CHAP. I. Of Tumours in generall .

WHat a Tumour is ( when we understand a Disease by the word ) is so sufficiently explained by Galen , Definition . that I shall not trouble my self with any farther disquisition about it . It is by him defined , A Disease in which the parts of the body recede from their natural state by an undue increase of their bigness .

Now by what Names the Ancients did express a Tumour in generall , many of which were afterwards appropriated to the particular Species of it , as Oedema , Apostema , Phyma , &c. I shall leave to the Criticks and men of leisure to enquire : it shall suffice me , that my Definition tells you what I mean .

The Causes of Tumours are variously delivered by sundry Authours , Cause of Tumours . with a larger repetition of which I shall not here trouble you . What my own thoughts suggest to me out of them upon this subject is this in short , viz. that they must be considered either with regard to their Time and Place , or to the Matter of which they consist .

I. In regard to their Time and Place we call them , 1. Antecedent , 2. Conjunct .

1. By an Antecedent Cause I mean that which yet hath not actually produced a Tumour , but is throughly mixed with the Bloud , Antecedent . or otherwise lodged in some convenient place where it is not troublesome to nature , at least not to this Part ; though it have a great inclination to be so , and , if not prevented , doth produce the feared effect . Of this sort I reckon all Impurities in the Bloud which do not yet start out into the solid parts : as the Matter of an Erysipelas , Phlegmon , Parotis , Bubo , &c. before a Crisis is made ; so also any Tumour in the body , which , lying in any part of it , is apt to be translated to another . This , though it may be the conjunct cause of the Tumour of the part where it is now lodged , is the antecedent cause of that Tumour which it raiseth in another place , to which it may be after derived , &c.

2. By a Conjunct Cause I mean the very Matter of the Tumour that is already impacted into the part , by others called the causa continens : Conjunct . upon the encrease of which the Tumour encreaseth ; on the diminution of it it diminisheth .

II. In regard of the Matter of which they are made , we do usually attribute their Original to , 1. Humour , 2. Wind , 3. the Interposition of a solid Body .

First , Humour : by Fluxion ; Humour produceth Tumour by , 1. Fluxion , 2. Congestion .

1. Fluxion is the sudden motion of Humours in the body to any part , and commonly depends upon one or more of these following causes : 1. the part transmitting ; 2. the part recipient ; 3. the condition of the Humour .

( 1. ) The part transmitting doth cause sudden Fluxion , when , being it self strong , it is provoked by the heat , sharpness , quantity , or other fault of a Humour , and , being so provoked , translates it to some weaker part , whether externall , or internall . This is most evident in the Crisis of Fevers , from which the Humour is often discharged inwardly by the way of Phlegmon upon the inward viscera ; or outwardly in the form of an Erysipelas , Bubo , Parotis , Carbunculus , &c.

( 2. ) The part recipient is the Cause of Tumours either , 1. passively , or , 2. actively .

1. Passively , when it receives Humours , and cannot expell them : whether it be through its weakness , laxity of Pores , over-widenesse of Vessels , as in a Varix ; or their too great streightness or obstruction , its position in a declining part , or its being disabled by externall accidents , as Bruise , Fall , &c.

2. Actively , when it attracts Humours to it self : either , 1. through heat , whether created by Humours already flowed , or by hot Medicines , blistering Plaisters , the Sun , Fire , Cupping-glasses , &c. or , 2. pain from corroding Medicines , wounds , bruises . I know this latter Head of Attraction may be quarrell'd at by some , who will reduce all Attraction to Pulsion , and so render other reasons of these accidents : But that troubles not me , who handle the notion in a practical way , leaving the speculation to curious men .

( 3. ) The condition of the Humour is the third and , indeed , great Cause from which Tumours do arise : in the explaining of which we must consider either the Plenitude of Vessels , or the Impurity of the Humours themselves .

1. The Plenitude of Vessels , otherwise called Plethora , when it happens , causeth an Extravasation of bloud , either by Ruption or Apertion of them : either of which , if they fall inwardly upon the Brain or some noble part , are of great danger ; as in Apoplexia , &c.

2. Impurity or Cacochymia ( to which some will also reduce Plethora ) is a Degeneration of the Humours into a preternatural state , from which Degeneration a multitude of Diseases do arise .

2. by Congestion . Congestion is then said to be the Cause of a Tumour , when the growth of it is slow and without pain , it commonly owing its original to a fault of Concoction in the Part , or at least a weakness in the expulsive faculty ; sometimes also to the want of heat , and the density of the skin , which hinders perspiration . These Tumours are generally cold , whereas those made by Fluxion are most frequently hot . The Matter of these is either thin and serous , or thick and phlegmatick , or apt to coagulate and grow hard , as many scirrhous Tumours and Exostoses , or made up of nutritious juices , as Sarcoma , Hernia carnosa , &c.

Secondly , Wind. As Humour , so Wind begetteth Tumours : which though it seldome appeareth alone , but usually mixed with some Humour which is the cause of it ; yet getting predominancy it denominateth Tumours , and is called Emphysema .

Thirdly , Interposition of a solid Body . The Interposition of a solid Body is frequently the Cause of a Tumour ; as in the Hernia intestinalis , zerbalis , Exomphalos .

Now from the variety of these Causes ariseth a great variety of Tumours , which do receive their several denominations from them .

I shall not trouble you with all the several divisions and enumerations , which , according to Sennertus's Arithmetick , make 226 in all : but I shall briefly instance in these following Heads , to which the rest may without difficulty be reduced .

1. The Blood it self is the matter of many Tumours ; and that two several ways .

( 1. ) When the serum is so extravasated as to carry something of the red or grumous part with it into the Tumour . In which case we find the Inflammation or Phlegmon , and the consequences of that , viz. Gangraena , or Sphacelus of which we have treated elsewhere : also Erysipelas , Furunculus , Epinyctis , Tereminthus , Phyma , Phygethlon , Bubo , Parotis , Carbunculus , Paronychia , Pernio , and Pterygion .

( 2. ) When the whole mass of Blood is so driven into a Tumour , as that the grumus is either principally concerned , or at least equally mixed with the serum . Examples of this are Varix , Ecchymosis , Aneurisma .

2. From Choler proceedeth Herpes .

3. From Phlegm , Oedema .

4. From Melancholy , Scirrhus .

5. From Atra bilis , Cancer , &c.

6. From waterish Humours , Hernia aquosa , Hydrops , Hydrocephalus .

7. From salt Humours , Scabies , Lepra , &c.

8. From Wind , Emphysema .

9. From interposition of a solid body , Hernia .

I have thus cursorily given you a summary view of the chief Heads of Discourse which are usually handled by our Chirurgical Writers , as a Preparatory to what I my self have to say . And first we shall treat of Humoral Tumours in general , descending from thence to as many of the Particulars as will be necessary for the Instruction of the young Artist .

CHAP. II. Of Humoral Tumours in general .

THe Causes of these Tumours have been sufficiently handled in the First Chapter , where we have discoursed how Tumours from Humours are produced : I shall here discourse the Diagnostick , Prognostick , and Cure .

If a Humoral Tumour be made by any external Cause , as by a Wound , Signs . Bruise , &c. it is easily discerned : but if there were no such preceding Cause , you may conclude that it ariseth from within . In this latter case you may judge whether a Tumour be made by Fluxion or Congestion thus .

That which is made by Congestion riseth gradually , Tumours by Congestion . and is collected into a compact Tumour without any preceding cause or sign of Fluxion , and is made with little pain , unless it begin in the Joynts , or parts of exquisite Sense . And then also in little Children the Tumour is some times made before it is discovered , and supposed a luxation of that Joynt , the Skin retaining its natural colour : yet as the Tumour encreaseth , the veins are frequently swelled in the surface of it , and as the Matter makes its way outward , if some times inflames and becomes painful .

If the Tumour be made by Fluxion , the part is affected with pain , Tumours by Fluxion . and swelleth suddenly , and is accompanied with Tension , Pulsation , and Fever . Now when the Tumour appears either before or with the Fever , no other Disease having preceded it , this is to be called Fluxion in the strictest sense of the word . But there are two other sorts of Tumours reducible to Fluxion , and those are made by , 1. Translation , 2. Attraction .

First , Tumours by Translation . The Translation of an Humour , in the sense I here mean it is , is that sort of Fluzion which happens from within upon the Crisis of some foregoing Disease ; which though it be really Fluxion , yet it differs from that which is strictly so called by these circumstances . 1. In Translation another Disease preceded ; in this , none at all . 2. In Fluxion , strictly so called , the Skin is first affected , and by degrees the neighbouring parts ; in Translation it is affected last , the Matter working it self from within outwards , insomuch that you may find Matter in the Tumour before the Skin is much changed . 3. In Translation there is often a real Extravasation of the serum of the blood between the Interstices of the Muscles , which falleth from some higher place ; nay , Pus it self may be bred above in some inward Cavity , and fall down thither actually formed before the Tumour begins : which is quite otherwise in Fluxion strictly so called .

Secondly , Tumours by Attraction . The other sort of Tumours reducible to Fluxion are those that are made by Attraction : which if they do happen , some of the visible Causes mentioned Chap. 1. did precede .

Tumours made by Fluxion have their several degrees and times , Times of Tumours made by Fluxion . as their Beginning , Augment , State , and Declination . Their Beginning is with the extension of the part affected : the Increase , when it riseth into a conspicuous Tumour , and is then accompanied with Symptoms increasing accordingly : the State is when the Tumour is made , and the Symptoms at the highest : the Declination is when the Tumour becomes less , and the Symptoms abate .

The Prognosticks of Tumours in general are taken from the Part affected , Prognosticks . as it is of more excellence and use ; also as it is internal , or external . By how much the more noble the Part is , by so much the more dangerous . The internal more dangerous than external . Prognosticks are also taken from the greatness of the Tumour , and Accidents that attend it ; and from the quality of the Humour that raiseth it , whether hot or cold , thick or him , malign or benign : for according to these circumstances the Cure is more or less difficult .

The manner of its Termination is to be considered : whether by Discussion , viz. insensible Transpiration ; or Suppuration , i.e. the converting the Humour ( which raised the Tumour ) into Matter ; or by Corruption , when the part affected is overcome by the ill quality of the matter , and putrefies ; or by Induration , when the Tumour is hardened , and the Symptoms of pain diminished ; or by Retraction , when the Tumour suddenly disappears , going back into the Body .

All Tumours which own their original to Humours terminate one of these five ways .

1. Signs of Discussion . The Signs of Discussion are the Relaxation , Diminution , and ease of the part , without Suppuration . 2. Of Suppuration . The Signs of Suppuration are Pain , Pulfation , &c. with Fever , according to Aphor. Hipp. Dum Pus conficitur , dolores ae febres accidunt . But the Matter being made , those Accidents cease , and the Tumour riseth in a Cone , and appears whitish : also the Matter fluctuates under your fingers . Yet it frequently happens in crude Tumours , and those that lie deep amongst the Muscles , that Matter is not so easily discover'd . 3. Of Corruption . The Signs of Corruption are a livid or blackish colour of the part affected , together with a sinking of the Tumour . 4. Of Induration . The Signs of Induration are , Diminution of the Tumour and Pain , with increase of Hardness . 5. Of Retraction . The Sign of its Retraction is , a sudden disappearing of the Tumour without Discussion or Suppuration : which , if it be from an inward cause , is always evill , and there ariseth Fever , ( if there were none before ) together with grievous Symptoms from the return of the Matter .

In the Cure of Tumours two things are chiefly to be considered : Cure . 1. the nature of the Part ; 2. the nature of the Tumour .

I. Things to be considered in the Part. In the Part it self we are to consider , 1. its Temperament , 2. its Conformation , 3. Situation , 4. Sense , 5. Use . 1. In Temperament , some are hot , as the Muscles ; some cold , as the Tendons , Glandules , and other exanguous parts . Some are moderately moist in themselves , and require to be treated with Medicines of the like nature , such as are neither violently drying , nor too much moistening , as the Fleshy parts : others dry in themselves , yet requires exiccants ; as Bones : others again overwhelmed with perpetuall Moisture , by reason of their situation and spongy substance ; as the parts about the Anus , Vterus , Axillae , Inguina , &c. 2. Conformation of the Part regards either its outward Figure , or inward Composition : which latter may consist of severall other lesser , whether similar or organicall ; as a Thigh , of Bone , Muscles , Veins , Arteries , Nerves , Membrances , &c. all which are duly to be considered , that so the nature of the Fluxion , the Vessels that feed it , the disadvantages or advantages of the Part , the best way of Revulsion , Discussion , &c. may be the more readily suggested to the fancy . We may also thereby be informed what Cavities or Interstices may be there for the receit of Humour ; and how great the degeneration is from the naturall state or figure . 3. Situation of the Part is of great importance : which , if it depend too much , must of necessity be raised ; otherwise the Fluxion will be increased . Therefore if it be a Hand or Arm , it must be raised to the Breast ; if a Leg , it must be laid on a Bed , Stool , or the like . 4. The Sensibleness of Parts is of much moment in the Cure of Tumours : which , if they light upon such as are of over-acute sense , produce exquisite torments , such as require often a more peculiar care of the Chirurgeon then the Tumour it self . Also its neighbourhood to such a place obligeth us to prevent its reaching to it . 5. The Vse of a Part , as it is more or less noble , is very much to be attended : whether it be of immediate importance to Life , as the Liver , Brain , Lungs , Heart , &c. or to great and noble uses ; whether of sense , as the Eye , Nose , Ear ; or of common excretion , as the Bladder , Anus ; or of generation , as the Testicles , Vterus , &c. Of all which Circumstances great care is to be had , that they may be treated accordingly . II. Things to be considered in the Tumour . Having thus considered the nature of the Part , you are next to attend to the Tumour it slf , both as to its Time and other circumstances . As to its Time , if it be already in the State , you have no more to doe but to regard the conjunct cause , viz. the Matter already lodged there ; the due removall of which sufficiently disposeth it to Cure : but if it be onely beginning , then the antecedent causes are to be likewise considered , and to be removed out of hand ; the Fluxion to be checked by evacuation of the Humour , by bleeding and purging , or by revulsion , derivation , interception , repulsion , discussion , &c.

These severall intentions will best be judged of by viewing the quality of the Tumour . If it be hot , and made by Fluxion , then it is to be treated by the aforesaid Method . If it be cold , and made by Congestion , then purging onely with resolvents , discutients , and strengtheners of the Part , are to be made use of . Where the Tumours are mixed , the intentions of Cure ought to be so too . Where Attraction is the cause of Tumour , the cause of the Attraction ought to be removed ; whether it be too much heat , drawing Medicines , blistering Plaisters , or the like . All which things as they will be sufficiently handled in the Particulars when we come to them ; so it will be much for the advantage of the young Artist , if we do here say something of them in generall .

Now since Tumours caused by Fluxion are like to employ the former part of this Treatise , I shall begin with those , and consider them in their severall estates , of Beginning , Increase , State , and Declination .

In the Beginning I have already told you of Bleeding , Bleeding . which potently checketh Fluxion , and ought to be proportioned to the greatness and violence of the Disease . In tender bodies and small Tumours the evacuation needs not be much : but if otherwise the Fluxion be great , and the body strong , we must take away large quantities .

Besides Bleeding , Purging . evacuation by Stool will be requisite : and , indeed , immediately before or after bleeding a Clyster or some other Lenitive ought to be exhibited . Nor is that to be rested in , but further purging , either by milder or stronger medicines , to be attempted , suitably to the condition of the Patient . It is true that in hot Tumours there may seem to be onely a Plethora , which notwithstanding will require evacuation by purging as well as bleeding ; it being seldom found that a Tumour is caused by a meer Plethora without Cacochymia ; which Cacochymia , if it doth not precede the Tumour , certainly accompanieth it , ( as will be made more manifest when we come to treat of particular Heads ) and therefore requires the method now mentioned .

Lenitive Purges are Sena , Rhubarb , Cassia , Tamarinds , Manna , with Cremor Tartar , Electuar . lenitiv . Diaprun . lenitiv . Diacass . cum manna , syr. rosar . solut. syr. de Rhabarb . &c. which is as high as we ought to go , if the Humour be hot . In cold ones stronger Catharticks are advisable : of which more anon .

These two are premised in regard of the antecedent cause : but that is not enough , unless the conjunct cause be also removed ; which , being the very matter of the Tumour , admits of severall intentions . They are reducible to these two Heads .

1. Translation to some other Part in the body : which is performed by , 1. Revulsion , 2. Derivation , 3. Repulsion . 2. Evacuation out of it : and that is obtained by , 1. Discussion , 2. Suppuration , 3. the Discharge of the matter by Apertion .

Translation , Revulsion . and , 1. by Revulsion , is chiefly intended for the defence of some noble Part which is endangered by the Tumour , or else for the lessening of the Matter when it is excessive . This intention regards as well the antecedent cause as the conjunct . The antecedent , when by Venaesection , Cupping-glasses , Leeches , &c. the whole mass of Humours is diminished : of which already . The conjunct , when the Tumour it self is lessened , or quite taken off , by translating it either into the mass of Bloud , or into some other remote Part.

The former of which is often very innocently done in the beginning of a Tumour , whilst the serum is yet onely extravasated , and not otherwise altered in its quality ; so that being remixed with the mass , it is capable of Concoction , and consistent with the health of the Patient . The latter is , when by Cupping , Blistering , Ligatures , Frictions , or the like , we raise a Tumour in the contrary part , and give Nature occasion of discharging the Matter in a place far distant , which otherwise she would have lodged here : in doing of which she often sucketh in the Humour again which she had before separated into the former place .

2. Derivation . Derivation differs from Revulsion onely in the measure of the distance and the force of the Medicines used . If we draw it to some very remote , or , it may be , contrary part , we call that Revulsion : if onely to some neighbouring place , and by gentle means , we call it Derivation .

3. Repulsion . To the making of either of these effectuall Repulsion is also necessary . For Humour that is already impacted will not so easily be drawn out by former remedies , if something be not applied to the Part to drive it back .

These Medicines are all astringent more or less . The milder sort of them , which are the most usuall in all hot Inflammations , as Lettice , Purslane , Navel-wort , Plantane , Bramble-tops , red Roses , Knot-grass , Horse-tail , House-leek , and , where the pain is more vehement , Poppy , Mandrakes ; these may be applied liquid , or in the forms of Liniments , Cerots , Cataplasms , or Emplasters : of which this Book will give you examples . The more astringent are Pomegranate rinds and flowers , Medlars , Quinces , Sloes , Acorns , Cypress-nuts , Mulberries , Sumach , Bole-armoniack , sanguis draconis , Vinegar , red Wine , &c. Compounds of both sorts are , Ol. omphacin . ol. rosar . unguent . rosar . popul . album , unguent . nutrit . cerat . refrigerans Galeni , Empl. è bolo , de minio camphorat . oxycratum , oxyrrhodinum , oxelaeum . ℞ succi solani , plantag. sempervivi , an . ℥ ij . aceti optimi ℥ j ss. mucilag . sem. psyllii , cydon . extract . cum aq. rosar . an . ℥ j. Misc . in which you may dip cloaths , and apply them to the Parts affected , renewing them often ; or you may adde to it pulv . gland . flor. ros. rub . balaust . an . ℥ ij . Bol. armen . ℥ iij. olei myrtillor . unguent . rosati , an . q.s . fiat mixtura . Apply it in the form of an Emplaster over and about the diseased Part.

Concerning these foregoing Medicaments it is to be cautiously observed , Cautions . 1. That they are proper onely in the beginning of the Tumour , whilst you intend to prevent it by driving it quite back into the Bloud again . For if the Humour be so impacted as not to be repellible , but that is must have its evacuation in the place by Suppuraiton , then if by bleeding you hinder concoction of the Matter , you prolong the Disease ; Nature in that case wants all its heat and all its serum . Much more do you hurt it if you use Repellents , which , being commonly cold and astringent , do close up the Pores , and keep out both the naturall heat and the serum of the bloud , the affluence of which and its mixing with the Humour is necessary to the dilution and the digestion of it ; so that both being hindred , the Part will grow livid and mortifie .

2. Caution is to be used in the application of these Medicines where the Tumour is malign , or the Crisis of a malignant Fever : for in all such cases the Retraction into the bloud is of very dangerous consequence : wherefore we then rather use Cupping-glasses and other Attractions to draw it out .

3. It is to be noted that these Repellents are often applied above the Tumour , as defensatives or intercipients : in which case they have regard to the antecedent cause , and in a strict discourse should have been handled under that Head ; but I rather accommodate my self to the method of Operation .

Evacuation is necessary for the discharge of that Matter out of the body by some more immediate way , which either cannot , or ought not , by the former intentions be driven back . Now that is of three sorts .

1. Discussion . Insensible , by Discussion or Resolution ; which is nothing else but a breathing out the Humour by insensible transpiration . Therefore the Humour so to be discharged ought to be thin , and the skin lax and rare : for if it be otherwise , or lie deep amongst the Muscles , it will not easily yield to Transpiration . The Medicaments called Discutients ought to be hot and of a subtil quality , powerfully penetrating : which quality renders them improper to be applied in the beginning of Inflammations ; ( for thereby the Part would be too much heated , and consequently the Tumour made great ; ) but they are proper being mixed with Repellents : in the beginning of the Augment , when the Tumour is hard , and not fit to be treated longer with Repellents alone .

These Medicaments are to be proportioned as the Matter and conformation of the Part requireth . Discutients and Emollients . The milder are emollient and rarifying , proper in soft bodies where there is Inflammation with hardness : and they are Radices & folia althaeae , malvae , violar . sem. lini , foenug . flor. chamaemel . meliloti , sambuci , far hordei , lentium , orobi , lupinor . wihch may be made up in Cataplasms with some of these following , which are of the same quality , viz. sallet-oyl , butter , axung . porcin . anseris , anatis , gallinae , sevum ovinum , vitulinum , vaccinum . The more recent these Fats are , the more emollient ; and the more rancid , the more discutient . Mel and cera are reckoned amongst the Discutients : also ol. cham . lumbricorum , sambuci , lini , irinum , &c. Empl. diachyl . simpl . cum gummi , ireatum , de mucilag . de meliloto , &c. The milder Discutients mixed with Repellents may be thus made : ℞ fol. & rad. althaeae M. j. flor. cham . M ss. coq. in sero lactis , & fiat cataplasma S. A. addendo in fine coctionis ol. ros. & cham . an . q. s . Or , ℞ fol. malvar . parietariae , plantag. an . M.j. sem. lini , foenug . an . ℥ j. summitat . absinthii , florum sambuci , an . M ss. flor. ros. rub . M.j. coq. in s . q. vin. tenuis , addendo farinae hordei ℥ iiij . & ol. olivar . immatur . q. s . fiat catapl . S. A. As the Humour discusseth , you may foment it with a Decoction of summitat . absinth . flor. cham . ros. rub . balaust . bacc . myrtill . or the like , in wine and water , by which you may dry up the remaining Matter , and strengthen the relaxed Part.

In Tumours where the Matter lieth deeper , ℞ rad. althaeae , ebuli , irid . recent . an . ℥ ij . rad. bryoniae , cucum . agrest . an . ℥ j ss. flor. cham . meliloti , summitat . anethi , an . M.j. sem. lini , foenug . an . ℥ j. fiat catapl . S. A. addendo axung . anseris , anatis , an . ℥ j. mell . com . ℥ ij .

These following are yet more attenuating , and proper in crude Tumours : summitates origani , thymi , calaminth . pulegii , rorismarini , hyperici , centaur . min. bacc . lauri , juniperi , sem. cymini , rutae , &c. Gumm . galbanum , ammoniac . bdellium , opopanax ; also sulphur viv . alumen , calx lota , sal nitri , cineres ligni quercini , sarmentor . vitis , brassicae . The compounds are , ol. scorpion . nardin . euphorbium , petroleum , oleum philosophor . unguent . aregon , martiat . Empl. de ranis cum & sine Mercurio , Empl. diasulphuris , de baccis lauri , cicutae cum ammoniaco , &c. The Matter may also be disposed for resolution by such like Fomentation : ℞ rad. enulae campanae , bryoniae , an . ℥ ij . summitat . pulegii , origani , scabiosae , abrotoni , an . M. j. bacc . lauri , juniperi , an . ℥ j. sem. cymini , ℥ ss. coq. in aqu . font . & vin. alb. an . lib. ij . colat . adde aceti vin . ℥ ij . salis nitri ℥ j. Misce . ℞ salis , nitri , ciner . sarmentor . an . ℥ j. ol. vet . ℥ vj. cerae ℥ iij. terebinth . clarae ℥ j. fiat Cerat . If the Matter be so gross and viscid as it yields not to the Remedies above prescribed , it may be reasonable to attempt it by Suffumigation with vinegar sprinkled upon the lap . pyritis , which sometime disposeth them well to Discussion . Caution . But in the use of these stronger Discutients you are to be carefull , that whilst you endeavour Resolution , you do not breath out the thin Humour , and fix the more gross , and so render the Part scirrhous .

2. Suppuration . If after the use of the milder Discutients proposed in hot Tumours the Symptoms of pain and inflammation do not lessen , you shall then forbear the farther use of Discutients , and hasten Concoction or Suppuration ; which is indeed the work of Nature , by the benefit of whose heat the Humours are digested , and pus generated . If the heat be strong , the Matter is for the most part well concocted ; and being so , it is white and of good consistence , and not ill sented : but if the heat be weak , the Matter is otherwise . It is therefore our work to cherish and increase the native heat in the affected Part , to perfect its Concoction : and that is furthered by hindering Transpiration , and defending it from outward air ; also by proportioning the quality of the Medicaments to the temper of the Part , and quality of the Tumour . And forasmuch as our naturall heat is temperate and moist , such also ought the Medicaments to be : they ought also to be emplastick . Yet it is not unfrequent to see a Suppuration made accidentally by cold Medicaments , which by a light , gentle astriction of the Pores do perform the office of Emplasticks ; as Vnguentum album , Sorrell roasted in embers . Nay , in cold Tumours I have seen Suppuration caused by the stronger Discutients .

Tumours do suppurate sooner or later according to the Humour of which , or the Place in which , they are generated . Those which are of Bloud , and in Fleshy parts , do easiest come to maturity . Those which arise from other Humours , and are near or in the Joynts , or Parts endued with little heat , ( especially those contained in a Cystis ) do difficultly suppurate .

The Matter differeth according to the variety and mixture of the Humours . Of Bloud always proceeds laudable Matter , especially if the native heat be strong : but if other Humours be mixed with it , as they get predominancy , so is the Matter more or less crude . In Furuncles or Boils it is clammy , and not unlike pith .

In Abscesses made by Translation the Matter is purulent , sometimes white and well-coloured , other times partaking of a yellow or green , sometimes of a brown colour ; and is more or less foetid according to the time it hath there remained .

Tumours made by Translation have sometimes Matter in them from their first appearance : but it being commonly lodged deep under the Muscles , the Matter is not felt till it hath raised the Tumour ; which is not done without pain , pulsation , &c. as in a Phlegmon , but deeper , and doth not affect the skin with Inflammation till the Matter reach near it . In these Tumours we do not attend the Symptoms of Suppuration , but open them as soon as any quantity of Matter offers it self . Whilst the Matter is making , the native heat of the Part is to be preserved and increased by Medicaments which may alleviate the pain , and further concoction .

Suppuratives are of two sorts : Suppurative Medicaments of two sorts . some are simple , others are compound . The simple are Aqua tepida , with which if you foment the lesser Phlegmons , it will suppurate , ( and sometimes by continuing its use it will discuss them , where the Matter is not fit for Suppuration . ) Hydrelaeum moderately heats and digest . Oleum maturum cherisheth the native heat , and supples and concocts Matter . Butter is maturative , and is profitably mixed with Anodynes and Suppuratives , especially in soft delicate bodies . Oesypum is also maturative ; and so are the Fats of all domestick Creatures . Fol. malvae , viol . parietaeriae , mercurialis , brancae ursinae , decocted in hydrelaeo cum farina tritici , butyro , & vitellis ovorum , are Suppuratives . A raw Onion is sharp and biting ; but roasted under embers loseth its acrimony , and suppurates Tumours that are difficult to digest . The Lilly-root is a known Suppurative . Out of these Simples Cataplasms are made : as , ℞ radic . althaeae , lilior . albor . an . ℥ ij . fol. tussilag . malvae , bismalvae , an . M. j. coq. in brodio , terantur , adjectis far. sem. lini ℥ j. far. tritici ℥ ij . axung . porcinae , butyri rec . an . ℥ i ss. croci pulv . ℈ ij . vitello ovi unius ; Misc . fiat Cataplasmae . In cold Tumours , or where the Matter lies deep , ℞ radic . bryoniae , lapathi acuti , an . ℥ ij . coq. & cribrentur per setaceum , addendo cappar . & allior . sub cineribus coctorum an . ℥ iij. fermenti acris ℥ ij . pulv . sem. lini & foenug . an . ℥ j. tritici ℥ ij . axung . porcinae ℥ ij . mell. com . axung . anseris ℥ j. croc . pulv . ʒ j. Misc . Where the Matter is tough , gum . galban . ammoniac . bdell. Empl. de mucilaginibus , &c. The Tumour being suppurated , be the Matter what it will , the evacuation of it is necessary , lest it corrupt within , and corrode the Veins , Arteries , Nerves , Tendons , or the Bone , if it lie near one : in which cases it is lawfull to open it before the Tumour is all suppurated . So also in the Joynts , and in the Head , if the Abscess lie over the Sutures : likewise in Abscesses in ano , where , through the weakness of the Part , a putrefaction is apt to follow ; or in the fauces , where the neighbouring parts may suffer by consent , and the Patient be in hazard of strangling . In these cases we wait not for perfect Suppuration , but by deep Scarification discharge the serous bloud , and prevent an Abscess . There is also care to be taken in Abscesses of the Breast and Belly , where the Matter is in danger of breaking inwards . Yet by opening these too soon they sometimes apostemate again , or become crude , and difficult to digest and cure .

3. Two ways of Opening . Incision . The way of Opening them is twofold ; by Knife , or Caustick . They are of use according to the place that is affected , and the quantity of Matter which is to be discharged . In the Face , where the Cicatrix may be unseemly , Incision of them is best : but in large Abscesses , where the quantity of Matter is great , or where we would keep the Abscess long open , or in a place where Bandage cannot be made to retain the Tent in , there a Caustick is most proper . Authours do not generally approve so well of the Caustick ; yet Sennertus proposeth it in a Hernia aquosa , where it is least safe : for in truth those cold Tumours do especially require to be opened by Incision ; yet when the habit of body hath been tolerable , I have in that also used the Caustick with good success , as I shall shew in the Cure thereof , and do commend it in the opening of large Abscesses as most safe and easie , the Matter being thereby discharged plentifully . And if the Caustick be applied in the declining part , the Abscess is sometimes near cured before the Escar separates , ( if the Matter be not contained in some peculiar Cystis ) and that without dilatation or Tents . Caution . Yet you ought to be wary how you make Fontanells with them in hydropick or very fat people , by reason of the weakness of their naturall heat .

Of Causticks there are various sorts ; Causticks . as of the lixivium saponis , cinerum sarment . vitis siliquarum fabar . &c. boil'd to a solid consistence : or in the boiling you may adde to them vitriolum Roman . pulver . from ʒ j. to ʒ ij . also opium ℈ ij . to ℥ vj. of the lixivium : or by a mixture of calx viva & lixiv . saponis you may make a Caustick . These are the stronger sorts in use amongst us : not but that there are Causticks made with Arsenick , &c. but , unless it be in great Sarcomata or such like , I use onely a milde preparation of calx viva with a little common soap , and a third part of the Caustick-stone . In children and tender soft bodies I often use calx viva made into paste with a little black soap . In these two latter there is no fear of their spreading ; a Pledgit of dry Lint and an Emplast . diachalciteos , or the like , is sufficient defence , leaving them on till the next morning . Caution . But in the application of the stronger Caustick there is more caution required . Those we endeavour to keep within compass by small snips of Emplast . hoping thereby to defend the parts about : but , in spite of all our endeavours , they will spread farther then was designed , if they lie any while on the Part out of our sight . For though the Part be outwardly defended with Emplasters , they will find a way under the skin , or at least under the cuticula , to spread , according to the quantity of the liquid salt in the Caustick . They do your work in less then an hour .

The Escar being made , you may divide it , and stupe the part affected with wine or milk , and dress it up with unguent . busilicon dipt in ol. lilior . warm , applying an Empl. diachalc . simpl . dissolved in some of the same oyl to the consistence of a Cerat : or apply an anodyne Cataplasm , and bind it up .

In the opening an Apostem by Incision , you ought to take care that the Apertion be made in that place where the Matter is most contained , the skin being for the most part thinnest there : and if it be not the most declining part , yet you may draw your knife towards it , for the more easie discharge of the Matter , then that the Incision be made according to the rectitude of the Fibres . If it be in the Groin or Arm-pit , it ought to be oblique : in other parts make it according to the length of the member .

In making the Incision you are to avoid wounding the Vein , Artery , or Nerve : nor must you discharge the Matter at once , especially in great Abscesses , lest you over-weaken the heat of the Part , or cause fainting .

The Instruments proper in opening Apostemations are made choice of according to the Part that is affected , and the greatness of the Abscess . Ambr. Parey proposeth some whereby you may more covertly open them : but we make use of Lancet or Knife , of which our Instrument-makers furnish us with choice . If the Fauces be affected , the Handle of your Knife ought to be long , and the Blade short ; some thereof crooked , and cutting on one or both sides . Your Instruments ought to be kept clean , for your credit ; and sharp , that you may perform the work with less pain .

The Incision being made , the Accidents or Symptoms that attend it are to be removed . In the first place the Bleeding is to be restrained , if any such happen , ( which is very rare ) with pulv . Galeni ex thure & aloe mixed cum albumine ovi . How you shall dress it if opened by Caustick , I have already shewed you .

Fainting , Fainting . which sometimes happeneth through weakness or timorousness in the Patient , may be relieved by laying the Patient upon his back , and sprinkling a little cold water on his face . But if the Fainting proceeded from some preceding sickness , and is continued by the greatness of the evacuation and noisome corrupt Matter , you shall in such cases provide some cordiall Juleps or Electuaries , of which he may take at pleasure . As , ℞ spec. diamarg. frig . ʒ ss. confect . alcherm . ℈ j. syr. è succo citr . Rhaead . an . ʒiij . aq. melissae , buglossae , cinnam . hordeat . an . ℥ i ss. Misc . Or , ℞ confect . de hyacinthoʒ ss. syr. garyophyll . rubi Idaei , an . ʒiij . aq. dracontii , card . benefict . Stephani , an . ʒi ss. Or , ℞ cons. borrag . melissae , cort . citr . condit . ros. rub . an . ℥ j. rad. eryng . conditae , nucis mosoat . conditae , an . ʒi ss. spec. aromat . rosat . ʒij . confect . alcherm . ʒiij . ol. cinnam . gut . iv . cum syrupo de cort . citr . q. s . fiat Electuarium . Of which the Patient may take a morsell any hour in the day . Mithridate and theriaca Veneta are proper in such cases alone , or mixed with cons. lujulae , or any of the forementioned Syrups or Conserves .

The spirits may also be refreshed with Epithemata made up of some of the aforesaid distill'd Waters and cordiall Species with acet . ros . &c. which for want of a Physician you may prescribe .

You are in the next place to consider the Abscess , whether after the evacuation of Matter there remain nay considerable hardness , either by reason that the Tumour was not enough suppurated , as in large Abscesses it frequently happens ; Fomentation . or that it be affected with pain and inflammation . Therefore at your next dressing it may be reasonable that you have a Fomentation ready of summitat . malvae , bismalvae , flor. cham . summitat . absinth . out of which a Stupe may be wrung , and applied over the Abscess , to give a breathing to it , and you leisure to consider how to dress it .

If it was opened by Incision , Digestion . it requires Digestion ; to which purpose this may be proper : ℞ terebinth . ℥ j. far. triticiʒij . croci pulv . ℈ j. vitell. ovi q. s . Misce . But if the lips of the Ulcer be painfull , a little of the Yolk of laid Egg with ol. ros . upon a proportionable Tent may be sufficient , and an Empl. of diachyl . simpl . with a mixture of unguent . dialthaeae applied in the form of a Cerat : or , in case of pain and hardness , this ; ℞ mucil . sem. lini , foenug . althaeae extract . in decoct . hordei ℥ ij . olei lilior . oesyp . amygd . dulc. an . ℥ j ss. terebinth . ℥ j. cerae ℥ vj. aut q. s . fiat Ceratum . Then with compresse and Bandage rowl it moderately , and after it is digested you may deterge , as shall be prosently shewed .

In Tumours by Congestion foment with decoct . Fomentation . absinth . flor. sambuci , ros. rub . baccar . myrtill . sem. foenug . in wine and water , adding afterward some sp. vini . These Abscesses requiring to have their heat kept up , and the relaxed parts strengthned . If the Opening was made by Caustick , dress it with a Pledgit dipt in a mixture of unguent . basil . with ol. lilior . hot : or , to rouse up the heat in the Part , and hasten separation of the Escar , adde a few drops of ol. terebinth . and apply Empl. diachyl . ireat . or Empl. de minio cum sapone , malaxed with ol. lini . After separation of the Escar , you may deterge with Mundif . Mundif . Paracels . Paracelsi thus made : ℞ terebinth . clarae , mellis despumati , an . ● ss. vitell. ovor . num. iij. coq. ad consist . unguenti . If there be required stronger Detersion , you may adde Merc. praecip . ʒj . to an ounce ; you may also adde alumen ust . but that will make the ulcer painfull : Mundif ▪ Apii . however some crude Ulcers may admit of it . Mundif . ex apio is also proper , as it is in the Pharmacopoeia Lond. or this : ℞ succ . absinth . ℥ ij . succ . brassicae , chelidon . an . ℥ j. mellis rosati colati ℥ ij . terebinth . ℥ iij. coq. ad succorum consumptionem , addendo pulv . myrrhae , sarcocollae , an . ʒi ss. pulv . rad . ireosʒj . rad. aristoloch . rot. pulv . ʒij . far. triticiʒiij . far. orobi , lupin . an.ʒj. Misce . If the Matter do not well discharge , you must help it by compression and Bandage : or if the Tumour was large , and the Opening but small or not enough in the declining part , lay it more open ; for without a convenient Orifice , whereby the Matter may plentifully discharge between Dressings , you cannot hope for a speedy Cure . That way of dilating by Piths or Sponges is meer trifling , unless it be to thin the skin for the more easie Incision .

If you deterge not with too sharp Medicaments , they may also serve to incarn : Urguentum incarnativum . Vnguentum Nicetianae . or you may use this , or such like ; ℞ terebinth . Venet. ℥ iiij . pulv . aristoloch . rot. ireos , thuris , an . ʒiij . mastich . myrrhae , aloes , an ℥ ss. cadmiaeʒ vj. mell . ros. q. s . fiat Vnguentum . Or , ℞ succ . Nicotianae lbj . picis , resinae , ol. olivar . immatur , an ℥ iij. terebinth . Venet. ℥ vj. cerae q. s . fiat Vnguentum . If the flesh grow loose or spongy , touch it with a Vitriol or Alume-stone moderately , and it will daily waste it , with little or no pain , and dispose the Ulcer to cicatrize : of which Stones you may have some fitted in Quills for your use .

The Ulcer being incarned , you may cicatrize with unguent . lithargyri : ℞ lithargyr . Vnguentum lithargyri . aur. & argent . an . ℥ iij ss. calcis decies lotae subtiliss . pulverzatae ℥ ij . cerussae ℥ ij . tutiaeʒ vj. olei myrtillor . ℥ vj. ol. rosati lb j ss. sevi vitulini ℥ viij . succor . plantag. laciucae , solani , an . ℥ iv . coq. sevum lento igne cum oleis & succis usque ad consumptionem succor . deinde colentur ; colaturae addantur unguenti rosati ℥ ij . cerae albae q. s . iterum coq. unieâ ebullitione ; postea auferatur ab igne , baculo agitando , cum mineralibus praedictis priùs optimè pulverizatis , & fiat Vnguentum . Or with unguent . desiccat . rub . aq. calcis . Or else you may cicatrize with this Water ; Aqua cicatrizans . ℞ myrobalan . citr . balaust . an . ʒ ij . alum . rup . ʒ ss. aq. germin . quere . equiseti , an . ℥ ij . vini albi ℥ j. bulliant parùm , & colentur pro usu : in which Pledgits may be dipped and pressed out . You must take care that the Ulcer be cicatrized seemly , neither too high nor too low .

Having thus treated of Tumours by Fluxion , we shall now say something of those made by Congestion ; which , though capable of most of the former intentions more or less , yet differ in the manner of governing them , viz.

Bleeding ought in this case to be less frequent ; but Purging more strong , with agarick , hermodactyles , scammony , jalap , aloes , colocynth , pil . rudii , cochiae , Cornachini , benedict. laxat . confect . hamech , elect . è succo rosarum , purging Diet-drinks , &c. as in the Chapter of Oedema , to which I refer you . The Revulsion hath little or no place here .

Derivation by Issues and Setons are usuall . Repulsion is proper in many of them , especially that of Bandage in oedematous Swellings of the Legs , Arms and Hands .

But Discussion is the principall intention of the Chirurgeon in this place , and ought to be done with hot Medicines : of which sort I have set you down some already , and more you will meet with in our particular Discourse of those Tumours .

Suppuration seldom happeneth in these Tumours , unless there be an admixture of bloud with it : in which case treat them with Suppuratives , as hath been said , and open them .

After Apertion , the method of healing differs little from that of Abscesses made by Fluxion : but of their Cure you shall be more informed in the Chapter of Oedema .

The next thing that offers it self to our consideration is Diet : Diet. and that is of two sorts ; the one regarding Tumours made by Fluxion , the other those by Congestion .

In hot Tumours made by Fluxion we are to propose such moderation as may take off from the great ferment in the Bloud , whereby it may be rendred less apt to flow into the weak Part. To which purpose the Ancients prescribed such a slender Diet as might onely support their Strength : yet with a regard to Custom , the Age and Constitution of the Patient , and greatness of the Inflammation . If the body be strong and abound with Humours , and the Inflammation great , their Diet may be the more sparing and cooling ; as Water-grewell , Panado , and such like . Where the Inflammation is less , or the Patient weak , Chicken-broath , with Wood-sorrell , Lettice , Purselane , or a boil'd Chichen , a potched Egg , &c. and such like meats of easie digestion . To others , Mutton , Veal , Pullet , Rabbit , and some sorts of the firmest Fish . In great Inflammations there is commonly Fever attending , in which case they have little inclination to eat . Their Drink should be Ptisans , or small well-boil'd Ale . If Wine be allowed , it ought to be small , or allay'd with water . Falopius , in his Discourse of hot Tumours , saith , he was wont where there was Plethora , to prescribe panem lotum in aqua , asperso succo aurantiorum cum modico zuccari , a little Bread dipt in water , and sprinkled with juyce of an Orange and Sugar , and that but twice the day ; and their Drink no better then water . Galen forbids Wine ; yet permits it to them qui habent ventriculum debilem , for their Stomack'd sake : which is necessary to be observed ; for unless that be kept up , in vain are all our endeavours .

The Air ought to be temperate by art or nature .

All Exercise is to be forborn : for the Bloud is thereby heated , and the Humours made more fluid . Sleeping in the day is also forbidden , out of hopes they may rest better in the night .

In Tumours by Congestion we allow such a Diet as is heating and attenuating ; their Meat rather roasted then boiled , and of good nourishment ; as Mutton , Veal , Kid , Pullet , Rabbit , Chicken , Pheasant , Partridge , Cock , Snipe , &c. All White-meats , Fish , Fruits , Sallets , are forbidden . Their Drink may be Ale or Beer : Wine is also allowed in these cases : and their Drink may be medicated with Sarsaparilla , China , lign . guaiaci , lentiscinum ; as you may see more particularly hereafter .

The Air ought to be warm and attenuating . Sleep in the day is absolutely forbidden , and ought to be moderated in the night . Passions of the mind are to be avoided both in this and all other Diseases .