Chirurgorum comes, or, The whole practice of chirurgery begun by the learned Dr. Read ; continued and completed by a Member of the College of physicians in London.

CHAP. IX.

Of the differences of the milder sort of compound Ʋlcers, and first of a sinuous Ʋleer with∣out any callosity.

HAving discoursed in the for∣mer Chapter of those things which make the milder fort of Ul∣cers to be accounted compound; to wit, a sickness, cause or symp∣tome complicate with an Ulcer; In this Chapter I will set down the differences of milder Ulcers, and the cure of them. These diffe∣rences are taken either from the Fi∣gure or Adjuncts. From the Fi∣gure these. Of the milder com∣pound Ulcers some are plain, some sinuous. I call that a plain Ulcer, wherein the Skin is eroded, and the subjacent flesh, and the whole Ulcer is presented to the sight, be∣ing bare and uncovered. No com∣pound Ulcer is to be accompted of an easie cure: because both skill and experience are required in per∣forming this.

And thô these plain Ulcers be fubject wholly to the sight, yet let no Man imagine that all of them are of equal facility to be cured; for according to the nature of Grief, the quality of the cause, and the invasion of the symptomes, the Ulcers with which these things are complicate, are either of more easie or difficult cure. A plain compound Ulcer has three scopes in the cure of it; for First, that must be removed which makes it com∣pound, whether it be a disease, cause, or symptome: Secondly, That which is by erosion lost, must be repaired; and Thirdly, The part must be cicatrized: How all these three indications are perform∣ed, I have set down at large in the former Chapter, so that I need not to repeat any thing.

Ʋlcus sinuosum, or a sinuous Ul∣cer, I call that which is like to a Cony-burrow; for sinus, or sinu∣osity, is a cavity or hollowness of parts under the Skin, separate by a Flux of an eroding Humor, which

according to Nature were uni∣ted.

There be two causes of these si∣nuous Ulcers, to wit, Apostemes lying deep a long time, or not time∣ly opened, although they be not so deep, and wounds not well cured: for Quittour lurking a long time, either in a Tumor suppurate, or in a deep wound not well cleansed, must needs corrupt and get a sharp quality, which makes to it self these cavities, which are not so easily fil∣led with Flesh and united: for unto the part affected, now weakened, excrementitious Humors slow, not only from the parts adjacent, but from the whole Body also, which make the Ulcer hard to be cured. These Burrows are found out by Probes of Silver, or Lead, and wax-Candles: If there be more Orifices than one, by Injections. They sometimes are superficial, sometimes deep; sometimes streight, sometimes oblique; sometimes there is but one cavern, sometimes there be more.

Of these sinuous or cuniculous Ulcers, some have neither hard∣ness nor callosity, such I will term Ʋlcera cavernosa, hollow Ulcers; some have both hardness and cal∣losity, these are termed Fistulae. First, ••hen I will shew you how cavernous Ulcers are to be cured, and then how Fistula's. There are two ways of curing of a ca∣vernous Ulcer: the First is by In∣jection of Medicaments: the Se∣cond is by opening and dressing, according to Art. If you go about to cure such an Ulcer by Medica∣ments, without opening, then two scopes offer themselves; to wit, the filling of the Cavity with Flesh, and the agglutination of the parts disjoyned. The incarnatives must be drying without erosion, and the glutinatives must have astricti∣on, besides desiccation. Both these intentions you may perform with the Injection of this Medicament following, ℞ Aq. decoct. hord. lb j. Mell is rosat. ℥ iij. Sarcocol. ʒ ij ss. Myrrh. Thur. an ʒ ij. Rad. Termen∣till. Bistort. Symphyt, an. ʒ j ss. Ba∣laust. ʒ j. Baccar. myrt. ʒ ij ss. Su∣mach. ʒ i ss. Vini odorifer. ℥ vj. Bul∣liant ad consumptionem tertiae par∣tis, ac coletur decoctum, cui adde Spirit. vini ʒ i. If you perceive that the Ulcer is not sufficiently mun∣dified, which you may conjecture, if the Quittour be either stinking, reddish, pale, blackish, or thin and waterish, then apply this Medica∣ment: ℞ Vini, in quo infusa sint marrubium album, Centaurium mi∣nus, Absinthium, Flores Hyrerici, & Carduus Benedictus ad lb, ss. Ʋnguenti Aegyptiaci ʒ ij. Mel ros. ℥ ss. misc. inject this. You can hardly devise more effectual Medi∣caments than these are for agglu∣tination of a cavernous Ulcer: Yet whosoever shall apply them, not dressing and binding the Ulcer ar∣tificially, shall hardly cure any such Ulcer: Wherefore I think ex∣pedient that I shew you the way of dressing: First, lay upon the whole process of the Cavity Dia∣palma cum succis, or Emplastrum album coctum, or Emplastrum con∣tra rupturam: Then inject your Medicament warm. Thirdly, in the Orifice put in a leaden Tent, or Pipe: but short, hollow, wider in the upper than lower part, and having the brims of the upper part turned. That it may be kept from

slipping in, shut the Orifice and the upper part of the Tent or Pipe with an Emplaster; let it be one of those named before: the Em∣plaster must be snipt, that it may give way to the Quittour which flows out of the Cavity: above the Emplaster apply a piece of a Sponge, which must be soft, moist∣ned with the Medicament with which you dress the Ulcer, and wrung out: for the Sponge sucks into it self the Quittour, keeps the brims of the Orifice dry, and preserves them from excoriation: above the Sponge lay a pledget of Tow: the lower Cavity, or from the bottom of the Ulcer to the Orifice, must be boulstered. Above all lay a double soft linnen Cloth. Begin your rowling at the bottom, where it must be somewhat strait, to bring the sides of the Ulcer to∣gether, both to express the Quit∣tour, and to procure agglutination, but let it cause no pain; for it would distemper the part: to∣wards the Orifice the rowling must be somewhat slack, that the Quit∣tour may have way to issue out. Every third day (if much water flow not) dress it, loose first the Rowler, the turnings whereof are about the Orifice, take away the Sponge and Emplaster; First, that you may come to cleanse the Ul∣cer; Secondly, that you may make trial whether Nature goes about to agglutinate the parts: which you shall discern, if the excrementitious Matter abate, be laudable in co∣lour and consistence, and have no ill smell, and if the Cavity be with∣out pain, and without any remark∣able Tumor. On the contrary, if the Quittour be plentiful, ill-coloured and stinking, if the Ca∣vity be painful, and a conspicuous Tumor appear, you may perswade your selves that no unition is pro∣cured. Dress the Ulcer according to this manner, until perfect ag∣glutination be caused, which yo•• shall know by the signs afore said going before; if no Quittour or very little appear in the Orifice, ï the Cavity be equal without Tu∣mor, and no pain be felt: when you perceive these signs, then ad∣dress your selves for the cicatrizing of the Ulcer. If after a dressing or two, thin gleeting Matter ap∣pear, yet despair not; for often∣times such Matter is wrung out of the parts by reason of the Medi∣cament drying; the nature of the part, as being nervous, membra∣nous, or glandulous; or Lastly, by compressing of the Ulcer by bolstering and rowling. As for the Emplaster applied to the Ca∣vity it self, it is to be renewed, when it is defiled with Quittour, or leaves cleaving. Dress the Ul∣cer as seldom as you can, contrary to Empiricks; for often dressing gives way to cold Air, which is hurtful to Ulcers, and hinders uni∣tion. Thus you may proceed in curing of cavernous Ulcers, if the excrementitious Matter have way to flow from them freely; which will be, if the Orifice be in a de∣pending part, or lateral, the Ca∣vity or Sinus being lateral also; for then, such a posture may be ap∣pointed, as will further evacuation of the Matter. But if by reason of other Figures of the Cavity, the Cavity cannot discharge it self of the filth of the Ulcer, then until this impediment be removed, no

expurgation, incarnation, or ag∣glutination can be expected: where∣fore way is to be made by incision or a caustick.

This you must do: First, if the Cavity be lower than the Orifice either directly, or obliquely, but not very deep: Secondly, if it go very deep also, as in Fistula's, and such Ulcers, penetrating in the Breast, where the Cavity most commonly is lower than the Ori∣fice. Thirdly, if the hollowness be very broad. In these cases way must be made by these means for the Matter, that it may be expur∣ged: otherwise, if it be kept in, it will erode the parts adjacent, and no incarnation or consolidation can be looked for. We may make way for the Quittour two manner of ways: First, by opening the lower end of the Sinus only; Se∣condly, by opening the whole Ca∣vity.

The first course we are to take, if the Sinus be of an enormous bigness, or if it be in a great joynt; for great wounds in such Joynts are mortal, according to Hippocrates: or if there be great Vessels, Nerves or Tendons of Muscles in the way; which are like to bring fearful fluxes of Blood, or lameness: which things skill in Anatomy will teach you. If none of these cases hinder you, then it is the su∣rest way to lay open the whole Ca∣vity, which is the second way. These two scopes we may attain unto by two means; to wit, by a Caustick and Incision.

The Caustick we are to use: First, if the party be timorous, and will not admit Section: Se∣condly, if the Cavity be in a part, wherein a great sear may cause de∣formity: Thirdly, if there be fear of a great flux of Blood: Fourth∣ly, if the diseased Party be sick and weak.

If a Caustick be to be applyed, if the situation of the part where∣in the Sinus is, be in the upper side, then apply your Lapis internalis: for it corrodes soonest, deepest, with less pain, and will not be so apt by running and spreading to burn the parts adjacent, or to cause a greater solution of unity than we intended. But if the Si∣nus be in the lower side, as in the sole of the Foot, or in a part very depending; then I advise you to use a Caustick made of strong Sope••lees and unslaked Lime, which will not run. It is an ordinary practice of some to ••ub the part with a Caustick-stone, and when the part is mortified then to open it: First, this is not to be done, but when the Skin is very thin; besides this, this rubbing causes far great∣er pain than the application of it to the part, being defended. Be ever of this mind in your practice, to use the mildest means; the fruits which you reap by so doing will be Respect, Love, Credit, and Gain. When you have perceived that the force of your corrosive Medicament has mortified all to the very Cavity, then procure the fall of the Eschar, with the application either of Dialthaea simplex, or But∣ter without Salt. There is no sub∣stance comparable to this for this purpose, When the Eschar is gone, then proceed in curing of the Ulcer, as hath been said, by mundificative incarnative, and cicatrizing Medicaments.

If the party be couragious and strong, use Incision: this is soon∣er performed; has less pain, and sooner will be cured. When you have made Incision, arm Dosils and Pledgets with a Medicament which strongly dries and mundifies; such is this: Take of Al••e Hepatica two drams, of black Rosin and Amber, of each a dram and a half, of Mill∣dust two drams, of unslaked Lime two drams and an half, with this Powder, and the white of an Egg, and the yolk beaten together, make a Medicament in consistence re∣presenting an Unguent: then ap∣ply the Medicament to the Sinus incised, filling it well, that the brims may be kept asunder. Open not the Sore till the end of the Second day, at the least; for this Medicament will both dry the su∣perfluous humidity of the Ulcer, and will excellently digest it. Af∣terward dress the Ulcer as the me∣thodical indications of Cure shall move.

If you find these Ulcers so hand∣led, do not heal to your mind, then hold your Patient to the decocti∣ons of Sarsaparilla, Guajacum, and the China root, with which mingle some of your most effectual Vul∣neraries, as Agrimony, St. Johns-wort, Sanicle, Avens, Ladies∣mantle, Virga aurea, Solomons seal, the roots of Comfrey, Tormentil, Bistort, Horehound, Borage and Bugloss. I will not conceal from you the description of a Decocti∣on, wherof I have made often proof in Ulcers of the Breast, Joynts and Belly: ℞ Sals. paril. ℥ vj. Rad. Sassafras. ℥iss. Scob. Guajac. ℥ iij. Eupator. Scabios. Tussilagin. Sani∣cul. Hyper. an. man. j. Rad. Sym∣phyt. Tormentill. Bistort. an. ℥ss. Rad. Borag. Bugloss. an. ℥j. Pas∣sul. major. enucleator. ʒ iij. Li∣quirit. ℥ ij. Infundantur infunden∣da per noct. in aq. font. fervent. lb. xxiv. Sequente die coquantur len∣to igne cum reliquis ad consumpt, lb. viij. Bibat aeger singul. dieb. lb. iiii. hujus decocti: Hauriat: lb. ss. mane, ac tantundem hor. quartâ pomeridiarâ: In prandio bi∣bat lb. j. ac tantundem in coena: Quum sit it, superest. lb. j. hauri∣enda. The Simples of this com∣position may plead for the effica∣cy of it. Let him continue the taking of this Decoction for the space of One and twenty days: du∣ring which time he is to use a spare Diet, and to eat Flesh af∣fording a good juice, and of an ea∣sie concoction. As for the local Medicaments which are to be ap∣plyed to an Ulcer, I have spoken of them already: too much re∣petition will breed loathing.