27 I have spoken of those wounds which are mostly inflicted by weapons. My next task is to speak of those which are caused by the bite, at times of a man, at times of an ape, often of a dog, not infrequently of wild animals or of snakes. For almost every bite has in it poison of some sort. Therefore if the wound is severe, a cup should be applied straightway of it; if slighter a plaster, especially that of Diogenes. If that is not at hand, then one of the others I have recommended against bites; failing such, the green plaster called Alexandrian; if not even that is to be had, then any one which suits recent wounds, so long as it is not greasy. Salt is also a remedy for bites, especially dog-bite, if a hand is then placed over the bite and struck by two
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fingers of the other hand; for this brings out sanies; and brine-pickle may also be appropriately bandaged upon such a wound.
But especially if the dog was mad, the poison must be drawn out by a cup; next, if the wound is not among sinews and muscles, it must be cauterized; if it cannot be cauterized, it is not amiss to bleed the man. After cauterizing, applications are to be put on as for other burns; if the wound is not cauterized, such medicaments as are powerful corrosives. After this the wound should be filled in and brought to healing, not by any new method, but as already described above. After the bite of a mad dog some send the patients at once to the bath, and there let them sweat as much as their bodily strength allows, the wound being kept open in order that the poison may drop out freely from it; then follows the administration of much wine, undiluted, which is an antidote to all poisons. And when this has been carried out for three days, the patient is deemed to be out of danger.
But when too little has been done for such a wound, it usually gives rise to a fear of water which the hands call hydrophobia, a most distressing disease, in which the patient is tortured simultaneously by thirst and by dread of water. In these cases there is very little help for the sufferer. But still there is just one remedy, to throw the patient unawares into a water tank which he has not seen beforehand. If he cannot swim, let him sink under and drink, then lift him out; if he can swim, push him under at intervals so that he drinks his fill of water even against his will; for so his thirst and dread of water are removed at the same time. Yet this
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procedure incurs a good danger, that a spasm of sinews, provoked by the cold water, may carry off a weakened body. Lest this should happen, he must be taken straight from the tank and plunged into a bath of hot oil. But as an antidote we should give especially the one which I put first, when that is not at hand, another; it is to be given in a draught of water, if the patient does not dread water yet; and if the bitterness is objected to, honey is to be added; if dread of water has already seized him, the antidote can be swallowed as a pill.
Serpents' bites again need a not very different treatment, although in this the ancients had very various methods so that for each kind of snake some prescribed one special kind of remedy, some another; but in all it is the same measures which are the most efficacious. Therefore first the limb is to be constricted above this kind of wound, but not too tightly, lest it become numbed; next, the poison is to be drawn out. A cup does this best. But it is not amiss beforehand to according to incisions with a scalpel around the wound, in order that more of the vitiated blood may be extracted. If there is no cup at hand, although this can hardly happen, use any similar vessel which can do what you want; if there is not even this, a man must be got to suck the wound. I declare there is no particular science in those people who are called Psylli, but a boldness confirmed by experience. For serpent's poison, like certain hunter's poisons, such as the Gauls in particular use, does no harm when swallowed, but only in a wound. Hence the snake itself may be safely eaten, whilst its stroke kills; and if one is stupefied, which mountebanks effect
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by certain medicaments, and if anyone puts his finger into its mouth and is not bitten, its saliva is harmless. Anyone, therefore, who follows the example of the Psylli and sucks out the wound, will himself be safe, and will promote the safety of the patient. He must see to it, however, beforehand that he has no sore place on his gums or palate or other parts of the mouth. After the suction, the patient should be put into a warm room, in such a position that the part bitten is inclined downwards. If there is no one at hand to suck out the wound, or to cup it, the patient should sip goose or mutton or veal broth and provoke a vomit; further a live chicken should be cut through the middle, and whilst warm applied forthwith over the wound so that its inner part is in contact with the patient's body. It will also do to slaughter a kid or lamb, and immediately to put the hot flesh upon the wound. The plasters also should be applied which have been mentioned above; the most suitable is the Ephesian plaster, or that noted next after it. There is ready help in on of the antidotes; if none is at hand, it is necessary to take in sips a draught of strong wine with pepper, or anything else which will stir up heat, to prevent humour from coagulating internally; for most poisons cause death by cold. All diuretics also are useful, because they dilute the diseased matter.
Such are the general remedies against bites of any kind. Experience has taught, however, that anyone bitten by an asp should in particular drink
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vinegar. The case of a certain boy is said to demonstrate this, for having been thus bitten, partly on account of the bite, and partly owing to excessively hot weather, he was tormented by thirst, and being in a dry place found no other fluid, so he drank the vinegar he chanced to have with him, and was saved. I believe this happened because although vinegar is a refrigerant, it has also the faculty of dissipating. Hence it is that earth sprinkled with it froths. Therefore it is likely that by the same faculty humour which is condensing inside a patient is dissipated by it, and so health is restored.
There are also against certain other reptiles remedies which are well enough known. For the scorpion is itself the best remedy against itself. Some pound up a scorpion and swallow it in wine; some pound it up in the same way and put it upon the wound; some put it upon a brazier and fumigate the wound with it, putting a cloth all round to prevent the escape of the fumes, afterwards they bandage its ash upon the wound. The patient should also drink wine in which have been steeped the seeds, or at any rate the leaves, of the herba solaris, which the Greeks call heliotropion. It is good also to apply to the wound bran soaked in vinegar, or wild rue, or roasted salt with honey. I have known, however, practitioners who merely let blood from the arm of those stung by a scorpion, that and nothing more.
For the sting of a scorpion also, or for that of a spider, it is good to put on garlic mixed with rue and pounded up with oil.
But when cerastes, or dipsas, or haemorrhois has
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bitten a man, poley-germander roasted, equal in amount to an Egyptian bean, is divided into two draughts, a little rue being added. Trefoil also and wild mint and allheal-juice, with vinegar, are equally efficacious. Costmary, casia, and cinnamon may appropriately be taken in draughts.
For the bite of a chelydrus, allheal-juice or laser 4 grams, or leek-juice in 250 cc. of wine, may be taken, and a quantity of savory eaten. Over the bite either goat's dung, or barley-meal boiled with vinegar should be applied, or rue, or catnip pounded with salt, with honey added. This last is equally efficacious for the bite of a cerastes.
But when a venomous spider has done the harm, in addition to the surgical treatment, the patient should be plunged often into the hot bath; and take equal quantities of myrrh and bryony berries in 250 cc. of raisin wine; or radish seeds or darnel root in wine; bran boiled in vinegar is to be put on the wound, and the patient is kept in bed.
But the foregoing classes of reptiles belong to foreign countries, and are especially poisonous, and they are mostly generated in hot countries. Italy and colder countries are healthier in this respect too, for the reptiles they produce are less dangerous. Against them sufficient remedies are betony or convolvulus or centaury or agrimony or germander or burdock or sea parsnip; any one or two of these is pounded up and taken in wine . . . and applied to the bite. It must be remembered that all snake-bites are more harmful when either the reptile or the man is hungry. Hence snakes are most injurious when
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brooding, and it is of the greatest importance when there is danger from snakes not to go out before taking some food.
It is not so easy to render assistance when poison has been taken in food or drink, first because patients do not perceive it at once as when bitten by a snake; and so are unable to afford themselves any help immediately. Moreover, the mischief starts, not from the skin, but from within. But the best thing, as soon as any one has perceived it, is to swallow a quantity of oil at once and vomit; then, when the praecordia have been emptied, to drink an antidote; or failing that undiluted wine.
There are, nevertheless, certain remedies proper for particular poisons, especially for the milder ones. If a potion of cantharides has been swallowed, all-heal pounded in milk should be given or galbanum with the addition of wine, or milk by itself.
If it be hemlock, hot undiluted wine with rue should be taken in a large quantity, then the patient should be made to vomit; and after that laser is given in wine; and if free from fever he should be put into a hot bath; if not free, he should be anointed with heating remedies. After this, rest is necessary.
If it be hyoscyamus, honey wine should be drunk hot, or milk of any kind, especially asses' milk.
If it be white-lead, mallow or walnut juice rubbed up in wine is best.
If a leech has been swallowed, vinegar with salt is to be drunk. When milk has curdled inside, either raisin wine or rennet or laser with vinegar.
If any one has eaten fungi that are not used, a
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radish or purslane is to be eaten alone or with a draught of salt and vinegar. Such fungi may be distinguished from the sorts in use by their appearance, and may be rendered safe by suitable cooking; for when boiled in oil, or along with a pear-tree twig, they lose all their noxious property.
Burns are likewise the product of external violence, and so it seems to follow that I should speak of them here. Now they are best treated by leaves either of lily or of hound's tongue or of beet, boiled in old wine and oil; any one of the above applied at once brings healing. But the treatment can also be divided into: first, a stage of moderately exedent and repressant applications both to check blisters and to roughen the skin; next, a stage of soothing applications for healing. Among the former is lentil meal with honey, or myrrh with wine, or Cimolian chalk pounded up with frankincense bark and mixed with water, and when it has to be used, diluted with vinegar. Subsequent applications include anything that is greasy; but the most suitable is that containing lead slag or yolk of egg. There is also another treatment of burns, namely, while the inflammation lasts, to keep lentil meal and honey on the wound; next, when the inflammation has subsided, flour with rue or with leek or with horehound, until the crusts fall off; then vetch meal with honey, or iris ointment or turpentine-resin, until the ulceration is clean, and finally dry lint.
28 From those lesions which are due to something from without we come to those which originate from within, when some bodily part has become corrupted. Of these none are worse than carbuncles, the signs of which are: redness, with a few pustules projecting
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a little, mostly black, sometimes livid or pallid; their contents seems to be sanies; the colour underneath is black; the actual tissue is dry, and harder than it should be naturally; and round them there is a sort of crust, and outside that an inflammatory ring; and there the skin cannot be pinched up, but is as it were fixed in the underlying flesh. The patient is somnolent; sometimes there is shivering or fever or both. And this lesion spreads, sometimes quickly, sometimes slowly, pushing out a sort of root underneath; on the surface too as it spreads the skin gets paler, then becomes livid, and a ring of small pustules arises; and if this occurs in the region of the gullet or fauces, often it suddenly stops the patient's breathing. The best thing is to apply a cautery at once; this is not a severe procedure, because the patient does not feel it, since the flesh is dead; and the cauterizing is topped when pain is felt all over the lesion. After that the wound is to be treated like other burns; for under erodent medicaments it follows that the crust becomes separated on all sides from the liv gate flesh, and takes off with it whatever has become corrupted; and the cavity when clean can be dressed with some preparation to make flesh. But when the lesion is on the surface of the skin, it is possible to cure it simply by exedents or at any rate by caustics. The strength of the remedy adopted is to be proportionate to the lesion. But whatever the medicament is, if it is sufficiently effectual, it forthwith detaches the corrupted part from the living; we may be confident that wherever the application works, the diseased flesh everywhere sloughs off. If the medicament is being mastered by the disease, certainly there must be no delay in
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applying the cautery. But in such a case there should be abstinence from food and from wine; it is a good thing to drink water freely. And this should be done all the more when there is feverishness as well.
A carcinoma does not give rise to the same danger unless it is irritated by imprudent treatment. This disease occurs mostly in the upper parts of the body, in the region of the face, nose, ears, lips, and in the breasts of women, but it may also arise in an ulceration, or in the spleen. Around the spot is felt a sort of pricking; there is a fixed, irregular swelling, sometimes there is also numbness. Around it are dilated tortuous veins, pallid or livid in hue; sometimes in certain cases they are even hidden from view; and in some the part is painful to the touch, in others there is no feeling. And at times the part becomes harder or softer than natural, yet without ulcerating; and sometimes ulceration supervenes on all the above signs. The ulceration at times has no special characteristic; at times it resembles what the Greeks call condylomata, both in a sort of roughness and in size; its colour is either red or like that of lentils. It is not safe to give it a blow; for either paralysis or spasm of the sinews follows at once. Often from a blow on it a man loses speech and faints; in some also, if the place is pressed, the parts around become tense and swollen. Then it is the worst kind. And generally the first stage is what the Greeks call cacoethes;
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then from that follows a carcinoma without ulceration; then ulceration, and from that a kind of wart. It is only the cacoethes which can be removed; the other stages are irritated by treatment; and the more so the more vigorous it is. Some have used caustic medicaments, some the cautery, some excision with a scalpel; but no medicament has ever given relief; the parts cauterized are excited immediately to an increase until they cause death. After excision, even when a scar has formed, none the less the disease has returned, and caused death; while at the same time the majority of the patients, though no violent measures are applied in the attempt to remove the tumour, but only mild applications in order to soothe it, attain to a ripe old age in spite of it. No one, however, except by time and experiment, can have the skill to distinguish a cacoethes which admits of being treated from a carcinoma which does not. Therefore, as soon as the lesion is first noted, caustic medicaments should be applied. If the disease is relieved, if tis indications are lessened, the treatment can be advanced to the use of the knife and of the cautery. If it is irritated at once, we may recognize that it is already a carcinoma, and that all acrid and severe remedies are to be avoided. But if the place is hardened without ulceration, it is enough to put on a fig of the fattest sort or the plaster called rhypodes. If there is an ulceration level with the skin, the rose cerate is to be applied, to which must be added powder from a crusted earthenware pot, into which a blacksmith has been accustomed to dip red-hot iron. If there is a considerable growth upon it, copper scales, which are the mildest of the caustics, are to be tried, until they check the tendency to
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growth; but only so if it is in no wise made worse: when the growth is less prominent we ought to rest content with the rose cerate.
There is also an ulceration which the Greeks call therioma. This may arise spontaneously, and at times it may supervene upon ulceration from another cause. It has either a livid or black colour, a foul odour, and an abundant mucus-like discharge. The ulcer itself is insensitive to touch and applications; there is just disturbance by itching. But around there is pain and inflammation; sometimes even fever is set up, occasionally blood is discharged from the ulceration. This also is a spreading disease. And all these signs often extend, and there results from them an ulcer which the Greeks call phagedaena, because it spreads rapidly and penetrates down to the bones and so devours the flesh. This ulceration is uneven, bog-like; there is a large amount of glutinous discharge; the stench is intolerable, and the inflammation is greater than accords with the extent of the ulceration. Both therioma and phagedaena, like all canker, occur for the most part in the aged or those of a bad habit of body. Both are treated in the same way, but treatment is more necessary in the severer form. Firstly, a regimen must be enforced, so that the patient rests in bed, abstains from food for the first days, drinks very freely of water; also has the bowels moved by a clyster; then, on the subsidence of the inflammation, takes digestible food, avoiding everything acrid; drinks as much as he likes, but for the time being contents himself with water, except that at dinner he may drink a little dry wine. But fasting is not to be used for patients with phagedaena
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to the same extent as for those with therioma. Over the ulceration too should be dusted dry lign-aloes pounded up or vine-flower, and if this does no good, copper ore; and if by erosion of flesh a sinew has become exposed, it must first be covered by lint, to prevent the medicament from burning it. If still stronger remedies are required, then recourse must be had to more active caustics. But whatever the medicament to be sprinkled on, it ought to be applied by means of the flat end of a probe. Over this should be put either lint soaked in honey or olive-leaves boiled in wine or horehound; and this is to be covered over by lint well wrung out of cold water; the inflammatory swelling around is to be covered with repressant poultices. If there is no benefit from these measures, the place should be burnt with the cautery, exposed sinews being first carefully covered over. The tissue burnt, whether by caustic or by the cautery, is first to be cleaned, then to be filled up with new flesh, as is clear to anyone from what has been stated before.
Ignis sacer should be counted also among the bad ulcerations. Of this there are two kinds; one is reddish or partly red, partly pale and roughened by a chronic pustulation, the pustules all of about equal size, but mostly very small: in them there is nearly always pus and often there is redness with heat. And sometimes the disease spreads while the first part attacked is healing; sometimes even after this is ulcerated, when the pustules have ruptured and the ulcer continues and a humour is discharged which appears to be continuing between sanies and pus. It attacks chiefly the chest or flanks or
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extremities, particularly the soles of the feet. The second form, again, consists of a superficial ulceration, not going deep, but wide, somewhat livid, yet patchy; while it heals at the centre, it extends at the margins. And often the part which apparently had healed again ulcerates. But the skin around, which is about to be invaded by the disease, becomes more swollen and harder and of a dusky red colour. And it is the aged who are mostly afflicted by this malady too or those with a bad habit of body, but chiefly in the legs. Now all cases of erysipelas, although the least dangerous of the ulcerations which spread, are the most difficult to relieve. A chance remedy for it is a one-day fever which carries off noxious humour. The thicker and the whiter the pus, the less the danger. It is also beneficial to make incisions below the opneings of the sores, to let a larger amount of pus escape, and to extract it because the body there is corrupt. If, however, slight fever supervenes, abstinence, rest in bed and a clyster are needed. In erysipelas of all kinds, neither mild and glutinous nor salted and acrid foods should be used, but material of the middle class, such as unleavened bread, fish, kid, poultry and all kinds of game, except wild boar's meat. When there is no feverishness, both rocking and walking are of service, and dry wine and the bath. And in this class of cases drink should be taken more freely than food. gut if the ulceration spreads slowly it should be fomented with hot water; if rapidly, with hot wine; then whatever pustules there are must be opened with a needle; afterwards applications are to be made which corrode
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putrid flesh. When the inflammation is relieved and the ulcer cleaned, soothing ointment should be applied. But in the former kind, quinces, boiled in wine and pounded, may prove beneficial, as also a plaster, either that of Heras or the tetrapharmacum, with a fifth part of frankincense added, or black ivy boiled in dry wine; and if the disease is spreading rapidly there is nothing better. When the ulceration has been cleaned, the same soothing remedies which I prescribed above for the superficial variety are sufficient to induce healing.
Again, the ulcer called chironean is large and has hard, callous, swollen margins. A sanies exudes, which is not copious, but thin. There is no bad odour, either in the ulcer or in its discharge; no inflammation; pain is moderate; it does not spread, so it brings no design, but it does not heal rapidly. At times a thin scab is produced, then in turn it is broken down and the ulceration is renewed. It occurs chiefly on the feet and legs. On it should be applied something which is at once soothing, and active and repressant, such as the following: copper scales, washed lead calcined, 16 grams each, cadmia and wax, 32 grams each, along enough rose-oil to give the wax together with the other materials a soft consistence.
Ulcers are also produced in winter by the cold, mostly in children, and particularly on their feet and toes, sometimes also on the hands. There is redness with moderate inflammation; some pustules arise followed by ulceration; the pain is
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moderate. The itching is greater; at times humour exudes, but not much; it seems to resemble either pus or sanies. In the first place, the ulcers are to be fomented freely with a hot decoction of turnips, or, if these are not to be had, some kind of repressant vervain. If there is not yet an open ulcer, copper scales as hot as can be borne are to be applied. If there is already an ulceration, then apply equal parts of alum and frankincense pounded together with the addition of wine, or pomegranate-rind boiled in water and then pounded. If the skin has become detached, in that case also soothing medicaments do good.
Struma, again, is a swelling, in which there occur underneath certain concretions of pus and blood like little glands; they are specially embarrassing to medical men, for they set up fever and yet do not quickly come to a head; and whether they are treated by incision or by medicaments, they are generally prone to recur in the neighbourhood of their scars, and this happens much more often after the application of medicaments; and in addition to all this, they are of long duration. These swellings arise particularly in the neck, but also in the armpits and groins and in the flanks. The surgeon Meges stated that he had met with them also in the breasts of women.
For these white hellebore is an appropriate remedy, and this must be taken frequently until they are dispersed; and also the medicaments which have been mentioned above are applied in order to draw out or disperse the humour. Some also use caustics
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which eat away, and by forming a scab harden the place; after which they dress it like an ulceration. Whatever the mode of treatment, however, after the ulcer has cleaned, the patient is to have exercise and nourishment until the scar is formed. Although these are the doctrines of the physicians; it has been found out by the experience of some country folk, that anyone with a bad struma may be freed from it by eating a snake.
The boil, again, is a pointed swelling attended by inflammation and pain, and especially so when it is being converted into pus. When it has opened and the pus gone out, it is seen that part of the flesh has been turned into pus, part into a greyish-reddish core which some call the sac of the boil. There is no danger in it, even although no treatment is adopted; for it ripens of itself, and bursts; but the pain renders treatment preferable in order to afford earlier relief. The special medicine for this is galbanum; but there are others also which have been mentioned above. If none of these are available a plaster that is not greasy should first be applied to disperse it; next, if this is not effective, something adapted to promote suppuration; if even that is not to be had, either raisin wine or yeast. When the pus has been squeezed out, no further treatment is needed.
A phyma is a swelling which resembles a boil, but is rounder and flatter, often also larger. For a boil rarely reaches the size of half an egg, and never exceeds it; a phyma commonly extends even over a wider area, but the pain and the inflammation in it are less. When it has been opened, pus appears in the same way; no core is found as in a
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boil, in fact all the corrupted flesh is turned into pus. Now in children this occurs more often and is more readily relieved; in young adults it is more rare and more difficult to treat. Where age has hardened the body, the disease does not even occur. By what medicaments it should be dispersed has been stated above.
Phygetron, again, is a wide swelling, not much raised up, in which there is a certain resemblance to a pustule. The pain and tension is severe, and more than would be expected from the size of the swelling; at times there is also feverishness. The ripening takes place slowly, and not much pus is formed. It occurs particularly on the top of the head, or in the armpits or groins. Our people call it panus, from its spindle-shape. And I have pointed out above by what medicament this should be relieved.
But although all these diseases are really only minute abscesses, that name implies in general a more extensive lesion, tending to suppuration; and it occurs usually either after fevers or after pains in some part, and particularly after those which have attacked the abdomen. And generally it is visible, since there is some rather widespread swelling, like that which I have previously described as called phyma, and it grows red and hot and shortly afterwards hard as well, and becomes more painful as it increases and occasions both thirst and insomnia: sometimes, however, there may be none of these signs to note in the skin, and especially when pus is forming more deeply; but along with the thirst and insomnia some stabbing pains are felt internally.
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And it is more favourable when it does not become harder on a sudden, and although it does not redden, nevertheless changes somewhat in colour. Such are the signs which arise when pus is already forming; the swelling and redness begin long before. But if the place is soft, the gathering of the diseased matter is to be diverted by poultices which are at the same time repressant and cooling; such as I have mentioned elsewhere, and just above under erysipelas: if it has become already hard, recourse must be had to poultices for dispersing and resolving; such as a dried and crushed fig, or wine-lees mixed with cerate, made up with hog's lard, or cucumber-root to which has been added twice the weight of flour, previously boiled in honey wine. Again, we may mix equal part by weight of ammoniacum, galbanum, propolis, mistletoe-juice, and of myrrh half as much by weight as of the other ingredients. And the plasters and emollients which I have described above have the same effect. A swelling which has not been dispersed by such measures must needs mature; that it may do so more quickly, barley-meal should be put on boiled in water with which also some herb should be mixed. The same applications are appropriate also for the smaller abscesses, the names and peculiarities of which I have referred to above; treatment is the same for all, only differing in degree.
Now a swelling is immature when the blood-vessels throb more as if they were bubbling and there is weight and heat and tension and pain and redness and hardening and, if the abscess is larger, shivering or even persistent feverishness; and a
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suppuration is completely concealed, if, instead of the signs presented by the skin in other cases, there are stabbing pains. When these signs subside, and the place begins to itch, and is either bluish or greyish, the suppuration has matured; and when it has been opened by means of these medicaments or even by the knife, the pus must be let out. Then if there are any abscesses in the armpits or groins, they must be dressed without inserting lint. In other parts also, if there is one small opening, if there has been moderate suppuration, if it has not penetrated deeply, if there is no fever, if the patient is strong, lint is equally superfluous. In other cases lint should be applied, but sparingly, and only if the opening is large. It is beneficial, whether lint is used or not, to apply lentil meal with honey, or pomegranate rind boiled in wine; these are suitable alone or mixed together. If the parts are hard, they should be softened by applying either pounded mallow or fenugreek or flax seed boiled in raisin wine. Whatever dressing is afterwards applied should not be tight but bandaged on lightly. No one should be misled into applying a cerate in this sort of case. All the other directions for cleaning the ulceration, forming flesh, and inducing a scar have been described in treating of wounds.
Sometimes, again, fistulae arise, both from abscesses of this kind and from other sorts of ulceration. A fistula occurs in almost any part of the body, but in each place it has some peculiarities. I shall speak first of its general characteristics. There are many kinds of fistulae, then, and whilst some are short, others penetrate deeper; some run straight
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inwards, others, and by far the most numerous, crosswise; some are simple, others beginning by one opening form two or three branches inside or even divide into several passages; some go straight, others are curved and tortuous. Some end in the flesh, others penetrate to bone or to cartilage, or, when neither of these is underneath, reach to the inner parts; some, therefore, are treated easily, others with difficulty; and some are even found to be incurable. The treatment is speedy when the fistula is simple, recent and only involving the flesh, and the body itself helps, when it is youthful and sound: contrary conditions are inimical; also if the fistula has damaged bone or cartilage or sinew or muscles; if it has involved a joint; or if it has penetrated either to the bladder of lung or womb or to large veins or arteries or to hollow regions, which as the throat, gullet or thorax. When too the fistula goes towards the intestines it is always dangerous, often deadly. When the body is either sick or aged or in bad condition, the case is much worse. First of all, however, it is prisoner to pass a probe into the fistula, that we may learn both its direction and depth, and at the same time whether it is moist or rather dry. This is known when the probe is withdrawn. But if there is bone in the neighbourhood, we can also learn whether the fistula has reached and penetrated the bone or not, and how far the damage has gone. For if what is touched by the end of the probe is soft, the disease is still limited to the flesh; if it meets with more resistance, the fistula has reached bone. But when the probe slides smoothly, there is not yet decay; if it does not so slide, but meets with an even surface, there is some decay although
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still slight; if what underlies is uneven also and rough, the bone has become more seriously eaten away. But the position of the fistula shows where there is underlying cartilage, and resistance to the probe shows when this has been reached. And from these signs we may gather the situation, extent and harmfulness of fistulae; whether too they are simple, or have several branches, can be estimated from the amount of pus; for it there is more than one opening will account for, it is clear that there are several branches; and since generally flesh and sinew and sinewy tissue such as sheaths and membranes are near the fistula, the character of the pus also will show whether the several branches have eaten into other parts of the body. For pus derived from flesh is smooth, white and fairly plentiful; from sinewy structures it is of the same colour but thinner and less in quantity; from sinews it is fatty and not unlike oil. Further also, the bending of the body indicates whether the fistulae have penetrated in several directions, because often when a patient has changed his recumbent posture, or held a limb in a different position, pus which had previously ceased, begins to discharge again; and it then becomes evident, not only that there is another branch from which pus is being discharged, but also that it is tending into another part of the body. But if the fistula is in the flesh, and is recent and simple, and is not tortuous or in a cavity or joint, but in a part which remains still unless moved with the body generally, a sufficiently effective application is a plaster such as is applied to recent wounds, so long as it is composed of either salt or of alum or of copper scales or of verdigris or some other metallic
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substances; and from this a tent should be made, thinner at one end, a little thicker at the other. This should be passed into the fistula with the pointed end forwards, and be kept until pure blood shows itself. Such are the general rules for the use of all tents for fistulae. Next, the same plaster spread on lint is put over the place, and over that is applied a sponge dipped in vinegar; it is sufficient to change the dressing on the fifth day. The class of food to be used is that which I have prescribed for making flesh. And if the fistula is at some distance from the praecordia, the patient should eat radishes at intervals on an empty stomach, and then vomit. A fistula of long standing becomes callous. Now no one can mistake callus, for it is hard and either white or pallid. But there is then need for stronger medicines: such as that which has of poppy tears 4 grams, gum 12·66 grams, cadmia 16 grams, blacking 32 grams, worked up water to form a tent. Or else there is the composition containing galls 1 gram, verdigris, sandarach, Egyptian alum, 1·16 gram each, roasted blacking 2·32 grams. Or that which is compose of copper ore and limestone, with half as much orpiment as of each of the other two; and these are taken up in boiled honey. But the quickest remedy is that prescribed by meges; rub up verdigris scrapings 8 grams, then dissolve ammoniacum for incense 1·16 gram in vinegar, and work the verdigris into this infusion; and this is one of the best remedies. But whilst the above remedies are
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the most efficacious, when they are not at hand it is easy to eat away the callus with any of the caustic medicaments; it is enough to smear one of them on rolled papyrus, or upon a pledget of wool twisted into the shape of a tent. Squills boiled and mixed with quicklime also eat away callus. If, however, the fistula is longer but runs crosswise, it is best to insert a probe and to cut down upon its end; then a tent is passed into each opening. But if we deem the fistula to be double or multiple, yet only short and confined to flesh, we should not make use of a tent, because it treats one part and omits the rest; but the same medicaments, dry, are put into a writing-quill, and that having been placed against the orifice of the fistula is to be blown through, in order that these medicaments may be forced in; or the same materials dissolved in wine, or, if the fistula is more foul, in honey wine, or, if more callous, in vinegar, are to be poured in. Whatever is introduced, refrigerants and repressants must be put on over the wound; for generally the parts surrounding the fistula are somewhat inflamed. It is not inappropriate, when changing the dressing and again before inserting fresh medicaments, to wash out the fistula, using an ear syringe; with wine if there is much pus; with vinegar if there is hard callus; if it is already clean, with honey wine or a decoction of vetch, to which also a little honey should be added. Thus it generally happens that that covering which is between the opening and the sound flesh is destroyed by the medicaments and comes quite away, and underneath is a clean ulceration; when this has occurred, agglutinants are applied, especially a sponge steeped in boiled honey. I am
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not unaware that many favour the insertion of lint formed into a tent and dipped in honey; but this agglutinates more quickly than flesh is formed. There need be no fear that clean flesh in contact with clean flesh will fail to unite: we see that there is often no need to add medicaments as well to effect this, since often when there is ulceration of the fingers, unless we have taken careful precautions, they become joined together whilst healing.
There is besides a class of ulceration which the Greeks call κηρίον from its resemblance to honeycomb, and of this there are two kinds. One is greyish, like a boil, but larger and more painful. As it is maturing, holes appear through which is discharged a glutinous and purulent humour; yet it does not properly mature. If it is cut into, there appears much more corruption than in a boil, and it penetrates deeper. It is rare except in the scapular region. The other kind is found only in the head; it projects less above the surface, is hard, broad, greenish or greyish-green in colour, more ulcerated; there are holes at the root of each hair, through which is discharged a glutinous greenish-white humour, in consistency like honey or mistletoe-juice, or at times like olive-oil. If it is cut into, the flesh within appears green. The pain also and inflammation are so severe that they generally cause acute fever. On a case which is only irritated by a few openings, suitable applications are a dry fig and linseed boiled in honey wine or plasters or emollients which draw out diseased matter, or the medicaments noted above for such purposes. For the other form of this, the same medicaments are good, also flour boiled in honey wine mixed with half its quantity of turpentine-resin;
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also a fig boiled in honey wine, to which a little pounded hyssop may be added; also black bryony berries, added to a fig, one part to three. If in either case medicaments are of little service, the whole ulceration ought to be cut away down to the sound flesh. When the ulceration is removed, medicaments are put on the wound, first to promote suppuration, next to clean it, and then to make flesh. There are also certain wart-like ulcerations, different in name and in their ill-effects. They call one acrochordon, when some material which is rather hard and at times somewhat rough, collects under the skin: its colour is that of the skin; it is thin underneath, broadening nearer the skin; of moderate size, as it is seldom larger than a bean. It is rare to find one alone, but generally there are several, and they are mostly found in children; and sometimes they go suddenly, sometimes they cause slight inflammation, and under this they even turn into pus. But that which is named thymion projects above the surface like a little wart, narrow near the skin, wider above, hardish and at the top very rough. The top in colour is like flowers of thyme, whence its name, and there it is readily split and made to bleed; at times the bleeding is considerable; it is generally about the size of an Egyptian bean, rarely larger, sometimes quite small. Sometimes one is alone, generally several grow together, either on the palms or soles of the feet. The worst, however, are situated upon the genitals, and there they bleed the most. But those called myrmecia are less prominent and harder than the thymion, their roots are more deeply fixed and they are more painful: they are broad underneath but thin above, they bleed less,
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and they scarcely ever exceed the size of a lupin. These also grow either on the palms or soles of the feet. The clavus, again, though occasionally found elsewhere, occurs mostly on the feet, and especially after contusions, although sometimes from other causes; it causes pain when walking, though not at other times.
Of these the acrochordon and thymion often end of themselves, and the more so the smaller they are. The myrmecia and corns scarcely ever subside without treatment. The acrochordon, if cut off, leaves no trace of a root behind, and so does not sprout again. When the thymion and clavus have been cut off, a small rounded root is formed underneath, which penetrates right down into the flesh, and if this is left behind it sprouts up again. The myrmecia are held by very broad roots, and so cannot be excised without causing a large wound. A corn is best scraped down from time to time; for thus, without any violence, it softens, and if also a little blood is let out, it often dies away. It is also removed if we clean the part round it and then put on resin mixed with a little powdered millstone. All the other varieties are to be burnt away by medicaments: for some the ash of wine-lees is best; for myrmecia the application made of alum and sandarach. But the skin all round should be covered with leaves that it also may not become ulcerated; afterwards lentil meal is put on. Even a fig in boiled water removes a thymium.
Pustules arise chiefly in the spring; there are many kinds. For at times a sort of roughness comes all over the body, or a part of it, resembling the pustules which are set up by nettles or by sweating; exanthemata the Greeks call them. At times
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they are red, at times no redder than the colour of the skin; sometimes a number occur resembling pimples, sometimes the pustules are larger, livid or pallid or black or otherwise changed from the natural colour; and there is humour underneath them. When these have burst the flesh below looks as if it were ulcerated; in Greek these are called phlyctaenae. They are produced either by cold or by heat or by medicaments. A phylacion is a somewhat harder pustule, whitish and pointed, from which moisture is squeezed out. But after pustules at times small ulcerations arise, either dry or moist, sometimes attended only by itching, sometimes also by inflammation and pain; the discharge is either pus or sanies or both; this generally occurs in children, selected on the trunk, often on the extremities. The worst kind of pustule is that called epinyctis; its colour is usually livid or black or white. And there is severe inflammation round it; and when laid open a mucous ulceration is found within, of a colour like its own humour. It gives greater pain than its size would suggest; for it is no larger than a bean. And this too grows on the extremities, and generally by night, whence also the name applied to it by the Greeks. Now in all kinds of pustules, the treatment first is much walking and exercise; and if anything prevents these, then rockings. Next food must be diminished, all things acrid and thinning avoided; and the same treatment should be applied to nursing women, if the sucking baby is so affected. Moreover, the patient who is robust, if the pustules are small, ought to go to the bath and sweat, and at the same time to dust the pustules with soda and to mix wine with oil and anoint
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himself, after which he goes down into the hot bath. If this does no good, or if the pustules are of the larger kind, lentil meal should be applied, and after the upper skin has been detached, we must pass on to soothing medicaments. The epinyctis, after lentil meal application, is appropriately treated by means of polygonum or green coriander. Ulcerations caused by the pustules are relieved by litharge mixed with fenugreek seeds, rose-oil and endive juice being added in turn until the mixture becomes of the consistency of honey. For the pustules which affect infants apply: pyrite stone 9·3 grams, mixed with fifty bitter almonds, and 125 cc. of oil added. But first the pustules should be anointed with white-lead, then smeared with the above.
But scabies is harder: the skin is ruddy, from which the pustules grow up, some moist, some dry. From some of these sanies escapes; and from them comes a persistent itching ulceration, which in some cases rapidly spreads. And whilst in some persons it vanishes completely, in others it returns at a definite time of the year. The rougher the skin, and the more the itching, the more difficult is its relief. Hence the Greeks call such scabies, agria that is, savage. In this case also the same regimen as that given above is necessary; at the beginning a suitable application is that composed of sublimed zinc oxide, saffron, verdigris 1· 16 grams each; white pepper and omphacium 4 grams; zinc oxide ore 9· 3 grams. But when ulceration already exists that com-
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posed of sulphur 1·16 gram, wax 4·65 grams, liquid pitch 250 cc., oil one litre; these are heated together until they are of the consistency of honey. There is also the composition ascribed to Protarchus. It consists of half a litre of lupin meal, 190 cc. of soda, 250 cc. of liquid pitch, liquid resin 168 grams, and 125 cc. of vinegar. Also a suitable mixture is saffron, lycium, verdigris, myrrh, and charcoal in equal proportions boiled in raisin wine; this checks everywhere all discharge of phlegm. And when there is nothing else at hand, lees of olive-oil boiled down to one-third, or sulphur mixed with liquid pitch, as I have suggested for cattle is also of service for men suffering from scabies.
Impetigo, again, has four species. The least bad is that which presents a semblance to scabies; for there is redness and some hardness and ulceration and erosion. But it is distinguished from scabies because there is more ulceration and there are pustules like pimples, and in it is seen an appearance as of small bubbles from which after a time little scales are detached; and this recurs at fixed seasons. The second kind is worse, almost like a pimple, but rougher and redder; it has various shapes; small scales are detached from the skin surface; there is more erosion; it spreads more rapidly and widely, and both comes and goes at fixed seasons even more markedly than the previous sort; it is called rubrica. The third kind is worse still; for it is thicker, harder and there is more swelling; there are cracks in the skin and more active erosion. This form also is scaly,
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but the scales are black. It spreads widely and not slowly. It varies less in the times at which it increases or subsides, and is never quite got rid of: its name is black impetigo. The fourth kind, which is quite incurable, differs in colour, for it is whitish and like a recent scar, and has small pallid or whitish scales; some are like lentils, and when these are removed there is sometimes bleeding. Otherwise its humour is white, the skin hard and chapped; it spreads widely. Now all these kinds occur generally on the hands and feet; they also attack the nails. There is no more efficacious remedy than that which I have mentioned above as prescribed by Protarchus for scabies. But Serapion used soda 2·32 grams, and sulphur 4·64 grams, taken up with plenty of resin.
Of papules again there are two kinds. There is one in which the skin is roughened by very small pustules, and is reddened and slightly erodes; in the middle it is a little smoother; it spreads slowly. This disease generally has a round shape at its beginning, and in the same fashion it spreads in a circle. But the other variety is that which the Greeks call agria that is, savage; and in this there is a similar but greater roughness of the skin with ulceration, more severe erosion, and redness; sometimes it even loosens the hair. It is less round in shape, heals with more difficulty, and unless it is got rid of, turns into an impetigo. But in fact a slight papule heals if it is rubbed daily with spittle before eating; a more severe one is got rid of best by an application of pounded pellitory. But turning to compound medicaments, that same one of Protarchus is efficacious in these cases, when the disorder is less severe. An alterna-
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tive for the same affection is the composition of Myron containing red soda and frankincense, 4 grams each, purified cantharides 8 grams, sulphur unheated, the same amount, and turpentine resin 80 grams, darnel meal a litre and a half, cumin 145 cc., and half a litre of raw pitch.
Vitiligo also, though not dangerous in itself, is still ugly and is due to a bad habit of body. There are three species. It is called alphos when it is white in colour, generally rather rough, and not continuous, so that it looks as if drops of some sort had been sprinkled about. Sometimes also it spreads still more widely with certain gaps. That called melas differs from it in being of a black colour and like a shadow; otherwise it is similar. Leuce is somewhat like alphos, but is whiter and extends deeper; there are hairs on it, white, and like down. All these spread, but more quickly in some people than in others. The alphos and melas come and go at various seasons; the leuce, once established, is not easily got rid of. The two former are not difficult to treat, the latter is scarcely ever cured, for even if the discoloration is mitigated, the colour of health does not right altogether. But whether any one of these is curable or not is easily learnt by this test. The skin should be cut into or pricked with a needle: if blood escapes, which it usually does in the first two species, there is place for a remedy; if a whitish humour, cure is impossible, and then we should even refrain from treating it. But to the species which admits of treatment we should apply lentil meal, mixed with sulphur and frankincense, pounded
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up together in vinegar. Another application for the same purpose, ascribed to Irenaeus, is composed of coral, soda, cumin and dried fig-leaves, in equal quantities, pounded up with vinegar added. The vitiligo is smeared with this in the sun, then it is soon washed off, lest it corrode too much. Some find it useful to anoint the species which I have said is called alphos with the following prescription ascribed to Myron: they mix sulphur 1 gram, split alum 0·66 gram, soda 1·33 grams with a cupful of dried myrtle leaves; then at the bath they dust bean-meal over the vitiligo and afterwards apply the above remedy. That which I said was termed melas is treated by pounding up together coral, frankincense, barley and bean-meal; and these are sprinkled on, using no oil in the bath before the patient sweats; then this kind of vitiligo is rubbed off.