Part 15

Though we cannot exactly subscribe to Alexander Simon’s declaration to the effect that it would fill whole volumes, if we wished to cite systematically and in full all that has been said by the oldest and earlier medical Writers on ulcerous affections that attack the sexual parts from the points of view of pathology and therapeutics, still the number of such passages is no doubt sufficiently imposing. Unfortunately their contents cannot be described as equally important; for the pathological side is sacrificed to the therapeutic,—in fact the great majority give nothing more than the general names ἕλκος (ulcer) or φλεγμονὴ αἰδοίου (inflamed tumour of the privates), and then at once pass on to discuss the remedial measures expedient. This mode of procedure is indeed quite consistent with the general character of medical science in those days, for it is always the case that the more medicine declines, the more practitioners think themselves bound to look for remedial means nowhere but in the prescription-books. Curiously enough we find that almost every thing given by the later physicians already has a place in the pages of _Celsus_; the latter probably utilized the Alexandrian physicians, on whose knowledge the later Writers appear to have made little advance.

Now with regard to ulcers of the genitals in general,—these are of frequent occurrence, as to begin with the parts are from their very constitution prone to putrefactive changes, as well owing to their moist nature, possessing as they do so many glands that draw moisture together, and being covered with hair, as because they are at the same time excretory organs[348]. The time of year exerts an influence on the appearance of such ulcers, for they show themselves chiefly in the summer,[349] particularly when a South wind is blowing,[350] a wind that is moist and warm and fosters a tendency towards the resolution of fluid and solid parts alike. Thus ulcers of the genitals are likewise subject to epidemic influence, as has been clearly demonstrated on previous pages. They are acquired by coition, and that equally by natural coition, as the instance of Hero mentioned on a previous page shows without a shadow of doubt, as by the unnatural forms, and particularly by paederastia, which last caused the malady of Naevolus’ slave also referred to in an earlier passage. Moreover in the hot regions of Asia and Africa want of cleanliness also, especially when men were uncircumcised, gave occasion, as in Apion’s case, to the establishment of ulcers of the genitals. These were looked upon by the Ancient physicians in most instances as an outcome of the evil humours of the body,—an opinion which need cause us less surprise as even in much more modern times a large number of physicians have endeavoured to explain the origin of chancres by an antecedent general infection, that manifested itself in this way, viz. by the appearance of these sores. Ulcers not unfrequently took the form of aphthae, particularly in women,[351] being in that case more superficial, but for that very reason readily eating their way over adjacent parts,—(_cancer_, eating ulcer). In many instances inflammation (φλεγμονὴ, ἐρυσίπελας—phlegmonous inflammation, erysipelas) and swelling of the parts affected were accompanying circumstances. They were often painful,—sometimes moist, sometimes dry. In the majority of cases they assumed under favouring conditions a putrefactive character (φαγέδαινα,—phagedenic or eating ulcer), under which circumstances worms actually bred in the sores, or else they manifested from the very first a marked tendency to pass over into gangrene (ἄνθραξ, _carbunculus_,—malignant pustule, carbuncle), where as a rule merely an ulcer developing from a minute bladder (bleb) or φύμα existed in the first instance. On the other hand its course was often very chronic, without phlegmonous ulcers at all, or if these were present, either they were callous, or else condylomatous outgrowths sprung from them.

In accordance with these varying factors did the _treatment of ulcers of the genitals_ vary, though without any universally recognized special distinction from that adopted for ulcers in general. Speaking generally, purgings by the rectum are not indicated; but preferably in affections of the genitals revulsory treatment by emetics is employed.[352] If blood-letting is resorted to, it must be either in the hollow of the knee or at the ankle.[353] As to local measures, fatty matters according to _Antyllus_ are not good for the genitals,[354] whereas astringents and desiccatives are beneficial, if that is to say the phlegmonous condition is absent.[355] On the contrary if the latter is found, this must in the first place be combated, then a mixture applied consisting of sifted resin and pounded cumin, or alternatively a poultice of barley-meal, hydromel and vine-leaves reduced to a pulp, or else cumin with butter and tree-resin.[356] Above all Galen[357] recommended in the early stages before the appearance of an eating or phagedenic ulcer (κατὰ τῶν ἐν αἰδοίοις φλεγμονῶν ἐν ἀρχῇ, πρὶν ὑποφαίνεσθαι τινα νομώδη σηπέδονα,—in phlegmonous affections of the privates at the commencement, before any eating ulceration appear) a _ceratum rosaceum_ (wax-salve of roses), the preparation of which he gives _in extenso_, and Aëtius copying from him; its activity is enhanced by the addition of a little _oleum sabinum_ (Sabine oil). If the ulcers are complicated with _swelling_, a compound of white-lead (ψιμύθιον) and triturated vine-leaves is applied,[358] sea-water compresses,[359] or poultices of boiled lentils and pomegranate rind.[360] For _painful_ ulcers pompholyx (flowers of zinc)[361] was particularly recommended, or a decoction of linseed with the addition of myrrh; also woman’s milk may be advantageously used as well,[362] especially with the addition of _anodynes_, and above all pompholyx or flowers of zinc. _Paulus Aegineta_ (loco citato) prescribed the application of butter and resin melted together in equal parts, or linseed ground up with myrrh and resin. In _raw_ and _dry_ ulcers of the genitals the aloe was very generally prescribed; it was powdered and sprinkled over the sore,[363] or if a phlegmonous condition was already established, dissolved in water.[364] In the second case _Oribasius_[365] prescribed likewise the use of lead,—and indeed it was a usual recommendation with regard to most of the recognized remedies that they should be pounded and triturated in leaden mortars with leaden pestles.

Superficial ulcers _of an aphthae-like character_ were treated as early as in _Hippocrates’_ time and indeed by him[366] with a decoction of myrtle-berries boiled in wine. As a remedy against _moist_ ulcers a certain mixture of Crito’s, compounded of frankincense and myrrh boiled in sweet wine, had a great reputation;[367] but above all the powder of _charta usta_ (papyrus ash), anise and _cucurbita_ (gourd)[368] was employed, after the ulcer had been washed with urine; further the _cortex pinus_ (cork-tree), _lapis haematites_ (bloodstone, haematite iron-ore),[369] to which frankincense was added in the case of more deep-seated ulcers,[370] also _cadmium ustum_ (burnt calamine) (Paulus Aegineta); likewise washing with urine proved beneficial.[371] In _spreading or eating_ ulcers (νομῶδες ἕλκος) a poultice was applied of lentils, pomegranates and oxymel[372] reduced to a pulp; but a still more usual remedy was to sprinkle verdigris over the sore,[373] and especially verdigris in conjunction with a salve made of _charta usta_ (papyrus ash), sulphur, lead-slag, honey and _ceratum rosaceum_ (wax-salve of roses); another remedy highly thought of was the _pastillus corax_ (corax cake), the ingredients of which were verdigris, chalk, gallnut, frankincense, turpentine, wax, oil of myrtles and beef-tallow; this was particularly beneficial in combating the carbunculous form of the disease. Very often however recourse to the cauterizing iron and the knife was unavoidable, especially if gangrene supervened, or if the callosity of the edges of the ulcer made cicatrisation impossible.

Such were the general methods of treatment employed for ulcers of the genital organs, but these naturally varied according to the various distinctions between the several sorts conditional on the situation of the sore. Thus it becomes our next business to indicate on what parts of the body ulcers were observed:—

A. ULCERS ON THE MALE GENITAL ORGANS.

It is invariably the case that forms of ulceration affecting the male genitals are the most familiar and best known, and this was equally true in Antiquity. Whatever information the Ancient physicians deemed it necessary to record on the subject is found as early as _Celsus_ laid down with something approaching to completeness in his writings (VI. 18.).

a. _Ulcers of the Prepuce._

According to Leonidas[374] fissures and cracks in the prepuce frequently occurred, in all cases of the latter being too tight and being forcibly drawn back. On these supervened pain and phlegmonous inflammation; and then if a cure were not speedily effected, the edges assumed a condition of callosity, necessitating the use of the knife for its removal. However, more often than not the wound broke out again, because as was noted as early as by _Hippocrates_,[375] wounds of the prepuce are as a rule obstinate in healing. To meet this eventuality _Galen_[376] provides an entirely suitable procedure. While ulcers of the glans penis demand desiccative remedies, those of the prepuce rather call for _epilotics_,[377] especially anise. Supposing the prepuce to become gangrenous, it must be cut away circularly, and the bleeding stopped by cauterization; if this treatment is not needful, a mixture of verdigris with honey, or pomegranate and vetch is applied.[378] Ulcers on the inner fold of the prepuce, as also on the skin of the penis generally, are mentioned by _Celsus_ (VI. 18.), the latter likewise by _Galen_.[379] Such ulcers on the inner fold of the prepuce, Celsus states, not unfrequently give occasion to the setting up of phimosis and paraphimosis; and yet another consequence, a morbid growing together of glans and prepuce was observed by _Oribasius_ (loco citato, 5.) and _Paulus Aegineta_ (VI. 56.), for which these authors prescribe appropriate medical and surgical treatment. Under the name of _cancer_ (eating ulcer) of the prepuce Celsus, it would seem, describes the νομὴ (spreading ulcer) of the Greek physicians, which commences by the ulcer turning black. Occasionally too the ulcers developed out of themselves morbid growths, excrescences or condylomata, particularly the form known as _thymion_ (warty excrescence).

b. _Ulcers of the Glans Penis._

These are, as pointed out by _Celsus_ (VI. 18.), best described by taking their pathological and therapeutic aspects together; but it would serve no useful purpose to quote once more in this place the passages dealing with this part of the subject, which have been so often printed already. He makes a distinction, as does _Galen_,[380] between dry and clean, moist and suppurative, ulcers, the latter of which readily lead to phimosis and paraphimosis. The discharge is sometimes thin and watery, sometimes purulent, and on occasion becomes evil-smelling; the ulcerations both spread superficially and penetrate inwards, and may actually destroy the glans underneath the prepuce, so that it perishes altogether. When this happens, _Paulus Aegineta_ (VI. 57.) has a leaden pipette inserted in the orifice of the urethra, to enable the patient to pass water. In other cases the prepuce grows into one with the ulcerated glans penis (_Celsus_, _Paulus Aegineta_, _Oribasius_). Ulcers _circa coronam glandis_ (round the crown of the glans penis) are mentioned by _Aëtius_.[381]

A special kind is the _cancer colis_ (eating ulcer of the member), probably the same as the νομὴ (spreading ulcer) of the Greeks, which Aëtius[382] delineates as a spreading, flaccid ulcer, which on pressure emits a thin bloody discharge, that subsequently becomes feculent. Hemorrhage is apt to supervene according to Celsus on the shedding of a cicatrix artificially produced by operation or the cauterizing iron. Another species of _cancer_ is the φαγέδαινα (phagedenic, eating ulcer) of the Greeks, which extends rapidly and penetrates to the bladder. It appears to be identical with ἄνθραξ (malignant pustule), though Celsus mentions the _carbunculus colis_ (carbuncle of the member) in a special category; for the description he gives, bk. V. ch. 28., of carbuncle is equally applicable to the phagedaena.[383] Ἄνθραξ (malignant pustule) begins with itching, later on a pustule, or else a number of little bladders or blebs resembling millet-seeds appear, which burst in much the same way as a blister due to burning does, leaving behind an _ulcus crustaceum_ (scab-encrusted ulcer), resembling the cicatrix of a burn; this is firmly adherent and black in colour. The surrounding tissue is likewise black and violently inflamed, the inflammation not unfrequently having an erysipelas-like character. _Galen_[384] designates the process ἀνθράκωσις, and declares that buboes are an accompanying feature. He holds the ulcers of the genitals occurring under the special climatic conditions laid down by Hippocrates above to have been partly ἄνθραξ,[385] the disease to which Hero succumbed.

Another kind of ulcer affecting the male genitals is mentioned by _Pollux_[386] under the name of θηρίωμα (malignant sore), which _Celsus_ (V. 28.) likewise speaks of, but without particularizing its situation. The same fact applies to ulcers of the glans penis as to those of the prepuce, viz. that many forms of morbid outgrowths arise from them; in other instances callosities on the edges of the ulcers are built up, leaving behind a callous protuberance, which the Greeks appear to have called ἥλος (a nail), the Romans _clavus_ (a nail).[387] The proper treatment to be followed in each of these special cases is given by Celsus and the Writers he cites.

B. ULCERS OF THE FEMALE GENITAL ORGANS.

In this connection, as indeed in the discussion of the female genital organs generally, we once again meet with the difficulty due to the indefiniteness of the names given to the several parts. Not only do the Greeks constantly make use of the general expression αἰδοία, μόρια (privates, parts), but they likewise employ ὑστέρον and μήτρα (the womb) sometimes as meaning the vagina, sometimes the uterus, though it is true the later Writers like _Galen_[388] designate the vagina ἡ ὑστέρα, the uterus ὁ ὑστέρος, yet without keeping consistently to the distinction. The same applies to the use in Latin of _locus_ (place), _pars_ (part), and _vulva_ (womb), which last word stands for the uterus in _Celsus_, _Pliny_ and most of the later Writers.

Passing over the indefinite expressions _dolores_ (pains), _inflammatio_ or _phlegmoné_ (inflammation) of the genitals, although the treatment prescribed for them clearly implies that very often ulceration was concurrently present, we find the various kinds of ulcers of the female genitals most fully and systematically described by _Aretaeus_,[389] _Paulus Aegineta_ (III. 65-68.) and _Aëtius_[390] following Archigenes, Soranus and Aspasia.[391][392]

_Abscesses_ _Aëtius_ says (loco citato, ch. 110.) occur on the female _labia_; if these extend in the direction of the anus, they must not be opened with the knife, as fistulas are liable to be set up, but there is no fear of this when they extend towards the urethra. The same author (p. 109.) speaks of _pustulae scabrae_ (scabrous, scurfy pustules) in the vagina and orifice of the womb, which throw off bran-like scales, as also (ch. 108.) of _tubercula miliaria_ (miliary tubercles) in the same localities. These may no doubt be recognized by touch, but are better diagnosed by means of the uterine speculum, or _Dioptra_, and _ex coitus affrictu_ (in consequence of friction in coition) interfere with menstruation and conception. Obviously what is here pointed to is the swollen mucous glands, which in our modern practice likewise are frequently observed in gonorrhœal cases. Often the ulcers take a form characterized by _fissures_ (ῥαγάδες, _fissurae_,—fissures, _rimae_,—cracks), particularly at the orifice of the uterus.[393] Sometimes they become callous, at others give rise to morbid outgrowths; as a rule the discharge is a thin watery juice, and pain is felt during coition.[394]

Ulcers strictly so called, says Aretaeus, are either superficial, in fact rather excoriations than ulcers, and far-spreading; they itch as though salt had been sprinkled on the surface, give off a small quantity of thick pus, free from smell, and are not malignant. To this class probably belong the aphthae-like ulcers of Hippocrates.[395] In other cases they are more deep-seated; being then painful, discharging an evil-smelling pus, and having a less mild character than the former, but still not such as to be described as malignant. If they penetrate yet deeper, the edges then become rough, the discharge takes the form of a malodorous juice, while the pain is more severe than in the other kinds. The actual tissue of the womb is partially destroyed in the latter case, while morbid outgrowths form, which make cicatrization extremely difficult. This last kind was known also as _phagedaena_, (eating ulcer); it is dangerous, especially if the pain increases and the patient falls into low spirits. An offensive juice is discharged, so foul that the patient herself is hard put to bear it; the ulcer is highly intolerant of being touched for the application of remedial means; it may end fatally, and is known under the name of “Crab-ulcer”. Νομὴ (spreading ulcer),[396] carbuncle and _sordida ulcera_ (foul ulcers) of the uterus are mentioned by _Aëtius_ (loco citato), who shows the mode of investigating them by means of the uterine speculum and a treatment consisting mainly of injections[397] and pessaries prepared of a number of different remedies. Not unfrequently unskilful treatment of ulcers of the vagina occasioned morbid outgrowths, which according to _Celsus’_ teaching,[398] must be removed by surgical means. Lastly the fact that ulcers of the genital organs of women were prejudicial to men who consummated coition with them and were for that reason dreaded by them, is clearly implied in the narrative of _Cedrenus_.[399]

4. Ulcers of the Fundament.

We have already seen how fissures and ulcers of the fundament were a not unusual consequence of the vice of the pathic, yet not the faintest indication of the fact is to be found in the medical Writers. The knowledge possessed by the Ancients as to affections of the fundament have been collected with a very considerable degree of completeness by _Aëtius_,[400] especially as copying Galen; the remaining authorities treat them as a rule in conjunction with the corresponding affections of the genitals, and mostly recommend the same remedies for them. So far therefore as they are concerned we refer back to the information given in connection with the latter. At the same time the remark may be permitted that this juxtaposition of the two seems to point to the Ancients having held, as we maintain they did, the view that affections of the genitals and affections of the anus arose from like causes and were of like character, as is shown by their dealing with the one and the other class of diseases on the same general lines.

_Ardentes dolores_ (burning pains)[401] and _pruritus_ (itching)[402] of the anus are not uncommon. _Inflammations_[403] often supervene as a consequence of fissures, morbid growths and ulcers. _Rhagades_ (cracks) and _fissures_[404] are found either in the sphincter muscle or in the rectum, and are an accompaniment of condylomata, whenever the latter become inflamed and spread, causing the surrounding tissue to rupture; the edges frequently assume a callous condition, and then require to be broken down and thus transformed into a simple ulcer. Often abscesses are set up[405] as a result of the inflammation, and these are liable to lead to fistulas. The ulcers[406] on occasion assume the character of the νομὴ φαγέδαινα (eating and spreading ulcer). Supposing them situated on the sphincter ani, they must neither be cut nor cauterized, as severance of the muscle makes it impossible for the patient to retain the faeces. This loss of retentive power may also occur apart from any operation, if the νομη (spreading ulcer) destroy the muscle. Supposing on the contrary the νομὴ to be below the sphincter, knife or cauterizing iron may either of them be employed. In some instances ulcers lead to a morbid growth at the orificium ani, that must be obviated by means of pipettes of lead.[407] In other cases _rhagades_ (cracks) and ulcers lead eventually to morbid outgrowths.

5. Buboes.

Bubo, panus (swelling resembling the thread wound on bobbin of a shuttle), paniculus (diminutive of same), inguen (swelling in the groin).

Under the name of _bubo_ the ancient Physicians understood any form of inflammation of the lymphatic glands. Now such inflammation occurs above all other places in the inguinal region, and thus inflammation of the inguinal glands came to be especially indicated by the word, as well as the inguinal region itself. Similarly the Romans used _inguen_ (the groin) both for the region and for the disease. Subsequently many distinctions were drawn; a phlegmonous affection combined with swelling was called a βουβὼν (bubo), while the name φῦμα (swelling) was appropriated to a swelling of the glands characterized by its rapid establishment and its tendency to suppuration (bubo with suppurative pustule in the centre), and φύγεθλον (burning swelling) to one conjoined with (cutaneous) inflammation of an erysipelas character,[408] which last form, if it passes on into induration, is known as χοιρὰς or _struma_ (scrofulous or strumous swelling). The best exposition from the points of view equally of pathology and therapeutics is found in _Galen_.[409] The glands in virtue of their spongy structure are peculiarly liable to take up rheums or fluxes of all descriptions; accordingly the glands of the groin, armpits and neck swell, directly ulcers are set up in the toes, fingers or head. The body being overloaded with evil humours is another reason for the establishment of buboes, and in this case they are more difficult to cure. Further, _Hippocrates_[410] derived buboes in women from interrupted menstruation, and maintains[411] that the most part owe their origin to some affection of the liver.