Book 13: Of Ulcers, Fistulas, And Hemorrhoids.
Table of Contents
I. On the Nature, Causes, and Differences of Ulcers.
Having previously discussed and addressed the nature, differences, causes, symptoms, and treatments of wounds involving flesh and blood, it seems reasonable and orderly to now turn our discussion to ulcers. We begin by clarifying the term’s ambiguity. According to Hippocrates, the term “ulcer” in its broadest sense can refer to any disruption of continuity; in this context, it is said that all pain is an ulcer. More specifically, as detailed in his work “De Ulceribus,” an ulcer, in the strictest sense, signifies a condition that could signal death if it dries up due to atrophy or lack of nourishment.
In this discussion, we will focus on ulcers in their specific and precise definition. We define an ulcer as a disruption of continuity in a soft tissue, characterized not by blood but by filthy and impure discharge, such as pus or other corrupt substances, often accompanied by unnatural and healing-obstructive conditions. To put it succinctly, as per Galen’s view, an ulcer is a break in continuity caused by erosion.
The causes of ulcers can be internal or external. Internal causes stem from defective humors, which are problematic in their quality or quantity, or both, leading to erosion in the skin and softer tissues due to their acrimony and malignancy. These issues often arise from poor diet or unhealthy functioning of the internal organs, which then expel these harmful substances into the body.
External causes include severe cold attacking a body part, particularly those far from the core body heat, resulting in pain. This pain is followed by the drawing of humors and spirits to the affected area, where they become corrupted due to a lack of or weakened native heat, ultimately leading to ulceration. Other external factors include physical trauma, the use of harsh or caustic treatments, burns, and exposure to infectious agents, as seen in virulent ulcers that stem from unsanitary sexual contact or close interaction with those carrying contagious diseases like syphilis.
To better understand the numerous types and distinctions of ulcers, refer to the detailed classifications outlined in the following sections.
A Classification of Ulcers
An ulcer is defined as a disruption in the continuity of soft tissue, characterized by the presence of filth and various forms of corruption. There are two primary types of ulcers: simple and compound. A simple ulcer is solitary and lacks complications associated with unnatural conditions. A compound ulcer, on the other hand, involves multiple complications and variations.
The differences in ulcers can be categorized by several factors:
1. Shape and Form:
– Round or circular
– Sinuous and irregularly spread
– Angular, such as triangular
2. Size:
– Length: long or short
– Breadth: broad, narrow, or moderate
– Depth: deep or superficial
3. Uniformity:
– Whether dimensions such as length, breadth, and depth are consistent or vary
4. Age and Development:
– Newly formed or old
– Duration of the ulcer and its healing process
5. Visibility and Position:
– Apparent or hidden
– Located at the front, back, above, below, or within specific body parts like the head, limbs, or torso
6. Affected Tissue:
– Involving skin, flesh, cartilage, or bones
– Specific sites like the nose, mouth palate, or ears
7. Additional Characteristics:
– Whether the ulcer resembles other conditions like cancers or is associated with specific symptoms such as pain, infection, or discharge
8. Cause of Ulceration:
– Resulting from trauma such as bruising, cutting, or corroding agents
– Could involve chemical irritation or infection
9. Nature of the Ulcer:
– Hot, cold, dry, moist, or a combination
– Associated with other conditions like erysipelas or cancer
10. Complex Symptoms:
– Painful, erosive, foul, or virulent characteristics
– Accompanied by other symptoms or diseases
These classifications can help in understanding the various types of ulcers, their potential complications, and appropriate treatment strategies. This systematic approach reflects the detailed study and categorization of ulcers as seen in historical medical texts, providing a foundation for modern diagnosis and management.
2. Signs Of Ulcers.
Ulcers exhibit a variety of signs based on their specific characteristics. Here are the distinguishing features of different types of ulcers:
1. Putrid Ulcer: This type emits a foul, putrid odor, reminiscent of decay, accompanied by offensive discharge.
2. Eating Ulcer: Recognized by its tendency to erode the tissue in which it resides, leading to hollowness and degradation of the affected area and its surroundings.
3. Sordid Ulcer: Identified by the thick, viscous discharge it produces, as well as the soft, spongy texture or crusty irregularity of the flesh that grows over it.
4. Cavernous Ulcer: Characterized by a narrow opening but with extensive and deep internal channels.
5. Fistulous Ulcer: Similar to a cavernous ulcer, but with the added feature of a callous hardness along the edges or walls of the ulcer.
6. Cancerous Ulcer: This ulcer is particularly alarming in appearance, with blackened, hardened, and swollen edges, discharging foul-smelling pus and sometimes blood, along with swelling of nearby veins.
7. Distempered Ulcer: This type arises from a significant imbalance in the body, whether due to excessive heat or cold, moisture or dryness, or a combination of these factors.
8. Malignant Ulcer: Difficult to treat and resistant to conventional remedies, this type is known for its stubbornness and poor prognosis.
9. Catarrhous Ulcer: Recognized by the discharge that nourishes it, which may originate from adjacent varicose veins, swollen blood vessels, or affected internal organs.
10. Aposthumous Ulcer: Identified by the presence of an unusual tumor, which can be assessed through visual examination and palpation.
11. Telephian Ulcers: Named after Telephus, these ulcers are notable for their size and lack of putrefaction; they do not emit a bad odor, cause significant pain, or eat away at the tissue, but their swollen and hardened edges make healing difficult. Although they can sometimes develop a scar, this is often fragile and prone to reopening, leading to a recurrence of the ulcer.
Telephian ulcers are considered more severe than those termed Cacoethe, or malignant, as they are believed to harbor deeper, hidden causes of malignancy beyond the typical humor imbalance. Such ulcers are often left behind after plague infections. Galen noted that ulcers that do not suppurate or produce any discharge are particularly concerning, as they are likely to be malignant in nature.
3. Prognostics of Ulcers
This section addresses the indicators and projections associated with ulcers. Understanding these prognostics is crucial for diagnosing and managing ulcerative conditions effectively. Analyzing the signs, symptoms, and potential outcomes can help inform treatment strategies and improve patient care.
The bone will inevitably become scaly, and hollow scars will form as a result of malignant ulcers that persist for a year or more and resist appropriate treatments. This scaling occurs due to the ongoing irritation and erosion caused by the harmful fluids that disrupt the natural cohesion and integrity of the bone. As for the hollow scars, they arise because the bone—being the foundational structure from which all flesh originates—loses parts beneath the skin. Consequently, the volume of flesh above must sink in proportion to the size of the bone that has deteriorated.
You can tell that death is imminent when ulcers that emerge during or before illnesses suddenly turn either livid, dry, or pale and withered. Such dryness indicates a failure of the body’s natural processes, which are unable to deliver the usual nourishment to the ulcerated area. Moreover, a livid or pale color suggests not only an excess of choler and melancholy but also the extinguishing of the body’s inherent warmth.
In cases where tumors appear alongside ulcers, the patients do not experience convulsions or fits of madness; this is because the tumor’s presence in a body already affected by an ulcer suggests that the nervous system and its origins remain untouched by harmful humors. However, if these tumors disappear suddenly without any apparent reason—such as the application of a resolving medicine or bleeding—those with tumors on their backs suffer from convulsions and spasms since the spine, which is largely composed of nerves, is affected. On the other hand, those with tumors on the front of their bodies may become frantic, or suffer from severe side pains, pleurisy, or dysentery if the tumors are reddish. This occurs because the front of the body contains many large blood vessels, and when disease-causing substances move into these vessels, they are quickly transported to parts of the body prone to such ailments.
Soft and loose tumors associated with ulcers are a positive sign, as they indicate a gentleness and mildness in the body’s humors. In contrast, crude and hard swellings are a cause for concern; digestion, in some respects, resembles a process of purification. Ulcers that appear smooth and shiny are particularly troubling, as they suggest the presence of a harmful humor that irritates and disrupts the hair follicles, compromising the natural structure of the skin’s pores. This is why individuals suffering from quartan fevers, leprosy, or syphilis often experience hair loss.
Furthermore, livid tissue in ulcers is a bad sign, as it can indicate decay or corruption of the underlying bones. This suggests the deterioration of vital heat and the corruption of the bone from which the flesh derives its integrity and vitality.
Ulcers that arise due to diseases such as dropsy are notoriously difficult to heal, as are those that continuously receive discharge from a swollen blood vessel due to an ongoing ailment. Ulcers with swollen, hard, and calloused edges, especially those that are circular or round in shape, also present significant treatment challenges. A condition known as Hypersarcosis, or excessive flesh growth, often occurs in ulcers that are not carefully cleaned; when located on the arms or legs, these can lead to a phlegmon or other types of swelling in the groin area, particularly if the body is laden with unhealthy humors, as noted by Avicenne. These areas, due to their delicate and weak nature, are prone to such issues.
Albucrasis identified nine reasons why ulcers are challenging to heal and fill with new flesh. The first reason is the lack of blood in an anemic body; the second is due to poor humors and impure blood; the third arises from the improper use of unsuitable medicines; the fourth is due to the dirtiness of the ulcer itself; the fifth occurs from the decay of the soft, rotting flesh surrounding the ulcer; the sixth is when they originate from a pervasive cause, such as those left by a pestilence; the seventh is due to the hardened edges of the ulcer; the eighth relates to environmental conditions, such as those found in Saragossa, Aragon, that exacerbate the ulcer; and the ninth is when the underlying bones are decayed.
An ulcer that discharges a white, smooth, and uniform fluid with little to no odor is generally easy to heal, as it indicates that the body’s natural heat is prevailing and that the underlying tissue remains intact. The smooth fluid we refer to is one that has been properly processed and presents no roughness to the touch, which would suggest that any portion of the humor is still unrefined. We describe the discharge as uniform when there are no noticeable variations in its composition, and “white” here refers not to a pure white but rather to an ash-colored hue, as noted by Galen.
However, it is concerning if, during a relatively stable healing process, a sudden flow of blood occurs in ulcers that throb intensely due to significant inflammation. As Hippocrates points out, a sudden bleeding accompanied by strong pulsations is a bad sign; blood escaping from an artery is difficult to control and often results from the intense heat and inflammation that nourish the ulcer. This blood can rupture its vessels, leading to a loss of the body’s natural heat, subsequently causing a failure of proper healing and potentially resulting in gangrene.
In the case of malignant ulcers, two types of discharges can occur. The thinner discharge is known as ichor or sanies, while the thicker discharge is referred to as sordes. The latter is virulent and can arise from irritated nerves and affected periosteum; the former typically comes from joint ulcers. The condition worsens if the discharge appears black, reddish, or ash-colored, or if it is muddy and uneven like wine lees, especially if it has a foul odor. Sanies resembles the water used to wash flesh and indicates an abnormal heat in the area; when it appears pale, it suggests a loss of that heat.
4. General Treatment of Ulcers
An ulcer can be categorized as either simple or compound. A simple ulcer has just one key treatment objective: drying out the area, which is particularly important because ulcers are generally moister than wounds. In contrast, treating a compound ulcer involves addressing multiple factors, and according to Galen, there is a specific order to follow. Priority should be given first to the most immediate issues, then to the underlying causes, and finally to any conditions that must be resolved for the ulcer to heal properly.
To illustrate this, imagine an ulcer located just above the ankle on the inside of the leg. This ulcer is painful, deep, and foul-smelling, with underlying bone decay. It is circular, with hard, swollen edges, and is surrounded by inflammation and varicose veins. Before directly treating such an ulcer, especially if there is severe pain, it’s crucial to consult a physician for a comprehensive approach. If Galen’s advice is followed and the entire body needs preparation, this should be addressed first. Depending on the specific ulcer, treatment might involve purgation, bloodletting, or both, particularly if the ulcer stems from an excess or poor quality of bodily fluids.
Once the underlying causes have been addressed, you can focus on treating the ulcer itself, starting with the most pressing issues. Pain relief should be the initial step, using treatments that counteract the source of the pain. For instance, if the ulcer has resulted from a long-standing inflammatory condition that has stiffened and swollen the area, begin by softening the affected skin with warm baths. This makes it easier to drain any problematic fluids. Next, remove some of the problematic matter either through scarrification, if the patient is brave enough, or more gently using leeches if they are more sensitive. Finally, apply a cooling ointment, such as Galen’s refrigerant ointment, to reduce the heat and soothe the area.
In conclusion, you should employ all the methods we previously discussed in our treatise on tumors to reduce the swelling associated with the ulcer. Once you have achieved the desired reduction, you will need to address the factors that cannot be resolved without further intervention. This involves systematically correcting the defects that are contributing to the ulcer, particularly the decay of the bone, which can be treated using cauterization.
At the same time, you should reshape the ulcer to a more manageable form, specifically a cornered shape, while removing any hardened tissue. It is also essential to address the necrosis. Afterward, you must facilitate the shedding of the eschar and prepare for the exposure of the bone using the methods we have outlined earlier. Finally, once the ulcer has been cleansed, it should be filled with healthy tissue to promote healing.
To promote the growth of new flesh, two elements must come together: the efficient cause and the material cause. The efficient cause is the overall health of the body and the specific condition of the ulcerated area. When these are optimal, they facilitate the attraction, digestion, addition, and assimilation of beneficial nutrients to the affected part. A healthy state is maintained by similar factors, while unhealthy conditions are improved by opposites.
The material needed for new flesh is high-quality blood, which should neither be excessive nor deficient in quantity or quality. During this process of flesh regeneration, two types of waste products are produced: a thinner, more fluid type called ‘sanies’ and a thicker type known as ‘sordes.’ Both are unnatural to the body and can impede the regeneration process, so they must be removed using appropriate treatments. This might include mildly drying agents or stronger or weaker cleansing agents, depending on the specific nature of the ulcer, the condition of the surrounding area, the amount and type of waste material, and the cleanliness of the ulcer.
The treatment should maintain healthy tissue with similar substances but combat the ulcer with opposites. Once the ulcer is filled with new flesh through natural healing processes and the assistance of a surgeon, it needs to be covered with a layer of tougher skin, known as cicatrization. This can be achieved by applying very drying powders that are not too harsh. Substances such as burnt alum and vitriol, turned into powder and lightly dusted over the area, can effectively form this protective layer.
Other substances that aid in this process include the root of Aristolochia, aloes, burnt lead, burnt pomegranate peels, litharge, tutia, and lead plates coated with mercury. These have sometimes been found by surgeons to be particularly effective and reliable for cicatrization compared to other treatments.
5. Understanding Distempered Ulcers
Before discussing a distressed ulcer, it is important to clarify the signs of different types of ulcers, so that the surgeon does not mistake one condition for another. An ulcer associated with a dry condition can be identified visually; it will appear wrinkled and will exude little to no moisture. You can also assess it by touch—if it feels rough and hard, it indicates a dry state.
To correct this condition, you should use moistening treatments, such as applying warm water compresses, as suggested by Galen, or using a mixture of oil and water (hydraelaeum). However, it is essential to first cleanse the body if it is burdened with harmful humors, or consider bloodletting if the body is overly full; otherwise, you risk drawing more humors into the area than it can handle.
Continue the fomentation until the surrounding flesh begins to appear red, becomes soft and moist, and the ulcer itself shows slight swelling. Be cautious not to overdo it; if you go too far, you could dissolve all the beneficial humors that you have drawn to the area, rendering your efforts ineffective. Once you have completed the fomentation, you should apply a suitable remedy directly to the ulcerated area.
Prescription: Take two ounces of barley cream, one ounce of mallow leaves cooked in water, one and a half ounces of pig fat, and half an ounce of common honey. Mix these in a mortar and make an ointment.
You will understand that a moist condition accompanies the ulcer due to the excess of waste humor it produces, as well as the spongy and fungous softness and growth of the surrounding flesh. To address this, you should use drying remedies known as sarcoticks, always considering the abundance of humor, the specific temperament of the affected area, and other indications previously discussed. Among various treatments, Galen highly recommends alum water, as it dries, cleanses, and strengthens the affected area. Additionally, the following fomentation may be applied effectively.
Prescription: Take equal parts of red roses, wormwood, betony, and Trifolium barbatus, 1 dram each; of oak galls and cypress nuts, 2 drams each; and 1 dram of rock alum. Make a decoction in plantain wine, and prepare a fomentation. Then let a plaster of ceruse or of red lead be applied to the ulcer.
I have found through experience that lightly sprinkling burnt alum powder on the ulcer is quite effective in this case. You can identify a hot condition associated with the ulcer by its redness or yellowness, the heat you can feel upon touch, and the nature of the pain. In such instances, you should turn to cooling remedies, such as Rose Water, Cooling Galen, or Populeon; you can also use cloths soaked in plantain water, nightshade water, or a vinegar-water mixture. I have often observed that scarification or the application of leeches tends to be more beneficial than any other treatment. This method helps draw away the irritated blood, which is prone to corruption, and alleviates the burden on the affected area.
Conversely, a cold condition can be recognized by the whitish or pale appearance, the surgeon’s touch, and the patient’s complaints about the coldness of the ulcerated area. To remedy this, you should apply bottles filled with warm water around the affected part or use swine’s bladders partially filled with the following decoction.
Prescription: Take equal parts of oregano, pennyroyal, chamomile, melilot, wormwood, marjoram, sage, and rosemary, 1 ounce each. Make a decoction in fine wine, adding enough distilled water to suffice.
Additionally, the ulcer can be effectively soothed by using sponges soaked in the same decoction. You should apply to it Emplastrum Oxycroceum, Emplastrum de Melilot, Emplastrum de Vigo with mercury, and without mercury. However, if the ulcer is affected by a mixed and compound condition, the treatments must similarly be combined and tailored. The remainder of the surgeon’s effort and care should be devoted to the specific and detailed healing of the ulcer as such. As previously mentioned in the earlier chapter, this involves cleaning the ulcer, promoting the growth of new flesh, and the subsequent healing of the skin.
6. On Painful Ulcers
Ulcers can often cause such intense pain that they necessitate the involvement of a physician. If the pain arises from an underlying condition, appropriate remedies should be employed, as discussed in the previous chapter. However, if the pain persists, we must consider the use of narcotics. Suitable options include poultices made from the leaves of mandrake, water lilies, henbane, nightshade, hemlock, and poppy seeds, as well as oils derived from these plants. Additionally, opium, populeon, and similar substances may be included.
If, however, the pain is due to a malignancy or corrosive humor that is damaging the flesh beneath the ulcer and its surrounding edges, then neither soothing nor narcotic treatments will provide relief; in fact, gentle applications may exacerbate the situation. In such cases, stronger treatments, known as caustics, are more appropriate for addressing severe ailments. You should apply a pledget soaked in a potent solution of Aegyptiacum or a small amount of oil of vitriol directly to the ulcer, as these substances can help alleviate the intense pain and tackle the harmful humors.
In the meantime, it is advisable to surround the ulcer with cooling agents to prevent the harshness of the strong medications from causing further irritation.
7. On Ulcers Characterized by Granulation Tissue Overgrowth
Ulcers can sometimes develop excess or overgrown tissue, either due to the negligence of the surgeon or the fault of the patient. To address this, it is necessary to apply medicines that are drying and mildly corrosive, such as galls, frankincense bark, aloes, antimony, pompholix, vitriol, and lead—all of which may be burnt and washed if required. These substances can be made into powders and mixed with a little oil and wax to create ointments. However, if the overgrown tissue, which is hard and dense, does not respond to these treatments, we may need to resort to caustics or surgical removal with a knife.
According to Galen, removing overgrown tissue is not a natural process like healing or regenerating flesh, but rather is achieved through vigorously drying medicines or surgical intervention. Among the treatments suitable for this, I find the powder of mercury with a small amount of burnt alum, or burnt vitriol alone, to be particularly effective.
For the hard and callous edges of the ulcer, softening treatments are required. These might include greases from calves, geese, capons, or ducks, oils from lilies, sweet almonds, or whelps, and mucilages from plants like marshmallows, linseed, and fenugreek, as well as substances like gum ammoniacum, galbanum, and bdellium. These can be mixed to create plasters, ointments, and liniments, or you might use specific preparations like Diachylon plaster or mucilaginous remedies from De Vigo with mercury.
After a few days of these treatments, applying a lead plate rubbed with mercury to the ulcer can be very effective in smoothing and pressing down the edges. If these methods do not work, we must again consider using caustics. If the caustics still cannot penetrate the callous edges, a gentle scarification might be necessary, or cutting into the tissue to create a way for the medicine to penetrate more effectively, as suggested by Galen.
Lastly, it is important not to overlook the advice of Hippocrates, which is to alter the shape of the ulcer from round to another shape, such as long or triangular, to facilitate healing.
8. On Ulcers That Are Putrid and Infested with Maggots
This section addresses ulcers characterized by putrefaction and infestation by maggots. Such conditions present severe complications due to the necrotic tissue that creates an environment conducive to parasitic invasion. The presence of maggots, while unsettling, can paradoxically imply both advanced decay and a natural form of debridement. Treatment strategies must focus on meticulous wound cleaning, odor control, and the use of appropriate antiseptics and antibiotics to eliminate infection and prevent further deterioration. A comprehensive and timely approach is essential for healing these challenging ulcers and restoring tissue health.
Worms often infest ulcers, leading to what are known as “wormy ulcers.” This occurrence is typically caused by excessive moisture that becomes putrid due to unnatural and excessive heat. Such conditions can arise from neglecting the ulcer, from imbalances and unhealthy humors in the body, or from a blockage preventing the expulsion of waste fluids. This is particularly common in ulcers located in the ears, nose, rectum, cervix, and other irregularly shaped ulcers.
However, it is important to note that not all putrid ulcers will necessarily contain worms, as we have previously defined a putrid ulcer. To treat these types of ulcers, it is crucial to first remove the worms and then eliminate the waste fluids that have caused their presence. To accomplish this, you should soak the ulcer with a specific decoction designed to kill the worms. Attempting to remove all the live worms at once can be misleading, as they often cling stubbornly to the affected area, making it difficult to extract them without causing significant pain and discomfort.
Prescription:
Take equal parts of wormwood and greater centaury, and two parts of horehound. Mix them together to make one dram. Make a decoction with half a pound of water, in which dissolve half an ounce of aloes and one ounce of Egyptian ointment.
Let the ulcer be gently fomented and cleansed with this remedy, and apply pledgets soaked in it directly to the ulcer. If the ulcer is complex or has many twists and turns, prepare an injection to reach all areas of it. Archigenes highly praises the following remedy:
Prescription:
Take one and a half ounces of cerussite (white lead) and one and a half ounces of mountain pine resin. Mix with enough liquid naval tar to make a liniment.
If the decay is so severe that these remedies are insufficient for healing, you may need to resort to more potent treatments, such as cauterization, hot irons, or surgical intervention. However, it is essential to start with gentler methods, like the one described by Galen.
Prescription:
Take 2 ounces of wax, 1 ounce of cerussite (white lead), 2 ounces of rose oil, 1/2 ounce of ammonium salt, 2 drams of scales (possibly indicating a type of resin or herb), 1 dram of frankincense, 1 dram of alum, and 1 dram of quicklime. Let it be made into a plaster.
Or
Prescription:
Take 2 ounces of distilled turpentine, 1/2 ounce of white wax, and dissolve them together by adding 1/2 dram of sublimated mercury, 1 ounce of roasted salt, and 1 ounce of calcined vitriol. Let it be made into a cleansing preparation.
Alternatively, you may use our Aegyptiacum on its own, which contains Sublimate in its formulation. In the meantime, it is important to protect the surrounding area of the ulcer with cooling and soothing substances to prevent discomfort.
9. On a Sordid Ulcer
This section discusses the nature and implications of a sordid ulcer, a term indicative of severe infection and poor hygiene conditions. Such ulcers often exhibit foul odors, necrotic tissue, and a high risk of complications due to the accumulation of pathogenic organisms. The etiology behind these ulcers frequently stems from neglect, pre-existing medical conditions, or inadequate wound care, leading to a detrimental cycle of infection and tissue degradation.
Effective management of a sordid ulcer requires a multifaceted approach. Key interventions include thorough cleansing, removal of necrotic tissue, and the application of appropriate topical agents to promote healing. Additionally, addressing the underlying causes—such as improving hygiene practices and treating associated health disorders—is vital for achieving a successful recovery. By prioritizing both local and systemic treatment strategies, healthcare providers can significantly improve patient outcomes in cases of sordid ulcers.
A neglected ulcer, following the overall healing of the body, should be treated with cleansing medicines. This approach is indicated by the presence of thick and hardened discharge that, along with the purulent material surrounding it, obstructs the ulcerated area and diminishes the effectiveness of even the most potent remedies. Therefore, we should start the treatment with warm compresses and washes as follows.
Prescription:
Take 1 pound of common lye,
1 ounce of wormwood, and
1 ounce each of centaury and St. John’s wort.
Boil them together and strain to obtain enough liquid.
Add 1 ounce of rose honey and
1.5 ounces of Egyptian ointment to create a mixture.
Then prepare the following cleansing medicine:
Take 2 ounces each of parsley and plantain juice,
1 ounce of honey,
1.5 ounces of turpentine, and
0.5 ounces each of powdered Florentine iris and aloes.
Mix these ingredients to create the remedy.
The surgeon must carefully consider how many dressings will be necessary to thoroughly cleanse the ulcer of any gross dirt or filth that clings to it, as well as to dry up any purulent discharge. Often, this can be accomplished in a single dressing; however, in patients with heightened sensitivity, it may take longer. Once the ulcer is cleared of such debris, it is crucial to avoid using overly harsh treatments, as they may cause pain, excessive discharge, inflammation, and erosion, which can deepen the ulcer.
Therefore, we should focus on remedies that dry and cleanse without harshness, thereby supporting the body’s natural healing process in generating new tissue. Suitable remedies include powders of aloes, mastic, myrrh, orris root, litharge, antimony, gentian root, barley flour, and similar substances. These should be sprinkled on the ulcer, covered with lint, and then topped with a lead plate that has been rubbed with mercury. The strength of these drying and cleansing agents should be adjusted based on the specific needs of the ulcer.
Excessive use of drying and cleansing agents can eventually lead to the ulcer becoming deeper, resulting in increased discharge as the healthy tissue is damaged by the harshness of the treatment. This can also corrupt the nourishing fluids that are meant to support healing. An inexperienced surgeon might mistakenly believe that an increase in discharge is a sign of needing even stronger drying agents, treating the discharge as if it were mere waste.
Galen warned us against this approach, recounting the story of a certain empiric who treated a foul ulcer with a harsh, corrosive medicine, which ultimately dissolved the flesh, deepening the ulcer and increasing pain and discharge. The careless application of increasingly harsh treatments only exacerbated the breakdown of tissue and the size of the ulcer.
Thus, it is essential to determine whether the ulcer is worsening due to its own condition and the overall impurity of the body, or if it is a result of tissue breakdown and corruption caused by the frequent and improper use of overly harsh treatments. Signs of this can include increased pain without apparent cause and heat and redness around the ulcer’s edges.
Above all, the surgeon must tailor the treatment to each patient’s individual needs, choosing remedies that are appropriate for their overall condition and the specific characteristics of the affected area. There is a significant difference in how a treatment may affect a laborer compared to a delicate individual, or how it may vary depending on whether it is applied to a limb or an eye.
Medicines that are only cleansing and drying for a dense and robust area may be corrosive and damaging to more delicate tissues, leading to further tissue breakdown and increased discharge. Conversely, treatments that effectively cleanse and dry a soft tissue may fail to adequately address the stubborn impurities of a tougher, denser area. Therefore, a skilled surgeon must know when to shift from stronger cleansing and corrosive treatments to gentler alternatives.
10. On Virulent, Consuming, and Malignant Ulcers, Also Known as Cacoethes, and Chironian Ulcers
This section delves into two specific types of ulcers that pose significant challenges to healing—the virulent, consuming, and malignant ulcers, commonly referred to as cacoethes, and the Chironian ulcers.
Cacoethes are characterized by their aggressive nature, penetrating deeply and rapidly into the tissue, and often resisting standard treatment measures. These ulcers are marked by their malignancy, with a propensity to spread and cause extensive damage. Their erratic and tenacious behavior necessitates early and aggressive intervention to prevent further deterioration of the affected area.
Meanwhile, Chironian ulcers derive their name from the centaur Chiron, known in mythology for his incurable wound. These ulcers are similarly stubborn, resistant to traditional healing methods, and are often chronic in nature. The Chironian ulcer’s persistent and unyielding nature often results in prolonged discomfort and distress for the patient.
Addressing these complex ulcer types requires a comprehensive and strategic approach. Management typically involves advanced wound care techniques, tailored antimicrobial therapy, and sometimes surgical intervention to remove necrotic or infected tissue. Additionally, a thorough investigation to identify and manage any underlying conditions that may contribute to the ulcer’s development is crucial. By employing an integrative treatment plan, healthcare professionals can strive to mitigate the adverse impacts of cacoethes and Chironian ulcers, aiming for recovery and improved quality of life for those afflicted.
Virulent and necrotic ulcers differ primarily in degree rather than kind. We refer to an ulcer as virulent when it produces a toxic discharge, known as “virus.” When this virulence becomes more severe, it begins to erode and consume the underlying tissues, resulting in what we call an eating ulcer. Galen refers to such ulcers as “dysepulotica,” meaning they are difficult to heal. He explains that an ulcer may be classified as dysepulotica either because the affected tissue is compromised in its condition or quality, leading to a corrupt humoral flow to the area—this type is specifically termed “cacoethes.” Alternatively, it may be due to the poor quality of blood reaching the site, which can prevent healing, especially if the tissue is overly moist. Galen further notes that a “Chironian ulcer” is even more malignant than those classified as cacoethe.
When it comes to treatment, it is important to recognize that these ulcers can vary greatly in severity, with some being more difficult to heal than others. Therefore, it is essential to have a variety of remedies available, each with distinct properties and strengths. It is no surprise that those who rely on a single treatment for all types of malignant ulcers often find their efforts unsuccessful. One remedy, as described by Asclepiades, is highly recommended by Galen for its efficacy.
Prescription:
Take 1 ounce of copper scales and
1 ounce of scraped verdigris,
1.5 pounds of wax, and
1.5 ounces of larch resin,
which should be melted together.
and prepare a poultice to apply directly onto the ulcer. It is important to surround the ulcer with a protective dressing to prevent inflammation. However, Galen notes that the Epuloticke of Primion is superior to other treatments, particularly for those stubborn ulcers that have been deemed incurable by many who have attempted to treat them. This remedy has proven to be effective and reliable.
Prescription:
Take 3 ounces of cut alum,
2 ounces of quicklime,
3 ounces each of frankincense and galls,
1 pound and 3 ounces of wax,
1 pound and 7 ounces of beef tallow, and
enough old oil to make a plaster.
11. An Advisory for Young Surgeons on the Timing for Dressing Malignant Ulcers
This section serves as a critical guidance for young surgeons regarding the optimal timing for dressing malignant ulcers. Understanding the appropriate intervals is essential for effective wound management and healing.
In addressing malignant ulcers, it is crucial to recognize that the timing of dressing changes significantly affects both the healing process and patient outcomes. Surgeons must remain attuned to the unique characteristics of these ulcers, as their aggressive nature requires careful consideration of when to apply or change dressings.
This advisory aims to provide emerging surgeons with practical insights on best practices for caring for malignant ulcers, stressing the importance of being both proactive and observant in their approach. By mastering the timing of interventions, young surgeons can enhance their skill set and ultimately improve patient care.
To illustrate the application of Asclepiades’ medicine as discussed in the previous chapter and to address the misconceptions held by certain surgeons who believe they are benefiting their patients by dressing malignant ulcers two or three times a day, I find it necessary to deviate slightly from my main topic and invoke the authority of Galen.
Galen rightly points out that Asclepiades included these specific instructions in his earlier description of the medicine: “Remove this after three days, then foment the ulcer, wash the same plaster, and apply it again.” He emphasizes that unless the medicine remains in contact with the skin for a considerable duration, it is unlikely to be effective. Despite this wisdom, many practitioners remain unaware, mistakenly assuming that by cleansing the discharge from the ulcer three times daily, they are providing better care than those who do so only twice a day. Conversely, those who tend to the ulcer just once a day are often criticized by patients for being negligent. This criticism is misguided; it is crucial to remember, as we have explained in much of our work, that the qualities of nearby substances influence and interact with each other to some extent, even when one is significantly stronger than the other. Over time, they can develop similar characteristics, despite their differences. When the properties of the medicine closely resemble those of the tissue needing treatment, the outcome tends to be more favorable.
Therefore, the individual who first proposed the use of the previously applied plaster deserves commendation, and we should be inclined to follow his guidance, especially since his reasoning has been validated by experience. Furthermore, it is no coincidence that he advised fomenting the wound every third day—at each dressing—given the potency of the medicine, which requires moderation.
Galen’s views, based on reason, can be further supported by another logical argument. It is well-established that medicines cannot exert their effects unless activated by the body’s natural heat, which stimulates the medicinal properties to take action. In the case of truly malignant ulcers, the natural heat of the affected area is significantly diminished, weakened by the presence of abnormal heat. Thus, a considerable amount of time is necessary for the medicine’s properties to become effective.
If, during this crucial period—when the body’s natural heat has sufficiently activated the medicine—the ulcer is disturbed or opened, and the previously applied plaster is discarded for a new one, the heat generated in the area may either dissipate due to exposure to air or become weakened and pushed inward. Consequently, the efforts made by the plaster would be rendered ineffective, interrupted in their course. When a new plaster is applied, the area must undergo an additional process to reestablish the heat necessary to activate the medicine’s properties.
All medicines possess their own unique properties and effects. Similarly, those who frequently replace dressings on the same day make a significant error by cleansing too aggressively. In doing so, they not only remove the waste humors—both the sordes and sanies—but also strip away essential nourishing substances such as rob, cambium, and gluten, which are vital for the formation of healthy flesh. Therefore, it is inadvisable to dress ulcers multiple times within a single day and to continuously apply new plasters, unless a serious symptom, such as pain, necessitates it. In such cases, the frequent changing of soothing treatments may be required to alleviate and mitigate the discomfort.
12. A Guide for Dressing Ulcers
13. On the Treatment of Specific Ulcers, Beginning with Those of the Eyes
According to Galen, the various indications for treating diseases are determined by the condition of the affected area, including its temperament, complexion, location, shape, and sensory response—whether dull or acute. Having briefly discussed the general treatment of both simple and complex ulcers, I believe it is now appropriate to address them as they relate to specific parts of the body, starting with those affecting the eyes. As noted by Celsus, eye conditions can arise from pustules, a sharp discharge that irritates and breaks down the layers of the eye, or from trauma.
Paulus outlines the various types of eye ulcers. He notes that if there is a small, shallow ulcer on the cornea, the Greeks refer to it as “Botryon.” If the ulcer is wider and less deep, it is called “Caloma.” An ulcer located around the iris or the rainbow-like part of the eye is known as “Argemon.” If it appears crusty and dirty, it is termed “Epicauma.” Generally, these ulcers require similar treatment as previously mentioned, which involves cleansing, promoting healing, drying, and forming a scar; however, the affected area necessitates gentler remedies.
To begin treatment, the patient should be purged and have blood drawn from both the arm and the temporal arteries, and a bath may be given if necessary. To address any discharge, cupping glasses with scarification can be applied to the shoulders, or freshly baked bread sprinkled with aqua vitae or good wine can be placed at the base of the spine. For the forehead and temples, an astringent plaster made from a mixture of “emplastrum contra rupturam,” “ung. Comitissae,” and “Resiccativum rubrum” should be applied. Additionally, the following eye wash, as described by Celsus and endorsed by Hollerius, should be instilled into the eye.
Prescription:
Take 1 ounce each of
burnt and washed copper and
burnt cadmium.
Mix with water to prepare an eye wash that is to be dissolved in egg liquid.
In the meantime, it is essential to monitor the eye closely to ensure that no significant pain is caused. To alleviate any discomfort, it can be beneficial to apply soothing remedies from time to time. You may also prepare eye washes using a decoction of plantain, fenugreek, and wormwood, sweetened with a small amount of sugar candy, along with tutia, gum tragacanth, myrrh, and dissolved vitriol. Once the ulcer has been cleansed, the following restorative treatment will be effective.
Prescription:
Take 3 ounces of sarcocolla nourished in women’s milk,
2 drachms of simple diaireos powder, and
1½ drachms of gum arabic and tragacanth.
Add enough fenugreek mucilage to prepare an eye wash.
But you must note that for moist ulcers, powders are more convenient than eye washes. When the ulcer is flattened or filled with its proper tissue, it may be healed with the following eye wash.
Prescription:
Take of prepared tutia,
cadmium as appropriate,
ceruse,
antimony, and of each:
1½ drachms; of
myrrh,
sarcocolla,
dragon’s blood,
aloes, and
opium, of each: ½ drachm;
mix with plantain water to make an eye wash.
Or the powder may be conveniently sprinkled on it. Celsus has noted that the healing of the eyes is subject to two dangers: either they are too hollow or too thick. If they are too hollow, they must be filled with the following remedy:
Prescription:
Take of poppy tears,
1½ drachms; of
sagapenum,
opopanax, and each: 1½ drachm; of
verdigris,
3 drachms; of cumin,
2 drachms; of washed cadmium and ceruse, each: 1½ drachm;
mix with rainwater to make an eye wash.
But if the scars are thick or coarse, the following remedy will thin them out:
Prescription:
Take of cinnamon and acacia, each: 1½ drachm; of washed cadmium, saffron, myrrh, and poppy tears, each: 2 drachms; of gum arabic, 1½ drachm; of white pepper and frankincense, each: 2 ounces; of burnt earth, 3 drachms;
mix with rainwater to make an eye wash.
But if the scar is on the cornea or the horny layer, such that it covers the pupil or sight, the vision will be obstructed by the thickness of the membrane. It should also be noted that scars on the cornea are white, whereas those on the conjunctiva are red, because the latter is more richly supplied with small veins than the former.
14. On Ozaena and Nasal Ulcers
The condition known as ozaena is characterized by a deep, foul-smelling ulcer within the nasal cavity, producing numerous crusty and malodorous discharges. According to Celsus, these ulcers are notoriously difficult to heal. Galen attributes their cause to the distillation of acrid and putrid humors from the head, which then flow into the nostrils around the mammillary processes.
For treatment, the patient should adhere to a modest diet, avoiding sharp or strong foods. It is essential to purge the body of the harmful humors. Additionally, the head should be treated to ensure it remains dry and fortified, preventing the accumulation of excrementitious humors.
Once these steps have been taken, attention can turn to the ulcer itself. To promote healing, the ulcer should be dried using a repellent remedy. An effective option is the juice of pomegranates, which should be boiled down to half its volume in a brass vessel. Other helpful substances include powdered calamint, cresses, white hellebore, and a mixture of cress juice with alum, all of which are discussed in Celsus’s writings.
Galen, following the recommendations of Archigenes, suggests drawing the juice of calamint into the nostrils. Alternatively, one could dry the calamint and grind it into a powder, which can then be blown into the nose using a quill. Others may opt for the following powder for similar purposes.
Prescription:
Take red rose, mint, aromatic calamus, angelica root, gentian, mace, and cloves, each in the amount of 1.5 drachms (ʒss). Add 4 grains of amber camphor and 6 grains of musk.
Make a very fine powder.
Manardus notes that while the urine of a donkey may be an unpleasant remedy, it serves as an effective treatment for this condition. However, if the stubborn and chronic issue does not respond to these remedies, one should resort to coprose, verdigris, sal ammoniac, and alum mixed with vinegar. It is often the case that the ulcer may spread and affect the ethmoid bones. In such instances, it is important not to forcibly remove them; instead, allow nature to take its course and wait for them to detach on their own. In the meantime, you can administer injections into the nostrils using aqua vitae that has been infused with cephalic powders to promote drying.
15. Ulcers Of The Mouth
Among this group are the aphthae, ulcers commonly seen in young children, as noted by Hippocrates. They often begin at the gums and can spread to the palate, affecting the uvula, throat, and the entire mouth, as Celsus describes. Galen categorizes aphthae into two types: one is easily treatable, typically caused by the acidity of the nurse’s milk that troubles children; the other is malignant, resulting from an influx of harmful humor (that is, poisonous and malignant) into the mouth.
For treatment, it is advisable to avoid all acrid substances. If the child is still nursing, it would be wise to mix the nurse’s milk with cooling foods, bathe the child’s entire body, and apply warm compresses to the breasts. This is important because children’s bodies are very delicate and sensitive, and their mouths are not accustomed to solid foods or drinks. When choosing topical treatments, select those that act quickly and effectively, as the condition of the affected area does not allow for prolonged application. If the ulcer is malignant, it should be gently treated with aqua fortis, which is traditionally used in metal separation, diluted with six parts of water. You may also use oils such as vitriol, sulfur, antimony, or mercurial water for the same purpose.
Aetius recommends that you treat such ulcers by applying a piece of wool dipped in hot oil, secured to the end of a probe, until the ulcers turn white and smooth. This method will help to contain their destructive and spreading nature, allowing healthy tissue to grow in place of the damaged areas. After this cauterization, it is beneficial to rinse the mouth with the following gargle, which can also effectively treat non-malignant aphthae on its own.
Prescription:
Take the following ingredients:
1 part of whole barley,
1 part of plantain,
1 part of common maidenhair fern (ceterach),
1 part of mouse-ear hawkweed (pilosella), and
1 part of agrimony.
Prepare a decoction with a total of 1 pound of this mixture. In this decoction, dissolve 1 ounce of rose honey and 1.5 ounces of diamoron. This mixture will be used as a gargle.
You can also prepare other gargles using pomegranate peels, balaustines, sumac, barberries, and boiled red roses, all dissolved in strained liquid with diamoron and dianucum, along with a bit of alum. Galen notes that simple mouth ulcers can be treated with substances that dry moderately, and both diamoron and dianucum fit this description. However, some ulcers may require stronger treatments.
If the palate is affected, greater diligence and care are necessary, as there is a risk that the underlying bone, which is delicate and moist, may become infected and deteriorate, potentially affecting the voice or speech. If the ulcer is of the syphilitic variety, you should forego the usual treatments for ulcers and instead promptly turn to the appropriate remedy for that condition, specifically mercury.
Fistulous ulcers often develop on the gums, leading to the decay of the adjacent tooth root. This decay can be so severe that the acrid discharge sometimes creates a passageway that opens on the outside beneath the chin. This condition can mislead many into believing they have scrofula, or the King’s evil, leading to fears of an incurable illness.
In such cases, Aetius and Celsus recommend extracting the rotten tooth, as this will eliminate the fistula. The gum will then naturally fill the space left by the removed tooth, and by addressing the root cause of the decay—the tooth itself—the remainder of the treatment will become much simpler.
Ulcers on the tongue can be treated with the same remedies used for other mouth ulcers. However, those that form on the sides of the tongue tend to persist for a long time. It is important to check for any sharp tooth opposite the ulcer, as it may prevent healing in that area. If such a tooth is present, it should be smoothed down with a file.
16. Ear Ulcers
Ulcers can develop in the auditory passage due to both external factors, such as a blow or a fall, and internal factors, like an abscess formed within. These ulcers often exude a significant amount of discharge, which may not originate from the site itself. Typically, such ulcers are small and located in a sensitive area; however, the brain may expel excess fluid in this manner.
In treating these ulcers, it is crucial to address the underlying cause that is sustaining the ulcer. This can be achieved through purgative medications, masticatories (substances to be chewed), and errhines (substances that induce nasal discharge). Below is a formulation for a masticatory.
Prescription:
Mastic, 2 grams; Staphisagria and Pyrethrum, each 2 grams; Cinnamon and Cloves, each 1.5 grams.
Prepare a masticatory. Use it in the morning and evening.
Put in the form of a nasal drop.
Prescription:
Juice of betony and mercurial: and
lemon balm, one ounce and a half;
of white wine, one ounce;
mix and apply frequently.
In the realm of topical treatments, it is essential to avoid all fatty and oily substances, as emphasized by Galen in his Method of Healing. He criticizes a follower of Thessalus who, by using the Tetrapharmacum, caused an ear ulcer to worsen significantly. Galen successfully treated this condition with the Trochisci of Andronius, which were dissolved in vinegar. The composition of this remedy is as follows:
Prescription:
– Balaustine, 2 drams
– Alum, 2 drams
– Shoemaker’s ink, 2 drams
– Myrrh, 2 drams
– Frankincense, 2 drams
– Galls, 2 drams
– Ammonium salt, 2 drams
Combine all ingredients with honey to form lozenges.
Galen also recounts instances where he healed stubborn ulcers, some as old as two years, using powdered iron scales boiled in sharp vinegar until they reached a honey-like consistency. Additionally, ox gall dissolved in strong vinegar, when applied warm, can help remedy and dry the discharge from these ulcers. Powdered iron scales, when boiled in vinegar, can also be dried and sprinkled onto the affected areas.
Should the narrowness of the ear passages prevent the expulsion of any matter, it may be necessary to extract it using a special instrument known as a Pyoulcos, or matter-drawer, which is illustrated here.
17. Ulcers of the Trachea, Esophagus, Stomach, and Intestines
These areas may become ulcerated due to either external factors, such as a harsh medicine or ingested poison, or internal causes, like a malignant, corrosive humor that can be as potent as poison generated within the body and localized in these regions. If swallowing or breathing exacerbates the pain, it indicates an ulcer in the throat or windpipe. The discomfort is most pronounced when the swallowed substance is sour or acrid, or when the air inhaled is hotter or colder than usual.
Should the source of pain be located in the stomach, the symptoms can become more severe. Patients may experience fainting, nausea, vomiting, convulsions, gnawing sensations, and almost unbearable pain, along with coldness in the extremities. When these symptoms occur simultaneously, few escape unscathed, except for the young and those with robust constitutions. While similar effects can impact the entire stomach, the ulcer at the entrance to the stomach—often referred to as the heart by the ancients—poses a greater risk due to the intensity of pain and the severity of the situation. Consequently, physicians tend to regard ulcers in the lower stomach with less concern.
We can identify ulcers in the intestines if pus or a significant amount of purulent matter is present in the stool. If blood is also present, accompanied by severe cramping, this indicates that pus has accumulated in that area, leading to a persistent urge to defecate. According to Galen, such ulcers are best treated with gentle foods and beverages rather than medications. Therefore, it is crucial to select foods and drinks that are mild and soothing, avoiding anything acrid. Substances like Tutia, Lytharge, Ceruse, and Verdigris should be avoided, as they are unsuitable for treating these types of ulcers, unlike in other cases.
When an ulcer is present in the throat or esophagus, it is essential to be cautious with what is consumed. Foods should have some viscosity or thickness and should be swallowed slowly and in small amounts at different times. Otherwise, they may not be effective, as they would simply slide down without providing any benefit. Therefore, all such items should be taken in the form of a thick mixture, known as an “eglegma,” while lying on your back. This allows for gradual swallowing and helps to relax the throat muscles. It is crucial to avoid swallowing large amounts quickly, as this can trigger a cough, which is particularly harmful for these types of ulcers.
To cleanse the affected area, crude honey proves to be highly effective, possessing unique properties that aid in the treatment of ulcers. Once the patient is able to swallow comfortably, you may mix dissolved gum tragacanth with astringent decoctions. For ulcers in the stomach, it is crucial to avoid all acrid substances, as they can lead to pain, inflammation, vomiting, and hinder digestion. Therefore, it is advisable to regularly consume a mild herbal tea and sweet jellies made with gum tragacanth and bole armeniacum.
When aiming to promote healing, it is beneficial to use austere, astringent, and adhesive substances that lack any acrid or unpleasant taste. Suitable options include hypocistis, pomegranate flowers and peels, terra sigillata, sumac, acacia, decoctions of quinces, lentisk wood, and the tops of vines, brambles, and myrtles, preferably prepared in astringent wine, unless there is a concern about inflammation.
For hydration, a mixture of hydromel (honey water) with sugar, violet syrup, and jujubes is recommended. Honey, when combined with other medicinal ingredients, serves as an effective remedy for ulcers in the intestines and other areas farther from the stomach. Astringent remedies alone can cling to the stomach and fail to reach their intended destination, but honey helps distribute them throughout the body and aids in cleansing the ulcers.
Ass’s milk can also be used successfully in place of goat’s or cow’s milk. The use of a healing potion is advisable, provided it is made from specific herbs that have a natural affinity for the affected areas.
It is important to note that ulcers in the intestines differ in their treatment. If the larger intestine is affected, they may be treated with enemas and injections, which should be sharp enough to correct any putrefaction; options include barley water or wine mixed with Aegyptiacum. However, if the small intestine is ulcerated, it is better to use potions and other remedies taken orally, as, according to Galen, substances administered rectally do not typically ascend to the small intestines, while those taken by mouth can reach them, albeit with some loss of potency.
18. Ulcers Of The Kidneys And Bladder.
Ulcers in the kidneys and bladder can arise from several factors, including the consumption of acrid meats, drinks, or certain medications such as cantharides. They may also develop due to the accumulation of acrid humors that either originate in that area or have been transported there. Additionally, ulcers can occur following the rupture of a blood vessel or when an abscess breaks down and transforms into an ulcer, which can happen from time to time.
These ulcers can be identified by their location, as the pain and heaviness associated with kidney ulcers often manifest in the lower back. Furthermore, pus or matter is typically expelled in a thorough manner, mixed with the urine.
The pus that flows from the kidneys is typically less foul-smelling than that which is expelled from the bladder. This difference can be attributed to the fact that the bladder, being a bloodless and fleshless membranous organ, lacks the ability to resist decay as effectively. Pus from the kidneys is always accompanied by urine; although it may eventually settle at the bottom of a container after being left for some time, initially it is well mixed with the urine. In contrast, pus from the bladder can sometimes be produced independently of urine.
Additionally, pus from ulcerated kidneys may contain small growths known as caruncles or hairs, in accordance with Hippocratic principles. If a person has thick urine that includes these little caruncles and hairs, it indicates a kidney issue. Conversely, if someone has thick urine that contains bran-like scales, it suggests that their bladder is affected by a scabby condition or ulcer.
For treatment, it is essential to ensure that the bowels are kept loose, either naturally or through the use of gentle laxatives and soothing enemas. Inducing vomiting occasionally can also be beneficial, as it helps to draw back the humors that may have contributed to the formation of the ulcer, making it more severe and contaminated. However, one must be cautious with strong purgatives, as they can cause the humors to become overly agitated, potentially causing harmful substances to settle in the kidneys or bladder. The following potion is highly effective for cleansing these types of ulcers.
Prescription:
Take 2 ounces of whole barley, 1.5 ounces of powdered and crushed licorice root, 6 grams each of sorrel root and parsley. Prepare a decoction with 1 pound of water. After straining, dissolve 2 ounces of honey in the liquid.
Let him take every morning the quantity of four ounces. Gordonius highly recommends the following troches:
Prescription:
Take the following ingredients: 4 ounces of whole seeds of majoram, white poppy seeds, mallow seeds, purslane, quince, myrtle berries, tragacanth, gum arabic, cleaned pine nuts, cleaned pistachios, and licorice. Also, take 2 ounces each of cleaned flaxseed, Armenian bole, dragon’s blood, rose petals, and myrrh.
These should be combined with hydromel (a mixture of honey and water) to form troches, each weighing 2 drachms.
Let him take one of these in the morning, dissolved in barley water or goat’s milk. Galen advises mixing honey and diuretic substances with medicines intended for ulcers of the kidneys and bladder, as they help to gently promote urination and serve as carriers for the medications to reach the affected area. Ulcers of the bladder can occur either at the base or at the neck and urinary passage.
If the ulcers are located at the base of the bladder, the pain is nearly constant; if they are at the neck, the pain is sharp and particularly intense during urination and immediately afterward. An ulcer at the base may produce certain scaly or thin discharges along with the urine, while one at the neck often leads to nearly continuous irritation. Ulcers at the base are generally difficult to treat due to the lack of blood flow and the sensitive nature of the area, compounded by the constant irritation from the acidity of the urine, which makes healing nearly impossible. Even after urination, remnants of urine often remain at the bottom of the bladder, as the bladder contracts and folds in on itself during the process.
Bladder ulcers can be treated with the same medications used for kidney ulcers; however, these should not only be taken orally but also administered via the urinary tract. Injections can be prepared using the previously prescribed Gordonius’ troches, dissolved in an appropriate liquid. Because bladder ulcers tend to cause sharper and more severe pain than kidney ulcers, the surgeon must be particularly careful to use soothing remedies. In my experience, oil of henbane, when expressed, has proven to be quite effective.
Additionally, the same care should be taken with poultices and liniments applied to the areas around the pubic region, lower abdomen, and perineum, as well as through the use of enemas. If there is a foul odor, it may be beneficial to make an injection of a small amount of Aegyptiacum dissolved in wine, plantain, or rose water. I have successfully used this remedy in similar cases on numerous occasions.
19. Ulcers Of The Womb.
Ulcers can develop in the womb due to a combination of factors, such as the presence of corrosive humors irritating the tissue, a tumor that degenerates into an abscess, or as a result of difficult and prolonged labor. They are typically identified by pain in the perineum and the discharge of pus and unhealthy fluid from the vagina. According to Avicenna, these ulcers can be classified into three categories: putrid ulcers, which emit a foul odor and have a color resembling water used for washing meat; sordid ulcers, which discharge various harmful and crude humors; and eating or spreading ulcers, characterized by dark discharge and a throbbing pain.
These ulcers can also be distinguished by their location. Some may affect the neck of the womb, which can be observed using a speculum, while others may be found at the base, indicated by the nature of the more liquid and serous discharges and the location of the pain. Treatment for these ulcers involves the same remedies used for mouth ulcers, including aqua fortis, oil of vitriol, and antimony, along with other milder substances. It is essential that the treatments applied to the ulcers act quickly, as they cannot remain in the womb for long, similar to those applied to the mouth.
Galen suggests that very drying medicines are particularly effective for uterine ulcers, as they help to prevent or limit putrefaction, a condition to which this warm and moist area is especially prone. Additionally, the entire body directs its waste toward this region. If an ulcer affects the base of the womb, it can be treated and strengthened with a specific injection designed for this purpose.
Prescription:
Take 2 parts of whole barley, 1 ounce of guaiacum, 1.5 ounces of iris root, and 1.5 ounces each of wormwood and both types of centaury. Prepare a decoction using 2 pounds of water, and in this, dissolve 3 ounces of honey and 3 ounces of wormwood syrup. This mixture will be used for injection.
To address the foul odor, I have often found the following remedy effective:
Prescription:
Take 1 pound of red wine and 2 ounces of Egyptian ointment. Allow it to simmer gently.
This should help correct the putrefaction and alleviate the painful malice of the humor. Once ulcers are cleansed, they must be promptly cicatrized, which can be achieved with alum water or plantain water, into which a little vitriol or alum has been dissolved. Lastly, if the remedies prove ineffective and the ulcer develops into a cancer, it should be treated with analgesics and appropriate cancer remedies, which you can find detailed in the specific treatise on cancers.
The treatment of ulcers of the rectum is to be considered alongside the treatment of those of the uterus; however, I believe it is more appropriate to refer that topic to the treatise on fistulas, just as I refer the treatment of urinary tract ulcers to the treatise on venereal diseases.
20. Varicose Veins and Their Surgical Treatment
A varix is the dilation of a vein, which may occur in a single vein or involve multiple branches. Varices can be either straight or twisted, often forming intricate loops within themselves. Various parts of the body are prone to developing varices, including the temples, the area of the abdomen beneath the navel, the testicles, the womb, and the rectum, but they are most commonly found in the thighs and legs.
The underlying cause of varices is typically attributed to a build-up of melancholic blood, as they often occur in individuals with a melancholic temperament, particularly those who consume heavy or rich foods that contribute to the production of such humors. Additionally, pregnant women frequently experience varices due to the accumulation of suppressed menstrual flow.
The primary triggers for this condition include vigorous physical activity, such as jumping or running, long walks, falls, carrying heavy loads, or experiencing extreme stress or strain. The presence of varices is usually evident through the size, thickness, swelling, and discoloration of the affected veins.
It is advisable to avoid intervening in cases of chronic varices, as treating such conditions may risk a reflux of melancholic blood to the vital organs, which could lead to serious complications such as malignant ulcers, cancer, madness, or even suffocation.
When multiple varices are present in the legs, they often swell due to congealed and stagnant blood, resulting in pain that worsens with movement or pressure. In such instances, the varices can be treated by carefully dividing the vein with a lancet, allowing the blood to be expelled by applying pressure both upwards and downwards. I have performed this procedure numerous times with favorable outcomes for my patients, who I advise to rest for a few days while applying appropriate treatments.
Typically, a varix is accessed from the inside of the leg, just below the knee, where its origin is usually visible. Attempting to treat a varix from its lower end, away from its source, complicates the procedure significantly, as the vein branches into multiple tributaries that the surgeon must then address individually.
A varix is typically excised to block the flow of blood and other humors that may be contributing to an ulcer located beneath it. This procedure also helps prevent the risk of the vessel rupturing due to excessive blood volume, which could lead to dangerous hemorrhaging.
Here’s how the procedure is carried out: First, have the patient lie flat on their back on a bench or table. Next, place a ligature around the leg in two spots, about four fingers apart, to create a section where the excision will occur. This technique causes the vein to swell, making it more visible, and allows you to mark it with ink for precision.
Then, gently lift the skin between your fingers and make a longitudinal incision along the marked line. Carefully free the exposed vein from surrounding tissues. Using a blunt-tipped needle (to avoid puncturing the vein), thread a strong double thread beneath the vein and secure it tightly. After this, make a small incision in the vein with a lancet, located midway under the ligature, similar to how you would open a vein, and allow an appropriate amount of blood to drain out.
Next, place another ligature around the lower part of the vein and remove the section of the vein between the two ligatures, allowing the ends to retract into the surrounding tissue both above and below. Leave the ligatures in place until they fall away on their own.
Once the procedure is complete, apply an astringent medication to the wound and the surrounding area. It’s important not to disturb the wound for three days. After this period, proceed with any other necessary treatments as you would for similar conditions.
21. Fistulas.
A fistula is a narrow, sinuous ulcer that often appears white and calloused, and it can sometimes be difficult to detect. The term “fistula” comes from the Latin word for “pipe,” as its shape resembles that of a hollow tube. Fistulas can develop in various parts of the body and typically arise as a consequence of abscesses or ulcers that have not been properly treated.
A callous is a fleshy substance that is white, solid, dense, hard, dry, and typically painless. It forms from the accumulation of dried phlegm or stagnant bodily humors surrounding the edges of an ulcer, effectively replacing healthy tissue.
The sinus or cavity of a fistula may sometimes be dry, while at other times it may produce a continuous discharge. Occasionally, the discharge may stop abruptly, leading to a misleading impression of complete healing. However, it is likely that the fistula will reopen and resume its previous state.
Fistulas can originate from various sources, including the decay of bone, nerve damage, or issues with membranes and other tissues. They may be straight or have twists and turns, and can possess one or multiple openings. Some fistulas occur near joints, while others can extend into cavities such as the chest, abdomen, or bladder. The ease or difficulty of treatment varies, and some fistulas may be entirely incurable.
There are different signs of fistulas depending on their location. For instance, if a probe meets resistance and produces a sound upon contact, it indicates that the fistula has reached the bone. If the probe glides smoothly, the bone remains intact, but if it encounters roughness, the bone may be damaged or decayed. Sometimes the bone is exposed, eliminating the need for probing.
A purulent discharge resembling the oily substance that nourishes bone can indicate bone involvement. The nature of the discharge reflects the condition of the affected tissue. If a fistula involves a nerve, the patient may experience sharp pain, especially during probing, particularly if the discharge is more irritating. Coldness in the area may lead to numbness and weakened motion, while the discharge from nerve-involved fistulas tends to be thin and viscous, resembling the humor that nourishes the nerves.
Fistulas that penetrate deeper into muscle or tendon tissues may produce a thicker and more copious discharge, which is smooth, white, and uniform. If the fistula extends into veins or arteries, similar symptoms may occur, but probing will typically cause less pain and discomfort. However, if the discharge is particularly corrosive, it can damage the blood vessels, leading to thicker blood from veins and thinner, more turbulent blood from arteries.
It is important to note that old fistulas, especially those that have persisted for many years, can be life-threatening if they suddenly close, particularly in elderly or weakened individuals.
22. Treating Fistulas
For treatment, the first step is to thoroughly examine the fistula using a probe made of wax, lead, gold, or silver to determine its depth and any twists or turns. If the fistula has multiple openings and is complex, making it impossible to explore all paths with a probe, you should inject a solution into one of the openings and observe where it exits. This will help you ascertain the number of openings and the extent of the cavities.
Next, you will need to make incisions to expose and remove the callous tissue. Use a scalpel or razor for the incisions, or consider applying cauterizing agents. Nature cannot heal or regenerate flesh unless the callous material is first removed. Hard substances cannot adhere to each other without a bonding agent, such as healthy blood. A callous tissue surrounding the ulcer prevents blood from flowing from the capillary veins, which is necessary for healing and reuniting the separated tissues.
If you decide to use caustic injections in the fistula, be sure to close the opening immediately to allow the treatment time to take effect. You can gauge the effectiveness of the treatment by observing the swelling in the area, the nature of the discharge, and its reduced volume. After this, encourage the eschar (scab) to detach, and then treat the ulcer as you would any other.
Often, the callous tissue within the fistula can be expelled entirely, resembling a pipe, leaving a clean ulcer beneath. I witnessed this in a gentleman whose bullet wound in the thigh was treated multiple times with a strong Egyptian remedy, followed by the application of a previously described balsam, leading to a quick recovery.
Caution is essential when dealing with fistulas close to major blood vessels, nerves, or vital organs. When a fistula arises due to a decaying bone, assess whether the damage is superficial or deeper, or if the bone is entirely necrotic. Superficial issues can be addressed with a scraping trepan, while deeper problems may require cutting tools after creating an opening with a specialized instrument. If the bone is completely rotten, it must be removed entirely, which is feasible in the joints of the fingers, the radius, and the ulna. However, such procedures should not be attempted on critical areas like the hip socket, femoral head, or spinal bones when they are necrotic, nor in fistulas that are inherently incurable.
In such cases, it is sufficient to provide the patient with a prognosis rather than attempting a definitive cure. This is especially true for fistulas that reach the intestines or occur in areas rich in blood vessels or nerves, which tend to affect more sensitive individuals who may prefer death to the pain of surgery.
Similar caution is warranted if cutting the fistula poses a risk of further complications, such as convulsions in nervous areas. In these instances, the surgeon should prioritize preventing the condition from worsening rather than seeking a complete cure. This can be achieved by preventing any new fluid accumulation in the area, managing the patient’s diet to limit the production of harmful humors, and ensuring that any generated humors are expelled at regular intervals or redirected to less critical areas. Meanwhile, it is crucial to reduce any excessive granulation tissue in the ulcer and to cleanse the area using gentle, non-irritating medications that do not cause further damage or decay.
23. On Fistulas of the Rectum
Fistulas in the anal region arise from similar causes as other types of fistulas, typically resulting from a poorly healed wound or abscess, or from a suppurated hemorrhoid. Those that are hidden may be identified by the presence of a discharge of purulent and bloody fluid from the anus, accompanied by pain in the surrounding areas. On the other hand, visible fistulas can be explored using a probe to determine their pathways and extent.
To investigate, the surgeon should first insert a finger into the patient’s anus, then introduce a lead probe into the fistula’s opening. If the probe reaches the surgeon’s finger without any obstruction, it indicates that the fistula extends into the rectal cavity. In such cases, the patient may experience a significant discharge not only from the anus but also from the opening created by the irritating fluid, which can sometimes lead to the formation of worms.
Fistulas may be assessed as complex and tortuous if the probe does not penetrate deeply, yet a considerable amount of discharge occurs, suggesting that more fluid is emanating than would be expected from a small ulcer.
In the openings of all fistulas, one can often observe a certain callous growth commonly referred to by surgeons as a “hen’s arse.” Fistulas in the anal region are typically accompanied by various symptoms, such as tenesmus, strangury, and a sensation of prolapse.
If surgical intervention is required to treat the fistula, the patient should lie on their back with their legs raised, allowing their thighs to press against their abdomen. The surgeon, after trimming their nails, should apply some ointment to their finger and gently insert it into the patient’s anus. Then, a thick lead needle should be inserted into the fistula’s opening, followed by a thread made of intertwined thread and horsehair. The surgeon should grasp this thread with their finger, slightly bending it, and pull it out through the anus, bringing the end of the thread along with it. The two ends of the thread should then be tied together with a loose knot, allowing for adjustment as needed. Before securing the knot, the surgeon should pull the thread firmly towards them, as if to saw through the flesh, which will help to cut the fistula while minimizing the risk of significant bleeding.
In some cases, fistulas may not penetrate into the rectum, making it impossible for the finger to locate the needle or probe due to the presence of a callous obstruction. In such situations, it is advisable to insert a hollow iron or silver probe and then use a sharp pointed needle through its cavity to prick and cut away the callous tissue. This method is necessary as the previously mentioned lead probe, with its blunt tip, would cause considerable discomfort and may not effectively address the issue.
A. Displays the needle.
B. Presents the hollow probe.
C. The needle accompanied by the probe.
D. The leaden needle drawing a thread behind it.
Once the callus has been thinned, the fistula should be dressed as we previously discussed. Superficial areas do not require binding; they simply need to be incised with a curved scalpel. After the callus has been sufficiently removed, the remainder of the treatment should proceed in the same manner as for other ulcers. However, it is important to note that if any part of the callous tissue is left untreated by either medicine or instrument, the fistula may reemerge, leading to a recurrence of the condition.
24. Hemorrhoids
Hemorrhoids, as commonly understood, are swellings at the ends of the veins surrounding the rectum, caused by an excess of a humor typically associated with melancholy, and they resemble a type of varicose vein. Some of these may bleed when a fissure occurs, which can sometimes form a callus over time; others simply swell without discharging any fluid. Some are clearly visible, while others remain concealed within.
Those that do bleed often release blood mixed with a yellowish, watery fluid, which can irritate the blood and cause the veins to open up due to its corrosive nature. On the other hand, those that do not bleed may appear as blisters, similar to those seen in burns, and are commonly referred to by practitioners as vesicles. These are typically caused by the accumulation of phlegmatic and serous humor.
Alternatively, they may resemble grapes, which is why they are sometimes called “vvales,” arising from a surplus of healthy blood in terms of quantity, although not in quality. Others may indicate an underlying condition, hence being termed “morales,” which arise from the stagnation of melancholic blood. Lastly, some resemble warts, known as “verrucales,” sharing a similar cause of formation as the morales.
This condition can lead to a variety of complications for individuals. The constant loss of blood can diminish the vibrant color of the face, lead to dropsy, and weaken the overall strength of the body. Hemorrhoidal bleeding typically occurs monthly, though it may happen as infrequently as four times a year. Often, significant pain, inflammation, and the development of an abscess may precede the discharge of hemorrhoids, which can ultimately result in a fistula if not managed with appropriate remedies.
However, if the hemorrhoidal bleeding is moderate and the patient tolerates it well, it should not be halted. This is because such bleeding can alleviate the risk of more serious ailments, such as melancholy, leprosy, and strangury. Conversely, if the bleeding is stopped without justification, it can lead to a reflux of blood into the lungs, causing inflammation or even rupturing the vessels. Additionally, it may flow back to the liver, resulting in dropsy due to the suppression of natural heat.
On the other hand, excessive bleeding can cool the liver and lead to overall weakness due to significant blood loss. Therefore, if the bleeding becomes excessive, it should be controlled using a tampon made of hare’s down dipped in the appropriate medicinal solution.
Prescription: Powdered aloes, frankincense, and dragon’s blood, each half an ounce. Mix them together with egg white to create a medicinal preparation for use.”
When the affected areas are swollen and stretched but not bleeding, it is advisable to crush a roasted onion with ox gall and apply this mixture to the swollen spots, renewing the application every five hours. This remedy is quite effective for internal hemorrhoids; however, visible hemorrhoids can be treated by using horse leeches or a lancet.
The juice or pulp of the herb commonly known as dead nettle or archangel can be applied to the swollen hemorrhoids to help open them up and promote the flow of any congealed blood. The same remedy can also be used for conditions like fungus and thymus that affect the anal area.
If the patient is suffering from intense heat and pain, it is best to have them take a bath, and then, if there are any ulcers present, apply the following remedy.
Prescription:
Take 3 ounces of rose oil, 1 ounce of wax, 1.5 ounces of litharge, 6 grains of new wax, and 1 grain of opium. Prepare an ointment according to the proper method.
Alternatively:
Take 1 drachm each of frankincense, myrrh, and saffron, along with 1 grain of opium. Prepare an ointment with rose oil and the mucilage of psyllium seeds, adding the yolk of one egg. You can easily continue with the remainder of the treatment according to standard medical practices.