Part 14

No doubt _Hensler_ and _Alex. Simon_ had already struck out this second way of exposition; but the latter writer merely examined the data of the several Writers by themselves without making any effort to build them up into one whole. To do this was, it is true, a proceeding quite foreign to the method adopted by the Ancients, but for our own time, accustomed as we now are to demand a systematic exposition of a subject, it seems absolutely indispensible. _Hensler_ on the other hand in his treatment of the question fixed his particular attention solely on the Middle Ages, and made it his immediate aim merely to prove that previously to the ninetieth year of the XVth Century local affections of the genital organs were already well known, and had been subjected to treatment.[297]

Now with regard to the actual exposition that follows, we shall refrain in it as much as possible from going into particulars, such as the text itself or the views of the Authors might seem to make obligatory, as the needful space fails us, at any rate for the present. Moreover the matter coming under review has been discussed already by many others, while as for critical elucidations, let them be as pressingly required as they may, we lack all the necessary _apparatus criticus_. In fact in the case of several Writers, the translation, let alone the original text, was with difficulty accessible, for which reason many a passage of those already known may perhaps have been passed by unregarded. A complete collection of all passages, including those still unknown,—for the harvest as was mentioned above has by no means been all reaped,—will certainly not be demanded by any reasonable reader from a Student of thirty, for hardly even a greybeard Enquirer surely could boast of having read all printed works of the ancient Physicians. For the rest, our present object is not at all to give an exhaustive exposition of all the ideas and observations of ancient Physicians as to affections of the genital organs; it only concerns us here to bring together what is true and directly available for our task. Under this head would certainly seem to come the following seven points:

1. =Gonorrhœa= (_Clap_).

Nimia profusio seminis,—excessive flow of seed (Celsus), γονόῤῥοια.

Gonorrhœa, the name of which is compounded of γονή (badly made semen) and ῥεῖν (to flow),[298] consists in an affection of the seminal vessels, not of the private parts themselves, which merely serve as the road for the excretion of the seed.[299] _Two kinds_ of gonorrhœa must be distinguished, according as the malady is, or is not, combined with erection of the penis.[300]

_Gonorrhœa with erection of the penis_ is called sometimes _Satyriasis_ or _Satyriasmus_ sometimes _Priapism_,[301] and is a species of cramp,[302] which however only attacks the penis, belongs to the category of the emphysemata, or inflations,[303] and is conditioned by an afflux of the humours, particularly of conspissated or badly compounded humours.[304] However this last phænomenon is only a symptom of that morbid lasciviousness which _Paulus Aegineta_ entitles Priapism, while he designates the condition connected with it by the name of Satyriasis, this having its origin in an inflammatory affection of the seminal vessels.[305] No proof is needed that both these views are right so far as this, that gonorrhœa is both spasmodic and inflammatory, and in either case may be accompanied by priapism. Nothing, or only very little, is evacuated of a nature to make the patients experience relief; and if there is, they are again attacked by the evil, until the original cause of the erection is eliminated, on which the penis relaxes of itself and subsides.[306] According to _Paulus Aegineta_ paresis of the spermatic vessels,—the second form of gonorrhœa,[307]—supervenes, if the disease is not relieved, or else general spasms. Patients attacked by such spasms succumb rapidly, suffering from cold sweats and tympanitic distension of the abdomen. _Alexander of Tralles_ (IX. 10) saw the erection even continue after the death of the patient. This form is not a common one; it occurs pre-eminently among young people,[308] and according to _Themison’s_ observations, who frequently saw the complaint in Crete, where however it was probably very often a result of pederastia, is subject to epidemic influence.

The _treatment_ of this form of gonorrhœa demands according to _Paulus Aegineta_ (loco citato) immediate general blood-letting,—this _Galen_[309] also recommends, and practised with advantage,—local cupping or leeching, simple clysters, cooling and composing embrocations and poultices of solanum (nightshade) or cicuta (hemlock) in the lumbar region, of litharge, Cimolian earth, psymithium (white-lead) with vinegar, water or sweet wine, on the perineum. Internal remedies are a decoction of mallows, mercury and birch-bark, sap of rue, decoction from the root of the iris, nymphaea (water-lily) and adianthum (maidenhair). Diuretics are injurious. Patients should at the same time be put upon a low, vegetable diet, and the supine posture avoided. _Galen_ (loco citato) recommended in addition emetics, but not purgatives, also embrocations of _ceratum rosaceum_, friction and subsequently gymnastic exercises. _Alexander of Tralles_ insists particularly on the patient avoiding[310] all wanton scenes and thoughts, and forbids the use of any cold, specially astringent things, whereby the resolution of the contraction is made more difficult (πάθος δυσδιαφόρητον γενέσθαι,—the affection is rendered hard to be resolved).

Gonorrhœa without erection of the penis, that is to say gonorrhœa proper, exhibits a persistent, involuntary discharge of the seed,[311] has some analogy with _incontinentia urinae_, and usually depends like the latter on weakness or failure in the retentive power of the spermatic vessels.[312] Very often an inflammatory stage supervenes, making the complaint approximate to the first form; patients secrete copious and hot semen, which provokes them to ejaculation,—an ejaculation however that is followed by great exhaustion. If they avoid copulation, headache is established, pains in the stomach and nausea, while nocturnal pollutions cause them similar inconveniences to those they incur from coition. The ejaculation is accompanied by heat and smarting pain,—and this not solely among men but with women as well; for one of these patients, _Galen_ writes,[313] told me that not only himself, but also _the women with whom he had accomplished coition_, experienced during the discharge a biting, burning pain. On the contrary, according to _Aretaeus_,[314] it would seem the only symptoms found in conjunction with the complaint are itching of the privates, a voluptuous feeling and a violent inclination to sexual intercourse. This datum admits of ready explanation if we consider the fact that in southern countries the inflammatory stage that makes its appearance is very brief and as a rule hardly noticeable, provided,—though no doubt this condition was pretty often broken,—coition was not indulged in during its course.

As a matter of fact in the great majority of instances the Physician had only the chronic form to treat. Generally speaking a patient first notices the complaint, when the discharge begins; and then the latter, when once the inflammatory stage is over, proceeds day and night undisturbed and without special voluptuous feeling, without wanton dreams,[315] often without any particular sensation at all. The actual discharge is a thin, cold, pale, sterile flux. Towards the end of the illness it becomes thicker, assumes an acrid quality, and eventually ceases altogether to flow.[316] But if the malady persists, especially in young people, then according to _Aretaeus_, the whole visage of the sufferers assumes a greyish look; they grow sluggish, atonic, spiritless, faint-hearted, indolent, dull, weak, emaciated, incapable of effort, unhealthy-looking,[317] pale, womanish, have no appetite, feel chilly, complain of heaviness in the limbs, are weak-loined, feeble and unfit for anything. According to _Galen_, the abdomen falls in, besides all the rest of the body collapsing more or less and withering; while patients become lean, of a yellowish pale complexion and hollow-eyed. In this way the complaint not unfrequently paves the road to paralysis, or else sufferers die of _tabes_ or wasting.[318] Specifically and in itself the disease is not dangerous, but it provokes various other complaints, and represents a highly disagreeable, ill-reputed affection (Aretaeus),[319] that almost always follows a chronic course,[320]—for which reason Aretaeus and Caelius Aurelianus actually treat of it under the head of chronic diseases.

Gonorrhœal pus is infectious, as is implied by the Mosaic Laws of Purification (Leviticus Ch. XV.), and the malady is communicated by coition, as is seen from the words of _Galen_,—p. 428. But as early as the Fourth Century the idea was prevalent that the _conjunction of the stars_ was not devoid of influence, as such or such a conjunction might from a man’s very birth determine that _the individual was to die of gonorrhœa_. This at any rate is maintained by _Julius Firmicus Maternus_,[321] who lived in the time of Constantine the Great. The disease has to be carefully distinguished from the nocturnal pollutions,[322] that are at times one of the sequelae of gonorrhœa.

The treatment is, according to _Aretaeus_, at the commencement that for an ordinary rheum or flux, by keeping the parts affected cool, in order to counteract the flow of the humours to them; by degrees going on to a heating and at the same time desiccating procedure, then the application of fresh wool to the part, the employment of friction, embrocations of _ceratum rosaceum_ or _oinanthinum_ with white wine, olive oil with melilot, marjoram, rosemary, poultices of barley-meal, saltpetre and dyll, but above all rue, with the addition of honey or, according to _Celsus_, vinegar; as further treatment, stimulating cataplasms, of a strength to redden the skin or even to bring out pustules on it, so as to draw off the afflux of the humours, or else as an alternative, plasters of the nature of the _emplastrum viride_ (green plaster), of _baccae lauri_ (laurel berries). As for internal treatment, the patient should drink decoctions of: _semen lactucae_ (lettuce juice), _cannabis_ (hemp), _rad. orcheos_ (orchis root), _nymphaeae_ (waterlily), _halicacabi_ (bladder-wort), etc.; and take _castoreum_ (beaver oil), or the antidotes of _Symphon_, _Philo_, or _Bestinus_, which are prepared from _viper’s flesh_. In case of very profuse discharge, the patient should be directed to drink hard red wine; if he is acrid with bile (χολωδέστερον καὶ δριμύτερον,—over-bilious and acrid), lukewarm baths are brought into requisition (Alexander of Tralles). On one point all authorities are agreed, that the main thing to depend on is diet. Both food and drink, says Celsus, must be cold, a precaution Themison also recommended in satyriasis, whereas Caelius Aurelianus denounces it. The patient must not indulge in semen-forming matters, such as cause flatulency, but take nourishing food, flesh of animals but not fish, a little light wine with it, for the constant ejaculation is weakening; he should be careful as to resting,[323] lie on a cool bed, either on the right side or the left (Paulus Aegineta), not on the back (Celsus).

Where the complaint is of longer continuance, exercise in the open air and the use of cold baths is to be recommended, which latter _Celsus_[324] it appears prefers to see resorted to, as well as cold aspersions, almost at the very commencement; a mode of treatment that is even now coming into fashion again among ourselves, as the water-cure mania makes further and further progress. _Galen_[325] recommended, besides diet and medicine, that with a view to retarding the preparation of semen, gymnastic exercises, particularly such as bring the upper part of the body into activity, e. g. ball-playing both with great and little balls and the casting of leaden disks, be resorted to. After bathing, patients must rub and wash over the hips with desiccative ointments, oil expressed from red, coarse olives, roses or quinces, wax-salves with the juices of _sempervivum_ (evergreen house-leek), _solanum_ (nightshade), _umbilicus Veneris_ (navelwort), _portulaca_ (purslain), linseed boiled in water, etc. I once saw, he says, the Intendant of a Gymnasium Athletes lay a leaden disk on the lumbar region of an athlete as a measure against nocturnal pollution,—a means _Caelius Aurelianus_ prescribed _also_ for gonorrhœal patients,—and afterwards recommended the same treatment to another sufferer from these, who was thankful for the advice. Others again found lying on the _agnus castus_ beneficial to them, as well as the taking of its juice along with rue. Violently active refrigerants in the form of ointments, prepared from poppy and _atropa mandragora_ should not be employed, and this equally applies to sleeping on these plants when they are in bloom, for they act injuriously on the kidneys. On the other hand sleeping on roses was advantageous,—Caelius Aurelianus added to the list the leaves and flowers of _vitex_ (agnus castus, Abraham’s balm). “Besides these I have excogitated many other specifics for patients of the sort, and found their utility confirmed in practice. For instance those afflicted with such a condition of body should pay particular attention to this. When the accumulation of semen that has to be ejaculated is at its greatest, they should during the day take a nourishing yet moderate meal, and then when they lie down to sleep accomplish sexual intercourse.[326] But on the following day, after taking their fill of sleep, they should on rising chafe themselves till the skin is reddened. Next they should rub the body all over with oil; then soon after take some well-leavened, pure bread, baked in the baking-pan, and mixed with wine, after which they may then go about their customary business. Between the rubbing with oil and the meal of bread patients may go for a walk, if there is a spot convenient for the purpose in the neighbourhood, _except in the colder time of the year, for at that season it is better for them to stay indoors_.”

With regard to _gonorrhœa in women_, it is all but impossible to arrive at any accurate knowledge of what the Ancient Physicians knew concerning it. The reason of this is that the views held as to the effect of deteriorated menstrual blood and of the ῥοῦς γυναικεῖος (female discharge), by means of which the whole body was supposed to purge itself of evil humours,[327] absolutely precluded the possibility of any unprejudiced observation, in precisely the same way as down to quite modern times the _fluor albus_ (white flux, blennorrhœa) conditioned the extremely imperfect knowledge possessed by the faculty of female gonorrhœa. We purpose to leave over the inquiry into the points which differentiate the two (male and female gonorrhœa) to another opportunity; and will only note here that gonorrhœa in women, strictly so called, was by no means utterly unknown,—in fact there is no doubt whatever as to its being distinguished from the ῥοῦς γυναικεῖος (female discharge), as is shown by the passage of _Galen_ quoted above, and still more clearly by _Aretaeus_,[328] who speaks of γονόῤῥοια γυναικεῖα (female gonorrhœa) distinctly as ἄλλος ῥόος λευκὸς, another species of white flux. Whether perhaps this knowledge was first accumulated at the epoch of Tiberius and his fellows cannot indeed be positively determined; but certainly the word ἐλέξαμεν (we have named it) of the text of Aretaeus may very well leave room for such a conjecture, and as a matter of fact Aretaeus would appear to have lived under Domitian, and was therefore a contemporary of Martial’s!

2. Ulcers and Caruncles in the Urethra.

We have already seen from Hippocrates, Celsus and Galen that the ancient Physicians had observed the inflammation and subsequent matteration of the small mucous glands of the urethra evidenced by the symptoms of painful micturition, and seeing that mere tenesmus, as well as dysentery, are denominated ἑλκώσις (ulceration) by them, it is by no means improbable that many a urethral ulcer and many a case of gonorrhœa may have been treated under the name of ischuria (retention of urine). This is the more likely, as we learn from a passage of _Celsus_[329], one usually misinterpreted in several respects, that the urethral discharge was explained as due to an extension of the ulcer to the spermatic cords (_vasa deferentia_,—seed-bringing vessels). Yet further confirmation is afforded by a passage of _Actuarius_,[330] already cited by Simon, and our own conjecture expressed on a previous page thus justified.

Ulcers however also occurred in the urethra[331] unconnected with tubercular swellings (ἀφανὲς ἕλκος,—invisible ulcer); these not unfrequently occasioned bleeding,[332] and made their presence known by the accompanying pain, while synchronously small irregularly-shaped particles (ἐφελκύδες) were ejected.[333] The appropriate treatment of these ulcers has been described by _Paulus Aegineta_ (loco citato); it consisted in injections of honey and milk (_Aëtius_, IV. 2. 19., and _Actuarius_ also recommended _enemata morsus expertia_,—clysters free from biting acridity), introduction of lotus pounded in a leaden mortar by means of a feather or a twisted piece of lint (λεπτὸν στρεπτὸν,—light material twisted,—an anticipation of the bougie?) along with a mixture of gall-apple, flowers of zinc (oxide of zinc), starch-flour and aloes smeared in equal parts with rose-sap and plantain-sap.

Not unfrequently such ulcers give rise to the establishment of _caruncles in the urethra_, particularly _in the neighbourhood of the neck of the bladder_, though they occur[334] also in the ear, nose, as well as in connection with the privates and anus, in the latter case presenting the symptoms of ischuria (retention of urine), interfering as they do with the outflow of the urine. The presence of these caruncles may be diagnosed by the preceding symptoms, as also by the circumstance that the urine is evacuated by the introduction of a _catheter_, that this occasions pain at the seat of ulceration and breaks through the caruncle, causing the urine to pass mixed with blood and the remains of the caruncle. It is necessary to know if a thrombus (blood-clot) or calculus blocks the urethra; but as to whether we pronounce the mischief to be situated in the urethra itself and the cause of the ischuria to be there as well, this is a distinction of no practical or scientific value.[335] For as a rule it was solely as being the excretory duct of the bladder that the urethra had some little attention directed to it; while any signs it exhibited were generally regarded simply as symptoms connected with the urinary bladder and the kidneys. Partial _growing up, or morbid extuberance, in the urethra_ (συσσάρκωσις,—a growing together) following on a previous ulceration is described by _Heliodorus_, as given in Oribasius,[336] occasioning either a narrowing of the urethral passage in one spot or its being filled up over its entire superficies with morbid outgrowths of tissue. Partial narrowing causes dysuria or strangury (difficulty of micturition), the narrowing of the whole canal by morbid outgrowths, ischuria (impossibility of micturition, retention of urine). The outgrowth must be removed by means of a small lancet. The mode of procedure is then as follows. The patient is placed on his back, the penis straight out; then with the fingers of the left hand the operator compresses it behind the spot where the growth is found, in order to prevent the blood from flowing inwards when the incision is made; next he takes the knife in the right hand, pushes the point into the urethra, divides it as far along as the base of the morbid growth, but not so as to go beyond it. This done, he proceeds to cut out the growth by means of a circular incision, and compresses the urethra between the fingers, causing the growth to spring forwards. Supposing it now projects but does not actually spring out, it is extracted by means of a _mydion_ (boat-shaped instrument). After the removal of the growth the urethra must be protected from contact with the urine, which during the first few days is best done by applying an _ipoterion_, or compress,[337] made of papyrus. The mode of preparing this is described in detail later on, and a sort of elastic catheter indicated. Catheters of copper and tin might also be used, or a quill taken for the purpose. The tin or lead catheters are not to be inserted till after the third day, and carry in front a projecting shield. The application of a bandage described is declared to be of great advantage. Scirrhosities of _the neck of the bladder_, abscesses and the like, are mentioned by _Galen_ (loco citato) as occurring occasionally. With regard to _diseases of the prostates_ subsequent investigations must authenticate the amount of knowledge possessed of these by the physicians of Antiquity.

_Inflammation of the testicles_[338] is usually characterized according to _Paulus Aegineta_[339] by pain under strong pressure by the fingers, while only a slight pressure causes no uneasiness. Redness and heat are slight externally, but the latter is perceptible deep in by an investigating finger. Sometimes fever is associated with it, and if the inflammation is not quickly combated, the pain, _Celsus_ tells us,[340] extends to the inguinal and lumbar regions, the parts swell, the spermatic cord grows thicker and at the same time indurated. Both authorities make the treatment consist at first in blood-letting at the ankle,[341] and the use of soft poultices of bean-meal,[342] pounded cumin, linseed, etc. to which in cases of induration is added later on a mixture of crocus and wine. In obstinate instances poultices are used of _rad. cucumeris agrestis_ (root of the wild cucumber);[343] _Paulus Aegineta_ under these circumstances prescribes grapes, peas, cumin, brimstone, nitre and resin, made into a cataplasm with honey, besides sundry wax-salves. A considerable list of remedial agents is found enumerated in _Marcellus_ (ch. 33.) intended to combat the _tumores et dolores testiculorum_ (swellings and pains in the testicles); of these we will only mention the salves of mutton-suet and nitre, the sea-water compresses, the poultices of _rad. cicutae_ (hemlock root), white of egg, frankincense and ceruse (white lead). _Aretaeus_[344] gives us an interesting piece of information to the effect that in order to counteract neuralgia of the testicles and spermatic cord, accompanied at the same time by intestinal colic, the spermatic cord was _cut out_, being looked upon as the cause of the suffering. Important too is the case related by _Hippocrates_,[345] where a patient at Athens suffered from _prurigo_ (itch) of the whole body, but above all of the _testicles_ and the forehead, his skin having grown thick and hard as it does in leprosy, so that nowhere could it be pulled up above the general surface.

_Induration_ of the testicles is mentioned by _Galen_,[346] who assigns it as one cause of sterility. The same author[347] likewise speaks of the testicles being affected with _aphthae_ (διδύμους ἀφθῶντας), which he says should be treated with _terra cimolia_ (Cimolian chalk) and myrtle-berries.

§ 41.

3. Ulcers of the Genitals.

φθινάς, ἄνθραξ, ἔσχαρα,—robigo, cancer. (Wasting ulcer, malignant pustule, scab,—ulcerous sore, eating, suppurating ulcer).