Chapter VII: Book 6: ) The incision is to be made long and narrow, and if any putrid (3)

Celsus gives the following list of incarnants: Carnem alit et ulcus implet resina pinea, ochra attice, vel asterace, cera, butyrum. He recommends the use of hot water; an application consisting of butter, roses, and a small portion of honey; or the tetrapharmacum with roses. He approves of giving wholesome and nutritious food, such as fowls, venison, pork, and even wine. The list of the Pseudo-Dioscorides contains nearly the same articles as that of Celsus. (Euporist. i, 186.)

Octavius Horatianus recommends a composition of equal parts of honey, turpentine, rosin, and wax, melted in a vessel; or a mixture of powdered rosin, wax, and fat.

Scribonius Largus recommends basilicon, and a composition consisting of calf’s marrow, the fat of geese, butter, stag’s marrow, wax, turpentine, honey, and roses.

Avicenna remarks, that in treating hollow ulcers we must not use very desiccative applications, as they dry up the fluids which are necessary for forming flesh; nor for the same reason, very astringent applications, nor abstergents of any greater strength than to remove the sordes. Rhases recommends a mixture of equal parts of olibanum, aloes, sarcocolla, and dragon’s blood. Camphor is an ingredient in one of his incarnative applications. Alsaharavius makes mention of an application from olibanum, like that of Rhases.

All the ancient authors say that round ulcers are more difficult to heal than those of any other shape; and Cassius Medicus and Alexander Aphrodisiensis assign various reasons for this, the most probable of which seems to be, that in this case the sound parts are further removed than in any other.

Apollonius Dyscolus states that ulcers are prevented from healing by pregnancy, by disease of the spleen, and by varicose veins. (Histor. Mirab. 42.)

SECT. XLI.—MEDICINES FOR CLEANSING FOUL ULCERS.

Foul ulcers, whether hollow or level with the surface, may be properly cleansed by birthwort in honey, turpentine with an equal portion of rose oil and honey, or instead of rose oil butter may be substituted, with Illyrian iris and honey; and by pickled olives applied. To nervous parts, turpentine melted with butter may be applied. When the sores are very foul and spreading, horehound with honey is a good application, which removes the eschars. The following are compound applications: Of boiled lees of oil, of scummed honey, of the species of alum called phormion, equal parts.—_Another_: Of the dried serapias, called also triorchis, of Illyrian iris, of dried horehound, of birthwort, of each, dr. viij; of the flour of tares, dr. x; use in a powder and with honey. And for foul ulcers the Egyptian cerate is useful, also those from salts when melted, the Indian, that called athena, the green plasters diluted, the powder of dried pumice stone, those from tares, the trochisk called melanchlorus, and in like manner that called criogenes.

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COMMENTARY. The following are the most important articles in Celsus’s long list of substances for cleansing ulcers: Purgant, ærugo, auripigmentum, quod ἄρσένικον a Græcis nominatur; (huic autem et sandarachæ in omnia eadem vis, sed validior est) squama æris, thus, resina, et pinea, et terebinthina liquida, misy, chalcitis, galla, sulphur, pix, oleum, ruta, ammoniacum, &c. Hippocrates makes mention of many of these, namely, arsenic, verdigris, flowers of copper, frankincense, myrrh, hellebore, &c.

Scribonius Largus recommends honey, Illyrian iris, and a compound application containing arsenic, scales of copper, elaterium, and burnt paper.

One may find in Galen and Aëtius many compound applications, but as they are all formed from much the same ingredients as those of our author, it will be unnecessary to take further notice of them. Aëtius commends a combination of turpentine and honey.

Avicenna and Haly Abbas recommend the same applications as our author. They make no mention of arsenic. Alsaharavius gives very particular directions for treating these ulcers; when the edges are hard, he directs us to rub them until they become red, or to cut them off and apply to the sore the green ointment; and when the ulcer is covered with much sordes, he recommends us to dress it with the Egyptian ointment. Rhases mentions antimony as an excellent application for cleansing foul ulcers. He properly recommends us to consider whether the foulness of the ulcer be the effect of too much or too little stimulation. He relates a case of the former description, in which the sore got worse under the application of the green ointment. (Cont. xxviii.)

SECT. XLII.—FOR WORMS IN ULCERS.

For worms which form in ulcers, the first thing to be done is to stop the humidity and the putrefaction which occasion them. Worms may be killed by all the things in general which are described for those in the ear. But for those which form in ulcers Archigenes says, mix equal parts of ceruse and poley with liquid pitch, and anoint with it.

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COMMENTARY. Aëtius recommends dried plantain, the ashes of the wood of figs, and the juice of calamint. Galen and Avicenna also mention calamint.

Pliny mentions the gall of frogs.

SECT. XLIII.—ON FUNGOUS ULCERS.

The fungous flesh of ulcers is to be removed by medicines which are powerfully desiccant, such as diphryges sprinkled upon it, the squama æris, all the testacea burnt, both the echini (the hedgehog and sea-urchin,) burnt entire. But the following things are moderately cleansing, and repress the fungous flesh: the flower of the Asian stone, and still more powerful than it, the sori and chrysocolla, chalcitis and misy (when burnt they are less caustic,) and the flos æris in like manner; but verdigris is the most powerful of all. Salts, when burnt, consume the foul flesh, and in like manner charpie that has been soaked in strong brine and dried, consumes fungous flesh that is moderately large. But verdigris with the squama æris is powerfully repressing. Of the compound applications the powder called rhodium, and the psarum, and that named yellow, repress fungous growth without being pungent. But the trochisks called phaustiani, when levigated and sprinkled on the sore, and the dry medicine (or powder) called heliocaes, make fungous flesh slough off to the bottom. But the application consisting of equal parts of calx viva, squama æris and manna, answers with fungous flesh; with honey it cleanses such as resemble a mushroom, and with cerate it proves incarnating.

_A powder for keeping down fungous flesh_: Of litharge, of chalcitis, of verdigris, of plumbago, equal parts.—_Another_, which represses strongly without being pungent, and applies also to spreading ulcers, and more especially the epulis of the gums, and whitens the teeth: Of quicklime, lb. j; of arsenic, oz. vj; having triturated the dried arsenic with water, add the lime washed like calamine, and, having rubbed them together dry and use. And of the trochisks, that called pantolmios, and those described for polypus, are excellent for repressing fungus in ulcers. But the green plasters, more especially the one from Cappadocian salts, and in like manner the isis, are most effectual in preventing fungous flesh in ulcers.

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COMMENTARY. The powerful applications mentioned by our author will be found amply sufficient to fulfil every intention in conducting the treatment of these ulcers. Many of them are mentioned by Hippocrates.

Galen lays it down as a rule that these fungous excrescences are to be repressed by powerfully desiccative substances, such as misy, chalcitis, or more especially verdigris; when burnt and washed they become mild detergents. (Meth. Med. iii.)

Aëtius gives many useful prescriptions for such preparations, but they are entirely formed of the ingredients which enter into those of our author.

Celsus gives a long list of caustics highly applicable in such cases: Adurunt, auripigmentum, atramentum sutorium, chalcitis, misy, ærugo, calx, charta combusta, sal, squama æris, veratrum et album et nigrum, cantharides, sandaracha, alumen scissile, &c. Pliny speaks of a composition of unwashed wool, with barley flour, and verdigris.

Octavius Horatianus recommends the Phrygian stone pulverized, and a powder consisting of the recrementum plumbi, verdigris, aloe, and quicklime.

Rhases and Avicenna copy from our author. Haly Abbas speaks of removing the superfluous flesh with an instrument.

SECT. XLIV.—ON SPREADING ULCERS, PUTRID ULCERS, AND PHAGEDÆNA.

Spreading and putrid ulcers are to be bathed with vinegar and oxycrate, an astringent wine, cold water, sea-water, or the decoction of lentil, of pomegranate rind, of the flowers of the wild pomegranate, of lentisk, of myrtles, of Egyptian thorn, or some other astringent and desiccant medicine. Cataplasms are to be applied to them of the flower of tares and liquid alum, the inner part of bread made of similago, an old goby fish, or some other old pickle, unwashed flesh, and liquid turpentine; these things are to be all pounded together in equal proportions. Or the parts may be anointed with equal proportions of birthwort, and the juice of the leaves of the Palma Christi, and half the quantity of verdigris, made with water to the thickness of honey; but if the eschar is not removed an equal proportion of elaterium is to be mixed with the verdigris. For putrid ulcers sori levigated and sprinkled on them is an effectual remedy, and above is to be put dried charpie; or the round birthwort and galls in equal quantities may be rubbed in with oil; or the root of the wild cucumber, or of cabbage, or of beet, or the leaves of dock are to be bound in a piece of linen, and put into ashes; when they are softened triturate with salt and apply; they will cleanse powerfully. Or apply green olive leaves boiled in wine with honey; or apply chalcitis, or parsley seed levigated, or apply linseed triturated with copperas, or use an application of thyme, dried grapes and boiled figs, or of fig leaves triturated with honey; or of nitre, cumin, and fine flour with honey; or of the root of the wild cucumber, or of squill boiled with honey; or of sori, dr. xij; of chalcitis, dr. x; of misy, dr. iv; triturate with half an hemina of the strongest vinegar until it is dried, and taking it off use by dipping a specillum in it, and rubbing it over the ulcer, and placing above it a double pledget out of wine and oil. But if it is inflamed apply henbane with polenta, or cabbage with honey.

_For putrid and spreading ulcers on all parts of the body._—Of quicklime, of chalcitis, of each dr. ij; of arsenic, dr. j. This may be used for pterygia of the fingers, for phagedæna and carbuncle, with honey if on the genital organs, but dry if on any other part of the body. Above apply an oblong pledget with rosin.

_An universally applicable powder for all spreading sores, and those of the mouth, for hemorrhages, and for repressing fungous flesh._ Of chalcitis, of misy, of both in a crude state, dr. xx; of squama ferri, dr. vj; of immature galls, dr. viij.

_For spreading and putrid sores._ Of salts, dr. ij; of any species of alum which has been burnt, dr. j; of squama æris, of burnt pumice stone, equal quantities. Scraped verdigris, with burnt misy mixed with liquid pitch; and the flakes of iron with oil also answer well.

_For spreading ulcers of the pudendum._ These things will apply to them, and also the composition called meliterium, the powder of the wild myrtle, and that from paper; also the composition from oxymel called coracion, the trochisk of Andron and the like, will answer with all spreading ulcers. The same things also apply with phagedæna; for phagedæna is an ulcer that spreads by eating.

_For foul and fetid ulcers._ The Lemnium sigillum (Lemnian earth) mixed with vinegar, oxymel, oxycrate, or wine, until it is of the consistence of clay, may be rubbed on them with advantage; or the leaves of cypress, its shoots, and tender balls (pilulæ), or the ashes of dried gourd burnt, or of the burnt bark of the plane tree, or of burnt dill in like manner, or of foul wool burnt, or of plaintain; also woad by itself or with polenta, or the dried root of hog’s fennel.

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COMMENTARY. It will be remarked that the milder applications mentioned in this section are all powerful desiccants and astringents. Most of them are mentioned by Dioscorides as possessing these properties.

Galen recommends the compound applications mentioned by our author, containing verdigris, squama æris, &c.

For these spreading and putrid sores Aëtius, among other prescriptions, gives one which would no doubt be applicable in the worst cases: “Of crude misy, of crude chalcitis, ā dr. viij; of ochre, dr. iij; of sandarach, dr. iv; of quicklime, dr. ij; of the scales of copper, of alum, ā dr. ij; of diphryges dr. iij; m.” These caustic and escharotic medicines enter into the composition of many of his applications. Some of them contain astringents and desiccants, such as sumach, galls, alum, fossil salts, frankincense, calamine, birthwort, pomegranate rind, &c. In short the ingredients in his applications correspond with Celsus’s list of corrosive substances: Rodunt, alumen liquidum, sed magis rotundum, ærugo, chalcitis, misy, squama æris, sed magis rubri, æs combustum, sandaracha, galla, thus, auripigmentum, calx, nitrum et spuma ejus, alcyonium, resina, squama ferri, atrumentum sutorium, veratrum, &c.

The other authorities give only combinations of these substances; for a full account of which preparations we refer the reader to Galen. (Med. sec. gen. iv.)

Octavius Horatianus recommends lentils boiled and mixed with honey; the leaves of cabbage, coriander, or ivy, all mixed with honey.

The Arabians, although they supply nothing new, add their authority in confirmation of the remedial virtues which the Greeks assigned to the substances mentioned above. Avicenna and Rhases recommend arsenic, copperas, misy, sori, chalcitis, flos æris, quicklime, alum, galls, ammoniac, the trochisk of Andron, &c. When a part becomes black and putrid, Haly Abbas directs us to open a vein leading to it, if the age and state of the patient permit, and afterwards to apply odoriferous things, such as camphor, &c.

SECT. XLV.—ON ULCERS REQUIRING CICATRIZATION.

By drying and constringing the flesh of ulcers requiring cicatrization to such a degree as not only to dissipate the preternatural superfluity, but also to touch upon that which is in its natural state, we may render the surface of the sore like skin, and make the ulcer cicatrize. This is promoted by immature galls, the moderately desiccant bark of pomegranate, and whatever else is desiccant without being possessed of pungent astringency. And such things as these promote cicatrization: myrrh, litharge, and oysters if burnt, for they must be sprinkled on the sore dry. And these things often produce cicatrization: pine bark with myrtle cerate, ivy flowers with cerate, the root of the lily with rose-oil, dried pine-rosin, burnt pumice stone, the flakes of copper; they are to be used in equal proportions dry. The following also repress: mix a small quantity of manna and of diphryges with levigated pumice, and use; or of litharge p. j; of diphryges p. ss, apply on a pledget with cerate. Birdlime with frankincense cicatrizes old ulcers, also verdigris with an equal portion of diphryges and with myrtle cerate, or the small centaury applied fresh. To the more humid apply the root of cypress. To those about the anus and pudendum, more particularly if inflamed, use levigated aloes, either in a dry state or with water, or squama æris; or soften chrysocolla in the sun with wax, and apply.

_A dry application for producing cicatrization._ Of oysters, dr. xij; of manna, dr. vj; of calamine, dr. iv. It applies also to spreading sores.—_Another_: Of birthwort, dr. vj; of pine bark, dr. vj; of manna, dr. vj; of pumice, dr. iv; of Colophonian rosin, dr. iv; of iris, dr. iv.—_Another_: Of hart’s horn burnt, dr. iv; of pine-bark, oz. vj: of ceruse, oz. iv; of scraped verdigris, oz. ix; of calamine, dr. xviij.—_Another_: Of the flowers of pomegranate, of copperas, of each, dr. xvj; of squama æris, of fissile alum, of each dr. viij; of galls, dr. j.—_Another_: Of ceruse, of litharge, of each, oz. viij; of the dross of lead, of galls, of dried myrrh, of each, dr. iv.

_A cicatrizing application._ Take of fissile alum, oz. j; and having levigated it, macerate in a sextarius of water: when dissolved in the water soak pledgets in it, and having dried them apply.

_A plaster for cicatrizing the more simple ulcers._ Of wax, dr. xl; of litharge, dr. xxxv; of diphryges, dr. viij; of myrtle-oil, half a hemina. The plaster called phœnicinum, that from calamine, the myrsinatum, and the like, are also applicable in such cases. For ulcers of difficult cicatrization: Of wax, of myrtle-oil, of each, dr. vj; of calamine, oz. vj; of lead, of frankincense, of each, dr. ij; of fissile alum, of burnt copper, of each, oz. j; of scraped verdigris, dr. ij; dissolve them singly. For chronic ulcers, and such as are of difficult cicatrization: Of calamine, dr. viij; of chrysocolla, dr. viij; of fissile alum, dr. viij; of verdigris, of the flakes of copper, of each, dr. j; of pine-rosin, dr. xl; of wax, dr. c; of myrtle-oil, q. s.—_Another_: Of wax, of pine-rosin, of each, oz. vj; of calamine, oz. vj; of crude chalcitis, oz. iij; of myrtle-oil, q. s. The calamine and the chalcitis are to be triturated with wine during the season of the dog-star; use it upon a broad compress, and apply above it a pledget and sponge out of wine.—_Another_: Of burnt copper, oz. ij; of fissile alum, oz. ij; of sal ammoniac, dr. ij; of wax, oz. vj; of Colophonian rosin, oz. vj; of myrtle-oil, oz. ij; the dry things are to be triturated in the vinegar in the sun for twenty days, and when it becomes of the consistence of honey, having melted the wax, mix it and soften. The medicine from pumice-stone, the isis, and the like, are also applicable in such cases.

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COMMENTARY. Celsus gives the following list of the more active articles of this class: Crustas ulceribus tanquam igne adustis inducunt, præcipue, chalcitis, utique si cocta est, flos æris, ærugo, auripigmentum, misy, et id quoque magis coctum.

For a variety of applications suitable to this class of ulcers, we refer the reader to Galen’s 4th book of ‘De Med. sec. gen.’ The ingredients of them are powerfully desiccative, astringent, and escharotic. Many of our author’s prescriptions will be recognized in it. For an account of the isis, and the other compound medicines mentioned towards the end of this section, we refer the reader to Galen (l. c.) and to the Seventh Book of this work. Galen, in another place, and after him Aëtius, give the following important directions for the use of these applications. The ulcers to which this mode of treatment is applicable, being very foul and filled with a vitiated discharge, are first to be wiped clean with a soft linen cloth, and then the cavity of them is to be filled with the medicine, and a splenium (oblong compress) applied externally. Then having put a piece of linen above the splenium and bound it on, we are to place over it a sponge squeezed out of cold water or wine, endeavouring to keep the sponge cold during the whole time of the treatment, which may easily be done by pouring cold water upon it without loosing the bandages. They are not be removed until the third day. Galen states that the articles which answer best in such applications are galls, pomegranate-rind, alum, chalcitis, misy, and the like.

A similar mode of treatment, without any material alteration, is described by the Arabians. Haly Abbas remarks, that cicatrizing medicines are powerfully desiccative with some astringency, such as galls, alum, and the like.

SECT. XLVI.—ON THE MALIGNANT ULCERS CALLED CHIRONIAN AND TELEPHIAN.

Old ulcers which are difficult to get cicatrized are called chironian, as if requiring Chiron himself to cure them; and telephian, from Telephus having long laboured under such a sore. We must attend then whether the whole body being in a state of cacochymy, sends such defluxions to the ulcer, and the prevailing humour is to be evacuated by appropriate remedies. Or if it is a varix which sends these humours to the legs, the ulcer being in it, it is to be cured as will be described in the Surgical part of this work; or the humours are to be evacuated by venesection, taking away blood frequently, and then using topical applications which have the property of extirpating the disease without being pungent. These therefore are simple applications; those from pumice and diphryges, and flakes of copper, verdigris, and lime moderately washed; sprinkle fissile alum levigated, or of unwashed wool, dr. iv; of dried grapes, dr. iv; of natron, dr. ij; having previously anointed with honey, sprinkle of flakes of copper, dr. x; of alum, dr. ij; and having softened in the sun with dr. x of wax, apply.

These are compound medicines. _A plaster for chironia._ Of ceruse, oz. viij; of fissile alum, oz. ij; of the flakes of copper, dr. ij; of sal ammoniac, of frankincense, of scraped verdigris, of pomegranate rind, of each, oz. ij; of quicklime, oz. j; of wax, lb. j; of myrtle-oil, lb. j. ss; triturate the dry things with wine. At first it removes callus; and it is laid by and kept, and at last when used, being softened with myrtle-oil, it cicatrizes.—_Another_: Of litharge, lb. j; of oil, lb. ij; of black chamæleon, of the roots of birthwort, of immature galls, of each, oz. j; of galbanum, of ammoniac perfume, of frankincense, of each, oz. ij; prepare, stirring with the roots of green reeds.

_From Archigenes, for chironia, and malignant ulcers in the legs and breast, for struma, and parotis._ Of the fat of an ox lb. iij; of turpentine, oz. v; of manna, oz. vij: of the earth called sarda which painters use, oz. v: having put the soluble and dry articles together and melted, use.—_Another_, of Archigenes: Of wax, oz. iv; of oil of unripe olives, of manna of frankincense, of diphryges, of the flakes of copper, of each, dr. iv; having triturated the powder with vinegar, and made of the thickness of honey, mix with the cerate, and use upon a pledget.—_Another_, for the malignant ulcers of women, and of other persons having a soft skin: Of Tuscan wax, dr. viij; of bulls’ fat, of turpentine, of burnt lead, and of pepper, of each, dr. j; use on a pledget with rose-oil or myrtle-oil.

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COMMENTARY. Celsus describes the chironian ulcer as being large, and having hard, callous, and swelled edges, with a copious discharge of thin sanies. It is attended with no inflammation, the pain is moderate, it does not spread, and therefore it is not dangerous, although not readily cured. Sometimes, he says, it becomes covered with a thin cicatrix, and then again the ulcer breaks out. It occurs mostly in the feet and legs. From this description it is evident that by the chironian ulcer Celsus meant merely an ill-conditioned ulcer, and that he distinguished between it and the _cacoethes_, or malignant ulcer, which last he held to be nearly allied to the carcinoma. However, most of the Greek authors apply the term malignant to the chironian ulcer. For the cure of it Celsus recommends an application consisting of squama æris, lead burnt and washed, calamine, wax, and a small quantity of roses.

Galen furnishes us with an account of the manner in which Thessalus the Methodist proposed to cure all chironian and malignant ulcers. Thessalus lays it down as a rule for the treatment of all sores which are difficult to cure, or which break out again when healed, to remove the exciting cause, whether local or constitutional, by means of proper alteratives. He adds: “In cases of chronic ulcers which cannot be got healed, we must remove the parts which prevent adhesion, and convert the sore into the state of a recent ulcer; and then having allayed the inflammation proceed accordingly. Those sores which heal up and break out again during their exacerbations, and when ulcerated, are to be cured like recent inflammations by soothing applications until the irritation subside, after which cicatrizing applications are to be used, and then the surrounding parts are to be covered with a malagma of mustard, or some other rubefacient and alterative, to remove the indolence. If this is not sufficient, we must attend to the general health, attempting to effect a change of the system by repeated exercise, gestation, a diet increased or diminished according to circumstances, and at the commencement by administering an emetic of radishes, or even the white hellebore.” (Galen, Meth. Med. iv.) Although Galen, who all along displays a strong hostility to the _Thessalian asses_, (so he calls the Methodists,) has animadverted in severe terms upon the rules here laid down, they would appear to be highly proper and ingenious. Galen in another place (Med. sec. gen. iv) gives from Asclepiades, Andromachus, and others, a great collection of applications for chironian, malignant, and indolent ulcers. One by Asclepiades consists of the scales of copper, scraped verdigris, wax, and larch rosin. Others by Andromachus contain sori, misy, chalcitis, verdigris, alum, turpentine-rosin, and the like, mixed with wax. Hippocrates directs us to treat a callous ulcer by applying to it septic medicines to make the hard parts slough off, after which the edges are to be brought together. (De locis in homine.)

The directions of Aëtius, more especially respecting the constitutional treatment, are highly important. In cases where there is a redundance of blood he recommends venesection, in others both purging and bleeding; and in certain cases he directs us to pay attention to the state of the liver and spleen. He relates a case of an ulcer on the hand, which he cured by opening a vein leading to it. He also directs us to scarify or cut off the callous edges of the ulcer. He gives various prescriptions for sores of this description, containing verdigris, sori, chalcitis, burnt copper, alum, &c.

Octavius Horatianus recommends a plaster consisting of equal parts of chalcitis, wax, and alum. For phagedænæ Pliny mentions an old shad-fish triturated with sandarach. (H. N. xxxii, 44.)

The Arabians treat of these ulcers very fully. Avicenna in particular gives very proper directions for the constitutional treatment. When the state of the ulcer is occasioned by an intemperament, it is to be corrected, and if the blood is deficient in quantity or quality, this is to be remedied by a proper diet; and when on the contrary it is connected with plethora, venesection is to be had recourse to, and if the veins leading to it are varicose, it may be proper to open them. When the sore is kept from healing by a spiculum of bone, we are to cut down and remove it. His applications consist of the same ingredients as those used by the Greeks, namely, the flower of copper, copperas, alum, ceruse, lime, arsenic, &c., mixed with wax and oil. The directions given by Rhases are less circumstantial, but to the same purpose. He particularly directs us to remove the callous edges by friction, scarifications, and septics. He speaks of turpentine as an excellent addition to other ointment. (Contin. xxviii.) He mentions that in case of malignant ulcer on the leg connected with varix, Galen opened the enlarged vein.

The _cacoethes_ of Celsus was evidently the disease called _noli me tangere_ by Theodoricus; a very absurd appellation, which however has been retained to the present day. Celsus has pointed out its resemblance to carcinoma, and recommended the only mode of treatment which ever does any good in these cases, namely, the application of septics, such as arsenic, quicklime, &c., or the actual cautery. As our limits will not permit us to enlarge further on this subject at present, we must be content with referring to No. 108 of the ‘Edinburgh Medical and Surgical Journal,’ where we have given a full exposition of the ancient principles of treatment. (See also the Commentary on s. xxvi of this Book.)

SECT. XLVII.—FOR BLACK CICATRICES.

Let the root of the white and black bryony be boiled in oil until they are reduced to the state of juice, and the oil applied will take away black scars; and so in like manner calamint boiled in wine, and litharge washed with white rose-oil. But the scars from lichen, and all other kinds are made like the other skin by anointing them with the fat of asses; or the seed of rocket triturated with the gall of a goat, of an ox, and of a sheep may be rubbed in with litharge; or a lamb’s foot burnt may be triturated with austere wine for the same purpose; or, ammoniac perfume may be rubbed in with swines’ gall. These are compound applications: Of litharge, of mint, of frankincense, equal parts with honey.—_Another_: of natron, of ammoniac perfume, of sulphur vivum, of myrrh, equal parts; having triturated with vinegar, white wine, or water, rub in but a very little, so as not to produce an ulcer.—_Another_: Of Cimolian earth, of pigeons’ dung, of soap, of frankincense, equal parts with vinegar. A detergent ointment for black scars: Of Cimolian earth, dr. xiij; of aphronitrum, dr. v; of white hellebore, dr. v; of the greasy dregs of nut-ben, dr. iv; scrub with it while in the bath.

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COMMENTARY. Avicenna condenses all the information contained in the authors who preceded him. He sets out with stating that the class of medicines which are applicable in such cases are the abstergents; of which he enumerates verdigris, stavesacre, the scales of copper, and even arsenic. Among the less active ingredients he mentions, like our author, the fat of asses. We need not give extracts from the other authorities, as no one has treated of this case so fully as Avicenna.

SECT. XLVIII.—ON SINUOUS ULCERS.

When the skin adjacent to an ulcer is not united with the parts below, we call such a complaint a sinus. When, therefore, the sinus extends upwards, the ichor readily flows out from the sore, and adhesion easily takes place; but when it extends downwards the ichor by remaining within corrodes the continuous parts, and unless you first make an incision for its discharge, you will be able to effect nothing; for the sores can neither be incarnated nor the parts made to unite. But if the sinus is in any of the limbs, as the arms or legs, one may produce adhesion without a counter-division by putting the limb in a declining position. Thus when the sinus is in the arm, and the mouth of the sore is near the elbow, by placing the hand in an elevated position, you will render the discharge from the ulcer below easy. And when the sinus is in the thigh, and has its outlet near the knee, you must make the position declining by putting a soft pillow below the back part of the knee, so that the groin may be in a lower position than the knee; and if the sinus does not require incarnation, forthwith by means of a straight and hollow pipe having a bladder attached to it, syringe it with honey so diluted with water that one could drink it, in order to clear away the ichor from the sinus. For promoting adhesion when about to take place, do it with wine, or wine and honey, and then proceed to the agglutinating medicine. But if the sinus being hollow requires incarnation, first inject a little of the composition from dried paper with much rose-oil, then plug up the mouth of it with charpie, and afterwards the plaster of iris, or of Machærion, or of some such, may be melted with liquid rose-cerate, and injected in like manner. If the sinus is moderately incarnated you may apply some of the agglutinating medicines, as if you were curing a case of recent bloody wound. Such are those called the barbarous, dichromos, and gilvus; and more especially that prepared from the oil of palma Christi and the metals without wax which is called the dun plaster of Galen, is applicable. After the application of the medicine, a recent sponge out of wine and honey, or wine alone, is to be put on particularly in a soft manner, and the bandaging is to commence at the bottom of the sinus and end at its orifice. The folds of the bandage should bind the bottom of the sinus firmly, yet so as not to occasion pain, but ought to be gradually relaxed towards its orifice; and the plaster which is put on should be so cut as to leave an opening at the orifice for the escape of the matter, but another small plaster of the same materials should be applied to it in a loose state, so as to favour the discharge. This is to be left on till the bandages are loosed, which is to be done on the third day, when they are to be taken off and changed, but the application along the sinus is to be left. You may judge whether the bottom of the sinus has adhered, from observing if the matter be small and well concocted, or if there be no discharge at all; and moreover if there be no sensible pain along the sinus nor swelling, but the whole part is contracted, dry, and free from pain. But if you see a little well concocted pus at the orifice, you may still more confidently entertain good hopes. If on the second or third day a thin ichor be discharged from the sinus, you need not despair that adhesion has taken place, for often the strength of the medicine squeezes out from the parts below a thin fluid, which being discharged the parts become dry and adhere. But if on the third or fourth day from the commencement the matter appear unconcocted as it runs from the opening, you may be sure that the sinus has not adhered, and you must persevere with the same application. When owing to the moisture of the part it falls off, as is not unlikely, it will not be improper to make some change in the medicine itself.

_On sinuous ulcers with a thin covering of skin._ When the abscess is too long opened, owing either to the unskilfulness of the surgeon, or the timidity of the patient, the skin which lies over it becomes thin and ragged, and it cannot be removed, then after the syringing which has been described, we must have recourse to an agglutinating application of a humid consistence, but of desiccative properties, such as that from chalcitis called phœnicinum, diluted with old oil, so as neither to be very hard nor of such a consistence as not to stain the finger; and afterwards it is to be mixed with moderately old wine, and applied in a circular form with corresponding bandaging. To skin in this ragged state honey, as was said, is not one of the least proper applications when boiled to the consistence of a plaster and applied. It will be better, however, if after spreading it on the rag you sprinkle over it from a sieve some myrrh finely pulverized, or aloes, or frankincense, or all of these together. I have also found the lesser centaury a wonderful application for the same purpose; next to it is comfrey, after which is the root of the Illyrian iris, and after these is the flour of tares. Sometimes during the process of boiling we sprinkle these upon the honey when the vessel is about to be taken off from the fire. It is better, however, to do so after it is taken off, and then it is to be stirred about, and when it becomes tepid applied to the sinus, and bandaged as aforesaid.

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COMMENTARY. Similar directions are given by Galen and Aëtius, but upon the whole those of our author are superior; and as those of the other two supply no additional information, it will be unnecessary to multiply extracts from them. (See Galen, Therap. ad Glauc. ii.)

Actuarius, in like manner, briefly directs that unless the sinus open downwards, it shall be cut open and dressed with an agglutinative application. You may think well of the case, he adds, when the part is dry and free from pain, or when only a little well-concocted pus is discharged from it.

In the translations of the Arabians, the sinus is described by the names of _absconsio_ and _caverna_. Avicenna states that the sinus differs from the fistula in having a larger cavity, and its edges not being indurated. He lays down very correct rules of treatment, but they are all copied from Galen. Thus he directs, when the orifice of the sore is above the cavity of the sinus, that it should be cut open; or, if this cannot be conveniently accomplished, he recommends us to introduce a tent smeared with some incarnant or detergent application. Upon the authority of Dioscorides he recommends the lesser centaury in such cases. His directions for the application of the bandages are similar to those of our author.

Celsus, and other of the ancient authorities, do not treat of the sinus separately from the fistula.

SECT. XLIX.—ON FISTULA.

Fistula is a callous sinus formed for the most part from abscesses, and deriving its appellation from the pipes of reeds (fistulæ). If, therefore, it terminate with a bone, it cannot be cured without a surgical operation, unless in process of time a scale of the bone come off spontaneously. But if it does not terminate with a bone, it is to be cured by the applications for removing callosities, and the agglutinative medicines. The applications for removing callosities are such as these: the root of spondylium scraped around and applied removes the callus of fistulæ. And in like manner black hellebore applied removes the callus in two or three days; also lees of oil boiled and injected; sori in a crude state, or burnt and injected with some diluted wine, or sori and crocomagma with hydromel. Or make collyria by mixing elaterium with turpentine, and apply. Or syringe with the juice of the root of laserwort. This melts down the callus: of verdigris, dr. xij; of ammoniac, dr. ij; mix with vinegar, and form into an oblong collyrium.

_A collyrium which I use for removing the callosities of fistulæ._ Mix with vinegar equal parts of ammoniac perfume, of copperas, of verdigris, of misy, of chalcitis, and of gum.—_Another_, from the surgical works of Heliodorus: Of calamine, of misy, of copperas, of burnt copper, of gum, of each, dr. iv; of crude chalcitis, dr. iij; mix with the urine of a young person not come to manhood, and form collyria. Put this collyrium into the fistula, and apply externally the inner part of bread soaked in water, changing it until the inflammation subside, and the eschar fall off.—_Another_, which I received in Alexandria: Of the roots of alkanet, of toasted misy, of chalcitis, of verdigris, of fissile alum, of copperas, of aloes, of each, oz. j; triturate along with fine cantharides in vinegar, and make collyria.—_Another_: Of copperas, dr. ij; of chalcitis, of verdigris, of each, dr. j; mix with ammoniac and use, and when the callus is thrown off, cleanse with verdigris and eight times the quantity of the purest honied water; but after the discharge of the callus, incarnants must be used. An incarnative collyrium: of aloes, of myrrh, of ammoniac, of the cinders of egg shells, equal parts; having triturated with water form collyria, and apply.—_Another_: Of myrrh, of aloes, of frankincense, of pomegranate rind, equal parts, mix with water; but some use bull’s gall. The oil of unripe olives is incarnative when injected. I knew a person who injected cedar-rosin into fistulæ, and succeeded surprisingly. After it is incarnated we must have recourse to the agglutinative medicine, according to the plan described for other sinuses. “When the fistula is narrow and long,” says Galen, “and does not appear to me to contain callus internally, but only sordes, I first inject lye into it, and then allowing it to remain in the fistula until I expect that the sordes has fallen completely off, I afterwards apply the medicine.” It was the one from the oil of palma Christi, mentioned above.

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COMMENTARY. We shall have occasion to refer to the Hippocratic treatise ‘De Fistulis,’ in the Sixth Book.

Celsus treats of fistulæ with more than his wonted minuteness. This is his definition: “Id nomen est ulceri alto, angusto, calloso.” He has described all the complications of it with great accuracy. He directs us to commence by making an inspection with a probe or sound, so as to ascertain the state of the parts and of the discharge. If a soft body is felt at the bottom, we conclude that the fistula terminates in the flesh, but if a hard one is felt, we know that it ends with a bone. If the probe slide readily over the bone, it is free from caries, but if it does not so, and yet no inequalities are felt on it, caries has taken place, but it is still smooth: if it feel unequal and rough, the bone is eaten with caries. For a simple and recent fistula, not deep-seated or in a joint, the plaster for recent wounds will be sufficient, provided salt, or alum, or the scales of copper, or verdigris, or any of the other metals, be added to it. The application is to be made upon a piece of linen, and a sponge soaked in vinegar is to be put over it, and is to be removed on the fifth day. The patient must live upon nutritious food. If the fistula is at a distance from the præcordia, emetics with radishes are said by him to be proper. When the fistula is old it becomes callous, and requires stronger applications, containing such ingredients as calamine, atramentum sutorium, verdigris, galls, lime, orpiment, or realgur. He mentions as a very ready application a solution of ammoniac in vinegar, with some verdigris added to it. However, he remarks, any other caustic will accomplish the same purpose. If the fistula is long and transverse, an incision is to be made at its commencement, after which the collyrium may be applied. When the fistula is double, or consists of still more passages, he recommends us to blow in with a writing pen the medicines in the form of powder, or to apply them dissolved in wine, mulse, or vinegar. But whatever the internal dressing be, he recommends us to apply on the outside of it something of a refrigerant and repressing nature, as the parts around are generally affected with inflammation. When the dressings are removed the fistula is to be syringed with wine if the discharge of the pus is copious, with vinegar if its edges are callous, but with mulse, or a decoction of tares, if the passage be clean. By the means we have been describing it will generally happen, he says, that the inner coat of the fistula will slough off, and leave the ulcer in a clean state. Agglutinants are then to be applied, especially a sponge smeared with boiled honey. When the sides of the fistula are clean there need be no apprehension lest they do not adhere, since, he remarks, we often see in ulcerations of the fingers that without great care one finger is apt to adhere to another.

In the ‘Euporista’ of the Pseudo-Dioscorides, it is recommended first to dilate the fistula with a piece of sponge, and then to use a stimulant application containing verdigris, ammoniac, &c.

Aëtius gives an excellent account of fistula, but it is mostly borrowed from Galen. We can afford room only for a few extracts. When a fistula extends obliquely, nothing can be done without making a free incision, for which purpose he directs us to introduce a sound and cut along it. His directions for examining into the nature of a fistula are such as ample experience alone could have dictated. He seems to be decidedly of opinion that, except in cases of a recent fistula, or when it is not deep-seated, an incision ought always to be made at first; after which applications for removing the callus may be used. When, however, the patient refuses to submit to an operation, and the case is recent, the cure may be attempted by means of escharotics and incarnants, such as verdigris, misy, alum, &c., mixed with frankincense, aloes, and myrrh.

Oribasius briefly recommends white hellebore, a mixture of equal parts of verdigris and ammoniac, and a few other such articles, as applications for fistulæ.

Scribonius Largus mentions several compound applications containing misy, chalcitis, verdigris, alum, &c.

Marcellus gives one consisting of ceruse, ammoniac, and oil.

Actuarius gives a brief but distinct account of the nature and treatment of fistula, but it is taken almost entire from our author.

Avicenna inculcates that a fistula is only to be cured by a free incision, or by removing the callous sides of it by burning with fire or caustic medicines, such as arsenic, ammoniac, sulphur, the flour of copper, or mercury. This in fact is the sum of the medical practice in such cases. There is nothing particularly interesting in Haly Abbas. Alsaharavius truly states that a diseased bone is the common cause of fistulous ulcers not healing, and inculcates that in this case there can be no hope of recovery until the carious portion be removed. Rhases, upon the authority of the celebrated Antyllus, directs us to use corrosive applications when a fistula cannot be operated upon with the scalpel. He intimates that this is particularly the case when the disease is seated in the groins.

The earlier modern surgeons, such as Gulielmus de Saliceto, Arnoldus, Rogerius, Rolandus, and Guy of Cauliac, in imitation of the Arabians, direct fistula to be treated by the application of septics, the actual cautery, or incision. Rogerius recommends a tent spread with quicklime and soap, or with arsenic. Guy of Cauliac, like Avicenna, speaks favorably of sublimed quicksilver or corrosive sublimate.

SECT. L.—FOR SORES WHICH BREAK OUT AGAIN.

Some sores which have become cicatrized, often after no long time become inflamed and break out again; for a bone being diseased, sometimes the flesh which covers it heals up readily and appears sound, but in a short time a strong defluxion taking place from the corrupted bone below, inflammation supervenes, and pus is formed which corrodes the cicatrix. What then is the cure of such ulcers? Dry the diseased bone to such a degree that it may exfoliate. But the diseased part of the bone may easily be brought up if you apply a cataplasm, consisting of fig leaves triturated with fine dried barley flour and wine. Or you may apply equal parts of the reed of henbane and of copperas triturated together. The root of hog’s-fennel speedily removes the laminæ of bones.

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COMMENTARY. This chapter is copied from Aëtius, who gives some additional prescriptions, such as one consisting of the scales of copper, frankincense, alum, sal ammoniac, pomegranate rind, and ceruse, with or without cerate; and another consisting of red arsenic finely triturated with bear’s fat.

Avicenna recommends strong attractive applications, such as a plaster of the leaves of the black poppy with fig leaves; and another containing the atramentum sutorium (sulphate of copper.)

SECT. LI.—ON ULCERS IN THE JOINTS.

The joints being drier than the fleshy parts, they therefore require when ulcerated more desiccative applications. Wherefore the trochisk of Polyides, when rubbed with wine until of the consistence of the sordes of baths, is an excellent application; and in like manner all equally desiccative medicines. And we have seen them benefited by bathing with sea-water and brine frequently. Wherefore we must use the most desiccative applications to the joints.

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COMMENTARY. This is copied from Oribasius. (Synops. vii, 19.)

SECT. LII.—THOSE THINGS WHICH EXTRACT SHAFTS, JAVELINS, THORNS, AND THE LIKE.

Javelins, reeds, and shafts, and thorns, are extracted by the two pimpernels, the round birthwort, ammoniac with honey, the fruit of henbane triturated and sprinkled upon the part. Mix the pounded root of calamus with honey, put it into a piece of linen, and use in great quantity; it will speedily extract them.

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COMMENTARY. This subject will be more fully treated of in the Sixth Book.

Our author copies from Oribasius. (Synops. vii, 17.)

Most of the articles here enumerated are mentioned by Dioscorides as possessing strongly attractive properties. Avicenna, Rhases, and Haly Abbas, speak of similar articles, without any new remedies of consequence. See in particular Haly. (Pract. iv, 24.)

The applications mentioned by Pliny are ridiculous. (H. N. xxx, 42, and xxxii, 43.)

SECT. LIII.—ON HEMORRHAGE FROM VEINS AND ARTERIES.

In cases of hemorrhage from parts, the contrary position to that for sinuses will be the proper one, that is to say, the upright, but that must not be in too great a degree, for there is danger of pain being excited, and of the blood bursting forth from the vessel again; for nothing produces hemorrhage and increases inflammation more than pain. Wherefore apply your finger immediately to the part from which the blood flows, putting it gently upon the orifice of the opening in the vessel, and pressing it so as not to excite pain, for by this means you will restrain the bleeding, and block up the opening with a thrombus, and should the bleeding vessel be deep-seated you will thereby ascertain most correctly its situation and magnitude, and whether it be an artery or a vein. After this, if the vessel be small we must use some of the styptics. The best of these are the obstruents, composed of roasted rosin, of fine flour of wheat, and of gypsum, and such like, mixed up with the white of an egg and applied upon the down of a hare. When the vessel is large seize it with a hook, stretch and twist it moderately. When the bleeding is stopped, endeavour if it is a vein to restrain the blood without a ligature, by the same medicines. But if it is an artery, one of two things must be done, either apply a ligature around it, or cut the vessel asunder, by which means you will restrain the blood. Sometimes, too, we are obliged to apply a ligature to large veins, and also occasionally to cut them asunder transversely. We are sometimes driven to this necessity with regard to veins which arise from a deep-seated place, more especially when they run through a narrow passage or important parts, for thus the portions will be retracted on either side, and the wound will be blocked up and covered by the parts above it. But the safer practice is to do both these things, applying a ligature to the root of the vessel and then dividing it. Having done these things, the wound is to be incarnated as quickly as possible, before the ligature slip from the vessel. For if it is not speedily incarnated, but the emptied portion is dilated, the disease called aneurism is formed. You may know whether it is a vein or an artery that pours forth the blood, from this, that the blood of an artery is brighter and thinner, and is evacuated by pulsations, whereas that of the vein is blacker and without pulsation.