Part 101

Avicenna has treated of difficult parturition with his usual accuracy, which exhausts every subject he handles. He states that the expulsion of the child is performed by the abdominal muscles. This was the opinion of Galen; and we are inclined, upon the whole, to think it pretty correct. He approves greatly of the bath, both before labour has come on and during the time of it. When delivery is difficult, owing to the size of the child, he directs us to apply a fillet round the child’s head, and endeavour to extract it. When this does not succeed, the forceps are to be applied, and the child extracted by them. If this cannot be accomplished, the child is to be extracted by incision, as in the case of a dead fœtus. This passage puts it beyond a doubt that the Arabians were acquainted with the method of extracting the child alive by the forceps.

Albucasis recommends us, when the membranes are tough, to perforate them by the finger or a spatumile. When the waters are discharged, he directs us to press down the woman’s belly so as to make the head descend. If it does not come down readily, he advises us to give a clyster, and afterwards to apply compression to the belly. Albucasis also approves of the tepid bath. To promote the delivery of the secundines, he recommends us to make the woman sneeze and retain her breath.

Alsaharavius (probably the same as Albucasis) treats fully of the causes of difficult labours. When occasioned by dryness and constriction of the vagina, he recommends baths, fomentations, and clysters, containing the decoctions of mallows, fenugreek, and linseed; and also directs the parts to be rubbed with warm oil. When obstruction of the rectum by fæces prevents delivery, he advises us to administer a clyster. When intense cold is the cause of the difficulty, he recommends clysters of hot oil, and the warm bath. When the membranes are tough and retard delivery, he directs the midwife to break them with a sort of reed or needle.

Haly Abbas mentions imperforate hymen among the causes of difficult labour. Such cases have been reported by modern writers on midwifery. See Baudelocque (§ 341), and Burns (Midwifery, x.) Fabricius ab Aquapendente relates a very curious case in which conception had taken place without rupture of the hymen. (Œuvres Chirurg. ii, 81.) When the difficulty arises from fatness and debility of the expulsive powers, Haly directs us to rub the parts with warm olive-oil, or other such emollients, and to make the woman sit in a bath prepared with chamomile, melilot, &c. He mentions, as an internal remedy, the infusion of a swallow’s nest (alcyonium?) When the difficulty proceeds from cold, he recommends the use of the tepid bath; and when from the contrary cause, he advises cooling things to be applied. According to Rhases, difficult parturition may arise from the mother, the fœtus, or the secundines. He appears to have considered all presentations unnatural except the head. In the other cases, he says, the life of the mother or child is endangered, although, he adds, many living children are born by the feet. When delivery of the head is found difficult, he recommends ligatures or fillets. When the feet or hands present, he directs us to restore the position, or if that is impossible, to bring down the feet. Many of his authorities mention the warm bath and lubricants.

From the sketch which we have given above, it will be seen that the Arabians have made mention of the forceps; but that most probably the Greeks and Romans were unacquainted with this instrument, as far, at least, as appears from their works on medicine which have come down to us. It is deserving of remark, however, that in the house of an obstetrix which has been excavated in Pompeii, there was found an instrument of art bearing a very considerable resemblance to the modern forceps. It is a well-known fact in the history of inventions that many useful discoveries have long been kept as family secrets. This was the case even of a late date with the Chamberlains, who were the first in modern times to use the forceps.

SECT. LXXVII.—ON ISCHIATIC DISEASE.

Ischiatic disease, being of the class of arthritic complaints, is distinguished solely by the cause of it being seated in the hip-joint. The cause of it then is a thick and pituitous humour fixed in the articulation of the hip-joint. The pain in these cases extends from the parts about the buttocks and groins to the knee, and often as far as the extremity of the foot. When we see such a patient, in the beginning of the complaint, after the evacuation of the hardened fæces by a clyster, we must abstract blood from the arm at intervals; but if the disease be of some standing, we must abstract the blood from the ankle of the affected leg. During the exacerbations we must use this embrocation: Of the oil of privet, viij cyathi; of vinegar, iv cyathi; of nitre, ij cyathi; of rosemary-seeds, j cyathus; to be rubbed in hot with unwashed wool. After which a cataplasm is to be applied of the flour of bitter lupines with oxymel; or of the flour of darnel with rosin, the root of the wild cucumber, nitre, calamint, rosemary-seeds, and bay-berries. Calamint alone with oxymel, or honied water, will form a proper cataplasm. And we may rub the parts with this paregoric-plaster: Of wax, dr. x; of turpentine, dr. xxv; of verdigris, dr. vj; of myrrh, of galbanum, of iris, of each, dr. vj; of gum vernix, dr. v. But they must take the propoma containing Cyrenaic juice to the size of a bitter vetch, or a drachm of castor with three oboli of opopanax. And the rind of the root of capers in a draught, or added to the cataplasms, is of use. When the pain is great, anodynes may have place, such as the antidote of Philo and that from two peppers. This injection is to be used: Of honey, iss cyathus; of oil, iss cyathus; of water, ij cyathi; of nitre, dr. viij; of turpentine, dr. iv. These are to be injected warm, and the anus fomented, that they may be the longer retained. It evacuates mucous matters, and sometimes blood when it affords more relief. But if the complaint be prolonged, which is rare, we must repeat it frequently, instead of the water substituting the decoction of centaury. Blood is also evacuated by injecting the seed of treacle-mustard, and the juice of elaterium, and the Sicyonian oil prepared from it, or from the roots of the plant. The brine also of pickled fish, or of pickled olives, may be properly injected. Cupping-instruments may be applied to the hip with much heat and with scarifications, or sometimes leeches may be used. When the affection is protracted, we must proceed to purging either with the hiera, or giving of the medullary part of colocynth properly triturated to the amount of a drachm in two cyathi of honied water, more or less, according to the strength of the patient and the good state of his bowels. And let rue be boiled in the honied water. The pottage made with colocynth purges excellently. In some cases emetics from radishes have proved beneficial at the commencement. During the remissions we may apply dropaces to them, and use the restorative unguents (acopa) from euphorbium, and particularly the one called the complex. The natural baths also are proper; or if these be not at hand, they may bathe in the others; using the restorative ointments formerly mentioned, and the compound ones,—the Æsculapian, and that composed of equal portions of euphorbium, adarce, black hellebore, castor, pellitory, pepper, and wild grape dried. After the bath, we must sprinkle upon the skin while still warm, of dried pitch, oz. iij; and of native sulphur, oz. ij; and let the part be covered with paper. If even these things do not succeed, a remnant of the disease remaining, it will be proper to apply a cataplasm of mustard along with dried figs, or by itself. These complaints are completely removed by the Iberian herb, which some call lepidium, and some the wild cardamus (cress). And the shrub which grows among us, having leaves resembling those of the bay, but much larger, is of approved efficacy, not only in ischiatic, but in other chronic complaints; but it is by far most efficacious in summer. Or if it should not have shooted out its leaves, we must bruise the rind of the root with axunge, so as to form a plaster; and then, spreading it on a thick rag, apply to the parts affected with the pain, namely, to the whole buttocks and thighs; and allow it to remain until the part become black, or, at all events, until the cuticle become livid; then take it away, and, having washed, apply this cerate: Of opopanax, oz. iv; dissolve in ij cyathi of vinegar; and add to the cerate of privet. If they do not admit the use of such caustics, we must use the plasters called extirpative, among which is the following: Of wax, of pine-rosin, of each, dr. xij; of wild pigeon’s dung, of recent lees of burnt wine, of each, dr. vj; of galbanum, dr. iss. And the plaster called the Lioness is of the extirpative kind. Those composed from strained lye and nitre are also proper. And some have continued to drink certain potions for a whole year, among which is the one composed of four ingredients: Of wall-germander, lb. j; of gentian, oz. ix; of round birthwort, oz. ix; of the dried seed of rue, j sextarius: pound these things together, sift, and give every day a spoonful to the patient when he has an empty stomach and his digestion is good, with two cyathi of cold water; and continue this for a year, until the complaint cease. And the medicine composed of seven ingredients, and that which takes its name from Proclus, are of the same reputation. Exercise may be taken by walking, frequent bending of the body, leaping, and running. The food should be moderately attenuant and digestible. If ischiatic disease do not yield to any of the remedies now mentioned, it sometimes terminates in suppuration; and sometimes, from a relaxation of the ligaments, the thigh is dislocated at the joint. Wherefore, when the affection is protracted, we must burn the joint in three or four places (as will be described in the Surgical part of the Work), and the ulcers are to be kept open for many days.

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COMMENTARY. Consult most of the authors referred to in the next Section.

Hippocrates gives a pretty correct account of the symptoms which attend an attack of morbus coxarius, or ischiatic disease. He says it most commonly arises owing to the fluids of the joint being dried up by exposure to the sun. It is accompanied, he justly remarks, with pain of the loins and vertebræ of the back, shooting down even to the knees. A sharp hot pain, he adds, is frequently seated in the groins. Upon any motion the most piercing cries are extorted. (De Dieb. Judic. 6.)

In ischiatic disease Galen recommends general bleeding, and most especially, emetics, which, he says, by occasioning a determination upwards, operate more beneficially than purgatives in this complaint. He disapproves of acrid embrocations, but approves of cupping. He also allows stimulant clysters of colocynth. He gives a long list of local applications from Andromachus, Asclepiades, and Democritus. He makes mention of the Iberian herb; for further information respecting which we refer the reader to Matthiolus (ad Dioscorid. i, 147), and Bernard (ad Nonni Epit. 215.) It was the Lepidium Iberis. He recommends, in certain cases, the part to be beaten with rods. (Meth. Med. xiv, 16.) See also Pseudo-Dioscorides. (Euporist. i, 240.)

Celsus says that morbus coxarius is a painful complaint and difficult to cure. He recommends warm cataplasms and fomentations, with various applications of an emollient or stimulant nature. If inflammation come on, cupping-instruments with scarifications are to be applied; diuretics are to be given; and the belly is to be opened if constipated. He also approves of friction, and even of forming issues by burning with a red-hot iron.

Various methods of performing the operation of burning are detailed by Aëtius, as will be explained in the Surgical part of this Work.

Cælius Aurelianus gives a long and interesting account of this complaint. Among the symptoms he mentions the lengthening and shortening of the limb, the wasting and paralysis of it. The periosteum, he says, is principally affected, but likewise the heads of the muscles. He correctly states that, when the complaint is protracted, collections are apt to form in the joint. He approves of the emollient treatment, the application of wool dipped in sweet oil, fomentations, and bleeding from the arm. He recommends gentle purgatives and clysters, but condemns the use of drastic cathartics, such as scammony, hellebore, and the like; because, he says, they occasion irritation. When the pains are protracted he approves of scarifications and leeching, after which the vapour of sponges squeezed out of hot water will be of service. He also makes mention of the bath of oil and various emollient ointments. He describes several methods of applying heat to the part, but condemns them in general, upon the principle that they increase the local irritation. He disapproves of diuretics as recommended by Diocles, and otherwise animadverts freely upon the practice of the other sects.

The Arabians adopt the views of Galen and his followers with little addition or alteration. Thus Serapion recommends bleeding from the arm and ankle; clysters of drastic medicines, such as colocynth, centaury, hermodactylus, &c.; soothing applications externally; quieting medicines internally; emetics consisting of radishes, vinegar of squills, or even of white hellebore. When these do not succeed, he recommends us to form an issue by burning the part with a red-hot iron. Avicenna agrees with Galen in condemning discutients and recommending emollients at the commencement, and in preferring emetics to cathartics. For this purpose he particularly mentions a solution of nitre and vinegar. When the disease is combined with inflammation, Haly Abbas directs us to begin with venesection if not otherwise contraindicated. He enjoins the necessity of abstaining from taking much food and things of difficult digestion. He directs us to pour water of a moderate temperature over the part, and to rub it with an emollient oil; but he forbids refrigerant and astringent things, as they are apt to drive the humour inwards. He joins the others in recommending particularly the hermodactylus (soureniaron), both by the mouth and in clysters. When other means fail to remove the pain, he directs us to apply a cupping-instrument with strong heat over the joint, or even to use the actual cautery. Alsaharavius recommends the same general plan of treatment. He directs the patient to abstain from the use of wine, or if he cannot observe this regimen, he recommends him to use the bath and friction with glass (pounded he probably means). He gives very excellent admonitions to guard against indigestion, and to avoid all things of a cold nature.

On the ancient cauteries for disease of the hip-joint, see Book Sixth, Sect. LXXII.

Most of the earlier modern writers approve of the application of the actual cautery for the cure of sciatica. See Rogerius (i, 74.)

SECT. LXXVIII.—ON GOUT AND ARTHRITIS.

It is not weakness of the parts alone that occasions gouty and arthritic complaints; for then the paroxysms would be without ceasing, inasmuch as the debility is always present in the weak parts. Neither is a humour the sole cause, for then the complaint had not attacked the joints only. But the disease is occasioned by a preternatural humour and a weakness of the parts meeting together. For when the nutritive power of the parts becomes debilitated from repletion with food inducing dyspepsia, the prevailing humour, fixing in some of the joints which are already in a weak state, and stretching the nervous ligaments, produces pain. For the inflammation is not an original affection of the nerves of volition; as then it would have affected also the parts between the joints, such as the middle of the legs, thighs, arms, and forearms; but those of volition are affected sympathetically. When, therefore, the humour is seated in the joints of the feet only, the complaint is called podagra; but when the cause is diffused over all the joints of the body, we commonly call it arthritis, in which the vertebræ, scapulæ, jaws, and every other joint are attacked with the disease. In certain cases the ears, teeth, and pharynx, and sometimes even the liver and spleen participate in the arthritic pains, when, if there is not a speedy translation of the disease to the joints, the patients will be in urgent danger. The prevailing humour is sometimes bilious, sometimes sanguineous, sometimes melancholic, but for the most part it is pituitous and crude, being engendered by excess of food, indigestion, and want of exercise. When the disease is protracted in the joints, the humours become thick and viscid, so as to form what are called tophi or chalk-stones. Sometimes the humour is of a compound nature, so that the disease is difficult to distinguish, and difficult to cure, or nearly incurable. The precursory causes of this affection for the most part are immoderate labour, violent walking, frequent exercise on horseback, the unseasonable use of venery, cold drink taken unseasonably, eating of much cold or unwholesome food, and drinking much wine. And some from accidents, as a blow, a sprain, or the like, have experienced the first attack of this complaint, the materials of the disease having previously remained quiet in the system until roused by the proximate cause. Sorrow, care, watchfulness, and the other passions of the mind, not only excite an attack of the disorder, but also generate a cacochymy either primarily or incidentally. Wherefore the causes of the complaint, as I have said, are various; but the differences of the noxious humours are in so far easily detected, being discovered by their colour and other symptoms. A bilious rheum, in addition to paleness and redness of colour, occasions a sensation of heat and acute pain, and is speedily determined to the skin, nor is it attended with much swelling. It is exacerbated by heating applications, and relieved again by cooling, which, for the most part, is the case with all the others, but more particularly when the exciting cause is bilious. Fever also frequently comes on at the height of the paroxysms, and then they are thirsty. Thus also you will find the skin darker when from a melancholic humour; white and watery when from a pituitous, in which case the pain is more latent and more slowly occasions swelling; and the colour is sanguineous when a bloody humour prevails. In order to form a more decided diagnosis, you will be assisted by taking into account the previous mode of life, and so forth.

The cure of rheums from a bilious humour. The commencement of the cure, when from yellow bile, more especially if the quality of it occasion the disorder, should be the evacuation of the offending humour by purgative medicines, such as that from rhodomel, that from quinces, the antidote called picra, and aloetic pills. During the paroxysms, we may apply externally rose-oil with the yelk of an egg, and some wine, rubbing the part gently with it; and apply the herbs of a cold nature, such as nightshade, purslain, henbane, houseleek, marsh-lentil, endive, poppy, knotgrass, rose-leaves, and the like. These things may be sometimes rubbed in, and sometimes applied in the form of a cataplasm, with crumbs of bread soaked in oxycrate, or from barley-meal with rose-oil. When the inflammation of the joints is of an erysipelatous nature, a decidedly paregoric application is the peel of a fresh gourd laid on the part, or the fleshy part of a pompion or cucumber, both alone and with bread; or the leaves of perdicium (pellitory of the wall?), and ivy with bread and fine polenta. And fleawort boiled in barley-flour mitigates the inflammatory heat in a wonderful manner; and so also the rose-cerate cooled with some of the frigorific juices, and that prepared from the flour of beans. It is prepared thus: Of wax, oz. v; of chamomile-oil, oz. iiss; of rose-oil, oz. iiss; of the flour of beans, oz. ss; the yelks of five eggs.—Another, a cataplasm: Pound green mallows boiled; and having made fleawort to the consistence of bird-lime separately, mix together; then add the red part of eggs and chamomile-oil, and apply as a cataplasm. When the pain is great and difficult to endure, we must have recourse to preparations of saffron, of horned poppy, and of opium, triturating them with oxycrate, and then using them in the form of liniments, or of cataplasms with crumbs of bread. Galen makes mention of this one: Of poppy-juice (opium), dr. iv; of saffron, dr. j; triturate with milk of a cow or of a goat; or add the inner part of bread, and having softened it by touching it with a little rose-oil, use for a cataplasm. Or triturate the opium and saffron with the milk, and add to the rose-cerate. And the cerate made from the torpedo and the oil of the same are possessed of similar properties.—And this one in like manner: Of crumbs of bread soaked in water or in oxycrate, and of houseleek, or of nightshade, or of purslain, and of the fleshy parts of dates, and of poppy-seeds, equal parts; of roasted yelks of eggs and rose-oil, q. s.; form a cataplasm. The use of narcotics must not be continued, but until the violence of the pain be abated; for the frequent use of them occasions impaction and tophi, and makes the difficulty of motion to be protracted. After the use of anodynes, then, we must have recourse either to diachylon dissolved in oil of chamomile, or the composition from marshmallows, or some such application. After we have warmed the congealed parts, we must strengthen them by a plaster of dates dissolved in vinegar and rose-oil or wine and rose-oil. Or, if the weight of the plasters prove troublesome, we may rub in the juice of acacia with oxycrate, or lycium along with saffron, horned poppy, and the juice of perdicias in oxycrate. The diet should be cooling and moistening, such as ptisans, and spoon-meats from chondrus, and of pot-herbs, the mallows, the lettuce, and the endive; and of birds, more especially the young of domestic fowls; and of fishes, those caught in rocky places, and the sea-urchin, shell-fish, and the like. Let them avoid all things that are heating and form pale and yellow bile, old wines both the yellow and dark, and repletion. Let them use baths of sweet water, even at the time of the defluxions, as far as regards the cause of them, unless something else prohibit. Let them avoid violent passion, abstinence, acrid food, drinking of wine, immoderate labour, and venery.

The cure of rheums from a sanguineous humour. In those cases in which the prevailing humour is sanguineous, we must have recourse to venesection without delay, and also in cases where the prevailing humour is phlegm or black bile; since in them the humour is for the most part contained in the veins, proving injurious by its quantity rather than its quality. We must have recourse then to venesection only at the first attack of the disease; since those who have had already frequent attacks of rheumatism are injured rather than benefited by the loss of blood, more especially when the body is naturally cold or weak. After the evacuation of the blood, if there was more than a plethora of blood, we must have recourse to purging with hiera after a short interval. And the Julian oxymel is a purgative suitable to these cases. Those who reject such purgative medicines may use these pills: Of aloes, of colocynth, of black hellebore, of scammony, of each, oz. j; of euphorbium, oz. ss; of nitre, oz. ss; mix with the juice of cabbage, and give according to the patient’s strength. It will be better, however, if prepared with the juice of quinces.—Another pill given to gouty persons in the paroxysms, during the remission, and from whatever humour: Of aloes, oz. vj; of agaric, oz. ss; of saffron, oz. ss; of costus, oz. j; of spikenard, oz. j; of schenanth, oz. j; of balsam fruit, oz. j; of cassia, oz. ij; of scammony, oz. ij; of dodder of thyme, oz. iiiss. A moderate dose is scr. ij; and a full one, scr. iv. Pills of Armenian stone also purge in a wonderful manner, being particularly applicable in arthritic cases, whether given at the commencement, in the decline, or during the remissions of defluxion. And since some avoid scammony because it is bad for the stomach, we may give them these things when a pituitous matter prevails: Of the medullary part of colocynth, of black hellebore, of bdellium, of gum, of aloes, of each, oz. j; of Alexandrian nitre, of euphorbium, of each, oz. ss. The dose is scr. iv. Instead of the gum I have substituted dodder of thyme. Some, in the paroxysms of all arthritic diseases, have recourse to purging with hermodactylus; but it is to be remarked that the hermodactylus is bad for the stomach, producing nausea and anorexia, and ought, therefore, to be used only in the case of those who are pressed by urgent business; for it removes rheumatism speedily, and after two days at most, so that they are enabled to resume their accustomed employment. I knew a person who did not give the substance of hermodactylus, nor any of the compound medicines containing it; but boiling the plant itself with some of the common remedies, such as anise or parsley, he gave the decoction to drink; and it was wonderful how those who got it, after having evacuations of the bowels, were freed from the rheumatism. It is necessary, however, as I said, because the medicine is bad for the stomach, to correct the mouth of the stomach afterwards by stomachics and tonics, along with things that are moderately heating. Alexander says that purging by coronopodium is preferable to that by hermodactylus, as it procures evacuation and relief from pain, and at the same time is not bad for the stomach. But topical applications are to be had recourse to in cases of pituitous rheumatism. When the pain is moderate, a green cabbage-leaf may be applied, and also parsley, fleabane, and the straight vervain; but when the pain is violent, take of the flour of fenugreek, p. iij; of the flour of darnel, p. j; of the flour of chick-peas, p. j; make a cataplasm with honied water, or thin wine, with a little oil of privet, or of nard, more especially if in winter. And the ashes of burnt cabbage-roots, or of their stalks, when formed into a cataplasm with axunge, have proved beneficial to many; but, in order that it may prove soothing, the axunge must be fresh, whereas, if we wish it to be discutient, it must be old and salted. And in like manner the dung of oxen, when boiled in honied water with barley-meal, or fresh moist dung applied with the leaves of cabbage; and so also goats’ dung by themselves, or boiled with barley-flour in oxycrate. And since some have derived relief from seemingly opposite remedies (for a mixture of various humours confounds the diagnosis), we must state the materials thereof promiscuously. Wherefore the wild and garden orach in a cataplasm with bread are beneficial, or the leaves of petty mullein, triturated with bulbi and bread, or with polenta, or the cataplasm of raw barley-meal. Upon the whole, when the cause of the complaint is obscure, we must change sometimes to medicines of the same class, and sometimes to the opposite, not continuing long with the same application when it does not afford relief. These things we see every day occur in professional matters. And often a certain remedy proves beneficial to one joint, while another joint of the same patient similarly inflamed is not only not benefited at the same time, but occasionally is even injured by it. And this is a wonderful circumstance, that one and the same joint, when treated with the same remedy, is sometimes benefited, and soon afterwards exasperated. When a viscid and thick matter prevails, it is not perhaps relieved by calefacients, but the acrid and hot quality of the humour prevailing is to be soothed by frigorific remedies; nor is it at all wonderful that a matter naturally cold, in the time of the inflammation, should become heated and glowing, to say nothing of the admixture perhaps of bile. The flour of lupines with oxymel or oxycrate, or the root of laserwort, or of bryony, with bread, prevent the formation of tophi. And the following composition is safely soothing and moderately discutient: Of lycium, oz. j; of ammoniac perfume, oz. j; having triturated with very old wine and oil of unripe olives, boil, and add of the flour of beans, q. s.; and having boiled moderately, apply as a cataplasm. After the acme of the complaint, if a swelling be left, apply a cataplasm with the bulbi by themselves, or with fine polenta, until it produce excoriation; for in this manner they act. When not relieved by the cataplasms, we may have recourse to embrocations and affusions on the parts (more particularly if the extremities be affected), with chamomile, melilot, or centaury in decoctions. The preparation of capers has entirely relieved some. The following is the most active of all the applications: Having boiled thyme, marjoram, savory, and calamint in the most acrid vinegar, bathe the parts affected with the vinegar, not only once, but often in a day, with confidence. This has relieved many when suffering not only from phlegm but also from bile.

Some observe this practice also: The acorns of the ilex being powdered, are pounded and much boiled, and the joints of the extremities at the commencement of the rheumatism are fomented for a considerable time with the decoction, but it is poured from a sponge upon the inner parts; whereby the violence of the offending matter is repelled. It also is applicable to bilious cases; and, in like manner, immersion in hot water without any decoction. For pains occasioned by intense cold, or infarction of the joints, this is a powerful remedy: Of old oil, lb. iss; of Alexandrian nitre, lb. j; of turpentine, lb. j; of euphorbium, oz. j; of iris, oz. ij; of the flour of fenugreek, a sextarius and a half. In these cases the remedies recommended for ischiatics are excellently applicable. Many, in the case of those who are thus affected from a cold cause, apply, after the acme, mustard with dried figs and the other rubefacients, but some the preparation from cantharides. But these things prove injurious afterwards, unless one use the emollient applications, such as that from fuller’s herb, the one called Pyxis, that of Basilius, that from the fir-tree, that from the poplar, those called Promium and Lysiponium, and the stronger of the Acopa: in which cases sympathetic affections of the nerves and impaction of the humours particularly take place. And the application from the urine of a mule, more particularly if applied at the acme, is beneficial in the cold rheums: and, in like manner, the trochisk from the two hellebores is applicable for the œdematous and spongy swellings; also fomentation with the toasted salts; or otherwise affusion or embrocation with hot sea water; and the plasters prepared from salts, those from strained lye and nitre, and the cataplasms of a like nature after the acme. Food of a drier nature, and not excrementitious, suits well with these; also abstinence from food, or a spare diet, and refraining from frequent baths. Having bathed, they should be rubbed with nitre and the other unguents used for friction. In the decline, they should have recourse in particular to gymnastic exercises and friction of the joints, and the natural baths, or the sand baths, and emetics from radishes and food from grain. Those properly prepared for it may be vomited or purged with the white hellebore.

On rheums from a mixture of humours. Those labouring under a mixture of humours, after the evacuation of the blood at the commencement of the disease, should use the topical remedies already mentioned. When the sanguineous plethora is of a more bilious and acrid nature, recourse may be had to those things recommended for bile; when it is of a colder and more pituitous or melancholic nature, those afterwards mentioned, with the exception of such as are very acrid; and if protracted, these also may be used. And this cataplasm is applicable at the commencement: Pomegranate rind, sumach, and polenta triturated with wine, are applied in the form of a poultice.—Another: Having boiled the leaves of cabbage, and triturated carefully, add the lees of vinegar, two yelks of raw eggs and a little rose-oil, and having triturated, apply, changing it frequently. Let them take food that is attenuant and of little nourishment. Let them, therefore, abstain altogether from flesh and pulse, from much wine of a dark colour; and, if possible, let them abstain from drinking wine altogether. For I have known many persons who have abstained altogether from this article alone, and all of them derived benefit. Those who did so in the commencement of the complaint were entirely freed from it; and those who were later in doing so experienced afterwards fewer paroxysms, and these not of great severity. If, therefore, no inconvenience occur, or be dreaded from it, they should abstain from wine all their life. Those who from weakness or coldness of constitution appear to sink under this regimen, after abstaining from wine for two years, may gradually accustom themselves to take a small quantity of diluted wine. Those who refrain from wine should take instead of it a decoction of anise, or of some such seeds, avoiding altogether the use of the autumnal fruits, and other things of a cold nature, and also venery. Of those who attempt to get rid of the complaint by continuing under a course of medicines for a complete year, many who suffer from pituitous and redundant humours have been benefited thereby, whereas such as are of a hot and dry intemperament have brought on sudden death, the offending matter being translated to the intestines, kidneys, side, lungs, or some vital part. It is better, therefore, for those who are bilious and sanguineous, to abstain from wine; as from this course there is no risk of falling into the dangers just mentioned. Those who are affected with cold and redundant humours should take the theriac of vipers more frequently if they have good digestion in winter, but more rarely in summer; for it either removes the complaint altogether or renders it more moderate, and proves injurious to none of the afore-mentioned parts. And since some persons compel us to administer the medicines called Antidotes, you should be aware that the following are all of the same kind, namely, that from water plantain, that of Agapetus, those called Atacton and Octaidon, that of Proclus, that from water germander, that from coral, and many others. The safest of them all, and yet of approved efficacy, is the one from coral, which dissolves tophi that are formed in the joints. The properties of all these things, the manner of using them, and the precautions to be observed with regard to them, you will find described in the Pharmaceutical part of this Work; and also the composition of depilatories for arthritic complaints, and the mode of applying them to these habits, I mean the pituitous. Some, for the entire removal of the complaint, boil whole wolves in oil, wherewith they cure arthritic cases; some throwing them in alive, and others dead, into a large caldron. And in like manner they boil hyænas, making a discutient oil from them; and then filling the cistern of the bath with it, and putting the arthritic patients into it, they direct them to remain in it for a considerable time. By these means it happens that not only the swellings about the joints, but the whole body, is evacuated.

On tophi, or chalk-stones. Since tophi are often formed in the joints, sometimes owing to a thick and terrene humour seating in the parts, and sometimes owing to the use of applications which are immoderately discutient and desiccant without being emollient, it is proper to know that the most suitable remedies are such as are at the same time emollient and discutient. Wherefore, old suet, marrow, ammoniac, bdellium, very old oil, and storax, are emollient; and nitre, salts, strained lye, adarce, euphorbium, and the like, are discutient and desiccative. This is an excellent application for tophi in the joints: Very old and acrid cheese pounded and applied with a decoction of fat swines’ flesh, it also being old. For the chalk-stone breaking spontaneously, a discharge of it takes place every day. The composition from ham (which is prepared in two ways) is also an approved remedy, and those described from strained lixivial ashes (potash?). And this one is particularly excellent: Of aphronitrum, of turpentine, of protostacton, of virgin wax (i.e. bee-glue), of each, oz. iv; of wax, oz. ix; of colophonian rosin, lb. j; of oil, oz. xvj; mix together, and use for chalk-stones and apostemes. The composition from dragon’s blood is of wonderful efficacy for chalk-stones and many other complaints, but is difficult to procure. But that from walnuts is not only efficacious but at the same time easily procured; and is applicable not only to those who are strong, but also to those who are sensitive, if mixed with honey or the composition from anemone, in the proportion of two parts to one of the composition. When these things are not at hand, an equal proportion of ceruse may often be mixed with it.—Another for tophi: Having triturated red arsenic, mix with mistletoe of the oak, and use.—Another, which is applicable also for fistula and ægilops: Of oil, one sextarius; of litharge, oz. viiiss; of arsenic, oz. j; boil the litharge and the oil until they do not stain, then sprinkle the arsenic well levigated, and before it catch fire, take off and use. The compositions from the flower of Assian stone, when used during the intervals, are applicable to all the collections which form in the joints; and some of the ancients attest that they remove the complaint entirely. The composition from the flower of salt, when applied in like manner during the remissions, is believed to dissipate whatever swellings remain.

On the prophylaxis of gout. Gout and rheumatism, when formed, are among the most difficult of diseases to cure, except by the methods we have described; but, before being fixed, it is easy to prevent their occurrence by restricting the diet, giving only such food as is of easy distribution and not excrementitious, with a moderate allowance of wine, and increasing the exercise as far as proper. As a remedy, salts triturated with oil and rubbed into the joints, are of great use to all who are anxious to avoid falling into a gouty affection, unless they be of a dry intemperament. They ought to use it morning and evening through life, and the same thing is to be used after the decline of the inflammation.

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COMMENTARY. Consult Hippocrates (Aphor. vi; Prognost. 15); Galen (Comment. in Aphor. Hippoc., de Med. sec. loc. ix); Celsus (iv, 24); Serenus Samonicus; Aretæus (Morb. Chron. ii, 12); Scribonius Largus (41); Cælius Aurelianus (Tard. Pass. v, 2); Alexander (xi); Aëtius (xii); Oribasius (Synops. ix, 58); Actuarius (Meth. Med. i, 21); Nonnus (216); Marcellus (de Med. 35); Octavius Horatianus (ii, 21); Demetrius Pepagomenos (de Podagra); Psellus (Opus Medicum); Macrobius (Saturnal. vii, 4); Lucianus (Tragodopodagra); Serapion (iv, 25); Avenzoar (ii, 3, 28, ii, 7, 31); Avicenna (iii, 22, 2); Haly Abbas (Theor. ix, 41; Pract. viii, 32); Alsaharavius (Pract. 38); Rhases (Divis. 102, ad Mansor. ix, 90, Libellus de Morb. Junct., and Contin. xxvi.)

The Prognostics of Hippocrates will be admitted at the present day to be correct. Those who are old, or who have chalk-stones formed in their joints, or lead a laborious course of life, or have dried bellies, cannot be cured by any human means. Young persons not having tophi formed in their joints, and who live guardedly, and whose bowels will bear the proper treatment, may be cured. These complaints are best removed by dysenteries or other evacuations downwards. His principal remedies are purgatives administered by the mouth or by injection, and local applications of a cooling nature, and even pouring cold water on the foot. When the pain of the gout becomes fixed in a joint, he directs us to burn it with crude flax.