SECT. XLVI.—ON THE MALIGNANT ULCERS CALLED CHIRONIAN AND TELEPHIAN.
Old ulcers which are difficult to get cicatrized are called chironian, as if requiring Chiron himself to cure them; and telephian, from Telephus having long laboured under such a sore. We must attend then whether the whole body being in a state of cacochymy, sends such defluxions to the ulcer, and the prevailing humour is to be evacuated by appropriate remedies. Or if it is a varix which sends these humours to the legs, the ulcer being in it, it is to be cured as will be described in the Surgical part of this work; or the humours are to be evacuated by venesection, taking away blood frequently, and then using topical applications which have the property of extirpating the disease without being pungent. These therefore are simple applications; those from pumice and diphryges, and flakes of copper, verdigris, and lime moderately washed; sprinkle fissile alum levigated, or of unwashed wool, dr. iv; of dried grapes, dr. iv; of natron, dr. ij; having previously anointed with honey, sprinkle of flakes of copper, dr. x; of alum, dr. ij; and having softened in the sun with dr. x of wax, apply.
These are compound medicines. A plaster for chironia. Of ceruse, oz. viij; of fissile alum, oz. ij; of the flakes of copper, dr. ij; of sal ammoniac, of frankincense, of scraped verdigris, of pomegranate rind, of each, oz. ij; of quicklime, oz. j; of wax, lb. j; of myrtle-oil, lb. j. ss; triturate the dry things with wine. At first it removes callus; and it is laid by and kept, and at last when used, being softened with myrtle-oil, it cicatrizes.—Another: Of litharge, lb. j; of oil, lb. ij; of black chamæleon, of the roots of birthwort, of immature galls, of each, oz. j; of galbanum, of ammoniac perfume, of frankincense, of each, oz. ij; prepare, stirring with the roots of green reeds.
From Archigenes, for chironia, and malignant ulcers in the legs and breast, for struma, and parotis. Of the fat of an ox lb. iij; of turpentine, oz. v; of manna, oz. vij: of the earth called sarda which painters use, oz. v: having put the soluble and dry articles together and melted, use.—Another, of Archigenes: Of wax, oz. iv; of oil of unripe olives, of manna of frankincense, of diphryges, of the flakes of copper, of each, dr. iv; having triturated the powder with vinegar, and made of the thickness of honey, mix with the cerate, and use upon a pledget.—Another, for the malignant ulcers of women, and of other persons having a soft skin: Of Tuscan wax, dr. viij; of bulls’ fat, of turpentine, of burnt lead, and of pepper, of each, dr. j; use on a pledget with rose-oil or myrtle-oil.
Commentary. Celsus describes the chironian ulcer as being large, and having hard, callous, and swelled edges, with a copious discharge of thin sanies. It is attended with no inflammation, the pain is moderate, it does not spread, and therefore it is not dangerous, although not readily cured. Sometimes, he says, it becomes covered with a thin cicatrix, and then again the ulcer breaks out. It occurs mostly in the feet and legs. From this description it is evident that by the chironian ulcer Celsus meant merely an ill-conditioned ulcer, and that he distinguished between it and the cacoethes, or malignant ulcer, which last he held to be nearly allied to the carcinoma. However, most of the Greek authors apply the term malignant to the chironian ulcer. For the cure of it Celsus recommends an application consisting of squama æris, lead burnt and washed, calamine, wax, and a small quantity of roses.
Galen furnishes us with an account of the manner in which Thessalus the Methodist proposed to cure all chironian and malignant ulcers. Thessalus lays it down as a rule for the treatment of all sores which are difficult to cure, or which break out again when healed, to remove the exciting cause, whether local or constitutional, by means of proper alteratives. He adds: “In cases of chronic ulcers which cannot be got healed, we must remove the parts which prevent adhesion, and convert the sore into the state of a recent ulcer; and then having allayed the inflammation proceed accordingly. Those sores which heal up and break out again during their exacerbations, and when ulcerated, are to be cured like recent inflammations by soothing applications until the irritation subside, after which cicatrizing applications are to be used, and then the surrounding parts are to be covered with a malagma of mustard, or some other rubefacient and alterative, to remove the indolence. If this is not sufficient, we must attend to the general health, attempting to effect a change of the system by repeated exercise, gestation, a diet increased or diminished according to circumstances, and at the commencement by administering an emetic of radishes, or even the white hellebore.” (Galen, Meth. Med. iv.) Although Galen, who all along displays a strong hostility to the Thessalian asses, (so he calls the Methodists,) has animadverted in severe terms upon the rules here laid down, they would appear to be highly proper and ingenious. Galen in another place (Med. sec. gen. iv) gives from Asclepiades, Andromachus, and others, a great collection of applications for chironian, malignant, and indolent ulcers. One by Asclepiades consists of the scales of copper, scraped verdigris, wax, and larch rosin. Others by Andromachus contain sori, misy, chalcitis, verdigris, alum, turpentine-rosin, and the like, mixed with wax. Hippocrates directs us to treat a callous ulcer by applying to it septic medicines to make the hard parts slough off, after which the edges are to be brought together. (De locis in homine.)
The directions of Aëtius, more especially respecting the constitutional treatment, are highly important. In cases where there is a redundance of blood he recommends venesection, in others both purging and bleeding; and in certain cases he directs us to pay attention to the state of the liver and spleen. He relates a case of an ulcer on the hand, which he cured by opening a vein leading to it. He also directs us to scarify or cut off the callous edges of the ulcer. He gives various prescriptions for sores of this description, containing verdigris, sori, chalcitis, burnt copper, alum, &c.
Octavius Horatianus recommends a plaster consisting of equal parts of chalcitis, wax, and alum. For phagedænæ Pliny mentions an old shad-fish triturated with sandarach. (H. N. xxxii, 44.)
The Arabians treat of these ulcers very fully. Avicenna in particular gives very proper directions for the constitutional treatment. When the state of the ulcer is occasioned by an intemperament, it is to be corrected, and if the blood is deficient in quantity or quality, this is to be remedied by a proper diet; and when on the contrary it is connected with plethora, venesection is to be had recourse to, and if the veins leading to it are varicose, it may be proper to open them. When the sore is kept from healing by a spiculum of bone, we are to cut down and remove it. His applications consist of the same ingredients as those used by the Greeks, namely, the flower of copper, copperas, alum, ceruse, lime, arsenic, &c., mixed with wax and oil. The directions given by Rhases are less circumstantial, but to the same purpose. He particularly directs us to remove the callous edges by friction, scarifications, and septics. He speaks of turpentine as an excellent addition to other ointment. (Contin. xxviii.) He mentions that in case of malignant ulcer on the leg connected with varix, Galen opened the enlarged vein.
The cacoethes of Celsus was evidently the disease called noli me tangere by Theodoricus; a very absurd appellation, which however has been retained to the present day. Celsus has pointed out its resemblance to carcinoma, and recommended the only mode of treatment which ever does any good in these cases, namely, the application of septics, such as arsenic, quicklime, &c., or the actual cautery. As our limits will not permit us to enlarge further on this subject at present, we must be content with referring to No. 108 of the ‘Edinburgh Medical and Surgical Journal,’ where we have given a full exposition of the ancient principles of treatment. (See also the Commentary on [s. xxvi] of this Book.)