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).
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]