Ars chirurgica a compendium of the theory and practice of chirurgery in seven books ... shewing the names, causes, signs, differences, prognosticks, and various intentions of curing all kinds of chirurgick diseases ... : to which is added Pharmacopoeia chirurgica, or, The medical store, Latin and English ... / by William Salmon ...

CHAP. IV. Of a SINUS in Tumors.

I. IT is called in Greek, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. in Latin, Sinus; and in English, the Hole of a Tumor or Apo∣stem.

II. The Description. Is it the hole or hollowness of a Tumor or Apostem, which being emptied of its Pus, is notwithstanding filled again; for which reason it is, that the sides of the said hollowness do not close, and grow together with the Flesh which is underneath it; but there is a certain cavity or hol∣lowness left remaining, very difficultly, if not-impossible, to be cemented.

III. Now the mouth and en∣trance into the Apostem and Ʋlcer, is generally strait and narrow; but within it is more profound or deep, enlarging it self into a proportional bredth.

IV. The Causes. They arise mostly from Apostems or suppurated Tumors, not soon enough opened, or not well cleansed.

V. For the Pus being longer kept in the Apostem than it ought to be, acquires a sharp or corroding quality; by which it makes many

winding and turning passages; to which there is an afflux of Humors from the adjacent parts, and many times from the whole Body: for which reason it is, that this Sinus, or Windings to and fro, is difficult to be filled up with Flesh, and healed.

VI. The Differences. They are manifold: 1. As to Magnitude; for some are greater, some lesser; some shallower, some deeper, some less capacious, others broader.

VII. 2. As to Figure; some are streight, others with many turnings and windings; some long and deep, others roundish, or globular.

VIII. 3. As to the situation, or way of Running: some run up∣wards, and so give better hopes of Cure; for that by its orifice the Pus may the more easily flow forth: some tend, or run down∣wards, so that the Pus cannot flow forth; for which reason, with the Syringotomos it may be opened on the lower part.

IX. The Prognosticks. If the Sinus is not speedily cured, it contracts a Callus, and degene∣rates into a Fistula; and will not then be cured, without much difficulty and danger.

X. The hopes of Cure are taken partly from the Sinus it self, as not being large, deep, winding, or depending: partly from the Part; as being in an upper part, not in a part depending: and partly from the Matter flowing forth; as being well digested, without much swelling, or any very sensible pain; being white in colour, and small in quantity.

XI. If the Pain is wholly vanisht, and the whole place is equal; not feeling with a hollow or yielding softness; it is a good Argument that the Sinus is already filled with Flesh.

XII. But if there is much pain, or any swelling or tumor, the matter flowing in great quantities, and as it were continually, of an evil colour, as green, blew, yellow, or blackish; and indi∣gested, or otherwise very putrid, and extreamly stinking; the hopes of Cure are very small.

XIII. The Cure. The Indica∣cations are taken from the Sym∣ptoms, which are chiefly two, Solution of Ʋnity, and Hollowness: and therefore there must be a Unition; which that it may be accomplished, the Hollowness must be filled with Flesh.

XIV. Now the Cavity cannot be filled with Flesh, except the temper of the Part is as it ought to be; and that the Sinus is free and clean from all its impurities and filth: we must labour there∣fore to remove the Distemper of the Member, if any be, and then that the Sinus be throughly cleansed.

XV. The former is done with Alteratives of a contrary temper; and Purging once or twice a week, with Pilulae Catharticae, Tinctura Purgans, Tinct. Cathartica, or Sal Mirabile, Pulvis Catharticus, or Pulvis Cornachini.

XVI. Then see to the Orifice of the Sinus, if it looks not down∣wards, cause it to look so, by opening the lower part thereof; that the filth may have a free passage forth; and such a like

Sinus, by applying Abstersives, is easily cured.

XVII. Now in this case, some∣times the whole Cavity must be laid open; sometimes an Ori∣fice must be opened only on the inferior part: but the opening the whole Sinus is most in use, because the Ulcer thereby may be the more easily cleansed and healed.

XVIII. Yet this is only when the Sinus is great, and the whole Part may be laid open without danger: otherwise we only open it in the bottom thereof; which done, it is throughly to be cleansed and dried, that no Pus be left remaining.

XIX. For if any of the filth be left behind, there are com∣monly Recidivations or Relap∣ses which follow it, or else it degenerates into into a Fistula: and tho' the parts may seem to be conglutinated, yet they stick not firmly together, but after∣wards separate again.

XX. Now to help on the re∣moval of the Pus, Pillows, or Bolsters and Swathbands are of great use, thereby straitly to com∣press the hollowness, from the higher part of the Sinus, to∣wards its Orifice.

XXI. This being said, we must come to consider of the Medica∣ments fit for this purpose; as 1. Bar∣ley-water, especially if mixed with a little Red-wine. 2. Mel∣icrate, or Water and Honey boil'd together. 3. Mulsum, or Wine and Honey boiled together; which both cleanses and cor∣roborates together.

XXII. To these things you may add, the White Potion, which is thus made: ℞ Strasburgh-Turpen∣tine ℥j. three yolks of Eggs, grind them together till they are well mixed, then add to them, Barley-water three quarts; with which wash the Sinus for some days.

XXIII. To these things we may add, Honey of Roses, Barley-meal, Bean-flower, Orobus-meal, meal of Lupins, Spirit of Wine, Alum-water, Oxymel, Unguentum Ae∣gyptiacum; which laft is the strongest of them, and to be used in the most filthy Ulcers.

XXIV. ℞ Honey of Roses strained ℥ ij. Barley-flower enough to give it a thick Body: or, ℞ Turpentine, Honey of Roses, A. ℥ j. juices of Wormwood and Smallage, A.℥ ss. boil them together; then add of Lupin, Bean, Barley flower, A. q.s. mix them well together.

XXV. Or, having for some days cleansed with the Mixture at Sect. 22. aforegoing, wash only with the following Mixture, with which sometimes the Cure is only and compleatly per∣formed. ℞ Well-water lbiv. Saccharum Saturni, Roch-alum, A. ʒ vj. white Vitriol ʒ iv. Spirit of Wine ℥ vj. mix them.

XXVI. But if the Sinus are manifold, or with many turnings and windings, or of an extraor∣dinary depth, so that it is alto∣gether impossible to open them wholly; nor that Unguents can possibly penetrate thro' the whole Cavity: in this case, liquid Abstersives must be used, which may (by the help of a Syringe) insinuate themselves into all parts of the Sinus.

XXVII. And sometimes, as

soon as the Medicine is cast in, the Orifice is to be stopt, (for some little time) that the Me∣dicament may remain there for a while; which may be best done with a short Syringe, if the Orifice is narrow, holding the Syringe in all the while, to pre∣vent the immediate flowing back.

XXVIII. ℞ Fair-water lbv. Honey ℥ iv. juices of Centory and Wormwood, A. ℥ ij. Aloes ℥ ss. dissolve by boiling, and strain.

XXIX. If it be very foul, ℞ Barley-water lbiv. Honey ℥ iij. Unguentum Aegyptiacum ℥ vj. mix them.

XXX. The Sinus being suffi∣ciently cleansed by the use of these things, or others of like nature, you must then come to the use of Sarcoticks, Incarnatives, or Flesh-breeders: for tho' Nature her self will generate Flesh, yet Art and Medicines many times assist her so, as to remove the recrements which hinder her in her operation; which since they are an impediment to her, are wholly to be taken away by means proper; so that the filth and impurities may be throughly taken away from the Ulcer, and the humidities dried up.

XXXI. Now Sarcoticks or Flesh-breeders, cannot be said properly or really to generate Flesh, for that is the work of Nature alone: but are so called from their being assistant to her, in removing (as was said before) the impediments, by their cleansing and drying qualities.

XXXII. Yet they ought not to be over-drying, but such as may agree with the natural temper of the Part: for as much as there is not the same degree or measure of driness in all Bodies, nor yet in all Members.

XXXIII. The more gentle Sar∣coticks are, Barley-meal, Bean-meal, Rosin, Frankincense: the stronger are, Orobus-meal, pou∣der of Orrice-roots, of Aristo∣lochia, Myrrh, Scammony, Aloes, Tutia, Pompholyx, &c. out of which you may make various Compositions.

XXXIV. A mild Sarcotick. ℞ Turpentine ℥ ij. Gum Elemi, Capivi, Frankincense, Mastich, Olibanum, Colophony, A. ℥ ss. Wax, Oil, A. q.s. mix, and make an Ointment.

XXXV. A strong Sarcotick. ℞ Round Birthwort-root, Orrice-root, Comfrey-root, all in pouder, A. ℥ ss. Mastich, Olibanum, Frank∣incense, Myrrh, Aloes, A. ʒ ij. Scammony ʒ j. Turpentine, Honey, A. q.s. mix them well together.

XXXVI. If it is Flesh of a harder kind which is to be gene∣rated, and in a Body more than ordinarily dry, and the Ʋlcer lyes open, then you may apply Topicks in a dry form, as Sarcotick Pouders, to strew on: as,

XXXVII. ℞ Frankincense, Mastich, Olibanum, Rosin, A. ℥ j. make all into a fine pouder. Or thus: ℞ Aloes, Frankincense, Mastich, Olibanum, Rosin, Sanguis Draconis, Sarcocol, A. ℥ j. make all into a pouder.

XXXVIII. This is better: ℞ Fine Scammony, and make it into a subtil pouder. Or this: ℞ Scammony, Myrrh, Olibanum,

A. ℥ j. make them into a fine pouder. Or this: ℞ Scammony in pouder ℥ iij. fine Aloes, Myrrh, A. ℥ j. Coloquintida in pouder, ℥ss. mix them.

XXXIX. This is a most ex∣cellent thing: ℞ Scammony in pouder, Mercurius dulcis levi∣gated, A. ℥j. Myrrh, Aloes, A. ℥ss. Coloquintida in pouder ʒ ij. mix them.

XL. But if the Sinus is not open, Sarcoticks of a liquid form are to be injected, after the manner of Cleansers; and the Orifice being kept close, they are to be kept in for a while.

XLI. For this purpose, red Port-wine, in which Myrrh, or Myrrh and Aloes has been dis∣solved, may be injected; or Wine, in which Scammon has been dis∣solved: or a Decoction of round Birthwort-roots in red Port-wine, in which you may dis∣solve Myrrh: also, a Deco∣ction of Comfrey-roots, Horse∣tail, red Roses, Myrrh, Frank∣incense, Aloes, &c. in red Port-wine, are admirable in this case.

XLII. After all, it may be a question, whether the deeper and more extream parts of the Sinus are well cleansed and congluti∣nated? But this you may know by the Pus that flows out, if it is but small in quantity, well digested, and no pain is per∣ceived: but if after the fifth or seventh day, a crude and raw Humor shall come forth, it is a sign of no good healing, or conjoining the Parts; and that Flesh is not as yet bred therein.

XLIII. In this case, you must use Medicaments which more forcibly dry, yet without any biting; which may be conti∣nued till the Sinus is in a man∣ner filled up.

XLIV. Then some aggluti∣nating Medicament is to be ap∣plied, which may gently, and with∣out any acrimony, close together, and heal the tender Flesh which is generated and bred, con∣joining the divided parts.

XLV. After the Agglutinative has been applied, you may put upon it a new soft Spunge, dipt in generous Wine, or in Mulsum, or in a Decoction of Pomgranate-peels, Red-roses, and Myrrh, made in red Port-wine, and you may bind it round on; which binding let begin from the bottom of the Sinus, and so go forwards to the Orifice.

XLVI. And about the bottom, let the swathing be as hard and strait as may be, (but so, as not to cause pain,) and then slacken it by little and little, till you come to the very mouth of the Sinus it self; over which let the Medicament be laid after a loose manner.

XLVII. Nor must you too closely stop up the Orifice, but leave a place for the Pus to come forth; for which purpose, the Emplaster laid on may have a hole cut in the middle thereof.

XLVIII. This was the ancient way of curing a Sinus, and hollow Ʋlcers; but Arcaeus in his Book of Wounds, l. 2. c. 7. gives us ano∣ther more compendious course, discovered by himself in curing

Apostems newly opened; by which, on the third or fourth day at farthest, all the aforesaid cavity of Apostems might be perfectly cured.

XLIX. If the Apostem or Tu∣mor (says he) is great, let it be opened as well as may be; so wide, that ones Finger may go into the Orifice; that thereby all the Pus contained may flow forth, by a gentle compression of the place.

L. The Pus being evacuated, stop the mouth of the Sinus with a Tent, and lay over the Sinus a Bolster; which let lye with∣out stirring it, till the next day following.

LI. Then loosen the ligature, and let the hollow Ʋlcer be care∣fully purified or cleansed from all the Pus: (I suppose he intends, with abstersive Lotions or In∣jections) that nothing may be left remaining underneath.

LII. This done, let a small Pipe of lead be put into the Ori∣fice, reaching even to the cavity or hollowness; but by no means be forced any farther: upon which lay Emplastr. Basilicon, spred upon linnen Cloth; in the which the Pipe also may be contained, that it falls not forth; but always leaving a hole at the orifice of the leaden Pipe.

LIII. Then on either side of the Sinus let triangular Bolsters be laid, that all the hollow space may be filled up with them; leaving the orifice of the Sinus in which is the leaden Pipe or hollow Tent, free and open; not letting it be stopt up with the Bolsters, nor any ways ob∣structed by the ligature or bind∣ing; so that all the Pus con∣tamed may wholly run out.

LIV. Then let the place co∣vered with the Bolsters be rowled about with a Rowler; beginning from the bottom of the Sinus, and so going towards its Ori∣fice, thereby to force away the remaining pus or filth.

LV. Thus bound up, leave it till the day following, then loosen the Ligature, and search how much of the Cavity remains, by which you will know, whether the Bolsters did exactly press upon the hollowness.

LVI. For all these placs or hollownesses, which were com∣pressed by the Bolsters, will all of them be found conglutinated, and joined fast together; the which being manifest, the Bol∣sters are again to be bound on after the same manner as before, and so to continue till the next day.

LVII. But now if any Pus or Humor seems to be left in any place, this is to be prest forth (as before) with the Bolsters and Swathing; by which means the gaping or hollow places will coalesce, and be joined close together.

LVIII. Which as soon as you perceive, the Bolsters are to be removed, and you may lay upon the Ʋlcer a Plaster of Arcaeus his Leonine-composition, spred upon linnen Cloth; or some other Emplaster of like kind, as Dia∣palma, &c. every day wiping and cleansing it six or eight times.

LIX. Now here is to be noted,

1. That Arcaeus his Method is only in use in Apostems newly opened; but in an old Sinus, or where it may be callous, or fistulous, the former Way is much the better and safer.

LX. 2. That the Bolsters be sufficiently compressed with the Rowlers; both to press forth the Pus, and also to conjoin the disunited parts; other∣wise no healing can be expected.

LXI. 3. That there may not remain any reliques of the indi∣gested or putrid Matter thro' the Part; which if any be, will be known by the continuance of the Tumor, and redness of the colour; and therefore the due and thorow Cleansing must be endeavoured with all the speed that may be.