The treatment of diseases must be tailored to the diverse temperaments, not only of the body as a whole but also of its individual parts. Factors such as strength, shape, form, location, and sensory function must all be taken into account. Having previously discussed tumors in general, I find it worthwhile to examine them in detail, focusing on those that specifically affect each part of the body, starting with those that impact the head. Tumors can either involve the entire head or be localized to specific areas, such as the eyes, ears, nose, gums, and so forth. For instance, Hydrocephalus and Physocephalus are examples of tumors that affect the entire head.
The Greeks refer to this condition as Hydrocephalus, likening it to a form of dropsy localized in the head, characterized by an accumulation of watery fluid. This ailment is predominantly seen in newborn infants. The external causes often include the excessive compression of the head during birth, whether from the midwife’s hand or due to trauma such as falls or contusions. Such pressure can lead to the rupture of a vein or artery, resulting in blood pooling beneath the skin. Over time, this blood may undergo changes, becoming whitish and eventually transforming into a watery humor.
Internally, the condition can arise from an excess of serous and acrid blood, which, due to its thinness and heat, seeps through the vessel pores. This fluid may accumulate in various locations: between the muscular layer of the scalp and the pericranium, between the pericranium and the skull, or even between the skull and the dura mater. In some cases, it may also collect within the ventricles of the brain.
The signs of hydrocephalus, when the fluid is located between the muscular skin and the pericranium, include a noticeable, painless tumor that is soft and easily compressible under finger pressure. When the fluid is situated between the pericranium and the skull, the symptoms are largely similar, although the tumor may feel slightly firmer and less yielding due to the intervening tissues, and there may be a greater sensitivity to pressure. If the fluid accumulates between the skull and the dura mater, or within the brain’s ventricles, the infant may exhibit signs of dulled sensory perception, particularly in sight and hearing. The tumor in this case will not yield easily to touch unless significant pressure is applied, causing it to sink slightly, especially in newborns, whose skulls are nearly as soft as wax and whose sutures are naturally lax. This laxity, exacerbated by the presence of the humor, allows the fluid to elevate the skull, particularly at the junctions of the sutures. Notably, when the tumor is pressed, the fluid tends to retreat into the brain’s hidden passages.
In conclusion, the pain associated with hydrocephalus can be intense, leading to pronounced swelling of the entire head. The forehead may protrude more prominently, the eyes can become fixed and immobile, and tears may flow due to serous humor leaking from the brain.
Vesalius recounts observing a two-year-old girl whose head was larger than that of any adult due to a tumor, with a skull that was not bony but membranous, resembling that seen in cases of aborted births. He noted that nine pounds of fluid were expelled from her head.
Abucrasis describes a child whose head grew progressively larger each day due to the accumulation of watery fluid. Eventually, the tumor became so immense that the child’s neck could no longer support it, resulting in death within a short period. I have treated four children afflicted with this condition; in one case, upon dissection after death, I found a brain no larger than a tennis ball. However, I have not witnessed any recoveries from tumors or fluid located beneath the cranium, although external tumors are often easily treated.
Whether the fluid is situated beneath the pericranium or within the muscular layer of the scalp, it is essential to first address it with resolving medications. If this approach fails, an incision must be made, taking care to avoid the temporal muscle, allowing for the drainage of all accumulated fluid. This fluid may resemble the washings from freshly killed flesh, blackish blood, or congealed and clotted blood, particularly when the tumor has resulted from trauma. Following drainage, the wound should be packed with dry lint, covered with double bolsters, and secured with an appropriate bandage.
The polypus is an abnormal nasal tumor, typically originating from the ethmoid bone—a spongy structure. It is named for its resemblance in shape to the tentacles of a sea polypus and in texture to the creature’s flesh. This type of tumor obstructs the nasal passages, impeding both speech and the ability to clear the nasal passages by blowing. Celsus describes the polypus as a growth, or excrescence, that varies in color from white to reddish. It attaches to the nasal bone and can expand to fill the nostrils, extending toward the lips or sometimes retracting back through the passage that connects the nose to the throat. As it grows, it may become visible behind the uvula and can dangerously obstruct breathing, potentially strangling a person by cutting off their air supply.
There are five kinds:
The first kind is a soft membrane, long and thin like the drooping uvula hanging from the middle gristle of the nose, filled with a phlegmatic and viscous humor. When breathing out, it extends outside the nose, but is drawn in and hidden when breathing in. It makes one snaffle in their speech and snort in their sleep.
The second type consists of hard tissue, formed from melancholic, unburnt blood. This obstructs the nostrils, thereby interrupting the airflow through them.
The third type is characterized by flesh that dangles from the cartilage, soft and rounded, and is composed of phlegmatic blood.
The fourth type is a firm tumor resembling flesh which emits a stonelike sound when touched. This is formed from dried melancholic blood, sharing characteristics with a confirmed, painless scirrhus.
The fifth type appears to be composed of numerous cancerous ulcers distributed across the broad surface of the cartilage.
Among all these types of polyps, some are non-ulcerated, while others exhibit ulceration and emit a foul and pungent discharge. Those that are painful, hard, and firm, exhibiting a livid or leaden hue, should not be handled, as they bear a resemblance to cancer and may often degenerate into it. However, due to the intense pain they induce, you may apply the previously mentioned anodyne medications commonly used for cancer, such as the following:
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Allow the ingredients to be finely ground in a lead mortar for an extended period to create a medicinal preparation suitable for application into the nostrils. Conditions that are soft, loose, and painless can sometimes be treated by removal with a specialized instrument designed for that purpose, or by the use of actual cautery applied through a pipe, ensuring it does not come into contact with healthy tissue. Alternatively, potential cautery, such as Agyptiacum—composed of equal parts of all the simples with vitriol known for its ability to destroy similar flesh—can be employed. Both aqua fortis and oil of vitriol possess the same destructive properties, capable of excising a polypus at the root; it is crucial to ensure that no part remains, as any residual tissue may regrow. When applying cauteries or caustic medicines to the nostrils, it is imperative to simultaneously administer cold, repelling, and astringent remedies to the nose and surrounding areas to alleviate pain and prevent inflammation. Examples of such remedies include Unguentum de Bolo, unguentum nutritum, and beaten egg whites mixed with rose leaves, along with several other similar preparations.
Parotitis is an unnatural tumor affecting the glandular tissues located behind and around the ears, areas known as the brain’s emunctories because of their loose, spongy nature, making them well-suited to absorb waste products from the brain. Some cases of parotitis are critical, where the matter of the disease, somewhat broken down, is directed to these sites by the body’s natural mechanisms. Others are symptomatic, where excess waste, either in amount or harmfulness, is forced into these areas spontaneously.
These abscesses often exhibit significant inflammation, as the caustic substances accumulating there tend to be more toxic in nature than in volume. Moreover, they frequently cause intense pain due to the stretching of highly sensitive tissues, and because of a nerve from the fifth cranial pair extending across these areas, as well as the adjacent brain membranes. This situation can lead not only to severe headaches but also swelling across the face. Nonetheless, this type of tumor is often instigated by a thick, sticky, and coarse humor.
This disease tends to affect young men more severely than older individuals; it typically accompanies a fever and insomnia. Its treatment can be challenging, particularly when it is caused by thick, sticky, and coarse humor that is directed to the area during a bodily crisis.
The treatment of this condition must be managed through dietary adjustments that counteract the characteristics of the humor in terms of its temperature and consistency in the foods consumed. If there is significant inflammation and redness, indicating an excess of blood, phlebotomy becomes not only beneficial but essential. However, as Galen warns, the approach to applying local treatments differs from that used for other types of tumors. Initially, we should avoid using repulsive medicines, especially if the abscess is critical; such methods could hinder nature’s attempt to expel the harmful matter forcefully. Even more crucial is avoiding the suppression of the humor if it is toxic, as its reflow to vital organs could be fatal. Instead, the surgeon should aid nature in drawing out the humor. Nonetheless, if the discharge is severe and the pain intense enough to potentially cause insomnia and fever, weakening the patient’s strength, Galen advises that it might be pragmatic to combine some repulsive agents with numerous resolving treatments. Therefore, initially, an appropriate poultice should be applied.
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Boil the farina, barley and linseed with honey or a decoction of chamomile. Add butter and chamomile oil to make a poultice.
And the following ointment will also be good:
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Make an ointment to be applied with moist and greasy wool to mitigate the pain.
Also somewhat more strong discussing and resolving medicines will be profitable, as:
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Boil marshmallow, bryony, rue, pennyroyal, oregano, chamomile and sweet clover in honey-water. Pound them and strain them. Add fenugreek flour, orobium, pale iris, chamomile, and sweet clover. Add one ounce of dill oil and rue oil, and make a poultice.
Should you decide to further address this issue, you may consider using Emplastrum Oxycroceum and Melilot Plaster. If the condition causes the humor to solidify and harden, you should turn to the treatments outlined in the chapter on Scirrhus. However, if it progresses towards suppuration, you should apply the medicine specified below.
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Mix together to prepare a poultice.
However, if the situation necessitates it, the tumor should be incised following the procedure previously described.
The Epulis is a fleshy growth on the gums that develops between the teeth, often gradually increasing in size to that of an egg. This condition can obstruct speech and eating, producing foul-smelling saliva and, in some cases, may progress into a cancerous form. The characteristics of the growth, including its color, pain, and other symptoms, can help discern its nature; therefore, one must avoid touching it if it is painful. However, if the growth does not cause discomfort to the patient, it can be safely removed. The following outlines the proper procedure for this removal.
Secure the growth with a double thread, which should be progressively tightened until the growth detaches. Once it falls off, the area should be cauterized either through a tube or using direct application of Aqua fortis or oil of vitriol. This must be done with utmost precision to avoid damaging the surrounding healthy tissue. Failing to cauterize the area might lead to the regrowth of the epulis.
I have frequently utilized this method to successfully remove large tumors of this type that protruded significantly from the mouth, causing considerable facial disfigurement. Many surgeons hesitated to intervene due to the livid appearance of the flesh, but I proceeded because these tumors were painless. By excising them and cauterizing the area, I achieved complete healing. However, this was not an immediate process; despite cauterizing the site after excision, the tumors occasionally regrew because a portion of the bone and the sockets where the teeth are anchored had become necrotic. I have observed that such tissue can gradually transform into a gritty, bony substance over time. Therefore, it is essential to initiate treatment as promptly as possible, as smaller tumors with no deep roots are more easily removed when they are still primarily composed of a viscous fluid. If left untreated, this humor can solidify, complicating future removal efforts.
Often, there is a type of tumor found beneath the tongue which impairs the ability to speak clearly. This condition is termed ‘Batrachium’ by the Greeks and ‘Ranula’ by the Latins because individuals affected by this often sound as if they are croaking rather than speaking. It results from the accumulation of a cold, moist, dense, tough, viscous, and phlegmatic substance that descends from the brain to the tongue. The substance is typically white and resembles the consistency of an egg white, though it sometimes appears in a citrine or yellowish hue.
To ensure a safe and effective treatment, it is advisable to open the tumor using a cautery or hot iron rather than a knife, as the latter method may lead to recurrence. The procedure for opening the tumor should be carried out as follows:
Procure a bent, hollow iron plate, perforated with a central hole. Have the patient hold their mouth open and adjust the plate so that the hole is directly over the area to be opened. Using a hot iron through this aperture ensures that no undamaged part of the mouth is harmed. To facilitate a more precise procedure, elevate the tumor slightly by pressing your thumb under the patient’s chin just as you are ready to apply the hot iron. Once the tumor is opened, expel the contained matter, and subsequently cleanse the patient’s mouth with a mixture of barley water, honey, and sugar of roses. This method will promote safe and expedient healing of the ulcer.
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Nature has positioned two glands near the roots of the tongue, situated opposite one another. These glands, resembling almonds in both shape and size, are aptly named for their appearance. Their primary function is to collect spittle that descends from the brain, serving two important purposes: to prevent an excessive flow of fluid from interfering with speech and to ensure that the tongue remains sufficiently moist, as if storing moisture to prevent it from drying out due to constant use in speaking. When a patient experiences feverish conditions that deplete this saliva, they often find it difficult to articulate words unless they first moisten their tongue through extensive rinsing of their mouth.
These glands, located in a warm and moist environment, are highly susceptible to inflammation. They often receive, along with the blood, a substantial volume of raw, phlegmatic, and viscous fluids, leading to swelling. This condition is frequently triggered by excessive consumption of potent, vaporous wines, overindulgence in food, and prolonged exposure to the outdoors.
Swallowing is often painful and distressing for the patient, who commonly experiences a fever. Frequently, the surrounding muscles of the throat and neck become swollen alongside these glands, leading to a constriction, much like what occurs in cases of quinsy. This can result in the airway becoming obstructed, potentially strangling the patient.
We combat this critical threat through various interventions including purging, bloodletting, and the application of cupping glasses to the neck and shoulders. Additional methods include massaging, applying tourniquets to the extremities, and cleansing the mouth and throat with astringent gargles. However, if an infection progresses to suppuration, it becomes necessary to use a surgical knife to incise the area and allow the pus to drain. Conversely, should these treatments, when applied skillfully, lead to an increase in effusion and pose a sudden risk of death by obstructing the airway, an emergency procedure is warranted. In such cases, an incision in the upper part of the trachea, or windpipe, is required at the point where it is most prominent. This procedure is deemed safer because the jugular veins and carotid arteries are located far from this area and it typically has little overlying flesh.
To facilitate the incision, the patient should be instructed to tilt their head backward, allowing easier access to the artery with the surgical instrument. Next, you will make a horizontal incision with a curved knife between two cartilaginous rings, ensuring that you do not injure or involve the cartilage itself; rather, you should only sever the membrane connecting the cartilaginous rings. You will know that the incision is deep enough when you observe air escaping through the wound. The incision must remain open until the immediate danger of suffocation has subsided, after which it should be closed without touching the cartilage.
If the edges of the wound appear hard and calloused, they should be lightly scarified to promote bleeding, which will facilitate a better healing process and adhesion, as we will discuss in greater detail in our section on the treatment of cleft lips. I have successfully treated many patients who had sustained substantial wounds to their airway along with the cartilaginous rings, which we will explore further when addressing the management of injuries to this area.
The uvula is a small, spongy structure shaped somewhat like a pineapple, hanging down from the upper and inner part of the palate. Its function is to mitigate the force of air drawn in during breathing as it travels to the lungs, and to serve as a quill that helps shape and modulate the voice. At times, the uvula can become enlarged due to the accumulation of moisture descending from the brain, gradually adopting a sharper appearance from a broader and more swollen base.
This enlargement can lead to various symptoms. The ongoing irritation caused by the dripping mucus can result in a persistent cough, which may disrupt sleep and impede speech. Additionally, the swelling can obstruct respiration, leading patients to find it difficult to sleep without keeping their mouths open. They may experience a frustrating sensation akin to having a morsel lodged in their throat, and they face the risk of asphyxiation.
This disease must be addressed through a combination of treatments, including purging, bleeding, cupping, administering enemas, using astringent gargles, and implementing an appropriate diet. If these methods prove ineffective, a more aggressive approach may involve the application of a caustic agent, such as Aqua fortis, which I have successfully employed on many occasions. However, if this option is not viable, it is preferable to take action rather than allowing the patient to remain in the imminent and lethal danger of asphyxiation.
Caution is paramount in this scenario. A surgeon should refrain from using instruments or caustics on a uvula that is excessively swollen, inflamed, or displays blackened characteristics akin to cancer. In contrast, if the uvula appears elongated, tapering to a sharp, loose, and soft point, and is neither excessively red nor swollen with blood—ideally appearing whitish and painless—the surgeon may proceed more confidently.
To facilitate a safer and more effective removal of the excess tissue, the patient should be seated in a well-lit area with their mouth open. The surgeon should then grasp the tip of the uvula with forceps and excise the portion deemed unnecessary. Alternatively, the surgeon may use the specialized instrument described below, attributed to Honoratus Tastellanus, a diligent and learned physician in service to the King and Chief Physician to the Queen Mother. This instrument can also be utilized for binding polyps and warts at the cervix.
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Squinancy, also referred to as Squinzy, is characterized by swelling in the jaws that obstructs airflow to the throat, hinders the escape of vapors and fluids, and complicates the swallowing of food. This condition manifests in three distinct forms.
The first form of this condition causes severe pain in the patient, though no noticeable swelling is present externally. This is due to the harmful humor being concealed behind the tonsils or glands located at the vertebrae of the neck, rendering detection difficult unless the tongue is held down with a spatula or an oral speculum. In such instances, redness and concealed swelling may be observed. The patient experiences difficulty breathing and is unable to swallow food or drink; their tongue protrudes from their mouth like a greyhound after a chase, and they keep their mouth open to facilitate airflow. Their voice becomes muffled, as if trapped within their jaws and nasal passages. They cannot lie flat on their back and must remain seated to breathe more comfortably. Due to the obstruction, liquids may escape through the nose, and their eyes may appear bloodshot, swollen, and bulging. Those affected by this form are at risk of sudden suffocation, often accompanied by a foamy discharge around the mouth.
The second form is marked by the presence of an internal tumor, which typically exhibits little to no visible swelling on the outside. However, there may be slight swelling observable in the tongue, glands, and jaws.
In contrast, the third form, which is the least dangerous, features noticeable external swelling while demonstrating minimal internal involvement.
The causes of Squinancy can be categorized into internal and external factors. External causes encompass trauma, such as a blow to the throat or a splinter lodged within it, along with exposure to extreme temperatures, whether cold or hot. Internal causes typically involve an excessive buildup of bodily humors or fluids from the brain, which usually consist of blood, bile, or phlegm; melancholy is rarely considered a contributing factor. The characteristics that differentiate these various humors and their combinations have been elaborated upon in a comprehensive treatise on tumors.
Squinancy becomes particularly perilous when harmful humors are less apparent, both internally and externally. In contrast, cases that present external symptoms are generally less dangerous, as they do not obstruct the passage of food or air. Patients may succumb to Squinancy within twelve hours, while others might endure for two, four, or even seven days. Hippocrates observed that individuals who survive the initial phase often face complications in the lungs, which can result in death within a week. However, if patients manage to surpass this critical period, the condition may resolve itself as the harmful humors are absorbed back into vital organs, such as the lungs (potentially leading to empyema) and other essential areas; failure of this process can lead to inevitable mortality. The disease may ultimately conclude through either resolution or suppuration.
The method of resolution is the preferred approach, especially when the matter at hand is minor and subtle. This is particularly effective if the physician takes blood through venipuncture and the patient uses suitable gargles. A severe case of Squinancy can often be fatal, as the substantial influx of harmful humors into the throat may suddenly obstruct the airway.
In such cases, broths prepared from capons and veal, flavored with lettuce, purslane, sorrel, and cooling seeds, should be administered. If the patient exhibits some weakness, they may find nourishment in poached eggs and barley creams, with the barley initially boiled with raisins in water and sugar, alongside other light foods. Wine should be avoided; instead, the patient can opt for hydromel (a drink made from water and honey) or hydrosaccharum (water and sugar), as well as syrups crafted from dried roses, violets, sorrel, lemons, and similar ingredients. Additionally, it is advisable to limit excessive sleep.
Meanwhile, the physician must remain vigilant, as this disease is one that allows no delays. Therefore, it is essential to open the abscess on the side where the swelling is most pronounced. Shortly thereafter, on the same day, the vein under the tongue should be opened to facilitate the evacuation of the accumulated matter. Cupping glasses should be applied to the neck and shoulders, sometimes with scarification and sometimes without. Massage and painful ligatures should also be employed on the extremities. Additionally, the impacted humor should be removed using enemas and sharp suppositories.
While the condition remains unstable, it is imperative to rinse the mouth immediately with astringent gargles to prevent the harmful humor from descending too rapidly, as this can pose a life-threatening risk despite the physician’s best efforts. Regular rinsing with oxycrate or a similar gargle is strongly advised to help mitigate this danger.
Prescription:
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Combine all ingredients and bring them to a boil in an adequate amount of water until the mixture is reduced by half. Next, incorporate 3 ounces of sour pomegranate wine and 1 ounce of diamoron. Continue boiling for a short time to prepare the gargle according to the correct method.
Furthermore, alternative gargles can be prepared using ingredients such as plantain water, nightshade, verjuice, rose julep, and other similar components. If the discharge is of a phlegmatic nature, it is advisable to include alum, pomegranate peel, cypress nuts, and a small amount of vinegar.
On the other hand, avoid applying repercussives externally; instead, opt for lenitives to relax and thin the external tissues, aiding in the diffusion or resolution of the humor. You can assess that the humor is beginning to resolve if the fever decreases, the patient swallows, speaks, and breathes more easily, sleeps soundly, and experiences considerable pain relief.
At this stage, it is crucial to assist Nature’s efforts with resolving medications or to administer both internal and external suppuratives, particularly if the discharge begins to purulate. Gargles made from the roots of marshmallows, figs, jujubes, Damask prunes, and dates — all thoroughly boiled in water — can offer valuable relief.
Gargles prepared with cow’s milk sweetened with sugar, along with sweet almond oil or warm violet oil, can also encourage suppuration and provide pain relief. Furthermore, applying suppurating cataplasms to the neck and throat, followed by wrapping the area with wool moistened in lily oil, can enhance the treatment.
Once the physician confirms that the humor has fully transformed into pus, the patient’s mouth should be examined using a speculum oris, and the abscess should be incised with a long, curved knife. Subsequently, the mouth should be rinsed periodically with cleansing gargles, such as:
Prescription:
The use of aenomel, a mixture of wine and honey, is also effective for this purpose. After the ulcer has been cleaned with these methods, facilitate healing by incorporating a small amount of roch-alum into the gargles.
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What the French refer to as “Goetra,” the Greeks as “Bronchocele,” and the Latins as “Gutturis Hernia” translates to the rupture of the throat. This condition manifests as a round tumor in the throat, with matter originating from within and becoming trapped between the skin and the esophagus. In women, it arises from the same underlying cause as an aneurysm.
The term “Bronchocele” encompasses a variety of conditions, since it can exhibit characteristics similar to meliceris, steatoma, atheroma, or aneurysm. Some cases present a fleshy substance accompanied by mild pain; others may be small in size, while some can be so large that they appear to nearly engulf the entire throat. Additionally, some may contain a cyst or sac, while others do not. Regardless of their specific attributes or eventual outcomes, their distinct signs allow for identification. Those that are deemed treatable may be addressed using either actual or potential cautery, or through incision. If possible, the matter should be evacuated immediately; if not, it should be managed over multiple sessions with appropriate remedies. Ultimately, the goal is to ensure that the ulcer heals and becomes scarred.
Pleurisy is an inflammation of the membrane that covers the ribs, resulting from the movement of subtle and choleric blood, which violently ascends from the hollow vein into the azygos vein and subsequently into the intercostal veins. This blood can accumulate in the spaces between the intercostal muscles and within the aforementioned membrane. When contained in this area, if it begins to undergo suppuration, it typically leads to sharp pain, fever, and difficulty in breathing. The purulent blood may be expelled in various ways: sometimes through the mouth, as the lungs draw it in and subsequently expel it into the throat; at other times through urine or occasionally via stool.
If nature is too weak to expel the purulent blood accumulated in the chest cavity, the condition can progress to empyema. In such cases, a surgeon must be consulted. The surgeon typically begins the procedure from the lower ribs, creating an opening between the third and fourth true ribs. This can be accomplished using either actual or potential cautery or by making an incision with a sharp knife directed upward towards the back, avoiding any downward movement to prevent injury to the vessels located beneath the rib.
This incision can be performed safely and effectively with actual cautery. The cautery instrument is designed with four perforations, allowing for a pin to be inserted at varying heights depending on the depth and direction of the incision. The pin is then pushed through a centrally perforated iron plate, which is positioned to ensure that any accidental movement does not compromise surrounding areas that should remain untouched. Additionally, the plate should be slightly concave to better conform to the curvature of the rib side and should be secured on the opposite side with four ties. For clarity, I have included illustrations to demonstrate this technique.
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The illustration of an actual cautery accompanied by its appropriately shaped plate for use in cases of pleurisy.
However, if the patient possesses a large body with a broad chest and prominent ribs, you may need to divide and perforate the ribs using a trepan. Regardless of the method used for the incision, it is essential to gradually evacuate the pus or infected material in stages. Furthermore, the chest cavity should be cleansed of purulent matter using a detergent solution composed of six ounces of barley water, two ounces of rose honey, along with other similar remedies detailed in our treatment for wounds.
Dropsy is an abnormal swelling caused by an excess accumulation of watery fluid, flatulence, or phlegm, which may gather throughout the body or be localized in specific areas, particularly within the abdominal cavity between the peritoneum and the intestines. This differentiation in location and types of fluid leads to various forms of dropsy. The type of dropsy that fills the abdominal space can be classified as either moist or dry. The moist form is referred to as ascites, named for its resemblance to a leather bottle or ‘borachio,’ as the watery fluid is contained within this cavity much like it would be in such a vessel.
The dry form of dropsy is known as tympanites, or timpany, because the abdomen, swollen with gas, produces sounds reminiscent of a tympanum, or drum. When the entire body is affected and distended by a phlegmatic fluid, it is referred to as anasarca or leucophlegmatia. In this latter type of dropsy, swelling typically begins in the lower extremities, which are more prone to accumulation due to their location and distance from the source of natural body heat. If pressure is applied to these areas, an imprint of the finger will remain for some time. Additionally, the patient’s face may become pale and swollen, providing a means to differentiate this condition from the other two forms of dropsy. In these cases, swelling first occurs in the abdomen, followed by the thighs and feet. Additionally, there are specific types of dropsy that are localized to certain areas of the body, such as hydrocephalus in the head, bronchoccele in the throat, pleurocele in the chest, and hydrocele in the scrotum, among others. Despite their different locations, they all share a common underlying cause: a weakness or defect in the body’s ability to alter or process fluids, particularly involving the liver. This dysfunction may arise from a scirrhus or other severe ailments, especially those induced by cold, whether as a primary condition or as a secondary effect of some hot disorder that diminishes the body’s innate heat. Such a form of dropsy is often incurable. Alternatively, dropsy can develop as a consequence of disease in a higher or lower part of the body. For instance, ailments in the lungs, diaphragm, or kidneys can easily affect the liver via the branches of the vena cava. Similarly, if the condition originates from the spleen, stomach, mesentery, or intestines—particularly the jejunum and ileum—it can penetrate the liver through the mesenteric veins and other branches of the portal vein. As a result, individuals suffering from asthma, tuberculosis, spleen disorders, jaundice, or even delirium may ultimately develop dropsy.
Finally, individuals who experience suppression or excessive flow of menstrual or hemorrhoidal blood, contrary to their usual patterns, may find that it either overwhelms, diminishes, or extinguishes their innate heat. This can be likened to a fire that is smothered by an excess of wood or, conversely, extinguished due to a lack of fuel. Similar consequences may arise from the elimination of waste from the bowels or bladder if it occurs too sparingly or excessively. Additionally, consuming an excessive amount of cold food haphazardly and without proper moderation can also lead to these issues. Ultimately, any disruption caused by external factors can result in errors related to diet or exercise.
Ascites is distinguished from two other types of dropsy by both the magnitude of its underlying cause and the severity of its symptoms, which include a diminished appetite, increased thirst, and abdominal swelling. Additionally, when the body is moved or turned to either side, a sound reminiscent of water sloshing in a half-full vessel may be heard. The fluid may shift upward or downward depending on the body’s position and the pressure applied to the abdomen, leading to various symptoms as it exerts pressure on surrounding organs. This pressure can cause difficulty in breathing and coughing due to the compression of the diaphragm; similarly, it can lead to sweating that mimics the symptoms of empyema by accumulating in the chest cavity.
Patients often describe experiencing a sensation akin to being alternately elevated to the heavens and submerged in water, a phenomenon I have come to understand not from scholarly texts but through firsthand reports from patients themselves. Moreover, when these fluids accumulate in the lower regions of the body, they can obstruct the natural passage of waste from the intestines and bladder by compressing the relevant passages.
When lying on their back, patients may notice that the abdominal swelling appears diminished, as the fluid disperses across both sides. Conversely, in a standing or sitting position, the swelling becomes more pronounced as the fluid is forced into the lower abdomen, leading to a sensation of heaviness in the pelvis. The upper body may show signs of atrophy due to a deficiency of nourishing blood, while the lower parts swell as the serous and watery humor accumulates. The pulse is typically small, rapid, and hard with a tense quality.
This condition falls under the category of chronic or long-term illnesses, which makes it difficult—if not impossible—to cure, particularly in individuals who are born with it. Such patients typically exhibit impaired gastric function, and this affliction is especially challenging to treat in those who are cachectic, elderly, or those whose natural bodily functions are weakened or impaired.
Conversely, young and robust individuals, particularly those without a fever, tend to recover more easily. Recovery is further facilitated for those who can engage in physical labor and exercises that are beneficial for addressing this disease. Early intervention by a physician is crucial, as timely treatment can prevent the accumulation of fluid from becoming putrid and infecting the intestines through its contamination.
The initial phase of treatment should commence with gentle and mild medications. We should only consider paracentesis after we have first attempted other remedies. Consequently, it is the physician’s responsibility to recommend a drying diet and medications that promote the expulsion of excess fluid through both stool and urine. Hippocrates prescribes this particular powder for individuals suffering from dropsy.
Prescription:
Incinerate the Spanish flies in a furnace until they are reduced to a fine powder. Administer two grains of this powder in white wine, as it has been observed that nature, aided by such remedies, can often cure dropsy.
To expedite the healing process, it is beneficial to stimulate the natural heat of the affected area through the application of remedies with a dispersing action. This can be achieved using bags, baths, ointments, and plasters. For the bags, use a mixture of dry and coarse bran, oats, salt, and sulfur, heating them thoroughly. If these materials are unavailable, alternatives such as sandalwood or frequently heated ashes can be used instead.
The most effective baths are those containing salt, nitrous, and sulfurous waters, whether derived from nature or created through preparation, specifically by dissolving saltpeter and sulfur. Enhancing these baths with the addition of rue, marjoram, fennel leaves, dill tops, and other similar herbs will further improve their efficacy.
Ointments should be formulated from the oils of rue, dill, bay leaves, and squills, with the infusion of either Euphorbium, Pellitory of Spain, or pepper. Plasters can be composed of frankincense, myrrh, turpentine, costus, bayberries, English galangal, honey, and animal dung from oxen, pigeons, goats, or horses. These elements may also be used independently.
If the illness persists, we must resort to synapisms and phoenigmata, which are rubefacient and vesicatory treatments. Once blisters have formed, they should be re-anointed, allowing fluid to gradually escape until all excess humor is eliminated and the patient is restored to health.
Galen notes that farmers in Asia, when transporting wheat from the countryside to the city in carts, would cleverly conceal stone jugs filled with water among the grains. This tactic would draw moisture into the jugs, thus increasing both the quantity and weight of the wheat. Upon reading this, some practical physicians surmised that wheat possessed the ability to extract water. They theorized that if a person suffering from dropsy were buried beneath a mound of wheat, the grains would absorb all the excess moisture from the body.
However, if the physician finds no benefit from these methods, he must resort to the primary remedy: paracentesis. Given the varied opinions of ancient physicians on this procedure, we will present and elucidate their perspectives.
Those who oppose paracentesis argue that it poses dangers for three main reasons. First, draining the accumulated fluid may also disperse and diminish the vital spirits, adversely affecting the natural, vital, and animal faculties. Second, they contend that removing the fluid deprives the liver of the support it previously received, causing it to sag due to its own weight. This, in turn, can lead to downward pressure on the diaphragm and the entire thoracic cavity, resulting in a dry cough and difficulty breathing. The third concern is that the peritoneum, due to its nervous tissue, cannot be pricked or cut without incurring significant risk. Furthermore, any tissue that has been pricked or cut does not easily reattach or heal, owing to its delicate, bloodless nature. Erasistratus, citing these arguments, deemed paracentesis to be deadly and argued that it was unproductive for several reasons. Specifically, he believed that draining the fluid does not address the underlying causes of dropsy, nor does it alleviate the inflammation and hardness of the liver and other organs. Consequently, the formation of new fluid can lead to a recurrence of dropsy. Additionally, the fever, thirst, and hot, dry conditions of the bowels—which were somewhat relieved by the presence of the retained fluid—are exacerbated once the fluid is removed. This reasoning seems to have influenced Avicenna and Gordonius, with one asserting that few survived the procedure. However, the counterarguments to all these claims are quite straightforward.
Galen argues that harmful dissipation of vital spirits and a weakening of bodily functions occur when paracentesis is not performed with the utmost care and precision. If this reasoning holds any weight, then phlebotomy should likewise be excluded from the category of beneficial treatments, as it involves the removal of blood—which contains far purer and more refined spirits than those that are purportedly diluted and mixed with the fluid associated with dropsy.
However, the danger associated with the second reason can be easily mitigated by instructing the patient to lie on their back in bed, which will prevent the liver from descending. As for the third reason—the apprehension of puncturing the peritoneum—it is an irrational concern. The complications arising from wounds to nerve-rich areas occur due to their heightened sensitivity; in contrast, the peritoneum, when affected by fluid accumulation, exhibits either minimal or no sensitivity at all. Both reason and experience demonstrate that many nerve-rich areas, as well as even the membranes themselves, can heal after injury, certainly more so than the peritoneum, which is firmly attached to the abdominal muscles. A dissector finds it laborious to separate it from the underlying flesh, underscoring its resilience.
However, the argument suggesting that paracentesis is ineffective is countered by the authority of Celsus. He stated, “I am aware that Erasistratus disapproved of paracentesis, believing that dropsy was solely a liver disease requiring treatment, and that any fluid released was in vain, as the impaired liver might regenerate.” Nevertheless, this issue is not exclusive to the liver. Even if the fluid originated there, its retention against the body’s natural order can harm both the liver and surrounding organs. It can either exacerbate their hardness or, at the very least, maintain it. Therefore, it remains essential to evacuate this fluid to facilitate the body’s healing process. Although the initial release of fluid may appear unbeneficial, it actually paves the way for medications that were previously obstructed by the retained humor. This serous, saline, and corrupt fluid does not alleviate fever and thirst; rather, it exacerbates them. Additionally, it worsens the cold condition, overwhelming and extinguishing the body’s inherent heat due to its excess. The esteemed physician Caelius Aurelianus, despite being a Methodic, provides insights that may address the concerns of Avicenne and Gordonius. He asserts, “Those who claim that all individuals who have undergone paracentesis have died are mistaken; we have witnessed many recover with this treatment. If any have died, it was likely due to the slow or negligent execution of the procedure.
I would like to add one important point that may eliminate any confusion or controversy: we often hesitate to resort to this remedy when the patient reaches a point of necessity requiring intervention. It is crucial at this stage to determine how the abdomen should be incised. If the dropsy originates from a liver issue, the incision should be made on the left side; conversely, if the cause lies with the spleen, the incision should be on the right. This precaution is vital because if the patient lies on the side of the incision, the pain from the wound will consistently trouble them, and fluid will continuously flow into the area of the incision, potentially resulting in a deterioration of bodily functions.
The incision should be made three fingerbreadths below the navel, specifically at the side of the right muscle, avoiding the region known as the Linea Alba, as well as the nerve-rich areas of the surrounding epigastric muscles. This approach is essential to minimize pain and facilitate healing. It is crucial that the patient lies on their right side if the incision is made on the left and vice versa if the incision is on the right side.
The surgeon, assisted by an attendant, should carefully lift the skin of the abdomen along with the underlying fatty tissue, separating them from the surrounding structures. Next, he should incise this layer down to the underlying flesh. Once this is accomplished, he must gently retract the divided skin upward towards the stomach. This maneuver ensures that when the subsequent incision is made in the underlying tissue, the skin will naturally fall into place, aiding in the healing process. Finally, the surgeon should make a small incision through the muscle and peritoneum, being careful not to damage the bowel or any internal organs.
Insert into the wound a trunk, or a curved pipe made of gold or silver, approximately the thickness of a goose quill and about half a finger in length. The portion of the pipe that extends into the abdominal cavity should feature a broad head with two small perforations. This design allows for a string to be secured, enabling the pipe to be fastened around the body in such a way that it remains immobile except at the surgeon’s discretion.
Next, place a sponge inside the pipe to absorb any excess fluid. When it is necessary to remove the sponge to evacuate the liquid, do so gradually rather than all at once. This precaution is important to prevent a sudden loss of vital spirits and the deterioration of bodily functions, a complication I once witnessed in a patient suffering from dropsy.
Impatient with his illness and the process of healing, he recklessly thrust a bodkin into his abdomen and expressed great relief as the fluid flowed out, believing he had liberated himself from both the excess humor and the disease. However, he tragically died within a few hours because the flow of fluid could not be contained, as the incision had not been made with proper technique.
It is essential not only to create an opening for the humor with the previously mentioned methods, but also to ensure that the external orifice of the pipe is sealed and reinforced with double layers of cloth and a strong ligature, to prevent any unwanted leakage of fluid.
Moreover, we must remember not to withdraw the pipe from the wound until the desired amount of fluid has been expelled, as dictated by the tumor’s needs. Once removed, reintroducing the pipe can be difficult and painful, as the skin and muscular layer tend to close around the wound. During the fluid evacuation process, it is crucial to pay careful attention to the patient’s nutrition and strength. If the patient begins to weaken, we must pause the fluid drainage for several days. Once the desired expulsion is achieved, the wound should be allowed to heal properly, with the surgeon vigilant to ensure that it does not develop into a fistula.
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The Design of a Quill-Shaped Pipe for the Evacuation of Fluid in Cases of Dropsy.
Others approach this procedure differently; they begin by making an incision and then use a needle and thread to bring together the edges of the wound. However, they carefully draw up a significant portion of the fleshy tissue with the needle to prevent the tissue from tearing due to the force used to bring the edges together. The thread is then wrapped around both ends of the needle, as is typically done in the case of a harelip, ensuring that the edges of the wound adhere so closely that not a single drop of fluid escapes against the surgeon’s intent. Occasionally, patients who recover from Dropsy may develop jaundice, which I typically treat in the following manner:
Prescription:
Dissolve the goose droppings in the wine
Note: In this context, “scruples” (ʒ) is an ancient unit of weight. One scruple is approximately 1.3 grams.
Make a potion and let it be given two hours before meat.
The Exomphalos, or swelling of the navel, occurs due to the peritoneum being either relaxed or ruptured. This condition often leads to the intestines or the caul descending into the navel area, and in some cases, excess flesh may develop there. Alternatively, this tumor can resemble an aneurysm due to an excessive accumulation of blood in the region or may result from the presence of gas or watery fluid.
If the swelling is caused by the caul, the affected area will maintain its natural color, mirroring the skin tone. The tumor generally appears soft, is accompanied by minimal pain, and can be pushed back without noise when pressure is applied or when the patient lies on their back. However, if the tumor is due to the intestines, it tends to be irregular, and when pressed, produces a noticeable sound, similar to that heard in an Enterocele.
In cases where the swelling is the result of excess flesh, it will be firmer and more resistant to retraction, making it difficult to push back into the body even if the patient is lying on their back and pressure is applied.
The tumor resulting from gas is softer but will not retract into the body; instead, it produces a sound under pressure, similar to that of a drum. If the swelling is due to watery fluid, it shares many characteristics with the gaseous tumor, except that it is less pronounced and produces no sound. A tumor arising from blood effusion will exhibit a livid color, and if the blood is arterial, it may display signs of an aneurysm.
When the tumor is caused by the intestines, caul, gas, or watery fluid, surgical intervention is necessary for treatment. However, tumors stemming from fleshy growths or blood suffusion do not require surgical procedures. For navel tumors arising from the caul or intestines, the patient should lie on their back to facilitate treatment. At this point, the caul and intestines must be carefully pushed back into their proper position using your fingers.
The skin surrounding the tumor should then be grasped with your fingers and pierced with a needle, drawing through it a strong, double-twisted thread. Next, the edges of the skin should be scarified to promote easier adhesion. The procedure may involve passing a needle through the area three or four times, depending on the nature and extent of the swelling. The thread should then be tightened to ensure that the bound skin eventually detaches along with the ligatures.
Alternatively, you may choose to excise the distended skin up to the ligature and proceed with appropriate methods for healing. A gaseous navel tumor can be treated with similar techniques, as described in the forthcoming section on treating a windy rupture. For the drainage of fluid, a small incision may be made, and the wound should be kept open until all the fluid has been expelled.
Ancient physicians identified various types of ruptures; however, only three are accurately classified under this term: the intestinalis, which pertains to the intestines; the zirbalis, referring to the caul; and those that are a combination of both. The other classifications of ruptures have been categorized primarily by their similarities rather than by any fundamental truth, as in these cases, neither the gut nor the caul displaces from their original positions.
The Greeks have assigned various names to these conditions, both based on the location of the tumor and its composition. For instance, an incomplete rupture that does not extend beyond the groin or descend into the scrotum is referred to as a Bubonocele. In contrast, a complete rupture that penetrates into the scrotum is called an enterocele if it involves the intestines, and an epiplocele if it involves the caul. When both structures are involved, it is termed Enteroepiplocele. If the tumor is caused by a watery fluid, it is labeled Hydrocele; if by gas, Physocele; and if due to both conditions, it is called Hydrophydocele. A fleshy growth around or within the testicle is referred to as a Sarcocele. Additionally, if the veins in the scrotum and testicles become swollen and intertwined in various patterns, the resulting tumor is named Cirsocele. When fluids are trapped or redirected to that area, the tumor is named according to the dominant fluid, as noted earlier in our discussion of tumors.
Multiple causes can contribute to these conditions, including excessive physical exertion, trauma, falls from heights, vomiting, coughing, jumping, riding on a trotting horse, exposure to the sounds of trumpets or sackbuts, and lifting heavy objects. Additionally, the excessive consumption of rich or gas-producing foods can also contribute to these issues. Such activities may either weaken or rupture the peritoneum, which is a delicate and expansive membrane. The signs of a Bubonocele typically include a rounded tumor in the groin that can be easily compressed inward when pressed.
The signs of an enterocele include a hard tumor in the scrotum that, when pressed, recedes with a distinctive gurgling sound and accompanying pain. In contrast, a tumor originating from the caul is softer and feels like wool; it is more challenging to reduce than the one arising from the intestines, but does not produce the same gurgling sound or pain. This difference arises because the intestines, as a continuous structure, move in a coordinated manner, resembling a dance, to avoid distention. Such distention can cause pain due to the unnatural change in their position. The caul, however, is an inert structure—largely insensate, heavy, dull, and immobile—making it less susceptible to these complications.
If the peritoneum is compromised, the tumor will increase suddenly and be associated with sharp, cutting pain. Conversely, when the peritoneum is only relaxed, the tumor develops gradually and is accompanied by mild pain. However, this pain recurs whenever the tumor forms again due to the descent of the intestines or caul, which does not occur when the peritoneum is ruptured. In the latter case, once a pathway is established for the protruding body, the tumor can reform without any associated distention or significant pain.
Additional signs related to this condition will be addressed in their appropriate sections. In some instances, the intestines and caul may adhere so firmly to the peritoneum that they cannot be repositioned back into their rightful place.
This persistent adhesion occurs due to the presence of viscous material or as a result of irritation caused by a surgeon’s rough handling when excessively attempting to reduce the gut or caul. Additionally, prolonged retention of the gut in the scrotum and the failure to wear a truss may also contribute to the formation of such adhesions. A complete and chronic rupture caused by a disruption of the peritoneum in fully grown men rarely, if ever, allows for successful treatment. It is important to note that with significant ruptures of the peritoneum, the intestines may protrude into the scrotum to a size comparable to that of a man’s head without causing much pain or threatening life. This is because, while fecal matter can easily enter due to the large opening created by the rupture, it can equally be expelled with relative ease.
Children are particularly susceptible to ruptures, especially those that are not fleshy or varicose but rather watery, windy, and notably those of the intestines. This vulnerability often arises from persistent and painful crying and coughing. Consequently, our first focus will be on their treatment.
When a surgeon is called to reposition a prolapsed gut, he should place the child on a table or bed in a position where the head is lower than the buttocks and thighs. Subsequently, he should gently and gradually apply pressure with his hands to guide the gut back into its proper position. To aid this process, the surgeon should apply an astringent fomentation to the groin, similar to that described for the treatment of a fallen womb. Following this, he can proceed with the application of this specific remedy:
Prescription:
Combine the ingredients and prepare them into a cataplasm according to established methods. For similar purposes, you may also use Emplastrum contra Rupturam. However, the primary focus of treatment lies in the use of folded cloths, trusses, and specially crafted ligatures to ensure that the repositioned intestine remains secure. To facilitate this, it is crucial to keep the child seated in a cradle for 30 to 40 days, as previously mentioned, while also preventing them from crying, shouting, or coughing. Aetius recommends soaking paper in water for three days, then forming it into a ball to be applied to the groin, ensuring that the intestine is properly positioned beforehand. This method will promote adhesion over the three days, effectively preventing the intestine from descending again. I believe that using astringent water, rather than common water, for steeping the paper will yield more effective results, as previously described in cases of uterine prolapse. I have successfully treated many patients with such remedies, effectively rescuing them from the grasp of Gelders, who exploit children for profit by preying on their testicles. These practitioners, through deceitful means, convince parents that the descent of the intestine into the scrotum is incurable. However, experience shows this claim to be false, provided the treatment is administered as outlined earlier, ensuring that the peritoneum is merely relaxed and not damaged. Over time, the condition causing the intestine to descend—akin to a steep slope—will naturally tighten and knit together as the child matures, while the intestines themselves also thicken.
A reputable surgeon has informed me that he has successfully treated numerous children using a particular method: he finely grinds a loadstone into powder and administers it in a mixture of pap, followed by anointing the groin with honey, from which the intestine has emerged. He then sprinkles fine iron filings over the area. This treatment is typically continued for ten to twelve days, with the affected region secured using appropriate ligatures and a truss. The effectiveness of this remedy appears to stem from the loadstone’s natural ability to attract iron, which, when applied to the groin, draws in the intervening flesh and fat with considerable force. This action compresses and constricts the looseness of the peritoneum, ultimately leading to a firm adhesion that prevents the descent of the intestine or caul. This principle seems no more irrational than observing a loadstone drawing iron through the thickness of a table. The same surgeon asserted that he has often and successfully employed the following remedy:
He burned red snails in an oven until they turned to ash, sealing them in an earthen pot, and then administered the resulting powder to young children in a mixture of pap, while older children received it in broth. However, we should not lose hope in treating this condition, as recovery is possible even in fully grown individuals, such as those around forty years of age, who have reached their full physical development, as demonstrated by the following account.
There was a certain priest in the Parish of Saint Andrews named John Moret, whose duty it was to chant an Epistle aloud in accordance with the solemnity of the day and the requirements of the occasion. However, he was troubled by an enterocoele and came to me seeking assistance, stating that he experienced severe pain, particularly when he strained his voice during the Epistle.
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The figure of a man depicted with a break on the side, wearing a truss, features a bolster with three tuberosities—two located at the upper section and one at the lower. It is essential that there is a hollow space between these tuberosities to prevent excessive pressure on the sharchone, which could lead to pain. I discovered the design of this particular truss not long ago, and it appeared to be both more effective and safer than others in preventing the descent of the gut and caul.
After observing the size of the enterocele, I encouraged him to obtain another truss to support him. With the approval of M. Curio Clearke, Deacon of Divinity, he placed himself under my care. I treated him according to established medical practice and instructed him to wear a truss at all times. He adhered to my recommendations. When I encountered him again about five or six years later, I inquired about his condition. He replied that he was in excellent health, having completely overcome the ailment that had once troubled him. I was initially skeptical of his claim until I confirmed its validity through careful examination of his genitals. Unfortunately, six months later, he passed away from pleurisy. I went to Curio’s house, where he had died, and requested permission to perform an autopsy to investigate whether nature had made any alterations in the area where the gut had descended. I call God to witness that I discovered a fatty substance around the peritoneum, roughly the size of a small egg, which adhered so tightly that I could barely detach it without damaging surrounding tissues. This was the primary reason for his recovery. It is worthy of note—and indeed, quite remarkable—that nature, with only minimal assistance from medical intervention, can heal conditions previously deemed incurable. The essence of the cure lies in effectively stabilizing the gut in its proper position, as illustrated by the accompanying figures.
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Another illustration depicts a man with a rupture on both sides, demonstrating the appropriate methods, types of trusses, and shoulder bands that he should use to secure each groin.
Meanwhile, we must not neglect dietary considerations. We should prohibit the use of anything that may relax, dilate, or disrupt the function of the peritoneum, a topic I have addressed sufficiently. In some cases, particularly in elderly individuals, the intestines cannot be repositioned due to a buildup of hardened fecal matter. In such situations, they should not be forcibly manipulated. Instead, the patient should remain in bed with their head lowered and knees elevated. The following cataplasms should be applied.
Prescription:
Boil the ingredients in clean water, then strain through a sieve, adding fresh, unsalted butter and oil of lilies as needed. Prepare a cataplasm in the consistency of a liquid poultice. Apply it hot to the groin and lower abdomen.
This remedy, when left on overnight, has often allowed the intestines to return to their proper position without surgical intervention. By alleviating the windiness that obstructed the reabsorption of waste materials back into the intestines, it facilitates their evacuation. However, if the waste does not revert in this manner and if flatulence persists, an emollient and carminative enema should be administered, incorporating a small amount of chemical oil of turpentine, dill, juniper, or fennel. Additionally, enemas made from muscadine, walnut oil, and Aqua vitae, combined with a small quantity of any of the aforementioned oils, are also effective for this purpose.
It is not uncommon for the intestines to remain unreduced due to the inadequacy of the peritoneal opening. When the intestines and waste materials have descended into the groin, they gradually harden and become engorged with gas, resulting in a tumor that cannot easily be reintroduced through the previously affected passage. This situation may lead to putrefaction of the trapped material, causing inflammation and increased pain, and ultimately obstructing the expulsion of waste, which may result in vomiting. This condition is commonly referred to as ‘Miscrere mei.’ To address this issue, one must be prepared to employ more aggressive remedies rather than allow the patient to succumb to such a distressing and repugnant fate. Surgical intervention should be undertaken as outlined in the following manner:
We will securely position the patient on their back on a table or bench. Next, we will make an incision in the upper part of the groin, taking care not to damage the intestines. To assist with the procedure, we will need a silver tube or pipe, roughly the diameter of a goose quill, which should be rounded and bulging on one end while slightly hollowed on the other, as illustrated in the following figure.
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The Figure of the Pipe or cane.
We must insert the instrument into the incision and position it beneath the peritoneum, which has been cut alongside the groin, extending the length of the incision. This will allow us to use a sharp knife to carefully divide the peritoneum along the cavity that is separated from the intestines, aided by the instrument in a straight line to avoid injury to the intestines. Once a satisfactory incision has been made, gently push the intestines back into the abdominal cavity using your fingers. Then, suture the portion of the cut peritoneum that appears sufficient, ensuring that the newly created passage is straightened, preventing anything from falling into the groin as it heals.
However, if there is a significant accumulation of hardened feces, either due to prolonged retention or inflammation, and the initial incision is insufficient to allow the feces to be properly relocated, you must extend the incision while inserting the instrument towards the abdominal cavity. This adjustment should facilitate the unobstructed return of the intestines into the abdomen. Afterward, suture the incision appropriately to prevent the intestines or omentum from descending, as the suturing will create a straighter alignment of the peritoneum. The wound will then heal in accordance with established practices. Before you proceed with this procedure, take careful consideration of the patient’s strength and do not undertake any actions until you have warned and informed the patient’s family about the associated risks.
If the hernia cannot be resolved through these various measures due to a significant disruption of the relaxed or ruptured peritoneum, and the patient, with the consent of their accompanying friends, is willing to face the risks in hopes of recovery, the procedure known as the Punctus Aureus, or Golden Tie, shall be attempted.
For this purpose, a skilled and steady-handed surgeon should be engaged. The surgeon will make an incision around the pubic bone and insert a probe similar to the aforementioned implement, positioned longitudinally beneath the peritoneal process. By lifting the probe, the surgeon will separate the peritoneum from the surrounding fibrous and nervous tissues to which it adheres. The next step involves gently retracting the spermatic vessels along with the cremaster muscle. Once this is accomplished, the peritoneal process will be isolated.
The surgeon will excise any excessively lax portion using small, delicate clamps with perforations in the center. Then, using a needle threaded with five or six strands, they will carefully pass the needle as close to the spermatic vessels and cremaster muscles as possible. The needle must then be retracted through the center of the remaining peritoneal process, capturing the edges of the incision in the process. The thread will be tied in a secure knot, ensuring that enough length is left protruding from the wound. This thread will gradually dissolve due to putrefaction; it must not be removed before nature has regenerated tissue in place of the ligature, or else all efforts will be in vain.
Finally, the wound should be cleansed, filled with granulation tissue, and allowed to cicatrize, forming a firm scar that can support the weight of the intestines or omentum.
Some surgeons prefer to perform the golden ligature using an alternative method: they make an incision above the pubic bone, where the hernia typically protrudes, extending down to the peritoneal process. They then wrap a small golden wire around this exposed area once or twice, carefully adjusting it just enough to correct the looseness of the peritoneal process while leaving the spermatic vessels unharmed. Afterward, they twist the ends of the wire two or three times using small clamps and trim any excess wire, ensuring that the remaining ends are turned inward to avoid irritating the surrounding tissue during healing.
The surgeons leave the golden wire in place and manage the wound similarly to other simple lacerations. The patient is advised to rest in bed for about fifteen to twenty days, with their knees slightly elevated and head positioned lower.
Many patients experience healing through this technique; however, some may relapse into the condition due to improper twisting of the wire.
There is another method of employing the golden tie that I believe to be quicker and safer, primarily because it leaves no external materials in the area after healing. In this approach, a leaden wire replaces the golden one, wrapped around the peritoneal process just once. The wire is twisted to a degree that is neither too loose—risking the possibility of a recurrence of the hernia—nor too tight, as excessive tension may lead to gangrene by obstructing the flow of vital spirits and nourishment. The ends of the wire are left exposed. As time passes, once the peritoneum appears to have formed a firm closure, the wire can be gently untwisted and removed. The remainder of the treatment is carried out according to established protocols.
However, it is crucial that the surgeon does not proceed with this procedure hastily or without the advice of a physician. Occasionally, the testicles may not descend into the scrotum due to nature’s sluggishness, particularly in some healthy children, causing them to remain in the groin and resulting in painful swelling. This complication may lead an inexperienced surgeon to mistakenly diagnose an enterocoele. While attempting to treat this swelling with repelling medicines and trusses, the surgeon inadvertently intensifies the pain and obstructs the normal descent of the testicles into the scrotum.
Recently, I observed a case involving a boy who had been mismanaged by an unskilled surgeon, causing him significant distress as though he were suffering from a hernia. Upon examination, I noted that he had only one testicle in the scrotum and confirmed that he had never been castrated. I advised the family to abandon the use of plasters and trusses and encouraged them to let him run and jump, allowing the dormant testicle to gradually descend into the scrotum. This approach proved effective, occurring slowly and without any pain, just as I had predicted.
To understand the underlying reasons for this condition, it’s essential to recognize that men and women differ primarily in terms of heat efficacy. Strong heat tends to expel, while cold retains. This explains why, in men, the testicles descend into the scrotum, whereas in women, they remain concealed within the lower abdomen. Consequently, in certain males with a naturally colder constitution, the testicles may remain retracted for a period, eventually being driven down into the scrotum by the fervor of youth.
However, returning to our previous discussion on the scrotum, it is important to note that while the method of treating hernias can involve pain and risk, it is ultimately safer than performing castration. The brutality of that procedure exposes the patient to a significant risk of mortality.
For those who perform castration, there exists a deep-seated fear that, despite the apparent success of the procedure, complications may persist. When they forcefully detach the peritoneum from the surrounding tissues to which it is adhered, they inadvertently impair a nerve from the sixth cranial nerve that innervates the testes. They impose similar violence upon the spermatic vessels. Such actions can lead to severe consequences, including intense pain, convulsions, hemorrhaging, inflammation, putrefaction, and ultimately death, as I have witnessed in many individuals I have autopsied shortly after their castration. Although some may survive these severe complications, they suffer a lifelong loss of reproductive capability, as the testes are essential organs provided by nature for the preservation of humanity. On this occasion, Galen has boldly asserted the superiority of the testicles over the heart. He argues that while the heart serves as the starting point of life, the testicles are the source of a more fulfilling existence. It is far nobler to live well than merely to exist.
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E The mullets to twist the ends of the wire together.
As a result, Eunuchs often exhibit more effeminate traits; they lack beards, possess soft voices, exhibit diminished courage, and may ultimately become cowardly. Unfit for many human endeavors, their existence is likely to be filled with suffering. Therefore, I will not endorse the removal of the testicles unless conditions such as Sarcocele or Gangrene affect them. To aid in your understanding of the Punctus aureus procedure, I believe it is beneficial to present the instruments used in this operation for your consideration.
Theodorick and Guido have developed an alternative method for performing this operation. They reposition the gut and caul that have descended, arranging the patient so that his thighs are elevated and his head is slightly lowered. Next, they gently retract the lower section of the peritoneum, along with the spermatic vessels and cremaster muscle, towards the ischium. They then apply a caustic agent appropriate for the patient’s age and condition to cauterize the area of the process, directly opposite the pubic bone where the gut has descended.
Afterward, they carefully excise the eschar created, cutting down to the underlying tissue. They subsequently apply another caustic agent in the same location, one potent enough to reach the bone, facilitating the detachment of the eschar formed in the previously mentioned process. Once this step is completed, they proceed to heal the resulting ulcer, which quickly develops a thick callous. This callous serves to support the gut and caul, preventing them from falling into the scrotum.
While this method of repositioning the gut and caul is considered safer and easier, the surgeon must refrain from attempting it if the gut or caul is so firmly adhered to the peritoneum that it cannot be detached or repositioned; such a situation could lead to further complications from the damaged gut. Additionally, caution is necessary if the dilated process causes a significant tumor due to the descending organs, or if the testicle remains in the groin as in a Bubonocele or a type of Enterocele, without having descended into the scrotum. Furthermore, it is critical that the patient be of an age where he can remain still and control his bowel movements during the procedure.
Epiplocele refers to the descent of the caul into the groin or scrotum and shares similar causes with an enterocoele. The associated signs have been previously described. While it is not as dangerous and does not lead to as many adverse symptoms as an enterocoele, the treatment for both conditions is the same.
Hydrocele, on the other hand, is a fluid-filled tumor within the scrotum, gradually accumulating between the membranes surrounding the testicles, particularly the Dartos and Erythroides. It can be considered a specific type of dropsy, arising from similar causes but primarily due to a deficiency in native heat. The signs of hydrocele include a slowly enlarging tumor that is heavy and exhibits a glassy transparency, which can be observed by shining a light through it. When pressure is applied to the scrotum above, the fluid shifts downward, and when pressed below, it moves upward, unless the volume is so large that it fills the entire scrotal cavity. Unlike the caul or intestines, which may be pushed up into the abdomen, the fluid in a hydrocele is typically contained within a cyst or sac. It is distinguished from a saycocele by its smooth and uniform appearance.
Initial treatment should focus on the use of resolving, drying, and discussing medications, which should be applied frequently prior to considering more invasive options. The following approach, which I have employed successfully on numerous occasions, is outlined in the chapter on dropsy.
Prescription:
Mix them together, and create a medicine for your comfort.
The water is digested and eliminated through this remedy, or rather, it is primarily dried up, especially if not in excessive amounts. However, if the swelling persists due to a significant accumulation of water that does not respond to these treatments, surgical intervention becomes necessary. A seton must be inserted through the tissues that contain the fluid—specifically, the scrotum and membranes—using a large, three-square-pointed needle threaded with silk. The needle should be carefully inserted through the pre-made openings in the skin, avoiding any contact with the testicular tissue. The silk thread should be left in place or removed two to three times daily, allowing the fluid to gradually drain and be expelled. If, however, the pain intensifies due to the presence of the seton, and inflammation develops, the seton must be removed. In such cases, it is crucial to focus on managing the symptoms rather than neglecting to address the underlying condition.
Some practitioners employ a different approach than using a seton; instead, they make an incision in the lower part of the scrotum with a razor or incision knife. This incision is typically about half a finger’s breadth in length and reaches the fluid accumulation, while carefully avoiding any damage to the testicular tissue and blood vessels. The wound is maintained in an open state until it appears that all the fluid has been expelled. This method is considered the most reliable way to treat a hydrocele, or watery rupture, where the fluid is contained within a cyst, as discussed in our treatise on tumors in general.
The pneumatocele is a gaseous tumor located in the scrotum, resulting from the accumulation of heat in the affected area. It is characterized by its round shape, softness, elasticity, and shiny appearance. Treatment involves a prescribed diet and the application of medicinal remedies aimed at dissipating gases, such as seeds of anise, fennel, fenugreek, Agnus castus, rue, origanum, along with other remedies mentioned by Avicenna in his Treatise on Ruptures. I have frequently found success using Emplastrum Vigonis with mercury, as well as Emplastrum Diacalcitheos, dissolved in quality wine such as Muscadine and combined with bay oil for this purpose.
A sarcocele is an abnormal tumor that forms around the testicles due to the presence of hard, fibrous tissue. This type of tissue arises from the accumulation of thick and viscous humors that the body struggles to overcome and assimilate, leading to an overgrowth similar to warts. The tumor is often accompanied by varices, or swollen veins, and is characterized by pain. It can be identified by its hardness, roughness, irregular surface, and uneven texture. The only effective treatment is surgical removal; however, it is crucial to ensure that the growth has not progressed too far up into the groin, as attempting surgery in such cases poses a significant risk to life.
However, should anyone believe that they can alleviate the patient’s condition by merely excising a portion of this soft tissue, they are mistaken. Even the slightest remnant will cause a fungus to develop, which is a far worse complication than the original issue. If the tumor is small or moderately sized, the surgeon should remove the entire affected area, including the swollen testicle and the surrounding tissue that adheres to it.
To perform the procedure, the surgeon should make an incision in the scrotum, extending down to the tumor, and then carefully separate the swollen testicle from the surrounding tissue. Next, a strong thread should be threaded through the middle of the stalk of the swollen testicle, above the affected area, and then passed through the same section a second time. Both ends of the thread should be tied together in a knot, ensuring that a portion of the peritoneum is included in the knot.
Once this step is completed, the surgeon can remove the entire stalk along with the testicle. The ends of the thread that were used to secure the upper part of the stalk should be left protruding from the incision. Following this, a suitable repercussive medicine should be applied to the wound and nearby areas, along with an appropriate ligature for support. The subsequent care should be conducted as previously described.
The cirsocele is a tumor characterized by dilated veins intricately woven around the testicle and scrotum, filled with thick and discolored blood. The causes of this condition are similar to those that lead to varicose veins, and its symptoms are quite evident.
To treat this tumor, an incision should be made in the scrotum, approximately two fingerbreadths above the affected varicose vein. A needle with a double thread should then be inserted beneath the varicose vein as high as possible to secure the roots of the vein. Subsequently, the needle should be reinserted in a similar manner around the lower section of the same vein, ensuring there is a two-finger breadth of space between the two ligatures.
Before tightening the thread of the lower ligature, the varicose vein must be opened in the middle, akin to how a vein is punctured in the arm for bloodletting. This action allows the thick blood responsible for the tumor in the scrotum to be evacuated, mirroring the treatment typically employed for varicose veins.
The resulting wound will heal according to standard medical practices used for other wounds, with the threads left in place falling away on their own in due course. In conclusion, once the area has healed, particularly at the site where the vein was ligated, it should form a callous. This will ensure that blood cannot flow or become obstructed in that area in the future.
Hernia Humoralis is a tumor that arises from the disordered mixture of various bodily humors within the scrotum or between the membranes surrounding the testicles, and it may also affect the testicular tissue itself. The causes, symptoms, and treatment of this condition are similar to those associated with other tumors. During the healing process, it is essential to ensure adequate rest and to employ trusses or appropriately fitted supports to elevate and support the testicles.
When the muscle known as the sphincter, which encircles the rectum, becomes relaxed, it is unable to adequately support the rectum itself. This condition is particularly common in children due to excessive moisture in the abdominal area, which can either soften and relax the muscle or exert unusual pressure from added weight, rendering the Levatores Ani—muscles responsible for lifting the rectum—insufficient for the task.
A severe case of bloody diarrhea can contribute to this condition. Straining to expel hard stools can also play a role, especially when accompanied by hemorrhoids that create excessive pressure on the rectum. Additionally, exposure to cold, as seen in individuals who wear no trousers in winter or who sit for prolonged periods on cold surfaces, can exacerbate the issue. Traumatic injuries, such as a fall or impact to the coccyx, and nerve damage affecting those that innervate the lifting muscles can further contribute to the descent of the rectum. Furthermore, the presence of a stone in the bladder can add weight and pressure, complicating the situation.
To promote healing of this condition, it is essential to restrict the patient’s intake of fluids, limit the consumption of broth, and avoid cold fruits. For local treatment, the affected area should be fomented with an astringent decoction composed of the rinds of pomegranates, galls, myrtles, knotgrass, shepherd’s purse, cypress nuts, alum, and common salt, all boiled in either smith’s water or red wine.
Following the fomentation, the intestine should be anointed with either rose oil or myrtle oil. Then, it should be gently repositioned, ensuring that the child understands the instruction to hold their breath. Once the intestine is properly restored, it is crucial to thoroughly wipe the area to prevent the intestine from descending again due to the slipperiness of the ointment. Next, introduce the prescribed powder for uterine prolapse into the rectum as far as possible. Finally, securely bind the lower back with a swathe, attaching a secondary strap at the back that can be tied at the pubic area, extending along the perineum to support the rectum. To further stabilize the area, place a sponge soaked in the astringent decoction to help keep it in position.
If the patient is mature enough to manage his own care, he should be washed after using the toilet. He should sit on two pieces of wood positioned a few inches apart to prevent the intestine from being expelled along with the feces during straining. However, if he is able to do so while standing, he should avoid straining that may cause the intestine to protrude.
If the intestine cannot be repositioned using the prescribed methods, Hippocrates recommends that the patient be suspended by the heels and gently shaken. This shaking may help the intestine return to its proper location. Additionally, Hippocrates advises applying an ointment to the anus, as this remedy possesses drying properties that can alleviate flatulent humors without causing irritation, which may contribute to the intestine’s inability to remain in place.
Paronychia, or panaris, is a painful swelling at the tips of the fingers characterized by significant inflammation. This condition arises from a malignant and toxic humor that spreads from the bones through the periosteum to the tendons and nerves in the affected area, leading to severe symptoms such as throbbing pain, fever, and restlessness. Those afflicted may exhibit behaviors akin to those suffering from carbuncles, tormented by their pain. Due to the severity of this condition, Guido and Johannes de Vigo consider it potentially life-threatening. Consequently, it is essential to seek the care of a skilled physician who can recommend an appropriate diet, purgation, and bloodletting. In the interim, the surgeon should facilitate the drainage of the virulent matter by making an incision on the inner side of the finger, extending down to the bone at the first joint. Vigo asserts that this is the most effective remedy if performed quickly and prior to the maturation of the abscess, as it protects the finger from the deterioration of bone and nerves while alleviating pain. I have personally and successfully employed this approach at the onset of the condition, before the virulence could take full hold.
Once the incision has been made, it is crucial to allow the wound to bleed freely. Following this, the patient should immerse their finger in strong, warm vinegar, which may be combined with dissolved treacle to help extract the virulent substance. To alleviate pain, the same treatments employed for carbuncles may be applied to the affected area. These include the leaves of sorrel, henbane, hemlock, and mandrake, all roasted over embers and then ground in a mortar with fresh Unguentum Populeon, rose oil, or unsalted fresh butter. Such remedies not only promote suppuration but also mitigate the excess heat affecting the area due to their cooling properties, while simultaneously enhancing the body’s natural heat that facilitates the process. This rationale led ancient physicians to prescribe these treatments for carbuncles.
However, if, due to the patient’s fear or the surgeon’s lack of skill, no incision is made, the affected area may succumb to gangrene or sphacelus. In such cases, it is necessary to excise all necrotic tissue using cutting instruments, and to continue treatment in accordance with medical principles. Often, it may not be necessary to amputate the finger entirely, as the tissue, along with the bone, can gradually disintegrate into a purulent, foul-smelling discharge.
In this condition, an eschar may arise due to the combustion of putrefied heat, beneath which exceedingly sensitive, excess flesh can develop. This too must be removed with precision to allow for healing, as the pain subsides with the abundant flow of blood.
Following prolonged and severe illnesses, tumors often develop in the knees, particularly among individuals with plethoric bodies or those with a buildup of unhealthy fluids after labor and exercise. Such conditions are common because the body’s humors tend to accumulate in areas that have been stressed by physical exertion. However, when these tumors arise after extended illnesses, they can prove dangerous and challenging to treat, and thus should not be overlooked. They are typically accompanied by intense pain, as the humor causes the membranes—of which there are many—to stretch and envelop the affected area. Moreover, the humor exhibits certain virulent and malign characteristics, whether it is cold or hot, once it settles in these regions. This is similar to the pain associated with joint issues and the effects of venomous bites.
For treatment, if the tumor is blood-related, a slender and cooling diet should be prescribed, along with phlebotomy to draw out the underlying cause. Various local treatments should be applied based on the changing conditions of the four seasons. To alleviate pain, anodyne or soothing medications should be administered. We have discussed these treatments in detail in the chapter on the management of phlegmon.
Given the delicate nature of these areas, if it becomes necessary to open the tumor, we must proceed cautiously and thoughtfully to avoid causing pain and other complications. This type of tumor is often caused by trapped wind; therefore, the surgeon must be vigilant to avoid being misled by the apparent presence of fluid when applying pressure with their fingers. It may seem as though there is matter trapped inside, which could lead to an erroneous decision to incise the tumor. If the trapped wind is released instead of actual fluid, it can result in serious complications due to the hasty incision made in such a sensitive region.
If watery humors cause swelling in the affected area, the first step is to purge the body using medications specifically designed to eliminate phlegm. Following this, local treatments that incise, attenuate, rarify, disperse, and effectively dry the affected area should be applied. We have extensively discussed these treatments in the chapter on Oedema. However, this humor often resides deep between the patella and the joint, making it difficult to resolve due to the weakness of the area and a lack of heat. Consequently, this excess humor may disrupt the proper alignment of the bones, a phenomenon I have observed in many cases.
In such instances, the use of irrigations with red wine, applied from a height, is highly recommended as it allows the medicinal properties to penetrate more effectively into the affected area.
I feel compelled to discuss in this context the peculiar tumor known as Dracunculus, which has been described by ancient texts. The nature and characteristics of this condition have been examined by numerous authors, yet, to date, we lack a comprehensive and reliable account upon which we can firmly base our understanding of its essence.
According to Galen in his sixth book, chapter three of “De Locis Affectis,” he asserts that the formation of the hairs expelled through urine is no less remarkable than that of Dracunculi. He notes that these peculiar entities are said to breed in the legs of individuals in a particular region of Arabia, exhibiting a nervous structure and bearing a resemblance to worms in both color and thickness.
Given that I have encountered numerous individuals claiming to have seen Dracunculi, yet I myself have never observed them, I find it impossible to make any precise conjectures regarding their origin or essence.
Paulus Aegineta notes that these Dracunculi are found in India and the high regions of Egypt, resembling worms that develop within the muscular tissues of the human body. They are said to inhabit areas such as the arms, thighs, and legs, and in children, they can be seen moving distinctly within the intercostal muscles.
Whether Dracunculi are indeed living creatures or merely resemble such, they should be treated with a hot fomentation. This treatment will encourage the Dracunculus to form a proper swelling, allowing it to be carefully extracted piece by piece with the fingers. Additionally, suppurating cataplasms can be applied, made from a mixture of water, honey, and flour derived from wheat and barley.
Avicenne presents a variety of perspectives, lacking a firm foundation for his conclusions. At times, he describes Dracunculi as living entities, while at other moments, he refers to them as a substance or humor confined to a specific area. Nevertheless, he accurately outlines the treatment and essence of this ailment, which we will discuss further.
Actius describes Dracunculi as resembling worms, noting that they can vary in size, appearing both large and small. He compares their development to that of flat worms that inhabit the intestines, as they glide effortlessly beneath the skin. Over time, the area surrounding the end of the Dracunculus becomes suppurated. Eventually, the skin ruptures, and the head of the Dracunculus emerges.
However, if the Dracunculus is forcibly removed, it can lead to significant distress, particularly if it breaks during the attempt. The remnants left behind can cause intense pain. To prevent the creature from retracting, the affected limb should be firmly bound with a strong thread. This procedure must be repeated daily, allowing the Dracunculus to advance gradually while being restrained by the binding, thus avoiding any breakage.
The affected area should be bathed with Aqua Mulsa and an oil infused with either wormwood or southernwood, or other medicinal remedies designed to treat intestinal worms.
If the Dracunculus is able to move forward on its own, it can be easily extracted without additional intervention. However, if it progresses to suppuration, we must continue applying cataplasms, Aqua Mulsa, and oil. Traditionally, after removing the cataplasms, it was customary to apply Emplastrum e Baccis Lauri. In cases of suppuration, the skin should be incised longitudinally to expose the Dracunculus, which must then be carefully removed. The incision should be packed with lint, and the usual suppurative treatment should be administered. This approach ensures that once the creature is successfully extracted, the wound can heal and eventually form a scar.
Rhasis notes that when the affected area forms a blister and the vein becomes accessible, it is beneficial for the patient to take half a dram of Aloes on the first day, one dram on the second day, and two drams on the third day. Similarly, the affected area should be fomented with Aloes, as this will help bring to the surface what is hidden. The emerging segment must then be coiled in a lead pipe weighing approximately one dram to allow it to hang down—this added weight will encourage further protrusion of the vein. Once the protruding segment has extended significantly, it should be cut, but not at the root; instead, a portion must remain visible so that a lead pipe can be attached. This is crucial, as failing to do so may result in the segment retracting into the skin and its hiding place, potentially leading to a putrid and malignant ulcer.
Therefore, we must approach this disease with care, gradually extracting the vein from the body until it is completely removed to prevent further complications. However, if it occurs that a significant portion of the vein is cut off at the root, the ulcer should be longitudinally incised with a surgical knife to ensure all remnants are fully excised. Following this, the affected area must be anointed with butter for several days until any remaining necrotic material is consumed by putrefaction and discharged. Subsequently, the ulcer should be treated with sarcotic agents to promote healing.
Thus, Rhasis articulates the same concept using various terms, equipping himself with iron and lead as if preparing to confront a fierce beast. In contrast, Soranus, a physician contemporary with Galen, holds a differing viewpoint, as noted by Paulus Aegineta in the previously cited reference. Soranus argues that the Dracunculus is not a living organism but rather a condensation of a small nerve, which appears to both physicians and patients as having some movement beneath the skin.
Thus, Soranus appears to have approached the truth more closely than others; however, he does not fully comprehend or grasp the essence of this disease, as we will demonstrate later. Manardus asserts that Dracunculi arise from corrupted and undesirable blood—specifically, from gross, hot, and melancholic blood or from excessively desiccated phlegm.
Gorraeus, a highly learned physician of our time, argues in his “Lib. de Definitionib. Medic.” that no physician today can adequately discuss Dracunculi, as it is a disease so rare in our regions that it is seldom encountered in practice. The author of the “Introduction and Medicinal Definitions” characterizes Dracunculus as a condition akin to Varices, noting that it causes significant pain as it gradually progresses. Consequently, it should be treated in a similar manner and by the same methods of section and incision employed for Varices. This comparison particularly seems to have influenced Guido in his treatise on impostumes, as he identifies Dracunculus with Varices, citing their shared causes and the similarity in their treatments.
While various names have been attributed to this disease by several authors, they all refer to it as a vein-related condition. Avicenne and Guido term it “Vena Meden,” as it is prevalent in the city of Medina. Albucrasis calls it “vena civilis,” while Haliabbas refers to it as “vena famosa.” Others simply label it “Vena Cruris,” or the leg vein. The existence of such a multitude of conflicting opinions—not only among different writers but also within their own arguments—clearly indicates the uncertainty surrounding the essence of this disease as expressed by those who have documented it. Moreover, it is noteworthy that contemporary physicians have contributed little further to the discourse on this subject. Although Jacobus Dalechamphius, a physician well-versed in all branches of medicine, has extensively addressed this issue in his book on French surgery published several years ago, he offers no substantial insight beyond diligently compiling the writings of the ancients without providing his own perspective, in an attempt to clarify this contentious topic.
However, my modesty compels me to choose the risk of being perceived as overly bold rather than allowing the question of Dracunculi to remain ambiguous and unresolved for any longer. Consequently, I will proceed by refuting the views of the ancients while presenting specific reasons to support my own understanding of the essence and treatment of this disease.
First and foremost, it is straightforward to refute the notion that Dracunculi are living organisms, akin to worms, or share the same origin as the flatworms found in the abdomen—a view held by Aetius. This can be demonstrated both through his writings and through logical reasoning. Aetius asserts that the broad worm, which he refers to as Tania, represents a transformation or metamorphosis of the inner lining of the small intestine into a living, mobile entity.
However, no one has ever claimed, nor will anyone admit, that Dracunculi originate from the tunic of the vein in which they are encased, or from the fibers of a nervous structure to which they are often attached. Even less likely is the notion that they derive their material causes of origin from the skin beneath which they reside.
Furthermore, the generation of worms or any other living creatures from putrefaction cannot occur without the corruption of some material. According to Aristotle, it is only from the more benign and superior aspects of that material, acted upon by vital heat, that nature can produce a living organism. Thus, for this process to take place, the material must possess a suitable disposition towards putrefaction, as is necessary for the generation of a creature like the Dracunculus. Additionally, it is essential that the accompanying causes work in concert with the primary factors in this process, and that the environment be appropriate for such generation to occur.
However, numerous causes may contribute to the life of Dracunculi. According to a general consensus among those who have studied them, their generation arises from a melancholic humor that is terrestrial and coarse. This humor, characterized by its initial coldness and dryness, as well as its subsequent acidity, is widely regarded as highly unsuitable for putrefaction; in fact, it is often seen as resistant to the processes of decay typically induced by heat and excessive moisture. Furthermore, if the material cause of this disease were indeed a humor undergoing putrefaction and transforming into a living organism, one would expect an accompanying stench, as this is an inseparable characteristic of putrefaction. Indeed, the excrement within the intestines, where these worms are generated, is inherently foul-smelling.
Therefore, the exhalations from the bodies afflicted with Dracunculi should presumably carry a foul odor, similar to those observed in individuals suffering from Pthiriasis or Lewsie-evil. However, none of the texts detailing the symptoms or occurrences associated with Dracunculi mention this phenomenon. Regarding the efficient cause of the significant heat that may develop in the areas just beneath the skin—enabling the formation of such creatures from a melancholic matter resistant to putrefaction—the Dracunculus is portrayed as one that transforms our bodies into fertile grounds for these monstrous entities. This is particularly intriguing given that the surface of the body is continuously ventilated by the fine arteries located beneath the skin and is aided by insensible perspiration, along with the cooling effect of the surrounding air. Yet, considering the material and efficient causes are either deficient or notably weak for producing such a complex result, what auxiliary factors could contribute to this process? Could it be the humidity present in certain foods? For instance, those individuals who consume warm and moist foods, such as milk, cheese, and summer fruits, generally see an increase in worm populations, as has been confirmed through observational evidence in children.
Conversely, Avicenna asserts that meats with a hot and dry temperament are primarily responsible for the onset of this disease, noting that it is less common among moist bodies—particularly those accustomed to bathing, as well as those who consume moist foods and moderate amounts of wine. However, one may wonder whether the atmospheric conditions in regions where this disease is endemic contribute to the proliferation of such creatures. Indeed, a warm, cloudy, and humid atmosphere—characteristic of early spring, when the environment resonates with the sounds of frogs, toads, and similar organisms that emerge from decay—could play a significant role in this process.
In contrast, Jacobus Dalechampius, supported by the consensus of physicians who have studied Dracunculi, claims that this disease arises in the arid and sun-scorched regions of India and Arabia. He suggests that if the part of the body directly beneath the skin provides an environment conducive to the generation and sustenance of such creatures, it lends some credibility to the assertion that the Dracunculus is indeed a living organism. However, if this area lacks the conditions necessary for generation or for nourishing such creatures—unlike the intestines, which are typically subjected to warmth and filth—it becomes less tenable to consider their existence. If this region is free from excessive heat and contamination, and if the only influence is from subtle exhalations that evaporate insensibly through the skin’s pores, it could appear to be a valid explanation for such monstrous and extraordinary outcomes. Nevertheless, these rational arguments will yield little value unless we decisively dismantle the entrenched defenses of the longstanding belief regarding Dracunculi.
Why have the ancients referred to this type of disease by the name of a living entity, specifically a Dracunculus or “little serpent”? In the field of medicine, names are often assigned to diseases based more on similarity than on the true nature of the condition. To illustrate this point, three examples suffice: cancer, polypus, and elephantiasis. These terms do not imply that crabs, polyps, or actual elephants can develop within the human body. Rather, the name cancer arises from the way the disease spreads into surrounding tissues, resembling the claws and limbs of a crab. Similarly, polypus evokes the texture of a sea polyp, and elephantiasis is named for the wrinkled, rough skin resembling that of an elephant.
In a similar vein, the disease we are currently examining seems aptly named Dracunculus, as its form, coloration, characteristics, and elongation all evoke the image of a serpent. However, one might ask, if it is indeed lifeless, what accounts for the observable motion? I would respond that the fluid responsible for this condition is both subtle and heated, allowing it to flow forcefully into affected areas, thus creating the appearance of movement.
When the Dracunculi are extricated, why do they appear to protrude their heads from their cavities? Here, the ancients were likely mistaken, as the process of suppuration and the subsequent opening of the ulcer may reveal a nervous structure that, under convulsive motion, mimics the serpentine writhing. Critics might argue that pain occurs only in living, sentient beings, yet the Dracunculus, when forcibly extracted—especially if it breaks—can indeed cause excruciating pain. I contend that this conclusion is flawed; such pain arises only when an inexperienced surgeon inadvertently pulls out a swollen nervous or membranous body filled with heated fluid, leading to intense discomfort in the region responsible for sensation.
It is, therefore, naïve to assert that the Dracunculus possesses the ability to feel, despite its ability to inflict sharp pain on the living body it inhabits. In concluding our inquiry into the nature, essence, and origin of these Dracunculi, I confidently assert that they are nothing more than a tumor or abscess, generated from the heated blood in a toxic state. Blood, driven forcefully through the veins to the extremities—particularly the arms and legs—can manifest as elongated, rounded tumors, which may extend from the shoulder joint to the wrist, or from the groin to the ankle, accompanied by tension, heat, pricking pain, and fever.
These tumors may extend both straight and obliquely, which has led many afflicted individuals to perceive their contorted limbs as a serpent wrapped around them. This is my account of the nature of Dracunculi, particularly those found in our own country.
The treatment for this condition bears similarity to that of a phlegmon resulting from a defluxion. In both cases, the remedies must be tailored according to the four stages of the disease. The same principles of diet, phlebotomy, and purging, as outlined in the treatment of phlegmon, must also be adhered to here.
The mention of Dracunculi brings to mind another rare form of abscess that the French refer to as “Cridones,” likely derived from the term “Crinibus,” meaning “from hairs.” This condition predominantly affects children, causing discomfort that feels like thorns pricking their backs, leaving them restless and unable to find relief. This ailment stems from small hairs, barely the length of a pin, yet thick and resilient.
To treat it, one should begin with a fomentation of water that is warm but not too hot. Following this, an ointment made of honey and wheat flour should be applied to entice and extract the embedded hairs. Once the hairs are drawn to the surface, they must be carefully removed using small forceps. It seems likely that this particular condition was unknown to ancient physicians.
The End of the Eighth Book.
Herpes is a type of tumor caused by pure bile that has separated from the other bodily humors. Due to its natural lightness and thinness, it travels to the outer skin and spreads across its surface. Galen identifies three types of this tumor. If the bile is of a pure and moderate consistency (not too thick), it produces simple herpes, which is named after its genus. If the humor is not as thin and is mixed with a small amount of phlegm, it will create small blisters on the skin resembling the seeds of a miller (a grain). This is why the Ancients referred to this type of tumor as herpes miltaris. However, if there is any mixture of melancholy (black bile), it will result in an erosive herpes (herpes exedens), which is severe due to its ability to erode the skin and underlying muscles.
There are three primary approaches to treatment. The first is to prescribe a diet similar to that discussed for the treatment of erysipelas. The second is to eliminate the underlying cause by using medicines that purge the harmful humor. Often, enemas are sufficient for this purpose, especially if the patient has a naturally easy constitution and if the urine flows as desired, as this can help carry a significant portion of the humor into the bladder. The third approach is to address the immediate cause with local medicines aimed at reducing the swelling and treating the ulcer. Therefore, the surgeon must focus on two aspects: resolving the tumor and drying up the ulcer, as every ulcer requires drying, which cannot be achieved unless the swelling is reduced. Since the primary concern is to eliminate the tumor, which is essential for healing the ulcer, he should apply a medicine that dissolves and dries, such as:
Prescription:
Or
Prescription:
Cook the barley flour and lentils in a decoction of pomegranate bark and plantain, adding powdered red rose and wormwood, then myrtle oil and common honey, to make an ointment as is customary.
For herpes miltaris, the following should be primarily used:
Prescription:
Mix to make an ointment for use.
I have often found that unguentum enulatum with mercury is very effective, as it destroys the pustules and partially reduces the humor contained within them. However, if the ulcer does not yield and continues to spread further each day, you should treat the edges and lips of the ulcer with a caustic medicine, such as Aqua fortis or oil of vitriol, or something similar. This type of remedy has often allowed me to heal stubborn ulcers that seemed completely incurable.
The primary causes are generally vigorous exercise, especially in hot weather, the consumption of heating and drying foods or medicines, significant abstinence combined with intense labor, and emotional stress such as worry or sorrow. The antecedent causes include an excess of bile in the body, and a hot and dry imbalance either throughout the body or specifically in the liver. The conjunct cause is the putrefaction of the choleric humor, which is abundant in certain areas outside the larger vessels within the body.
Signs of these fevers include shivering or shaking, similar to the sensation of having urinated on a cold winter morning, along with a significant prickling, stretching, or stiffness throughout the body, as if pins were being thrust into the skin. This is due to the acridity of the choleric humor that spreads erratically and violently throughout the body, affecting the sensitive membranes and nervous tissues at the onset of the fever. The heat then becomes intense, and the fever ignites like a fire in dry straw. The pulse is strong, rapid, and regular; the tongue is dry; and the urine appears yellowish, red, and thin.
Symptoms include restlessness, thirst, nonsensical talking, irritability, and an inability to stay still at the slightest noise. These fevers typically resolve with significant sweating. They are common in choleric young men, particularly those who are lean, and tend to occur in the summer. Following the fever, there may be choleric vomiting and yellowish stools. After the episode, there is a complete intermission, with no remnants of the fever until the next episode, because the choleric material is easily expelled from the body due to its natural lightness and fluidity. In contrast, quotidian fevers leave a lingering sense of discomfort due to the stubbornness of phlegm, which resists motion. Each episode usually lasts 4, 5, or 6 hours, although it can extend to 8 or 10 hours. This fever generally concludes after seven episodes and is usually not dangerous unless errors are made by the physician, the patient, or caregivers. Tertian fevers are shorter in summer and longer in winter.
The onset of the episode is often marked by stiffness or stretching, while the state of the fever is characterized by sweating. If the nose, lips, or mouth develop pimples or scabs, it is a sign of the fever’s conclusion and indicates the body’s ability to expel the underlying cause of the illness from the center to the surface. However, these pimples do not appear in all declining tertians, but only when the choleric humor causing the fever resides in the stomach or is drawn there from another part of the liver. The finer portion of this humor can travel through the internal membranes to the mouth and nose, where its acridity can easily cause pimples in those areas. Treatment involves both dietary measures and pharmacological intervention.
The diet should be designed to counteract the six non-natural factors, promoting cooling and moistening as much as the digestive ability allows. Suitable foods include lettuce, sorrel, gourds, cucumbers, mallows, barley creams, and well-diluted wine (thin and small quantities), and it should be consumed sparingly, avoiding food until signs of digestion appear in the urine. At the onset of the fever, the patient should refrain from eating for three hours prior to an expected episode, to prevent the heat from corrupting any undigested food, which could worsen the fever. However, the strictness of this rule can be adjusted based on the patient’s strength; weaker patients may need to eat before or during the episode, but only in small amounts to avoid excessive depletion of strength.
Frequent use of soothing enemas made with decoctions of prunes, jujubes, violets, bran, and barley can be very beneficial. If the patient experiences delirium or nonsensical talking due to the heat and dryness affecting the head, particularly from an excess of choleric humor, the head should be cooled by applying oils of violets, roses, or breast milk to the temples and forehead, and oil should be placed in the nostrils. The feet and legs should be soaked in warm water, and the soles of the feet should be anointed with violet oil or similar substances.
In the later stages, a bath made from vine branches, willow leaves, lettuce, and other cooling ingredients boiled in clean water can be beneficial if taken three hours after a light meal. It is important to understand that this bathing should not occur at the onset of the disease but rather during the decline, allowing the already processed humors to be more easily expelled to the skin due to the warmth of the bath. Initiating a bath too early may cause a blockage in the skin and body by drawing thick and dense humors without prior evacuation.
After general purgations, it is advisable to induce sweating by drinking well-diluted white wine. Urination can be promoted using decoctions of smallage and dill. Sweating is highly beneficial in any putrid fever as it helps eliminate the underlying cause of the disease, especially in tertians, due to the inherent lightness of bile. For sweating to be effective, it should occur on a critical day and be preceded by signs of digestion that align with the nature of the disease. Slower sweats can be encouraged through both internal and external applications; internally, by consuming white wine or decoctions of figs, stoned raisins, grass roots, and other laxative ingredients; and externally, by applying sponges soaked in hot herbal decoctions (such as rosemary, thyme, lavender, marjoram, etc.) to the groin, armpits, and back.
To further promote sweating, two pig bladders or stone bottles filled with the same decoction can be placed on the feet, sides, and between the thighs. The endpoint of sweating should be determined when the patient begins to feel cold, meaning the sweat has turned from hot to cold.
It is widely agreed that bloodletting should not occur after the third episode, but rather at the onset of the fever, in accordance with Galen’s guidance. Since this fever typically resolves after seven episodes, waiting until after the third episode would mean the fever has reached its peak. Hippocrates advises against any interventions during this state, as it may distract nature from its process of resolving the illness.
There are only two types of cold tumors: edema and scirrhus. Although Hippocrates and the Ancients used the term “edema” broadly to refer to all kinds of tumors, Galen and later physicians refined this definition to refer specifically to a particular type of tumor.
An edema is a soft, loose, and painless tumor caused by the accumulation of phlegmatic humor. The Ancients identified eight variations of tumors resulting from phlegm. The first type they called a true and legitimate edema, which arises from natural phlegm. They recognized that unnatural phlegm, due to the mixture with another humor, could lead to three types of tumors: for example, an edema caused by blood was termed an “edema phlegmonodes,” and similar distinctions were made for other mixtures.
Additionally, when they observed unnatural phlegm either inflated with gas or overly watery, they categorized some as flatulent edemas and others as watery edemas. They also noted that when this same phlegm often transformed into a plaster-like substance, it led to another type of edema, which they referred to at different times as “atheroma,” “steatoma,” or “melicerides.” Lastly, they called the type of edema caused by putrid and corrupt phlegm “scrofulae.” It is important to note that phlegm can sometimes be natural and merely excessive, leading to true edema. Other times, it is unnatural, which can occur due to the mixture with foreign substances like blood, bile, or melancholy, leading to the three types of edemas mentioned earlier. It can also become unnatural through the putrefaction and corruption of its own substance, resulting in struma and scrofulae, or through solidification, leading to kernels and various types of wens, ganglia, and knots, or through resolution, resulting in flatulent and watery tumors such as hydrocele, pneumatocele, and all forms of dropsy.
The causes of all edemas are either the flow of phlegmatic or flatulent humor into a specific area or the gradual accumulation of the same in any part due to its weakness in processing nourishment and expelling waste.
The signs of edema include a whitish color similar to the skin, a soft tumor that is rare and lax due to the abundant moisture it contains, and a lack of pain since this humor does not produce a sense of heat or noticeable cold. When you press it with your finger, the imprint remains because of the density of the humor and its sluggish movement. Edemas are more likely to develop in winter than in summer, as winter is more conducive to the accumulation of phlegm. They primarily affect the nervous and glandular parts of the body, as these areas are devoid of blood, cold, and more receptive to the influx due to their looseness. For the same reason, individuals with poor humors, the elderly, and those who are sedentary are particularly susceptible to this type of tumor.
An edema can resolve sometimes through resolution, but more often through solidification, and rarely through suppuration due to the low amount of heat in that humor.
A symptomatic edema, such as that which occurs following dropsy or consumption, cannot be treated unless the underlying disease is addressed first.
The general cure consists of two main aspects: the evacuation of the accumulated matter and the prevention of its recurrence. We achieve both primarily through four methods.
The first method involves establishing a suitable lifestyle and recommending moderation in the use of the six non-natural factors. Therefore, we must choose air that is hot, dry, and subtle; recommend wine of moderate quality for drinking; ensure the bread is well-baked; select meats that can generate good blood, preferably roasted rather than boiled. All fruits, broths, and dairy products should be avoided; instead, the patient should eat fish caught in rocky rivers. The patient should practice moderation in eating, but especially in drinking, to avoid excess moisture. After meals, they should use digestive powders or common digestive aids; if the patient does not naturally have loose bowels, they should be made so artificially.
The patient should engage in exercise before meals to gradually reduce this humor and restore natural heat. They should sleep little, as excessive sleep generates cold humors, and avoid grief and sadness. If the patient is weak, they should abstain from sexual activity to prevent further weakening that could lead to an incurable coldness, which would increase the severity of the accumulated moisture. Conversely, if the body is strong and robust, moderate exercise and sexual activity can help to dry and heat the body.
This aligns with Hippocrates’ assertion that sexual activity can be beneficial for phlegmatic diseases, as Galen mentions in his writings. The physician can further address the issue by focusing on the area from which the phlegmatic humor originates. If the problem arises from the stomach or another specific area, that area must be strengthened. If the issue is systemic, then medications that are attenuating, penetrating, and opening should be prescribed.
The third approach involves evacuating the accumulated humor in the affected area using localized treatments tailored to the different stages of the tumor. Galen advises using a fomentation of oxycratum with a sponge at the beginning and during the increase of the condition. If the edema is on the arm or leg, a repelling roller applied from below upwards is very effective.
The following remedies are also suitable for this purpose:
Prescription:
Mix all together and make a decoction in which wet sponges can be soaked and then applied to the area.
Additionally, you may use the following poultice:
Prescription:
Mix to create a poultice.
During the later stages and decline of the condition, drying and resolving medicines should be employed, such as:
Prescription:
Boil with lye; foment with a sponge, then immediately apply the following poultice:
Prescription:
Boil in honey-water, mash, strain, and add 1 ounce each of crushed red rose, chamomile, and sweet clover to create a poultice.
Finally, you can successfully use resolving plasters and ointments after first heating or stimulating the area with either moist or dry massage or fomentations; otherwise, the plasters may not work effectively due to the coldness of the area, which can hinder the absorption of nourishment and the expulsion of excess and unhelpful humor.
A fomentation can be made with white wine, boiled with sage, rosemary, thyme, lavender, chamomile, and sweet clover flowers, as well as orris roots, staecha, and similar herbs, with a small amount of vinegar added. Soak hot bricks in this decoction and apply them wrapped in linen cloths to the affected area, allowing vapor to be released that has attenuating, penetrating, resolving, and strengthening properties. Alternatively, you can use hog or ox bladders filled halfway with the same hot decoction. Massage should be performed with hot linen cloths to help restore the natural heat along with blood and spirits to the area, resolving the stagnant humors trapped beneath the skin and partially restoring the strength of the area.
I have previously stated that the term edema encompasses not only flatulent and watery tumors but also those formed from congealed phlegm, such as Atheromata, Steatomata, and Melicerides. Flatulent or windy tumors are caused by vapor and gas that are trapped either beneath the skin or within membranes, such as the periosteum and pericranium. This leads to severe pain due to the distention of these areas, which are highly sensitive. Sometimes, the internal organs, like the stomach and intestines, become swollen and stretched from gas, as seen in tympanites (abdominal distention).
These tumors differ from true and legitimate edema in that when you press on them with your finger and then remove it, there is no residual mark left, because they are distended by vapor rather than fluid. The vapor, when pressed, quickly returns to its original state, similar to balls or bladders filled with air.
The cause of such tumors is the weakness of the body’s natural heat, which struggles to dissolve and eliminate the phlegm that leads to the formation of these windy tumors. This is akin to how the morning sun (which somewhat resembles our natural heat) cannot dissipate the mists in the air, but can easily convert them into clear air by noon. In a similar way, our weaker internal heat can stir up vapors from phlegm it cannot dissolve, and these vapors become the material for swellings or tumors. However, even if the natural heat is sufficiently strong, if the humor is situated deep within or trapped by the thickness of a membrane, tendon, or ligament, the vapor cannot escape. Consequently, as it gradually accumulates, it produces a tumor.
The signs of such a tumor include a certain resistance felt when pressing it with your finger, and sometimes a sound like striking a drum, especially if there is a significant amount of gas trapped inside, as often occurs in the hollow of the abdomen and in the spaces between larger muscles. The tumor is neither red nor hot, but rather cold and white, resembling edema. It often affects the joints, particularly the knees, and is very difficult to resolve. If such flatulence accumulates in the intestines, it can lead to wind colic, where the distention may become so severe that it results in death due to the tearing of the intestinal walls.
We will primarily treat flatulent and watery tumors through three main methods. First, by the same diet that we prescribed for edema; second, by strengthening the organs responsible for digestion, particularly the stomach and liver, mainly through the moderate use of aromatic substances such as Diacuminum, Diacalamenthae, Aromaticum caryophyllatum, and Aromaticum Rosatum, which should be prescribed according to the physician’s discretion; lastly, by eliminating the accumulated matter using hot, drying, and attenuating medicines known as carminatives, so that the affected area becomes less dense, allowing the humor and gas contained within to disperse and dissipate. However, these remedies should be adjusted based on the specific area affected; for some treatments are suitable for the stomach, others for the intestines, others for the joints, and others for fleshy areas. For colic, carminative enemas should be administered, resolving bags or pouches should be applied, and cupping glasses should be attached to the navel. If an external area is affected, we use fomentations and liniments, especially if pain is present; we may also use poultices and plasters, such as:
Prescription:
Boil these in lye, adding a little vinegar for a fomentation to be used with sponges.
Galen recommends fomenting the area with rose vinegar and a little salt added, and suggests that a sponge dipped in this mixture should be left on the affected area for some time.
Prescription:
Mix everything together to make a liniment, which should be used to anoint the area after fomentation.
Prescription:
Cook the flour in a decoction of the other ingredients.
Prescription:
Cook the flour of broad beans and peas in common lye. Add the rest of the ingredients.
This will create a plaster for the aforementioned use.
The Vigo plaster with mercury, both with and without it, is also very effective for this purpose. It is important to note that such medicines should be applied to the area while it is still warm, and that heat should be maintained and renewed by surrounding it with linen cloths, hot bricks, bottles, and similar warm objects.
Once the humor and gas that was trapped in the area have been resolved, it is essential to strengthen the area to prevent the recurrence of similar issues. This can be achieved through the following fomentation and poultice:
Prescription:
Boil everything in equal parts of bean water and sour wine, and use this as a fomentation in bags, or apply the decoction with a sponge.
Prescription:
Use as much of the aforementioned decoction as needed to create a sufficiently liquid poultice, and apply it hot to the affected area after using the fomentation.
The signs of a watery tumor are similar to those of a flatulent tumor; however, it appears shiny, and when pressed with your fingers, you can hear a hard noise or murmur as if it were a bladder partially filled with water.
Therefore, if the watery tumor does not respond to the aforementioned resolving medicines, an incision must be made to open it, similar to the method we discussed for treating a phlegmon. Often, this type of remedy is necessary, not only due to the stubbornness of the humor that resists resolving treatments but also because it is contained within its own cyst or bag, the thickness of which prevents the resolving medicines from penetrating effectively. I learned this through experience several years ago with a seven-year-old girl who suffered from a hydrocele (a fluid-filled sac). When I hastily applied various resolving treatments, I ultimately had to open it with my knife—not only to evacuate the fluid but also to remove the bag itself, as failing to excise it completely would result in a relapse. John Altine, a doctor of medicine, called me to assist with this case, and James Guilemeau, the King’s surgeon, oversaw the treatment.
Although these tumors might be considered part of the same category as other edematous tumors, they differ in that their contents are enclosed in a sac or pouch, as if contained in a unique cell. However, they also differ from one another: the substance of the Steatoma, as the name suggests, resembles tallow, but it is often found filled with various hard substances, such as stones, bones, or callous materials resembling the claws of a hen. Philoxenus reports that he sometimes saw flies in a Steatoma at its opening, along with other foreign bodies that are entirely different from the typical matter found in tumors. The material contained in an Atheroma is similar to the porridge that is fed to small children. A Meliceris contains a substance that resembles honey in both color and consistency; these tumors appear and develop without any preceding inflammation.
You can identify these tumors as follows: a Steatoma is harder than the other two and does not yield to finger pressure; however, once it does yield, it does not quickly return to its original shape due to the denser matter it contains. It has the same color as the skin, is painless, and has an elongated shape. The Meliceris, on the other hand, yields to touch, being a loose and soft body, and as it is easily displaced, it quickly returns to its original form. It differs from the Atheroma in both shape and substance, being more rounded and composed of a subtler, shinier matter; it also occupies a larger space and is more pliable to touch, and like the others, it is painless.
Regarding the surgeon’s manual operation for treating these tumors, it seems that the specific type of substance—whether it resembles tallow, honey, or porridge—is not of great importance, as there is one straightforward method of operation: you simply remove the contained fluid and the sac in which it is held. However, it is essential to note that some tumors may appear to hang loosely on the skin’s surface and can be easily moved in different directions, while others are deeply embedded and firmly adhere to surrounding tissues, requiring a skilled hand and careful technique to avoid excessive bleeding or the risk of cutting a vein, which could lead to convulsions.
There are many other types of tumors, such as the Testudo (or Mole), Nata, Glandula, Nodus, Botium, and Lupia, which, in terms of their composition (as they are all made up of thick, sticky, and viscous phlegmatic humor), also share similarities with Atheroma, Steatoma, and Meliceris. Furthermore, when these tumors are opened, you may often find various substances that differ significantly from the typical tumor matter, including stones, chalk, sand, coal, snails, straw, corn husks, hay, horn, hair, hard and spongy flesh, cartilage, bones, and even entire creatures, both living and dead.
The generation of such substances (due to the corruption and alteration of humors) should not surprise us if we consider that, just as nature has made man a microcosm—a small version of the larger world—so too does it allow for all kinds of motions and actions to manifest within him, as long as the material for generation is present. However, since there is little, or rather no, mention of these tumors in ancient texts, we will briefly outline the opinions of later writers regarding them.
Now, they say the Testudo is an abnormal growth that is soft, diffuse, or vaulted, resembling a tortoise; sometimes it appears on the head in the form of a mole, and is then referred to as a mole.
The Nata is a large, fleshy tumor, somewhat resembling a melon or the flesh of a man’s buttocks, which may explain its name, as it tends to occur more frequently in that area than elsewhere on the body.
The Glandula derives its name from the acorn (called “glans” in Latin), as it somewhat resembles an acorn in shape and size; it most commonly develops in the glands or ducts of the human body.
The Nodus, or knot, is a round, hard, and immovable tumor, named after a knot tied in a rope. Guido Cauliacensis asserts that knots typically grow in nervous tissues, but they are now more commonly found on the bones of individuals suffering from the French disease.
A Wen, or Ganglion, is a tumor that can be hard or soft, but is always round, typically forming in dry, hard, and nervous tissues. Some tumors mentioned in the previous chapter are immovable because they are not enclosed in a cyst or sac; others can be moved up and down when touched because they are enclosed in a bag or bladder. Generally, Wens have their own bladder to contain them, which is why we find it appropriate to discuss their treatment more freely and in detail, as they are often more difficult to cure, especially when they are old and longstanding.
The primary causes of these tumors are blunt trauma, falls from heights, strains, and similar incidents. The associated and contributing causes are the same as those for Atheroma, Meliceris, and Steatoma.
The description given earlier will help you recognize when they are present; they typically grow slowly from very small beginnings to a considerable size over six or seven years. Some of them yield significantly to touch, and almost all are painless.
To prevent the growth of those that are just beginning, you can rub them strongly and frequently with your fingers. This will cause the bladder and skin to thin, and the contained fluid will become hot, thin, and resolve. However, if this does not work, you should apply your entire hand or a flat, heavy piece of wood until the cyst or bag is broken by pressure. Afterward, apply and tightly bind a plate of lead, coated with mercury, as I have found through experience that it has a remarkable ability to dissolve and reduce the contained fluid. If the Wen is in a location where strong pressure cannot be applied, such as the face, chest, abdomen, or throat, you should use a plaster with resolving properties, such as the following:
Prescription:
Liquefy the ammoniac gum, bdellium and galbanum in vinegar and strain through a fine cloth. Add the lily oil, laurel oil, a little aqua vitae, and orris powder, ammonium salt, live sulfur, and Roman vitriol.
Mix them all together to create a plaster according to the art.
If the tumor cannot be resolved in this way, it must be opened with a knife or cautery. After the eschar is removed and the bag is treated with Egyptian ointment, mercury, or similar substances, the ulcer must be cleaned, filled with healthy tissue, and allowed to heal.
Sometimes Wens grow to such a size that they cannot be treated with the remedies described, and must be removed entirely by hand and instrument, provided there is no danger due to their size, and that they do not adhere too closely to surrounding tissues or major veins and arteries; in such cases, it is better to leave them alone.
To remove them, make a small incision down to the bag, and insert a probe about the thickness of a finger, hollowed in the middle and rounded at the end, as long as necessary. Then, move it around between the skin and the bag to the root of the Wen, so as to divide the skin lengthwise. Next, make another incision crosswise, so that the cuts intersect like a cross. Then, carefully pull the skin away from the bag from the corners of the Wen towards the root, using your finger covered with a fine linen cloth, or a razor if necessary.
You must be aware that a Wen always contains certain vessels that start small but can increase significantly over time as the Wen grows, acting like roots. Therefore, if any hemorrhage occurs, it is important to stop it by binding the vessels at their heads and roots, or by making a ligature at the roots of the Wen using a piece of whipcord or a doubled thread, leaving the ends hanging until they fall off on their own.
It is not enough to simply remove the tumor; you should also excise a portion of the skin covering the tumor, leaving just enough to cover the area, and then stitch the edges of the incision together. In the meantime, place tents in the bottom of the ulcer until it is completely cleaned, and perform the remainder of the treatment properly, including the healing process.
The surgeon Collo and I used this method, in the presence of Master Dr. Violanius, the King’s physician, to remove a Wen from Martial Colard, the Mayor of Bourbon. It hung from his neck, as large as a man’s head, and weighed eight pounds, making it so troublesome and burdensome that he had to carry it wrapped in a towel, like a satchel.
Indeed, if these types of tumors have a slender root and a broad top, they must be tightly tied and then cut off. However, it is very difficult and fraught with danger to remove Wens located in the neck, near the jugular veins, under the arms, in the groin, or behind the knees due to the potentially deadly consequences that may arise from such procedures. We can only speculate about the nature of the material contained within them, and we can only ascertain its type when it is revealed to us through incision.
In cases where the Wen is very hard and resists touch, it is often found that the material inside resembles small stones or pebbles.
Once, when called to perform an autopsy on a great lady, I discovered a mass in one of her breasts that was about the size of a hen’s egg, hard and compact like a rough pebble. While she lived, both physicians and surgeons believed it to be cancer, because the hardness caused her significant pain even with gentle pressure.
A few years ago, I was called to treat a very respectable woman suffering from a similar ailment, who strongly resisted the physicians and surgeons’ claims that it was cancer. The tumor had not taken deep root, the tissue color remained unchanged, the veins around it were not swollen, and there were no other convincing signs of cancer. This woman had regular menstrual cycles, was in good health, had a good complexion, and experienced no pain except when the affected area was pressed. Moreover, the tumor did not grow any further, and she experienced no other adverse effects; indeed, she lives happily and well, both physically and mentally.
There are also certain small tumors similar to Wens, known as Ganglions, which grow on various parts of the body, but most commonly on the wrists and ankles. These tumors appear on the surface of the skin and do not lie deep within. The cause of these ganglions is usually the weakness of a nerve or tendon, resulting from twisting, stretching, a blow, labor, or other similar causes. As a result, the nourishing fluid that flows to these areas cannot be properly processed or assimilated into the surrounding tissue, and instead, it transforms into a cold and thick humor. Over time, this fluid accumulates gradually around the fibers and the very substance of the tendon, eventually solidifying into a tumor.
It is not advisable to use any metal instruments on these ganglions that affect the tendons and joints. Instead, apply a mixture of ammoniac gum and galbanum dissolved in vinegar and aqua vitae. The recipe is as follows:
Prescription:
Dissolve ammoniac gum and sagapen in aqua vitae. Boil over warm ashes to form a plaster, and at the end, add powdered live sulfur to make a plaster for use.
Additionally, Vigo’s plaster with double mercury would also be effective for the same purpose.
Once the tumor has been softened by these remedies, it should be manipulated, rubbed, or pressed until the bladder or sac breaks under your fingers, which I have done several times. After this, it is advisable to immediately apply and bind a lead plate rubbed with mercury over the area, which will help to break down the remaining tumor.
Sometimes ganglions appear to hang by a small root, resembling a string. In these cases, they should be tied at the root with a string and gradually pulled tighter each day until they fall off. The rest of the treatment can then be carried out according to the common rules of medical practice.
Scrophulae are swollen tumors that arise in glandular areas, such as the breasts, armpits, groins, and primarily in the glands of the neck. They can appear as single or multiple tumors, depending on the amount of matter from which they originate, typically contained within their own cyst or sac, similar to Atheromas, Steatomas, and Melicerides.
These tumors consist of a thick, cold, viscous, and phlegmatic substance, with some mixture of melancholy. They differ from other glandular tumors primarily in their number; scrophulae often appear in clusters, stemming from a deeper root than typical glandular tumors. Some scrophulae are movable, while others are intertwined with nearby nerves and remain fixed.
Ganglions usually appear in smaller numbers and are painless, whereas scrophulae can often be painful, especially when they become inflamed due to putrefaction, occasionally degenerating into cancerous ulcers that should not be treated with instruments or harsh medicines.
Individuals who are phlegmatic, melancholic, gluttonous, or who consume cold and moist foods, such as fish and cold water, and lead a sedentary lifestyle are more prone to developing scrophulae. Treatment involves a very light diet, as this allows the body’s natural heat to focus on the material cause of the tumors, gradually reducing them.
They can also be treated by purging excess humors and applying emollient, resolving, and suppurative topical medicines, prepared as follows:
Prescription:
Mix together to form a plaster, using enough wax as necessary
The ointment for the French disease and the Emplaster of Vigo with mercury are excellent for this purpose, especially if treatment continues until the patient experiences salivation, as this allows Nature to rid itself of the humor causing the scrophulae, which I have sometimes successfully observed.
Prescription:
However, if the scrophulae cannot be resolved through these means and tend towards suppuration, you must use suppurative treatments, such as:
Prescription:
Boil the marshmallow and lily in common water, then strain and add the lily oil, goose fat and duck fat, along with enough flaxseed meal to form a poultice.
It’s important to advise the surgeon not to open the scrophulae until all the contained humor has fully transformed into pus. Otherwise, the remaining humor will remain unripe and may take a long time to mature. This principle should be particularly followed with scrophulae and sometimes with other abscesses that have reached suppuration. We should not hasten to open the abscess as soon as any portion of the contained humor appears to have turned into pus. The portion that has already suppurated helps the remaining humor to convert into pus, which can be observed in inanimate bodies. For example, fruits that begin to rot will cause the rest to spoil quickly unless we immediately remove the decaying part.
Another reason is that the body’s natural heat is the effective cause of suppuration; if the sore is opened prematurely, this heat will diminish due to the escape of vital spirits along with the humor, making it difficult for the remaining humor to suppurate. However, if the swollen part is prone to corruption and putrefaction, or if the contained matter is malignant or critical, it may be better to hasten the opening.
There is also another method of treating scrophulae that involves surgical intervention. For those located in the neck and lacking deep roots, incisions can be made through the skin to pull and cut them away from the surrounding tissues. Special care must be taken not to damage the jugular veins, carotid arteries, or recurrent nerves. If there is any risk of significant blood loss, after removing the tumors, they should be tied at their roots using a needle and thread, binding the thread securely on both sides so that the tumors can detach themselves gradually and safely. The remaining treatment can proceed according to standard medical practices.
A quotidian fever recurs daily, lasting for about eighteen hours, followed by a noticeable intermission for the remainder of the day. The primary causes of this fever include the coldness and humidity of the surrounding air, prolonged consumption of cold foods and drinks, as well as items that are prone to spoilage, such as summer fruits, raw fish, and the neglect of regular physical activity.
The antecedent causes consist of a significant accumulation of tumors, particularly phlegmatic ones. The conjunct cause is the putrefaction of phlegm within the body and its primary regions outside the major veins.
The signs of this fever can be categorized into three groups. First, those related to natural factors: this fever or ague primarily affects individuals with a cold and moist constitution, such as the elderly, women, children, and eunuchs, who tend to have an abundance of phlegm. It particularly targets the elderly due to their diminished natural heat, which prevents them from converting food into healthy blood and bodily substance. In children, the fever occurs more by chance; although they are naturally hot and moist, their voracious appetites and excessive, unrestrained activity after eating lead to the accumulation of crude humors, making them susceptible to this fever. Consequently, overweight children often suffer from this type of fever because their bodily passages may be constricted or blocked, or they may be affected by worms, leading to pain from the corruption of their food, which in turn causes a hot disturbance from putrefaction and the release of putrid vapors, ultimately irritating the heart and making it vulnerable to this fever.
From the perspective of unnatural factors, the signs of this fever are observed primarily in winter and spring, particularly in cold and moist regions, among those who lead a sedentary lifestyle, and through the consumption of foods that are not only cold and moist but also hot and dry, if consumed in excessive quantities that overwhelm the body’s natural heat.
For example, although wine is inherently hot and dry, drinking it excessively can lead to the accumulation of phlegmatic humors and cause cold-related illnesses. Thus, drunkenness, gluttony, the consumption of raw foods, and physical exertion immediately after eating can introduce crude substances into the body and bloodstream. In conclusion, any factors that significantly increase phlegm in the body may lead to a quotidian fever. Additionally, due to its tendency to follow cold diseases, this fever often arises when the body’s center, circumference, and overall condition are chilled.
Symptoms of this fever include pain in the stomach area, where phlegm is typically concentrated, often resulting in vomiting or expulsion of phlegm. The face appears pale, and the mouth remains moist without thirst, often during the fever itself because the stomach, filled with phlegm, causes the watery and thinner portions to continuously rise into the mouth and tongue through the continuity of the stomach lining shared with the esophagus and mouth.
The individual experiences coldness in the extremities, a small and weak pulse, which, despite the vigor of the fit, may become stronger, larger, fuller, and quicker. Similarly, the heat of this fever initially feels mild, gentle, moist, and vaporous, but eventually becomes more acrid—much like a fire kindled in green wood, which starts small, weak, and smoky but eventually burns brightly as the moisture is overcome.
Patients are often relieved from their fits through minimal sweating, which initially occurs sparingly but becomes more abundant as the crisis approaches. Initially, the urine is pale and thick, sometimes thin when there is an obstruction. However, once the matter is processed, it turns red. If the patient vomits a considerable amount of phlegm at the onset of the fit, followed by substantial sweating, this indicates that the fever will not last long, suggesting the body’s strength and the expulsion of the underlying cause of the fever.
Treatment involves two approaches: diet and medication. The diet should be light and reducing; the patient should breathe in moderately warm and dry air. Recommended foods include well-baked bread, chicken or hen broths with boiled roots such as parsley and sorrel. Occasionally, the use of hot foods, especially spiced and salted items, can be beneficial, particularly for those whose stomachs and livers are significantly cooled. Suitable foods include chicken, mutton, partridge, small birds, and river fish that are either fried or broiled, as well as raw eggs and similar items. Fruits such as raisins, stewed prunes, almonds, and dates are also good choices. The patient should drink small amounts of white wine mixed with boiled water. Moderate exercise and full-body massages are helpful, as is sleep taken at appropriate times, ensuring that sleep does not coincide with the fever’s onset, as this can exacerbate the condition by drawing heat inward and intensifying the fever.
For mental well-being, it is important for the patient to remain cheerful and hopeful about recovery. Some recommend immersing the feet and legs in hot water infused with chamomile, dill, melilot, marjoram, sage, and rosemary at the onset of the fever.
Medicinal treatments should include digestive and aperitive syrups. Laxatives should be prepared as potions or administered in the form of a bolus with sugar, depending on the physician’s judgment regarding the patient’s condition.
Regarding the state of the illness, it is crucial to care for the stomach, particularly the mouth, as it is the primary site of phlegm accumulation. Therefore, it is advisable to anoint the mouth every other day with chamomile oil mixed with a little white wine, and to expel phlegm through vomiting induced by radish juice and copious amounts of oxymel or a decoction of asarum seeds and chamomile. A syrup made from vinegar is particularly beneficial at the beginning of the fit when nature and the humors begin to stir. For a chronic quotidian fever, if no other remedy is effective, a dram of old treacle taken with sugar in the form of a bolus or dissolved in aqua vitae is thought to be particularly helpful.
These tumors include hardness, resistance to pressure, a dark color, and the dilation of the veins in the affected area, which may also appear dark due to the abundance of thick humor. The illegitimate or bastard scirrhus, which is entirely painless and insensible, as well as the cancerous type, do not respond to treatment, and the true legitimate scirrhus only rarely yields to any form of remedy. Those that progress to suppuration can easily transform into cancers and fistulas; although these tumors may initially appear small, they tend to grow significantly over time.
First, the physician should prescribe an appropriate diet that is sober and moderate, focusing on moisture and a neutral level of heat. The patient’s lifestyle should be calm and free from disturbances such as anger, grief, and sadness, and they should avoid sexual activity.
The second approach involves the evacuation of the underlying matter, which may require bloodletting if necessary, as well as purging. This can be done by encouraging hemorrhoids in men and menstrual flow in women. Prescriptions for purgatives may include Discatholicon, Hyera, diasenna, polypody, and Epythymum, according to the physician’s expertise.
The third approach consists of the appropriate use of topical medicines, which should be emollient at first and then immediately followed by resolving agents, or a combination of both emollient and resolving properties, as Galen teaches. Using only emollient substances carries the risk of putrefaction and cancer, while using only resolving agents may lead to the resolution of the finer parts while the coarser parts settle.
The emollient preparation can be as follows:
Prescription:
Boil the marshmallow and lily roots in common water. Strain. Add Chamomile, lily oil, moist oesp, plaster and enough white wax to create a suitable ointment.
Prescription
Combine 2 ounces of the oesp plaster as described by Philagrus.
Melt everything together, adding enough wax to create a sufficiently soft ointment.
After adequately using emollient substances, fumigate the tumor with strong vinegar and aqua vitae poured over a heated piece of millstone, flint, or brick. This will help to rarefy, thin, and resolve the softened humor. After some time, reapply your emollients and then again use your resolving agents to eliminate what remains, as it may not be possible to address everything at once. This method is how Galen cured a scirrhus in Cercilius, his son. Goat dung is also very effective in treating scirrhous tumors, but the Vigo plaster with double the amount of mercury is particularly effective, as it both softens, resolves, and eliminates all tumors of this type.
A cancer is a hard tumor that is rough and uneven, round in shape, immovable, and has an ash or livid color. It is horrifying due to the veins that surround it, swollen with dark blood, and it spreads out resembling the stretched legs and claws of a crab.
This type of tumor is difficult to identify at first, as it may be no larger than a chickpea. However, after a short time, it can grow to the size of a hazelnut, unless it is provoked to grow suddenly larger by overly harsh treatments. As it increases in size, the patient experiences tormenting pricking pains and a sharp heat, as the thick blood in the veins becomes heated, causing a sensation similar to being pricked by needles, although the patient may sometimes find some relief.
Because this type of tumor has veins that extend and spread around it like claws and feet, and because it is of a livid and ash color, accompanied by rough skin and a thick consistency, it resembles the clawed appendages of a crab. Therefore, I thought it appropriate to include an illustration of a crab here, so that the reasoning behind both the name and the characteristics of the condition might be clearer.
Here we recognize two primary causes of cancer: the antecedent and the conjunct. The antecedent cause arises from an irregular diet, which leads to the generation and accumulation of thick, unhealthy blood; it is influenced by a morbid condition of the liver that predisposes it to produce such blood; it is also affected by the weakness of the spleen in its ability to attract and cleanse the blood; and it may result from the suppression of menstrual cycles, hemorrhoids, or any other usual bodily evacuations.
The conjunct cause refers to the thick and melancholic humor that becomes trapped in the affected area, much like being stuck in a narrow passage. This melancholic blood, which is less malignant and milder, can lead to a non-ulcerated form of cancer when it is heated slightly. However, when the humor is more malignant and acrid, it can lead to an ulcerated form. For instance, the humor responsible for carbuncles can, when heated and corrupted, corrode and ulcerate the tissue it affects.
Cancer can be exacerbated by foods that inflame the blood, as well as by emotional disturbances such as anger and stress. Additionally, the use of overly acrid, oily, and inappropriate medicinal applications can worsen the condition.
When it comes to the types of cancers, two main categories stand out: ulcerated (or manifest) cancers and non-ulcerated (or occult) cancers. Some cancers affect internal organs like the intestines, uterus, and rectum, while others impact external areas such as the breasts. There are also newly formed cancers and those that have become chronic. They can vary in size, with some being small and others large; some are aggressive and malignant, while others are milder in nature.
Cancer is generally regarded as nearly incurable, or at the very least, very difficult to treat, as it is a wholly malignant disease, often compared to a specific form of leprosy. Aëtius notes that cancer is not easily contained until it has completely consumed the area it occupies. It tends to affect women more than men, particularly in areas that are soft, rarefied, fungous, and glandular; thus, they are more prone to accumulating thick humor, such as in the breasts and other delicate regions.
When cancer affects the breasts, it can lead to inflammation in the armpits and swelling in the nearby glands. Patients often report sharp pain that can radiate to the heart, collarbones, and even the inner sides of the shoulder blades. If the condition worsens and spreads to critical areas, surgery may be the only viable option for treatment. However, in weakened individuals whose strength has diminished, especially in cases of chronic cancer, aggressive treatments such as surgical intervention, cauterization, or harsh medications should be avoided. Instead, the focus should be on preventing the condition from worsening and spreading further, employing gentle remedies and palliative care.
Many individuals suffering from cancer have lived to a ripe old age by adopting such an approach. Hippocrates advises that it is often better not to treat occult or hidden cancers; he suggests that patients who undergo treatment for these tend to die quickly, whereas those who are left untreated may live longer.
One should avoid thick and muddy wines, vinegar, dark bread, cold herbs, aged cheese, and preserved meats such as beef, venison, goat, and hare. Foods like garlic, onions, mustard, and all acrid, sour, or salty items that could thicken the blood and inflame the humors should also be excluded. Instead, a cooling and moistening diet should be prescribed. Fasting, sleeplessness, excessive labor, sorrow, anxiety, and mourning should be avoided.
The diet should include light broths made with ingredients such as mallows, spinach, lettuce, sorrel, purslane, chicory, hops, violets, borage, and the four cooling seeds. The patient may eat mutton, veal, kid, capon, young hares, partridges, fish from rocky rivers, and fresh eggs. White wine may be consumed moderately.
The affected area should be treated gently, avoiding heavy or overly solid applications. Instead, soothing and mitigating remedies should be used, applying substances that counteract venom or poison, such as treacle and mithridate, at appropriate times. Ass’s milk is particularly effective in alleviating the acrimony of the cancerous humor; it should be taken both internally and applied externally as a poultice to the affected area.
An ulcerated cancer exhibits many characteristics similar to its non-ulcerated counterpart, including the rounded shape of the tumor, its uneven and rough texture, and the pain associated with it. To the eye, the tumor may seem soft, yet it feels hard when touched. The ulcer itself is quite foul, with thick, swollen, and knotted edges that protrude outward, creating a ghastly appearance. It discharges a repugnant, ichorous fluid that resembles rotting flesh, sometimes black, at other times mixed with putrid debris, and occasionally accompanied by a significant amount of blood. This type of ulcer is malignant, resistant to treatment, and tends to worsen with harsh remedies. The pain, fever, and other symptoms escalate, leading to a decline in the patient’s strength, resulting in wasting and ultimately, death.
If the cancer is small and located in a part of the body that can be amputated, and if the patient’s condition allows, it is wise to first cleanse the body and draw blood. Following this, surgical intervention should be employed to remove all diseased tissue, even down to the quick, ensuring that no traces of contagion remain. After the amputation, it is important not to immediately stop the bleeding; rather, allow it to flow freely for a while to drain the veins filled with dark, melancholic blood. Once a sufficient amount of blood has been drawn, the area should be treated with actual cautery. This will help strengthen the affected area, draw out any toxins, and stop any further discharge. Afterward, soothing remedies should be applied to promote the separation of the eschar.
In conclusion, we can determine that all cancerous tissue has been successfully removed and the malignancy eradicated when the ulcer begins to discharge healthy fluid and new, healthy flesh starts to grow, resembling the seeds of a pomegranate, with alleviation of the sharp pain and other symptoms. The treatment of an ulcerated cancer affecting the lips can be conducted more gently and effectively, without the need for caustic agents after excision, leading to minimal deformity during the healing process. This innovative method, which I believe has not been previously documented, was developed and applied to a fifty-year-old man in the presence of Doctor John Altine, a highly esteemed physician, alongside James Guillemeau, Master Eustachius, the King’s surgeons, and John Le Jeune, the respected surgeon of the Duke of Guise.
The method is as follows: the cancer must be pierced through the lips on both sides, above and below, using a needle and thread. This allows you to control the cancer with your left hand using the thread, preventing any part from escaping during the excision. Then, with scissors in your right hand, cut it off in one swift motion; however, care must be taken to leave some tissue from the inner part of the lip, adjacent to the teeth, if the cancer has not fully penetrated. This remaining tissue will serve as a foundation for new flesh to fill the void. Once sufficient bleeding has occurred, the edges of the wound should be scarified on both the right and left sides, both internally and externally, with a somewhat deep scarification. This will make the flesh more pliable and suitable for stitching, similar to the technique used for repairing a hare-lip. The remainder of the treatment should proceed in the same manner as we would treat hare-lips, which we will discuss further.
Initially, we employ repercussive medicines such as the juices of nightshade, plantain, henbane, lettuce, sorrel, houseleek, water lentil (or duckweed), knotgrass, pomegranates, and similar herbs. Additionally, we use rose oil, powders of sumac, barberry, litharge, ceruse, burnt lead, tutia, quicksilver, and the like. These can be combined to create fomentations, liniments, ointments, cataplasms, and plasters. The diacalcitheos plaster, dissolved with nightshade juice and rose oil, is particularly suitable for non-ulcerated cancers. Pompholix or tutia, washed in nightshade or plantain juice, works well for ulcerated cancers. The following preparation is also highly regarded:
Take equal parts of litharge and ceruse (1 ounce each), grind them in a mortar with rose oil until they reach the consistency of a liniment or ointment.
A resolving and repercussive ointment can be made with the following ingredients:
– 1.5 ounces of washed burnt lead,
– 1.5 ounces of pompholix,
– 1 ounce of pontic wormwood,
– 3 ounces of rose oil,
– 6 drachms of wax,
– Sufficient juice of solanum to achieve the desired thickness for an ointment.
Theodorick’s emplaister is highly praised for alleviating the pain associated with ulcerated cancers:
– 1.5 ounces of rose oil,
– 1.5 ounces of pomegranate and solanum juice,
– 1 ounce of washed ceruse,
– 0.5 ounces of washed burnt lead and prepared tutia,
– 2 drachms of frankincense and mastic.
Combine these to create a soft emplaister.
I have often successfully used the following ointment:
– 1 ounce of old theriac,
– 0.5 ounces of crab juice,
– 0.5 ounces each of lettuce and rose oil,
– 2 cooked egg yolks,
– 1 drachm of camphor.
Grind all ingredients in a mortar to create an ointment.
Combine 0.5 pounds of fresh lard with 0.5 pounds of good oil and 3 cooked egg yolks to make an ointment. Store for use, and when needed, mix it with a little rose ointment. I have also found relief from severe pain by applying leeches to a non-ulcerated cancer, particularly at the site of most intense discomfort, thereby alleviating some of the malign humor. Similarly, I have used young puppies, kittens, pigeons, or chickens cut lengthwise and applied to the ulcer, changing them as soon as they lose their warmth, along with other applications for their natural heat in soothing or mitigating medicines.
John Baptista Theodofius, in his writings, claims that a cataplasm made from crushed erysimum (or candock) is excellent for non-ulcerated cancer. For ulcerated cancers, he recommends boiling the same herb in honey water and using it for injections and washes to cleanse the ulcer and reduce pain.
When the cancer affects the womb, patients may experience sharp pain in the groin and kidneys, often accompanied by difficulty urinating. If ulcerated, it may discharge a foul, putrid matter in large quantities, the noxious vapors of which can lead to fainting spells. To alleviate pain in such cases, the following remedies are beneficial:
– Fomentation: Use mucilage from flaxseed and fenugreek, extracted in rose and plantain water, while warm.
– Cataplasm: Boil 0.5 pounds of althea root in honey water, strain, and add a little rose oil.
You may also prepare various pessaries to address different types of pain, as well as injections made from a mixture of plantain, knotgrass, lettuce, and purslane juice, ground in a lead mortar with rose oil. This type of remedy is recommended by galen for all forms of ulcerated cancer.
Another effective remedy is:
– 4 pounds of cow dung,
– 1 pound each of robert’s herb, plantain, live forever, henbane, purslane, lettuce, and endive.
Crush all together and distill in a lead alembic, saving the liquid for use in injections or, if possible, washing the cancerous ulcers with it. Wet lint pledgets soaked in this liquid can be applied and frequently changed, as it helps to reduce inflammation and alleviate pain.
Galen recommended using powdered burnt river crabs mixed with rose ointment applied on lint to ulcerated cancers.
For the cervix, it is advisable to use an instrument made of gold or silver that allows for the free and safe expulsion of cancerous matter and the release of foul vapors. This instrument should be hollow, approximately five or six fingers long, and about the size of a thumb at the upper end, with multiple holes for drainage. The lower end should be about two fingers thick, designed with a spring mechanism to adjust the opening as needed. Two strings or ties should be attached to secure it in place, as illustrated in the accompanying diagram.
A Vent made like a pessary for the womb affected with a cancerous ulcer.
The remedy for non-ulcerated cancers, which involves a plate of lead coated with quicksilver, should not be dismissed. Galen himself attests that lead serves as an effective treatment for malignant and chronic ulcers. Additionally, Guido Cauliacensis, a respected figure in ancient medicine, notes that these lead plates, when treated with quicksilver, act as antidotes to malign ulcers that resist the effects of other treatments, effectively diminishing their malignancy and harmful nature.
This remedy was prescribed by the esteemed physician Hollerius, who instructed me to apply it to the Lady of Montigni, a maid of honor to the Queen Mother, who was suffering from a cancer in her left breast that was the size of a walnut. Although this treatment did not completely heal her, it successfully prevented further growth of the tumor.
Eventually, weary of the situation, she sought the help of another physician who boldly promised swift relief. Tragically, she discovered, at the cost of her life, how perilous and ineffective a treatment for cancer could be when approached as one would treat other ulcers. This physician, having discarded our remedy, began a treatment regimen involving softening, heating, and drawing agents. However, as pain, inflammation, and other symptoms intensified, the tumor expanded to such a degree that the fluid could no longer be contained, causing the breast to stretch and rupture, akin to a pomegranate splitting open at maturity.
In the aftermath, an excessive flow of blood ensued, prompting the physician to apply caustic powders to address the hemorrhage. Unfortunately, this only exacerbated the inflammation and pain, leading to fainting spells. Ultimately, instead of achieving the promised health, the poor soul succumbed in the physician’s care.
The fever that occurs in scirrhous tumors resembles a quartan fever, or at least closely aligns with its characteristics, due to the nature of the melancholic humor from which it arises. This humor, confined to a specific area where the tumor forms, generates putrid vapors that excessively heat the heart and inflame the humors contained within it, leading to the onset of fever. A quartan fever is defined as one that recurs every fourth day, with two days of remission in between.
The primary causes of this fever stem from factors that exacerbate melancholic humors in the body. These include the prolonged consumption of legumes, coarse and burnt bread, salted meats and fish, as well as heavy foods such as beef, goat, venison, aged hare, old cheese, cabbage, thick and muddy wines, and other similar items.
Natural Factors: Individuals with a cold and dry temperament, particularly those in old age, as well as cold and corpulent men with small, hidden veins and a swollen, weak spleen, are commonly affected by quartan fevers.
Unnatural Factors: This fever, or ague, often occurs in autumn—not only because this season is cold and dry, which facilitates the accumulation of melancholic humors, but also due to the transformation of these humors into adust melancholy as a result of the preceding summer’s heat. This transformation can lead to more severe and dangerous quartans than those arising from simple melancholic humor. Additionally, during cold and dry seasons in similarly temperate regions, individuals with comparable dispositions are more susceptible to quartans, especially if they lead a life marked by pain, danger, and sorrow.
Contrary to Nature: The fever episodes are characterized by intense shaking, which can create a sensation akin to the breaking or rattling of bones. Each episode typically occurs every fourth day and is accompanied by an itching sensation throughout the body, often manifesting as thin scales and pustules, particularly on the legs. Initially, the pulse is weak, slow, and deep, while the urine appears white and watery, tending towards a darker hue.
As the fever subsides and the matter is processed, the urine may turn black—not due to any malign symptom or excessive heat, which would be fatal—but rather as a result of the expulsion of the accumulated matter. Each episode of quartan fever lasts approximately 24 hours, with a 48-hour intermission. It frequently originates from obstructions, pain, and scirrhus of the spleen, as well as the suppression of menstrual flow and hemorrhoids.
Quartan fevers that arise in summer tend to be shorter in duration, whereas those that occur in autumn can be prolonged, particularly if they persist into winter. Fevers resulting from a succession of liver, spleen, or other pre-existing diseases are typically more severe than those that arise independently and often culminate in dropsy. However, quartans that develop without underlying bowel issues and in patients who adhere to a physician’s dietary guidance tend to be less harmful, potentially alleviating more serious and chronic conditions such as melancholy, epilepsy, convulsions, and madness. This is because the melancholic humor, responsible for these ailments, is expelled every fourth day through the quartan fever’s episodes.
A quartan fever, assuming no errors in treatment, typically does not persist for more than a year. However, according to the opinion of Avicenna, some quartans have been known to last up to twelve years. Generally, a quartan that begins in autumn often resolves by the following spring.
When the quartan is caused by adust blood, choler, or salt phlegm, it is usually easier and quicker to cure than one that arises from adust melancholic humor. The melancholic humor, being inherently terrestrial, is more challenging to resolve than other humors. When subjected to adustion (where the finer particles dissolve and the coarser ones settle), it becomes even more stubborn, dense, malignant, and acrid.
The treatment for quartan fever primarily relies on two approaches: diet and medication. The dietary recommendations should counteract the underlying cause of the fever, particularly concerning the six factors deemed unnatural, as much as possible. Therefore, the patient should avoid pork, flatulent, viscous, and glutinous foods, as well as marshy fowl, salted meats, venison, and any items that are difficult to digest. The consumption of white wine, which is moderately warm and thin, is beneficial for thinning and breaking up the dense humors, as well as for promoting urination and sweating. Indeed, at the onset of a fit, a glass of such wine can induce vomiting—a remedy of such significance that many have found relief through it.
If one wishes to provoke vomiting, there is no better time than immediately after a meal. At this point, it is more easily elicited due to the stomach’s fibers being moistened and relaxed, facilitating a quicker onset of vomiting. This, in turn, leads to a more abundant, effective, and comfortable expulsion of phlegmatic and choleric humors. During a quartan fever, the stomach often harbors various crudities due to an increased influx of melancholic humor, which, with its cold and dry qualities, disrupts natural functions.
Additionally, engaging in exercise and massage before meals can be beneficial. The patient should also cultivate positive emotions that counteract the underlying cause of the fever, such as laughter, feasting, music, and other enjoyable activities that promote pleasure and joy.
At the outset, the patient must be treated with care and gentleness, and we should refrain from administering strong medications until the disease has persisted for some time. The humor, which is particularly stubborn at the beginning when nature has yet to make any efforts, becomes even more resistant, terrestrial, and dry due to the almost fiery heat of acrid medicines.
If the body is abundant in blood, it is necessary to draw some by opening the median or basilic vein in the left arm. Care should be taken: if the blood appears thick and dark, we should allow it to flow more freely; if it seems thinner and tinged with a healthy red color, we should stop the flow immediately.
To address the underlying matter of this fever, it must be matured, digested, and reduced using syrups made from Epithymum, Scolopendrium, Maidenhair, and Agrimony, along with waters derived from Hops, Bugloss, Borage, and similar herbs. I sincerely attest, before God, that I have successfully treated many cases of quartan fever by administering a potion of a small amount of treacle dissolved in about two ounces of aqua vitae. Additionally, at the onset of a particular fit, I have sometimes used two or three grains of musk dissolved in Muskadine, particularly after general purgations when the humor and body are prepared and the patient’s strength is robust. Indeed, an entrenched quartan fever can rarely be resolved unless the body is significantly heated by food and medications.
Therefore, it is not entirely implausible that many assert they have successfully alleviated quartan fever by consuming a draught of wine infused with sage leaves each morning upon rising. Additionally, it is beneficial to anoint the entire spine with warming oils shortly before the onset of a fever, particularly those that target the nervous system. Oils such as those derived from rue, walnuts, and peppers, combined with a small amount of aqua vitae, can be effective.
For this purpose, oil of castoreum, prepared by boiling it in an apple of colocynth (with the seeds removed) over hot coals until reduced by half, and mixed with a small quantity of powdered pepper, pelitory of Spain, and euphorbium, is particularly excellent. Such applications not only help mitigate the severity of the intense shaking associated with the fever but also promote sweating. The humid heat of these oils can help dispel the stubborn humor that resists the body’s expulsive efforts, as melancholy can be likened to the dross and sediment of the blood.
Conversely, if the quartan fever is caused by acrid bile, one should anticipate a cure through the use of cooling and moistening medicines, such as sorrel, lettuce, purslane, and broths made from cucumbers, gourds, melons, and pumpkins. In this scenario, employing hot medications would exacerbate the condition by resolving the subtler components of the humor.
Thus, Trallianus claims to have treated such quartan fevers solely with the repeated application of cooling epithems just before the onset of the fit. This encapsulates the approach to curing true and legitimate intermittent fevers—those stemming from a single humor. The treatment of what are termed “bastard intermittent fevers,” which arise from impure or mixed humors, can also be easily inferred. For instance, when a fever results from a blend of phlegmatic and choleric humors, the remedies must be similarly mixed. In cases of a confused fever that exhibits both quotidian and tertian characteristics, treatment should involve a combination of medicines aimed at expelling both phlegm and bile.
An aneurysm is defined as a soft, palpable tumor formed by blood and vital spirits accumulating beneath the skin and muscles due to the dilation or relaxation of an artery. The author of the definitions suggests that any dilation of a venous vessel can be termed an aneurysm. Galen describes an aneurysm as an opening resulting from the anastomosis of an artery. It can also occur when a wounded artery closes too slowly, while the tissue above it becomes agglutinated, filled with flesh, and cicatrized. This often happens following poorly executed surgical procedures or negligent healing. Consequently, aneurysms arise from anastomosis, dilation, rupture, erosion, and wounding of arteries.
These conditions can occur in any part of the body but are more frequently observed in the throat, particularly in women after a difficult labor. During intense efforts to hold their breath for childbirth, the arteries may dilate and rupture, leading to an effusion of blood and vital spirits beneath the skin. The signs of an aneurysm include a swelling that may vary in size, accompanied by pulsation and a color consistent with the natural complexion of the skin. The tumor is soft to the touch and may completely disappear if pressed, as the arterial blood and spirits rush back into the artery. However, once pressure is released, the pulsation returns almost immediately. Some aneurysms emit a noticeable hissing sound when pressure is applied, due to the vital spirit moving forcefully through a constricted passage.
In cases of significant rupture, such sounds are absent because the spirit flows through a larger opening. Large aneurysms, particularly in the armpits, groin, and other areas with major vessels, are often inoperable. The substantial blood and spirit loss that follows such an incision can lead to death, making surgical intervention perilous. I once observed this with a priest from Saint Andrews, M. John Maillet, who had an aneurysm near his shoulder the size of a walnut. I advised him against surgery, warning that it could endanger his life. Instead, I recommended alleviating the condition with double cloths soaked in nightshade juice and whey cheese, or with cooling and astringent remedies, applying a thin plate of lead to support the area. He was advised to avoid anything that could thin or inflame the blood, particularly excessive vocal strain.
Despite adhering to this regimen for a year, the tumor continued to grow. Eventually, he sought the help of a barber who mistakenly treated it as a common abscess, applying a caustic agent that resulted in a significant opening. The next morning, an overwhelming amount of blood flowed from the wound, and he, astonished, called for assistance, regretting not having followed my advice. Tragically, before I could arrive, he succumbed to his injuries.
Thus, I caution young surgeons against hastily opening aneurysms unless they are small and located in less critical areas devoid of large vessels. Instead, they should consider a more cautious approach: make a small incision in the skin over the aneurysm until the artery is visible, gently separate it from surrounding tissues, and then use a blunt, curved needle threaded with a string to bind it. The string can then be cut, allowing nature to heal the artery by forming new tissue over the cut ends. The remainder of the treatment can proceed as with simple wounds.
Aneurysms occurring in internal organs are generally incurable, particularly those arising from prior treatments for the French disease. In such cases, the blood becomes so heated and thinned that it cannot be contained within the arterial walls, leading to extreme dilation. I encountered this in the body of a tailor who collapsed while playing tennis due to an aneurysm in the arterial vein. Upon dissection, I discovered a large volume of blood in his chest cavity and an artery dilated to an alarming size, with its inner wall exhibiting a bony structure.
This phenomenon illustrates the remarkable providence of nature, which acts to create a new barrier to mitigate the violent flow of blood and vital spirits. However, one should also consider whether the application of cooling and astringent medicines contributes to this hardening, as suggested by Galen’s writings.
Be cautious not to misinterpret the signs of an aneurysm. In large cases, there may be no detectable pulsation, nor can blood be forced back into the artery by applying pressure to the skin. This may occur if the volume of blood exceeds the capacity of the artery or if it has become solidified into clumps. When this happens, the lack of proper circulation can lead to putrefaction, resulting in severe pain, gangrene, and ultimately, death.