, the woman must be purged in a way suitable to each humour, and more particularly with the picra from aloes; then an injection with the whey of women’s milk is to be administered, and a more suitable diet thought of. Pituitous humours are to be evacuated by exercise, sudorifics and emetics, or downwards by the bowels. The following medicine may be given: Of dodder of thyme, of euphorbium, of pepper, of carrot-seed, of the seed of Macedonian parsley, equal parts; triturate all together, and give to the amount of two drachms to drink. This purges well and heats the womb, so that it often makes the menses flow in cases where this discharge was stopped. As soon as this correction has become apparent, and the menses flow properly, then one must enjoy the woman as soon as the menstrual evacuation stops. When flatus in the womb prevents conception, the symptoms of which may be recognized from what we have said on inflation of the uterus, it is to be cured first by a spare diet, and administering cumin, dill, parsley-seed, and that of rue and anise; and by giving many of the aromatics, some to drink and others by pessaries. When the mouth of the uterus is shut up, it must be opened by injections of aromatics, and by using fomentations from mallows, linseed, fenugreek and oil, and sometimes of honey; or, by the stronger ones, composed of mugwort, fleabane, calamint, pennyroyal and chamomile. In addition to these we may use turpentine, nitre, wild cucumber, elaterium, cassia, and tar-water. When the mouth of the womb gapes, the diet, fomentations and medicines should be of a desiccant nature and astringent; and the flowers of pomegranates, lentisk, the roots of brambles, myrtle-berries, and those things applicable for a humid intemperament. Distortions of the uterus are to be rectified by fomentations and emollient pessaries. In such cases, coition _a posteriori_ would seem to promote conception.

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COMMENTARY. Hippocrates, in his ingenious work on Sterility, assigns the following causes for a woman’s not conceiving: First, because the os uteri is turned obliquely from the passage to it. Second, because the inside of the uterus being too smooth, either naturally or in consequence of the cicatrices of ulcers, it will not retain the semen. Third, when, owing to suppression of the menses, any obstruction takes place about the os uteri, it is apt to prevent impregnation. Fourth, when menstruation does not take place, the veins of the uterus become so gorged with blood that they do not retain the semen; or, on the contrary, the same effect may arise from profuse menstruation whereby the retentive faculty of the vessels is weakened; or a return of the menstrual fluid in too great quantity may wash away the semen. Fifth, prolapsus uteri, by rendering the mouth of the womb hard and callous, prevents impregnation. The treatment is delivered at so great length that we cannot venture even to give an abridgment of it.

Aëtius treats very fully of sterility, but his views are much the same as our author’s. See also Oribasius (Synops. ix, 45.)

In cases of sterility, Octavius Horatianus directs us to ascertain whether the os uteri be turned aside or shut up. He delivers the treatment of these cases with singular minuteness. His principal remedies are pessaries, which of course are composed of various ingredients. We shall give the composition of one of the simplest of them in his own words: “Nullo etenim remedio meliore et magis innoxio, aut corrigi matrix poterit, aut purgari, quam usus nitri suppositione.” That is to say, a suppository of soda is one of the safest and most effectual remedies.

Serapion, like Aëtius and Paulus, regulates his treatment entirely upon the principle of correcting the intemperaments, which he considers as the most common causes of sterility. A humid intemperament, he says, occasions sterility in the same manner that wet ground proves injurious to seed which is sown upon it; and a hot intemperament dries up the semen as the earth scorches the seed during the heat of the dog-days. Such being his ideas of the causes of sterility, one can readily comprehend his principles of treatment. Avicenna, Rhases, and Avenzoar likewise direct their attention to the correction of the intemperaments, but also recommend attention to any other local complaint about the genital organs. Haly Abbas, among other remedies, directs us to correct the state of the uterus by means of stimulant fumigations. One of his prescriptions contain arsenic. This would prove a potent but dangerous application. Alsaharavius expresses his distrust in the virtues of many specifics which had long retained celebrity for the cure of sterility. Like the others, he directs us to find out the cause of it, and remove it if possible by suitable remedies.

Plutarch thus enumerates the causes which had been supposed to explain why a woman does not conceive after every act of coition. Diocles, the physician, maintained that it is either because no semen has been emitted, or less than necessary; or because it does not contain the prolific principle; or from a deficiency of heat, coldness, moisture, or dryness; or from relaxation of the uterus. The Stoics held that it is from the obliquity of the penis, so that it does not project the semen straight forward; or from the disproportion between the genital members. Erasistratus taught that it is occasioned by callosities and fleshy excrescences; or from the uterus being more spongy or smaller than natural. (De Placit. Philos. v, 9.) The causes of barrenness are fully and ingeniously treated of in the tenth book of Aristotle’s ‘History of Animals,’ which, however, is of very doubtful authenticity.

SECT. LXXV.—ON FISSURES, CONDYLOMATA, AND HEMORRHOIDS OF THE UTERUS.

Fissures occur about the mouth of the uterus from difficult parturition, and at first they escape notice while the pains from the labour are recent; but afterwards they are slightly felt, either upon manual inspection or during coition, when they bleed, owing to the friction. They are also discovered when the vagina is distended, for ruptures in the circle of the mouth are perceived. In these cases all surgical aid, and medicines of an irritating nature, must be avoided, and recourse had to the simpler hip-baths and pessaries. The medicine called Tetrapharmacon diluted is befitting. But if it be callous, we must use that from paper, with rose-oil. If they cannot bear the strength of it, mix Illyrian iris with turpentine, and apply it. When the ulcers are cicatrized, it will be proper to use the medicine from cadmia, or some of the applications to the anus, such as that from litharge. It sometimes happens that these fissures, becoming chronic, are converted into condylomata, in which case the callus is to be removed by similar remedies, and the condylomata cicatrized. Hemorrhoids form about the mouth and neck of the uterus, which will be discovered by the speculum; for eminences may be detected which, during the exacerbations, are painful, bloody, and red, but, during the remissions, are wrinkled, free from pain, somewhat livid, and emit a slight discharge. If possible, therefore, in these cases, one must seize upon them during the remissions with a forceps and cut them out; or if not, we may touch them with astringent medicines, sometimes applying dried pomegranate-rind with galls, or something such; and sometimes using those recommended for hemorrhages of the uterus, which will apply both for fluxes and hemorrhoids. These are recognized by the uterus discharging blood constantly, or if at intervals, not in the menstrual period.

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COMMENTARY. This section is mostly compiled from Aëtius (xvi, 97, 107.) The astringent applications recommended by Aëtius contain alum, pomegranate-rind, ceruse, litharge, burnt lead, hypocistis, &c. For condylomata, the Pseudo-Dioscorides recommends an application containing arsenic. (Euporist. ii, 218.)

Avicenna and Rhases give a similar account of these complaints. They direct us to apply to hemorrhoids either such astringents as those directed above, or to remove them by a ligature. Haly forbids caustic medicines, as they may prove injurious to the uterus; and prefers extirpating them by a surgical operation. For fissures he directs us to use basilicon, with the fat of a duck or hen, and oil of violets, along with pitching and cataplasms. Alsaharavius directs us to extirpate hemorrhoids by an operation; and when the basilicon ointment does not succeed with the condylomata, to treat them similarly. As the ancients have not described polypus uteri by name, we are inclined to think that they must have comprehended it and all the other tumours about the uterus under the general appellation of hemorrhoids.

SECT. LXXVI.—ON DIFFICULT LABOUR.

Difficult labour arises either from the woman who bears the child, or from the child itself, or from the secundines, or from some external circumstances. From the woman in labour, either because she is gross and fat, or because her whole womb is small, or because she has no pains, or is affected with fear, or because the uterus or some other part is inflamed or otherwise diseased, or because, from some natural weakness, she is unable to expel the fœtus, or because the labour is premature. From the child, either because it is too large; or small, and of little weight; or from its having a hydrocephalous head; or from being a monster, such as having two heads; or because it is dead; or, although alive, because it is weak and unable to advance outwards; or because there happens to be several children, as Herophilus relates a case of five; or because the position is preternatural. For the natural position of the child is, first, when its head presents with the hands bent upon the thighs, and having its head directly applied to the mouth of the womb; and next to that, when it descends by the feet, and there is no turning aside. All the other positions except these are preternatural. Or from the secundines, either because the membranes cannot be torn, owing to their thickness; or because they have been torn prematurely, owing to their thinness; for when the waters are evacuated unseasonably, the fœtus gets out with difficulty, from the dryness of the parts. From external circumstances, either from cold contracting or immoderate heat dissipating the powers, or from some accidental occurrence. Wherefore, if the difficulty of parturition arise from constriction, and, as it were, impaction of the fœtus, we must first endeavour to produce relaxation by injecting frequently hot sweet-oil with the decoction of fenugreek, of mallows, of linseed, or with eggs, as a paregoric. Then we must apply cataplasms to the pubes, abdomen, and loins, of linseed, or of honied water, or of oil and water; and use hip-baths of a similar nature. We must also avail ourselves of the relaxation produced by baths, if neither fever nor any other cause prohibit; and the woman is to be moved on a couch in a moderately warm air. Some have had recourse to powerful shaking, and have applied sternutatories. If the woman be in low spirits, she is to be encouraged; and if she is inexperienced in labour, she is to be directed to keep in her breath strongly, and to press down to the flanks. If she be in a swoon, she is to be resuscitated by such strong-smelling things as are not stimulant; and when moderately recovered, she is to be supported with a little food. A woman that is fat is to be placed in bed in a prone position, bending her knees upon her thighs, in order that the womb, being carried to the abdomen, may present with its mouth direct. By means of the fingers the mouth is to be smeared with cerates or fatty substances, and gently dilated. And if there be any complaint in the parts, it must be previously attended to; and hardened fæces when retained must be expelled by an emollient clyster. The membranes may be divided either by the fingers, or by a scalpel concealed within them, the left hand directing it. And some of the fatty liquids may be thrown up into the uterus by a syringe. When the fœtus is in a preternatural position, we may restore the natural position, by sometimes pressing it back, sometimes drawing it down, sometimes pushing it aside, and sometimes rectifying the whole. If a hand or foot protrude, we must not seize upon the limb and drag it down, for thereby it will be the more wedged in, or may be dislocated, or fractured; but fixing the fingers about the shoulders or hip-joint of the fœtus, the part that had protruded is to be restored to its proper position. If there be a wrong position of the whole fœtus, attended with impaction, we must first push it upwards from the mouth of the womb, then lay hold of it, and direct it properly to the mouth of the uterus. If more than one child have descended, they are to be raised upwards again, and then brought downwards. Everything is to be done gently, and without pressure, the parts being smeared with oil. The time for placing the woman on the stool is when the mouth of the womb is open and meets the finger, and when rupture of the membranes is at hand. If, owing to the death of the child, or any other cause, it do not advance, we must proceed to embryotomy.

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COMMENTARY. Hippocrates has treated fully of Difficult Parturition in the first book of his treatise ‘de Morbis Mulierum,’ from which we shall select a few remarks to give the reader some idea of his practice in these cases. When the child presents doubled at the mouth of the womb he directs us to push it upwards, and rectify the position so that the head may come down. When a hand or foot of a living child protrudes, it is to be pushed up in like manner, and the head made to present. When the leg or arm of a dead child protrudes, it is best, he says, to proceed in the same manner if possible; but otherwise they are to be amputated at a joint and the head opened. The process of opening the head is minutely described by him. He advises us likewise to open the chest when any difficulty of delivering it is experienced. When in feet presentations the head is retained after the body is delivered, he advises us to introduce a hand between the os uteri and the head and deliver it. When the secundines are retained, he orders us to extract them slowly, and for this purpose directs that the woman being placed on a stool, the child not having been separated is to be allowed to hang down, so that by its weight it may produce separation; and, lest its weight should occasion too strong pulling, he advises it to be laid on wool, or bladders filled with water, which being perforated, the child shall sink down gradually and draw away the placenta. We shall have occasion to treat of this practice further in the Sixth Book.

Aristotle states that delivery takes place naturally by the head, but sometimes preternaturally by the feet. (H. A. vii, 7.)

Celsus directs us when the child is dead, to introduce the hand, finger by finger, into the womb, and examine the presentation, which will be the head, the feet, or the body laid transverse. He states that the object of the operator is to bring down the body either by the head or the feet. When the arm presents, he directs us to bring down the head, which is to be seized by means of a hook fixed in the eye, ear, mouth, or forehead, and cautiously pulled along; and in doing this he properly directs us to pull with one hand and keep the other fixed at the instrument. When the feet present, they are to be brought down and delivery accomplished in this way. When the child lies across, he recommends us, if the position cannot be got rectified, to fix the hook in one of the armpits and pull it down; but if other means fail, he directs us to divide the body at the neck and extract the parts separately. In extracting the secundines, he properly directs us to stretch the cord gently with the left hand, and introducing the right into the uterus, to separate the placenta from the womb and remove it along with the coagula of blood lying there.

The causes of difficult parturition, and the methods of remedying them, are more fully treated of by Aëtius than by any other ancient writer; but, as Paulus evidently copies from him, we shall merely supply a few things which our author has omitted. Among the causes of difficult labour, he mentions too compact a union of the ossa pubis. When the woman is too young or too old, he justly remarks that she wants strength to accomplish delivery readily. He mentions that in the delivery of twins, the two children may get entangled. He means, probably, that the head of the one may follow the delivery of the breach of the other. Of this singular complication, a fatal case was published in the ‘Edinburgh Medical and Surgical Journal’ some years ago. He expresses himself favorably with respect to feet presentations. All cross presentations are said to be difficult to rectify, but the child is to be brought by the head or the feet according to circumstances. When delivery is retarded by rigidity of the parts, he strongly recommends the warm bath. When fulness of the bladder occasions obstruction, he properly directs the urine to be drawn off by a catheter. When a foot or hand presents, he directs us not to pull down the part, lest it become more firmly impacted, or lest it should be fractured or dislocated; but the projecting part is to be pushed up and the position restored.

According to Eros, one of the most common causes of difficult parturition is heat and tumefaction of the external parts. In this and in other cases, he directs the patient to sit in a bath prepared with emollient herbs, and to get the parts about the belly rubbed with oil of violets or of roses.

Serapion treats this subject in nearly the same terms as our author. Like the Greeks, he approves of emollient oils and baths to produce relaxation. The same practice is recommended likewise by Rhases. When the membranes are tough, he advises us to tear them with the fingers, or to open them with a knife.

Avicenna has treated of difficult parturition with his usual accuracy, which exhausts every subject he handles. He states that the expulsion of the child is performed by the abdominal muscles. This was the opinion of Galen; and we are inclined, upon the whole, to think it pretty correct. He approves greatly of the bath, both before labour has come on and during the time of it. When delivery is difficult, owing to the size of the child, he directs us to apply a fillet round the child’s head, and endeavour to extract it. When this does not succeed, the _forceps_ are to be applied, and the child extracted by them. If this cannot be accomplished, the child is to be extracted by incision, as in the case of a dead fœtus. This passage puts it beyond a doubt that the Arabians were acquainted with the method of extracting the child alive by the _forceps_.

Albucasis recommends us, when the membranes are tough, to perforate them by the finger or a _spatumile_. When the waters are discharged, he directs us to press down the woman’s belly so as to make the head descend. If it does not come down readily, he advises us to give a clyster, and afterwards to apply compression to the belly. Albucasis also approves of the tepid bath. To promote the delivery of the secundines, he recommends us to make the woman sneeze and retain her breath.

Alsaharavius (probably the same as Albucasis) treats fully of the causes of difficult labours. When occasioned by dryness and constriction of the vagina, he recommends baths, fomentations, and clysters, containing the decoctions of mallows, fenugreek, and linseed; and also directs the parts to be rubbed with warm oil. When obstruction of the rectum by fæces prevents delivery, he advises us to administer a clyster. When intense cold is the cause of the difficulty, he recommends clysters of hot oil, and the warm bath. When the membranes are tough and retard delivery, he directs the midwife to break them with a sort of reed or needle.

Haly Abbas mentions imperforate hymen among the causes of difficult labour. Such cases have been reported by modern writers on midwifery. See Baudelocque (§ 341), and Burns (Midwifery, x.) Fabricius ab Aquapendente relates a very curious case in which conception had taken place without rupture of the hymen. (Œuvres Chirurg. ii, 81.) When the difficulty arises from fatness and debility of the expulsive powers, Haly directs us to rub the parts with warm olive-oil, or other such emollients, and to make the woman sit in a bath prepared with chamomile, melilot, &c. He mentions, as an internal remedy, the infusion of a swallow’s nest (alcyonium?) When the difficulty proceeds from cold, he recommends the use of the tepid bath; and when from the contrary cause, he advises cooling things to be applied. According to Rhases, difficult parturition may arise from the mother, the fœtus, or the secundines. He appears to have considered all presentations unnatural except the head. In the other cases, he says, the life of the mother or child is endangered, although, he adds, many living children are born by the feet. When delivery of the head is found difficult, he recommends ligatures or fillets. When the feet or hands present, he directs us to restore the position, or if that is impossible, to bring down the feet. Many of his authorities mention the warm bath and lubricants.

From the sketch which we have given above, it will be seen that the Arabians have made mention of the forceps; but that most probably the Greeks and Romans were unacquainted with this instrument, as far, at least, as appears from their works on medicine which have come down to us. It is deserving of remark, however, that in the house of an _obstetrix_ which has been excavated in Pompeii, there was found an instrument of art bearing a very considerable resemblance to the modern forceps. It is a well-known fact in the history of inventions that many useful discoveries have long been kept as family secrets. This was the case even of a late date with the Chamberlains, who were the first in modern times to use the forceps.

SECT. LXXVII.—ON ISCHIATIC DISEASE.

Ischiatic disease, being of the class of arthritic complaints, is distinguished solely by the cause of it being seated in the hip-joint. The cause of it then is a thick and pituitous humour fixed in the articulation of the hip-joint. The pain in these cases extends from the parts about the buttocks and groins to the knee, and often as far as the extremity of the foot. When we see such a patient, in the beginning of the complaint, after the evacuation of the hardened fæces by a clyster, we must abstract blood from the arm at intervals; but if the disease be of some standing, we must abstract the blood from the ankle of the affected leg. During the exacerbations we must use this embrocation: Of the oil of privet, viij cyathi; of vinegar, iv cyathi; of nitre, ij cyathi; of rosemary-seeds, j cyathus; to be rubbed in hot with unwashed wool. After which a cataplasm is to be applied of the flour of bitter lupines with oxymel; or of the flour of darnel with rosin, the root of the wild cucumber, nitre, calamint, rosemary-seeds, and bay-berries. Calamint alone with oxymel, or honied water, will form a proper cataplasm. And we may rub the parts with this paregoric-plaster: Of wax, dr. x; of turpentine, dr. xxv; of verdigris, dr. vj; of myrrh, of galbanum, of iris, of each, dr. vj; of gum vernix, dr. v. But they must take the propoma containing Cyrenaic juice to the size of a bitter vetch, or a drachm of castor with three oboli of opopanax. And the rind of the root of capers in a draught, or added to the cataplasms, is of use. When the pain is great, anodynes may have place, such as the antidote of Philo and that from two peppers. This injection is to be used: Of honey, iss cyathus; of oil, iss cyathus; of water, ij cyathi; of nitre, dr. viij; of turpentine, dr. iv. These are to be injected warm, and the anus fomented, that they may be the longer retained. It evacuates mucous matters, and sometimes blood when it affords more relief. But if the complaint be prolonged, which is rare, we must repeat it frequently, instead of the water substituting the decoction of centaury. Blood is also evacuated by injecting the seed of treacle-mustard, and the juice of elaterium, and the Sicyonian oil prepared from it, or from the roots of the plant. The brine also of pickled fish, or of pickled olives, may be properly injected. Cupping-instruments may be applied to the hip with much heat and with scarifications, or sometimes leeches may be used. When the affection is protracted, we must proceed to purging either with the hiera, or giving of the medullary part of colocynth properly triturated to the amount of a drachm in two cyathi of honied water, more or less, according to the strength of the patient and the good state of his bowels. And let rue be boiled in the honied water. The pottage made with colocynth purges excellently. In some cases emetics from radishes have proved beneficial at the commencement. During the remissions we may apply dropaces to them, and use the restorative unguents (_acopa_) from euphorbium, and particularly the one called the complex. The natural baths also are proper; or if these be not at hand, they may bathe in the others; using the restorative ointments formerly mentioned, and the compound ones,—the Æsculapian, and that composed of equal portions of euphorbium, adarce, black hellebore, castor, pellitory, pepper, and wild grape dried. After the bath, we must sprinkle upon the skin while still warm, of dried pitch, oz. iij; and of native sulphur, oz. ij; and let the part be covered with paper. If even these things do not succeed, a remnant of the disease remaining, it will be proper to apply a cataplasm of mustard along with dried figs, or by itself. These complaints are completely removed by the Iberian herb, which some call lepidium, and some the wild cardamus (_cress_). And the shrub which grows among us, having leaves resembling those of the bay, but much larger, is of approved efficacy, not only in ischiatic, but in other chronic complaints; but it is by far most efficacious in summer. Or if it should not have shooted out its leaves, we must bruise the rind of the root with axunge, so as to form a plaster; and then, spreading it on a thick rag, apply to the parts affected with the pain, namely, to the whole buttocks and thighs; and allow it to remain until the part become black, or, at all events, until the cuticle become livid; then take it away, and, having washed, apply this cerate: Of opopanax, oz. iv; dissolve in ij cyathi of vinegar; and add to the cerate of privet. If they do not admit the use of such caustics, we must use the plasters called extirpative, among which is the following: Of wax, of pine-rosin, of each, dr. xij; of wild pigeon’s dung, of recent lees of burnt wine, of each, dr. vj; of galbanum, dr. iss. And the plaster called the Lioness is of the extirpative kind. Those composed from strained lye and nitre are also proper. And some have continued to drink certain potions for a whole year, among which is the one composed of four ingredients: Of wall-germander, lb. j; of gentian, oz. ix; of round birthwort, oz. ix; of the dried seed of rue, j sextarius: pound these things together, sift, and give every day a spoonful to the patient when he has an empty stomach and his digestion is good, with two cyathi of cold water; and continue this for a year, until the complaint cease. And the medicine composed of seven ingredients, and that which takes its name from Proclus, are of the same reputation. Exercise may be taken by walking, frequent bending of the body, leaping, and running. The food should be moderately attenuant and digestible. If ischiatic disease do not yield to any of the remedies now mentioned, it sometimes terminates in suppuration; and sometimes, from a relaxation of the ligaments, the thigh is dislocated at the joint. Wherefore, when the affection is protracted, we must burn the joint in three or four places (as will be described in the Surgical part of the Work), and the ulcers are to be kept open for many days.

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COMMENTARY. Consult most of the authors referred to in the next Section.

Hippocrates gives a pretty correct account of the symptoms which attend an attack of morbus coxarius, or ischiatic disease. He says it most commonly arises owing to the fluids of the joint being dried up by exposure to the sun. It is accompanied, he justly remarks, with pain of the loins and vertebræ of the back, shooting down even to the knees. A sharp hot pain, he adds, is frequently seated in the groins. Upon any motion the most piercing cries are extorted. (De Dieb. Judic. 6.)

In ischiatic disease Galen recommends general bleeding, and most especially, emetics, which, he says, by occasioning a determination upwards, operate more beneficially than purgatives in this complaint. He disapproves of acrid embrocations, but approves of cupping. He also allows stimulant clysters of colocynth. He gives a long list of local applications from Andromachus, Asclepiades, and Democritus. He makes mention of the Iberian herb; for further information respecting which we refer the reader to Matthiolus (ad Dioscorid. i, 147), and Bernard (ad Nonni Epit. 215.) It was the _Lepidium Iberis_. He recommends, in certain cases, the part to be beaten with rods. (Meth. Med. xiv, 16.) See also Pseudo-Dioscorides. (Euporist. i, 240.)

Celsus says that morbus coxarius is a painful complaint and difficult to cure. He recommends warm cataplasms and fomentations, with various applications of an emollient or stimulant nature. If inflammation come on, cupping-instruments with scarifications are to be applied; diuretics are to be given; and the belly is to be opened if constipated. He also approves of friction, and even of forming issues by burning with a red-hot iron.

Various methods of performing the operation of burning are detailed by Aëtius, as will be explained in the Surgical part of this Work.

Cælius Aurelianus gives a long and interesting account of this complaint. Among the symptoms he mentions the lengthening and shortening of the limb, the wasting and paralysis of it. The periosteum, he says, is principally affected, but likewise the heads of the muscles. He correctly states that, when the complaint is protracted, collections are apt to form in the joint. He approves of the emollient treatment, the application of wool dipped in sweet oil, fomentations, and bleeding from the arm. He recommends gentle purgatives and clysters, but condemns the use of drastic cathartics, such as scammony, hellebore, and the like; because, he says, they occasion irritation. When the pains are protracted he approves of scarifications and leeching, after which the vapour of sponges squeezed out of hot water will be of service. He also makes mention of the bath of oil and various emollient ointments. He describes several methods of applying heat to the part, but condemns them in general, upon the principle that they increase the local irritation. He disapproves of diuretics as recommended by Diocles, and otherwise animadverts freely upon the practice of the other sects.

The Arabians adopt the views of Galen and his followers with little addition or alteration. Thus Serapion recommends bleeding from the arm and ankle; clysters of drastic medicines, such as colocynth, centaury, hermodactylus, &c.; soothing applications externally; quieting medicines internally; emetics consisting of radishes, vinegar of squills, or even of white hellebore. When these do not succeed, he recommends us to form an issue by burning the part with a red-hot iron. Avicenna agrees with Galen in condemning discutients and recommending emollients at the commencement, and in preferring emetics to cathartics. For this purpose he particularly mentions a solution of nitre and vinegar. When the disease is combined with inflammation, Haly Abbas directs us to begin with venesection if not otherwise contraindicated. He enjoins the necessity of abstaining from taking much food and things of difficult digestion. He directs us to pour water of a moderate temperature over the part, and to rub it with an emollient oil; but he forbids refrigerant and astringent things, as they are apt to drive the humour inwards. He joins the others in recommending particularly the hermodactylus (_soureniaron_), both by the mouth and in clysters. When other means fail to remove the pain, he directs us to apply a cupping-instrument with strong heat over the joint, or even to use the actual cautery. Alsaharavius recommends the same general plan of treatment. He directs the patient to abstain from the use of wine, or if he cannot observe this regimen, he recommends him to use the bath and friction with glass (pounded he probably means). He gives very excellent admonitions to guard against indigestion, and to avoid all things of a cold nature.

On the ancient cauteries for disease of the hip-joint, see Book Sixth, Sect. LXXII.

Most of the earlier modern writers approve of the application of the actual cautery for the cure of sciatica. See Rogerius (i, 74.)

SECT. LXXVIII.—ON GOUT AND ARTHRITIS.

It is not weakness of the parts alone that occasions gouty and arthritic complaints; for then the paroxysms would be without ceasing, inasmuch as the debility is always present in the weak parts. Neither is a humour the sole cause, for then the complaint had not attacked the joints only. But the disease is occasioned by a preternatural humour and a weakness of the parts meeting together. For when the nutritive power of the parts becomes debilitated from repletion with food inducing dyspepsia, the prevailing humour, fixing in some of the joints which are already in a weak state, and stretching the nervous ligaments, produces pain. For the inflammation is not an original affection of the nerves of volition; as then it would have affected also the parts between the joints, such as the middle of the legs, thighs, arms, and forearms; but those of volition are affected sympathetically. When, therefore, the humour is seated in the joints of the feet only, the complaint is called podagra; but when the cause is diffused over all the joints of the body, we commonly call it arthritis, in which the vertebræ, scapulæ, jaws, and every other joint are attacked with the disease. In certain cases the ears, teeth, and pharynx, and sometimes even the liver and spleen participate in the arthritic pains, when, if there is not a speedy translation of the disease to the joints, the patients will be in urgent danger. The prevailing humour is sometimes bilious, sometimes sanguineous, sometimes melancholic, but for the most part it is pituitous and crude, being engendered by excess of food, indigestion, and want of exercise. When the disease is protracted in the joints, the humours become thick and viscid, so as to form what are called tophi or chalk-stones. Sometimes the humour is of a compound nature, so that the disease is difficult to distinguish, and difficult to cure, or nearly incurable. The precursory causes of this affection for the most part are immoderate labour, violent walking, frequent exercise on horseback, the unseasonable use of venery, cold drink taken unseasonably, eating of much cold or unwholesome food, and drinking much wine. And some from accidents, as a blow, a sprain, or the like, have experienced the first attack of this complaint, the materials of the disease having previously remained quiet in the system until roused by the proximate cause. Sorrow, care, watchfulness, and the other passions of the mind, not only excite an attack of the disorder, but also generate a cacochymy either primarily or incidentally. Wherefore the causes of the complaint, as I have said, are various; but the differences of the noxious humours are in so far easily detected, being discovered by their colour and other symptoms. A bilious rheum, in addition to paleness and redness of colour, occasions a sensation of heat and acute pain, and is speedily determined to the skin, nor is it attended with much swelling. It is exacerbated by heating applications, and relieved again by cooling, which, for the most part, is the case with all the others, but more particularly when the exciting cause is bilious. Fever also frequently comes on at the height of the paroxysms, and then they are thirsty. Thus also you will find the skin darker when from a melancholic humour; white and watery when from a pituitous, in which case the pain is more latent and more slowly occasions swelling; and the colour is sanguineous when a bloody humour prevails. In order to form a more decided diagnosis, you will be assisted by taking into account the previous mode of life, and so forth.

_The cure of rheums from a bilious humour._ The commencement of the cure, when from yellow bile, more especially if the quality of it occasion the disorder, should be the evacuation of the offending humour by purgative medicines, such as that from rhodomel, that from quinces, the antidote called picra, and aloetic pills. During the paroxysms, we may apply externally rose-oil with the yelk of an egg, and some wine, rubbing the part gently with it; and apply the herbs of a cold nature, such as nightshade, purslain, henbane, houseleek, marsh-lentil, endive, poppy, knotgrass, rose-leaves, and the like. These things may be sometimes rubbed in, and sometimes applied in the form of a cataplasm, with crumbs of bread soaked in oxycrate, or from barley-meal with rose-oil. When the inflammation of the joints is of an erysipelatous nature, a decidedly paregoric application is the peel of a fresh gourd laid on the part, or the fleshy part of a pompion or cucumber, both alone and with bread; or the leaves of perdicium (_pellitory of the wall?_), and ivy with bread and fine polenta. And fleawort boiled in barley-flour mitigates the inflammatory heat in a wonderful manner; and so also the rose-cerate cooled with some of the frigorific juices, and that prepared from the flour of beans. It is prepared thus: Of wax, oz. v; of chamomile-oil, oz. iiss; of rose-oil, oz. iiss; of the flour of beans, oz. ss; the yelks of five eggs.—_Another_, a cataplasm: Pound green mallows boiled; and having made fleawort to the consistence of bird-lime separately, mix together; then add the red part of eggs and chamomile-oil, and apply as a cataplasm. When the pain is great and difficult to endure, we must have recourse to preparations of saffron, of horned poppy, and of opium, triturating them with oxycrate, and then using them in the form of liniments, or of cataplasms with crumbs of bread. Galen makes mention of this one: Of poppy-juice (_opium_), dr. iv; of saffron, dr. j; triturate with milk of a cow or of a goat; or add the inner part of bread, and having softened it by touching it with a little rose-oil, use for a cataplasm. Or triturate the opium and saffron with the milk, and add to the rose-cerate. And the cerate made from the torpedo and the oil of the same are possessed of similar properties.—And this one in like manner: Of crumbs of bread soaked in water or in oxycrate, and of houseleek, or of nightshade, or of purslain, and of the fleshy parts of dates, and of poppy-seeds, equal parts; of roasted yelks of eggs and rose-oil, q. s.; form a cataplasm. The use of narcotics must not be continued, but until the violence of the pain be abated; for the frequent use of them occasions impaction and tophi, and makes the difficulty of motion to be protracted. After the use of anodynes, then, we must have recourse either to diachylon dissolved in oil of chamomile, or the composition from marshmallows, or some such application. After we have warmed the congealed parts, we must strengthen them by a plaster of dates dissolved in vinegar and rose-oil or wine and rose-oil. Or, if the weight of the plasters prove troublesome, we may rub in the juice of acacia with oxycrate, or lycium along with saffron, horned poppy, and the juice of perdicias in oxycrate. The diet should be cooling and moistening, such as ptisans, and spoon-meats from chondrus, and of pot-herbs, the mallows, the lettuce, and the endive; and of birds, more especially the young of domestic fowls; and of fishes, those caught in rocky places, and the sea-urchin, shell-fish, and the like. Let them avoid all things that are heating and form pale and yellow bile, old wines both the yellow and dark, and repletion. Let them use baths of sweet water, even at the time of the defluxions, as far as regards the cause of them, unless something else prohibit. Let them avoid violent passion, abstinence, acrid food, drinking of wine, immoderate labour, and venery.

_The cure of rheums from a sanguineous humour._ In those cases in which the prevailing humour is sanguineous, we must have recourse to venesection without delay, and also in cases where the prevailing humour is phlegm or black bile; since in them the humour is for the most part contained in the veins, proving injurious by its quantity rather than its quality. We must have recourse then to venesection only at the first attack of the disease; since those who have had already frequent attacks of rheumatism are injured rather than benefited by the loss of blood, more especially when the body is naturally cold or weak. After the evacuation of the blood, if there was more than a plethora of blood, we must have recourse to purging with hiera after a short interval. And the Julian oxymel is a purgative suitable to these cases. Those who reject such purgative medicines may use these pills: Of aloes, of colocynth, of black hellebore, of scammony, of each, oz. j; of euphorbium, oz. ss; of nitre, oz. ss; mix with the juice of cabbage, and give according to the patient’s strength. It will be better, however, if prepared with the juice of quinces.—Another pill given to gouty persons in the paroxysms, during the remission, and from whatever humour: Of aloes, oz. vj; of agaric, oz. ss; of saffron, oz. ss; of costus, oz. j; of spikenard, oz. j; of schenanth, oz. j; of balsam fruit, oz. j; of cassia, oz. ij; of scammony, oz. ij; of dodder of thyme, oz. iiiss. A moderate dose is scr. ij; and a full one, scr. iv. Pills of Armenian stone also purge in a wonderful manner, being particularly applicable in arthritic cases, whether given at the commencement, in the decline, or during the remissions of defluxion. And since some avoid scammony because it is bad for the stomach, we may give them these things when a pituitous matter prevails: Of the medullary part of colocynth, of black hellebore, of bdellium, of gum, of aloes, of each, oz. j; of Alexandrian nitre, of euphorbium, of each, oz. ss. The dose is scr. iv. Instead of the gum I have substituted dodder of thyme. Some, in the paroxysms of all arthritic diseases, have recourse to purging with hermodactylus; but it is to be remarked that the hermodactylus is bad for the stomach, producing nausea and anorexia, and ought, therefore, to be used only in the case of those who are pressed by urgent business; for it removes rheumatism speedily, and after two days at most, so that they are enabled to resume their accustomed employment. I knew a person who did not give the substance of hermodactylus, nor any of the compound medicines containing it; but boiling the plant itself with some of the common remedies, such as anise or parsley, he gave the decoction to drink; and it was wonderful how those who got it, after having evacuations of the bowels, were freed from the rheumatism. It is necessary, however, as I said, because the medicine is bad for the stomach, to correct the mouth of the stomach afterwards by stomachics and tonics, along with things that are moderately heating. Alexander says that purging by coronopodium is preferable to that by hermodactylus, as it procures evacuation and relief from pain, and at the same time is not bad for the stomach. But topical applications are to be had recourse to in cases of pituitous rheumatism. When the pain is moderate, a green cabbage-leaf may be applied, and also parsley, fleabane, and the straight vervain; but when the pain is violent, take of the flour of fenugreek, p. iij; of the flour of darnel, p. j; of the flour of chick-peas, p. j; make a cataplasm with honied water, or thin wine, with a little oil of privet, or of nard, more especially if in winter. And the ashes of burnt cabbage-roots, or of their stalks, when formed into a cataplasm with axunge, have proved beneficial to many; but, in order that it may prove soothing, the axunge must be fresh, whereas, if we wish it to be discutient, it must be old and salted. And in like manner the dung of oxen, when boiled in honied water with barley-meal, or fresh moist dung applied with the leaves of cabbage; and so also goats’ dung by themselves, or boiled with barley-flour in oxycrate. And since some have derived relief from seemingly opposite remedies (for a mixture of various humours confounds the diagnosis), we must state the materials thereof promiscuously. Wherefore the wild and garden orach in a cataplasm with bread are beneficial, or the leaves of petty mullein, triturated with bulbi and bread, or with polenta, or the cataplasm of raw barley-meal. Upon the whole, when the cause of the complaint is obscure, we must change sometimes to medicines of the same class, and sometimes to the opposite, not continuing long with the same application when it does not afford relief. These things we see every day occur in professional matters. And often a certain remedy proves beneficial to one joint, while another joint of the same patient similarly inflamed is not only not benefited at the same time, but occasionally is even injured by it. And this is a wonderful circumstance, that one and the same joint, when treated with the same remedy, is sometimes benefited, and soon afterwards exasperated. When a viscid and thick matter prevails, it is not perhaps relieved by calefacients, but the acrid and hot quality of the humour prevailing is to be soothed by frigorific remedies; nor is it at all wonderful that a matter naturally cold, in the time of the inflammation, should become heated and glowing, to say nothing of the admixture perhaps of bile. The flour of lupines with oxymel or oxycrate, or the root of laserwort, or of bryony, with bread, prevent the formation of tophi. And the following composition is safely soothing and moderately discutient: Of lycium, oz. j; of ammoniac perfume, oz. j; having triturated with very old wine and oil of unripe olives, boil, and add of the flour of beans, q. s.; and having boiled moderately, apply as a cataplasm. After the acme of the complaint, if a swelling be left, apply a cataplasm with the bulbi by themselves, or with fine polenta, until it produce excoriation; for in this manner they act. When not relieved by the cataplasms, we may have recourse to embrocations and affusions on the parts (more particularly if the extremities be affected), with chamomile, melilot, or centaury in decoctions. The preparation of capers has entirely relieved some. The following is the most active of all the applications: Having boiled thyme, marjoram, savory, and calamint in the most acrid vinegar, bathe the parts affected with the vinegar, not only once, but often in a day, with confidence. This has relieved many when suffering not only from phlegm but also from bile.