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.
The majority of Writers however are agreed that among other occasioning causes ulcers hold the first place,[412] though none of them speak expressly of ulcers of the genitals, unless indeed we see good to make the passage of Hippocrates discussed a little above refer to these. No doubt in this passage the words ἑλκώματα, φύματα ἔξωθεν ἔσωθεν τὰ περὶ βουβῶνας (ulcerations, tumours external and internal in the inguinal region) might admit of such an explanation, in which case the words must be taken not as referring to each single patient, but rather held to mean that ulcers and glandular swellings with a tendency to suppuration were set up, the latter occurring in some patients in the urethra, in others in the groin. Such an interpretation is favoured by the case of the Eunuch discussed in § 20, for there can be no doubt the metathesis of buboes into fistulous ulcers was noted by Celsus and other observers. Still it is highly improbable that ulcers on the feet should have afforded the sole and only cause of buboes; it is much more natural to suppose that this, as being the more rare case, was for that very reason brought into special prominence by the ancient Physicians. Besides we have seen above that the old Physicians seldom or never really had an opportunity of seeing the sympathetic buboes, as patients treated the ulcers themselves, and the buboes then disappeared spontaneously. Oribasius no less than other Writers holds buboes following on an ulcer to be without danger.
Lastly the cases are very rare in which secondary buboes under the prevailing tendency and course of the disease are thrown out on the skin, and if they do arise, the ulcer as a rule heals up. This being so, the Physician is consulted, only supposing the buboes refused to disappear. On the contrary if the ulcer was still there, the Physician sought actually to stimulate it to enhanced activity, as is distinctly implied by what Galen says (loco citato). Lint smeared with tetrapharmacum (compound of wax, tallow, pitch and resin), liquified by the addition of oleum rosaceum (oil of roses) was applied and warm poultices over that; while on the actual bubo was laid in the first instance wool moistened with oil, to which when the pain and swelling of the part were relieved, was added an admixture of salt. Plethoric or cacochymic (generating evil humours) subjects are to be bled or cupped. If the bubo is inflamed and inclined to suppurate, it must be scarified, the patient having first been purged. Dispersion is then attempted, in this case by means of pulp and honey poultices, but not by plasters, as these are apt to provoke inflammation. If pus appears, recourse must not be had at once, as some advise, to opening with the knife; rather the poultices should be persevered with till the inflammation is relieved. Acrid poultices are suitable only when the metathesis to induration has already begun.
If dispersion does not follow and the matter has collected in greater quantities, then the most elevated spot, the same where the skin is the thinnest, should be opened. Should a part of the skin be discoloured, it must be cut away. Some advise always cutting out a piece in the shape of a myrtle-leaf, others make very long incisions; but this not only causes a disfiguring scar, but often also interferes with the movement of the part. As a general rule a single incision is sufficient, which should be made diagonally across the inguinal region, not parallel with the direct diameter of the thigh, as then the edges are brought actually into contact when the limb bends.[413] After the opening of the abscess, it should be treated by preference with finely sifted frankincense, as should all forms of ulcer. We may mention further that according to Sextus Placitus Papyriensis[414] the wearing of a stag’s genitals was considered a prophylactic against buboes.