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. XX. Of an ƲLCER FISTƲLOƲS, or, of a FISTƲLA.

I. WHAT the Greeks call 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Fistula ille morbus, & Ulcus fistulosum we in English call purely, A Fistula, Fistulous Ulcer, or, An Ulcer fistulated.

II. The Definition. It is a sinuous or hollow Ʋlcer, which is narrow, with a callosity or bardness in the inner side of the parts; suffering a solution of Ʋnity, and yielding a stinking and virulent Humor.

III. The Differences. It dif∣fers from a sinuous Ʋlcer only in this, that the sides are callous: whereas a sinuous Ulcer is totally without callosity.

IV. This Callus, is a thick and infensible heaviness; and it many times becomes so hard, that the sides can by no manner of means be agglutinated or united.

V. Fistula's also differ among themselves; some of them proceed from an Apostem, some from a simple Ʋlcer, from the Parts af∣fected: some are in Fleshy Parts, others in Tendinous, or in the Bones or Joints: and some enter into the Cavities of the Brest or Belly.

VI. They differ also in their magnitude; for some are greater, some lesser: in their Conti∣nuance; for some are inveterate, others recent: in their Figure; for some are streight and nar∣row, and some deep or shallow; others are winding, or capa∣cious: in the Number of their Sinus's; for some have but one Sinus; others two, or three, or more; which are also either strait or winding, and many times penetrate to the Bone.

VII. The Causes. Wiseman says, the Callus is hastned, (or made) by the transpiration and resolution of the thin and subtil Humors, and the incrassation of the more pituitous: by the con∣gestion of which, a long Pipe of (hardned or brawny) Skin is made, which branches it self inwards from the Orifice, quite thro' all the Cavities of the Ulcer.

VIII. Sennertus says, that Fi∣stula's have their original Causes for the most part from Apostems; in which, either by the impurity of the Body, or the too great abundance of the evil Humor, being long contained, a Callus is bred.

IX. Or, they may be caused from the unkilfulness of the Artist, not applying proper Medicaments, or delaying the Cure; whereby the Pus, from its corrosiveness, and long detention, makes as it were Coney-burrows, 'till they become at length very deep, and withal callous, of an insen∣sible brawney hardness.

X. They are said to proceed also from Flegm, or adust Melancholy, degenerating into a fetid and virulent Humor.

XI. The Signs. The edges of a Fistula are white and hard, having little or no pain; and in∣deed the whole Fistula is gene∣rally void of pain, unless it be in a Joint, or near to, or touches a Nerve, Tendon, or Membrane.

XII. The Pathognomick Signs of a Fistula are taken from its essence; being of a Pipe-like figure, with callosity.

XIII. The Accidental Signs are taken from the differences: if the Orifice and Sinus is but one, or single, the Quittor is less; but if the Sinus's are manifold, the Pus or Quittor is more in quan∣tity; and it is ever filthy, viru∣lent and stinking, and sometimes may be prest out thro' the Ori∣fice of the Fistula: the changing also the position of the Body, or part will shew them: for the flowing of the Matter having ceased, if after the changing the position, it runs out again, it shews that there are more Si∣nuosities.

XIV. By a Probe you may search the cavity of a Fistula; but in an oblique, crooked or winding, you must use a Wax-candle, which is best also to be used when the Fistula is in the fleshy and sensible Parts: the Probe is most convenient, when it pene∣trates to the Bone.

XV. If the Fistula is only in the fleshy Parts, that which is touched by the Probe, is soft; and the matter which comes out, is white, equal, and in great quan∣tity.

XVI. If it penetrates an Arte∣ry, that which comes forth is thin, and shining, and comes forth with leaping: but if the cavity joins to a Vein, the matter is like dregs of Claret-wine, but red∣der and thicker, where the Vein is eroded.

XVII. If it touches a Nerve, there is puin in probing it to the bottom; and the Pus is as it were fat and oily, but less in quantity; and the action of the Part is made uneasy, causing a pricking pain, with a certain numbness.

XVIII. If it extends to a Bone, what the Probe touches is hard, not yielding, and painful, while the Periosteum is not corroded, not if it is corroded, or consumed, and the Bone is foul, you will find it rough and unequal to the touch, with a thin, stinking, and black matter, and void of pain.

XIX. If the Probe being pressed slip, no cariosity has seized upon the Bone, for a sound Bone is smooth and slippery: but if the Probe stay upon it, appearing smooth, it is disposed to cariosity; and if the Bone feel unequal and rough, it is carious.

XX. If there are more Orifices than one, you may know whether

there be more Fistula's than one, by injecting a Liquor with a Sy∣ringe into one of the Orifices: for if the Liquor flow forth again by all the Orifices, then it is all but one Fistula; but if it comes not forth at the other Orifices, then there are more Fistula's than one.

XXI. And this is likewise dis∣covered in part, by the colour of that which comes forth: for if that which flows forth by all the Orifices is of one colour, it is a sign that the Fistula is but one; but if of a different colour, it shews that there are more than one.

XXII. If by searching, the parts are pained, or if Blood follows your Probe, the Fistula is not confirmed; but if neither happens, 'tis a Fistula beyond all dispute.

XXIII. The Prognosticks. All Fistula's are hard of cure, and some incurable: and it is parti∣cularly to be observed, that some certain Fistula's ought not to be cured, viz. such as are old and inveterate, by which the superfluous Humors have for a long time been vented: for such Fistula's as these (in regard they preserve Men from divers Diseases) are by no means to be closed up; because, as Hippocra∣tes, Epidem. lib. 6. sect. 3. saith, that when they are shut up, they cause many Maladies. And there∣fore, on the contrary, if at any time such should chance to be healed, they ought to be opened again.

XXIV. A recent Fistula in the fleshy parts alone, and not deep, in 〈◊〉〈◊〉 y••ung Body of a good constitution, is more easily cured: but an old, deep Fistula, having many Si∣nus's, or being near any noble or principal Member, or being in an old, or cacochymick, or he∣ctick, or emaciated Body, is of very difficult cure.

XXV. If the edges are not very hard, but somewhat soft and mat∣tery, they promise a more speedy cure: but coming in those places where Nature is accustomed to discharge her self of vitious Humors; as the Abdomen, Groins, Buttocks, Cods, Perinaeum, and Fundament, they are of much more difficult cure.

XXVI. They are also difficultly cured, and for the most part incu∣rable, which touch the Arteries, Veins, Nerves, Tendons; and those which are in the heads of the Muscles, or in the Joints, Vertebrae, cavity of the Thorax, Abdomen, Womb, Bladder, or Guts.

XXVII. Those among the Bones and great Joints, are very difficult to cure; by reason of the sensi∣bility of the parts, which for the most part admit neither of In∣cision nor Dilatation.

XXVIII. Those which are in such places, where you may safely lay them open, or remove the Cal∣lus, are more easy of cure: so also such as are shallow, passing no deeper than the Membrana car∣nosa, or at the farthest, than the Membrane of the Muscles or Muscle; because by incision they may easily be cured.

XXIX. Fistula's winding and turning, and with many Coney∣burrows or cavities, require Incision, that Medicaments may be con∣veyed

to other parts; otherwise they admit not of cure: and these are of more difficult cure, than those which have but one Sinus.

XXX. But indeed no Fistula is of easy cure, because of the un∣aptness of the Part for conveniently applying of Medicaments: for un∣less they reach to the very bot∣tom of the Fistula; (which is not easily to be done) no cure succeeds. Besides, the Medica∣ments which are able to remove a Callosity, are vehemently sharp and biting; causing Pain, sym∣ptomatical Fevers, Fainting, &c. and the Humor which causes the Fistula, is oftentimes malign and stubborn, not easily yielding to Medicines; for which reasons the Cure many times succeeds slowly, and ill.

XXXI. Fistula's ending in the Tunicles of Arteries and Veins, are thought to be incurable, because of Hemorrhages: for if you en∣large the Orifice, or take away the Callosity by sharp Medica∣ments, the flux of Blood will be renewed or increased. This hap∣pens most commonly in Bubo's of the Groin, not speedily cured, and Parotides under the Ear, and in Phlegmons in the Arm∣pits: because these Parts being Emunctories, are near to the divarication of the great Ves∣sels, viz. the Aorta and Vena cava, descending and ascen∣ding.

XXXII. If in a Fistula in the Back, the Spine be carious, 'tis 'tis no prudence to undertake a Cure; for at length an exte∣nuation of the Body will be induced, and the Animal Spirits diminished; and withal they will not be communicated (as they ought to be) to the extre∣mities of the Body, whereby Death will not long after suc∣ceed.

XXXIII. Fistula's in the Joints are dangerous; (for even great Wounds in the Joints in Bodies of a good habit, are pronounced by Hippocrates to be mortal.) For seeing the Joints are framed of very sensible parts, as Nerves, Tendons, Membranes, and Liga∣ments; and that Corrosives must be applied to remove the Callus, great pain will ensue, which may endanger a Flux of Humors, Inflammation, &c. all which will detard the Cure. Be∣sides, these being depending Parts, and not fleshy, they are less able to discuss a Flux of Humors received, by reason of the weakness of the Natural Heat of the Parts.

I. The true or absolute Cure of a Fistula,

XXXIV. The Cure of a Fi∣stula, is either Real, or Pallia∣tive.

XXXV. The real and true Cure, is that which removes the Callus, and compleats the Cure, as in other Ulcers.

XXXVI. The Palliative Cure, is that which meddles not with the Callus, but only dries the Fistula within, and skins it without, the hollowness never∣theless remaining, commonly continuing some little while closed, but easily breaks forth

again, being to be kept under by a regular Diet, Purging, and taking good Wound-drinks.

XXXVII. In order to the real and true Cure, there are several Indications: 1. To abate the Humor which flows. 2. To cor∣rect the vitious Habit of the Body, by Traumaticks. 3. To remove the Callus. 4. To heal up the Ulcer, with Sarcoticks and Epuloticks.

XXXVIII. As to the first Indi∣cation, which is to abate the Humor that flows, there are several In∣tentions: 1. That the Patient keeps a regular and good Diet; eating things sweetning the Juices and Humors of the Bo∣dy, or at least breeding sweet Juices, and of a sparing nou∣rishment, (unless the Sick be in a Hectick, or Consumption) that the Sore may not be supplied with a superfluity of Humors: such are Bilket, Meats roasted, (not boiled or baked) Fowls or Birds of Mountain-places, Par∣tridges, &c. of which we have spoken plentifully in other places: he may eat also every Morning fasting, an ounce or better of Green-ginger, which strengthens the Stomach, corrects in some measure the evil Ha∣bit, and drys up superfluous Humors.

XXXIX. 2. To evacuate the evil Humors contained in the Body, which supply the Fistula with Matter and Humor: this is done by Universals; as general Purges and Vomits, which carry off and diminish the Humors, and cause a Revulsion of the same.

XL. For this purpose, you may use Emeticks, which empty the Stomach, and cause a Revulsion upwards; the chief of which are from Antimonials; as the Infu∣sion of Crocus Metallortun, Vinum Benedictum, Vinum Antimoniale, Tartar Emetick, Pulvis Antimonii, Pulvis Rheumaticus, Mercurius Vitae: and among Vegetables, we commend Oxymel Scilliticum; than which there are not many better things: but in using these things, you must consider the strength and habit of the Bo∣dy, and accordingly make your choice, and pursue them.

XLI. Emeticks having been used their due course, you are next to cleanse the Bowels by proper Cath∣articks; such as Tinctura Par∣gans, Sal Mirabile, Mercurius praecipitatus Principis, Aurum Vitae, Syrupus Catharticus, Pulvis Catharticus, Pulvis Cornachini, Electuarium Catharticum, Pilulae Catharticae, Pilulae Mirabiles, and Our Family-Pills; choosing out of all these things, those which may most agree with the Humors of the Body, and comport with the strength or weakness of the Sick.

XLII. And these things are to be continued for some time; or are to be constantly resumed and made use of, at due intervals of time; as the nature of the Disease requires, and the Body of the Sick can bear.

LXIII. The second Indication requires to correct the evil Habit of the Body, by Traumatick Diet-Drinks. Now altho' we have, in Lib. 4. Cap. 30. given you ma∣ny and various Prescriptions of Diet-drinks, out of which you

may choose what most agrees with your present occasion; yet we shall for order sake, give you some other Examples in this place, which Authors have very much commended.

XLIV. Tagaultius prescribes this Diet-drink. ℞ Agrimony M.iii. Plantane M. ii. Olive-leaves M. i. cut, bruise, and boil in Canary-Wine, q.s. of which let the Sick drink ℥iii. or iv. every day.

XLV. Or this: ℞ Osmund∣royal P. iii. Centory the less P. i. Wine q.s. boil, and make a De∣coction: it corrects the Humors, makes a good Habit of Body, expels and drives forth broken Bones: add in its use, a little Spirit of Wine.

XLVI. Or this: ℞ Sanicle, Mugwort, Speedwel, Saracens-Consound, Wintergrcen, A. ℥ iv. Horstail ℥ii. Canary-Wine q.s. boil, and make a Decoction.

LXVII. This, if you would have its Operation yet stronger, you may in drinking of it, add to each Dose, of levigated Crabs-eyes ℈ i. for Crabs-eyes and Savin are of sin∣gular use, in expelling Pus, and other putrified Matter, in con∣suming and removing a Callus, and driving forth corrupted Bones.

XLVIII. Another Dict-drink. ℞ Avens, Carduus ben. Savin, A. ℥iii. Sanicle, Saracens-Consound, Speedwel, A. ℥ii. Tormentil-roots ℥i. Wine q.s. boil, and make a Decoction.

XLIX. Authors mightily com∣mend the roots of Gentian and round Birthwort; ʒi. of either of them being taken in White-Wine in the Morning, either every day, or every other day, fasting two Hours after it.

L. The juices also of Agrimony, roots of Bistort, of Borrage, of Comfrey, of Tormentil, and of Osmund-royal; the juices of Cen∣tory the less, Golden-rod, and white Horehound, and of Plantane, Periwincle, and Horstail, being mixed with Ale and drank every day; sweetned with Sac∣charum Rosatum, wonderfully contribute towards the healing: so also the Decoction of Gua∣jacum, Sarsaparilla, and Burdock-roots, being given morning and evening for a Month or two together.

LI. ℞ Raspings of Guajacum ℥vi. Sarsaparilla split ℥iv. Rai∣sons stoned ℥iii. Liquorice bruised ℥ii. roots of Tormentil, Osmond∣royal, Bistort, Comfrey, Coriander and sweet Fennel seeds, A. ℥i. Agrimony, Golden-rod, tops of Hypericon, Solomons-seal, A. M.i. boiling Water ten quarts: infuse for 24 hours, then boil with a gentle Fire, 'till a Gallon is eva∣porated; strain, and keep it for use. Dose, half a pint in the Morning fasting, a pint at Din∣ner-time, half a pint at 4 in the Afternoon, and a pint at Supper∣time: if the Patient cannot drink this quantity, let him drink as much as he convenient∣ly can.

LII. The third Indication of Cure, is the removing of the Cal∣lus; which how that is to be performed, and whether by Me∣dicaments or Instrument, or both, we shall anon shew un∣der the next Head, where

we shall treat of it at large.

LIII. The fourth Indication of Cure, is the healing-up of the Ʋl∣cer. The Callus being removed, or dissolved into a slough, and cast off, you may deterge with this. ℞ Turpentine washt in Aq. Vitae ℥iii. juices of Smallage and of Hounds-tongue, A. ʒvi. Honey of Roses strained ℥jss. boil to the consumption of the Juice; and add to it pouder of round Birthwort root, of Tobacco, Myrrh, meal of Lupins, A.ʒii. Scammony ʒi. mix.

LIV. And if you add to the former, pouder of Orrice, of Frankincense, of Myrrh, and Sar∣cocol, it will become incarnative; and then you may cicatrize with Ʋnguentum desiccativum rubrum, &c.

LV. Or you may wash and cleanse with this. ℞ Plantane and Rose water, A. lbi. Ung. Aegyptiacum ℥i. white Vitriol ℥ss. Syrup of dried Roses ℥v. mix, and dissolve for an Injection.

LVI. Or: ℞ Plantane-water, or rather Lime-water, which is better, lbi. white Vitriol calcin'd ℥ii. fine Bole ℥i, S.V. ℥j ss. in which let Camphir ʒvi. be dis∣solved, mix them. With these, you may wash and cleanse the Fistula; more especially, those into whose bottoms you cannot easily convey other Medica∣ments.

LVII. Sennertus also says, you may inject by a Syringe Lixivium, (not very strong) Aqua mulsa, Sea-water, Lime-water, and Wa∣ter of the bot Baths, and Aqua Vitae, or S.V.

LVIII. Now of how great Vir∣tues Spirit of Wine is, in these kinds of Cures, we have already declared in Cap. 12. Sect. 15. and 16, aforegoing: and here again, we cannot but by the way observe, That if it is mixed with other convenient Medica∣ments, it is then of admirable use and benefit in cleansing and drying sordid and filthy Ulcers; and will perform ten times more, being mixed with other Medicaments, than they could do, if used alone without it, or if used alone with them; which the industrious Artist, if he pleases to try, may easily prove.

LIX. If you use cleansing Pou∣ders, you may blow them into the Ʋlcer by a Pipe, its end being put into the Sinus of the Fistula, the Fistula being but a little way within the Flesh: but if it is long, it may be opened on the opposit part, and so on both sides the Medicaments may be cast in.

LX. And here likewise we can∣not but intimate, what we have before said, in the Cure of a Sinus, and of a Cavernous Ʋlcer; that we must use our utmost endea∣vour, that the orifice of the Fistula may be open downwards, that so the Humors may the more freely flow forth; or if it be not open, then in that very place it is to be opened, unless there be some weighty reason which may hinder it.

LXI. Some inject Lime-water, in which Mercurius dulcis levi∣gated has been put, and shaken together: or the Ablution of Turpethum Minerale; but scarce∣ly any thing exceeds the Water

of the Griffin, which in healing Ulcers does Wonders.

LXII. Some deterge with this. ℞ White-wine ℥viii. Ung. Aegyptiacum ℥ss. S.V. ℥i. mix them; with which you may in∣ject warm once a day, or oftner, if you see occasion.

LXIII. You may know when the Fistula is sufficiently cleansed, if the Pus or Matter is uniform, equal, smooth, thick, white, and without any ill or stinking smell.

LXIV. If the Bone be carious, you must consider how far the caries has entred into it, and endeavour the removal of it either by Actual Cautery, or boring with the Trepan, or rasping, shaving, or scraping; then by Desquamatories hasten the exfoliation of the Bone; and so proceed in the rest of the Cure, with Sarcoticks and Epuloticks.

LXV. But if the Fistula is near, or over some noble Part; or if there is a Nerve, Tendon, or Artery near; or if it is deep in the great Bones, or in the Joints, where you cannot proceed by the actual or potential Cautery, and it will not yield to milder Medicaments; you must then come to the palliative Cure, by gentle Purgings, Diet-Drinks, Waters, Balsams, and Ointments; which may give a quietness and ease to the Part affected, as we shall anon de∣clare.

LXVI. The second Intention of this fourth Indication, is to unite and consolidate the Parts dis∣joined: this is done in part, by continuing the use of traumatick Diet-drinks, or some such Li∣quor as this. ℞ Angelica, Avens, Bawm, Hyssop, Fetherfew, Mint, Marjoram, Savory, Tyme, Peni∣royal, Savin, A. M. ii. Burnet, Centory, Sanicle, Plantane, Knot∣grass, Yarrow, Solomons-seàl, A. M. i. roots of round Birthwort, of Bistort, Comfrey, Gentian, Tormen∣til, Zedoary, A.℥ii. Wine a gallon: put all into a glass Alembick, and draw off in B.M. a quart or three pints of Spirit: the dregs strain out, and the straining clarify with whites of Eggs: to this clarified Liquor put a quarter or more of its weight in Honey, which dis∣solve, and then add the distilled Spirit to it, and keep it for use. It may be given inwardly, ℥iii. at a time, Morning and Night; and also injected into the Ulcer, to incarnate it; applying in∣carnative Balsams or Ointments after it.

LXVII. The third Intention of the fourth Indication is, to produce the Cicatrice; of which we need not say much here, considering we have said so much of it in former places: only this you may note, that you may know when the Ulcer is near whole, and sit for cicatrizing; for that the Humor which flows from it, will be little, thick, and concocted, and the place will be void of pain and tumor; and when you find it altogether dry and skinned, you may then say that the Fistula is perfectly cured.

II. The Way of removing the Callus.

LXVIII. We are first to consider whether the Callus can be removed by Medicaments, or not; if it can,

whether it can be taken away with∣out laying the Sinus open, or not: if it can, then the first thing to be done; is to widen the mouth thereof, for the better and more easy application of Medicaments thereto.

LXiX. The Callus in the Orifice may be perceived at sight, but the Callus in the Sinus it self, is to be discovered by Instrument: for the Instrument or Probe being put in, if there is little or no pain, and it bleeds not, but a certain hardness it self, there is a Callus.

LXX. In those who are young, whose Flesh is soft and tender, Emollients and Digestives are sufficient, to dissolve or dis∣sipate the Callus; with which, as you see occasion, you may mix Abstersives.

LXXI. But the narrow Orifice is first to be dilated, (if it is too straight) which is performed four several ways: 1. By Incision; which is to be used to strong Bodies, if the Fistula is not deep, and runs along only under the Skin, no deeper than the Membrane of a Muscle, and if it is in a fleshy Part.

LXXII. 2. By things which swell; and these are to be used before Inci∣sion, if the Fistula has many sinuo∣sities: of this kind are roots of Briony, wild Rape, Birthwort, Gentian-roots, Elder-pith, Puff∣balls prepared and prest; Sponge twisted, and bound about with Thread very hard, and then kept in a Press for some time: this dilates more than the other things, and imbibes more moi∣sture.

LXXIII. Some prepare the Spunge by dipping it in simple Melilot-Emplaster, when very hot, the•• put between two Trenchers, and prest strongly in a Press, and after an hour or two, when it is cold, to be taken out; it will be firm, and almost resemble green Sage-Cheese.

LXXIV. Others dip the Spunge into Glair or Whites of Eggs, and then in like manner, keeping them in the Press' till they are dry, and so taking them out. Either the former or this may be cut out into Tents, of what form, or fashion, or bigness you please; which being put into the Fistu∣la, will exceedingly dilate it, by sucking to it the humidity.

LXXV. 3. By the Fistula-Tent: which your may make of fine downy Lint (the Threads being all taken away,) with this doun, and the Glair of Eggs, you may make Tents of what bigness and length you please, even to the depth of the sinuosicy. You may do it on piece of Deal-board.

LXXVI. And you may enlarge the bigness of the Tents, to dilate the Fi∣slula as much as you please: for these Tents being dried, will pierce into any cavity, like a Probe, without bending, (if they are well made) by reason of their stiffness.

LXXVII. 4. The fourth and last way, is by Hellebor-root; which opens by a kind of Ca∣theretick, or Caustick Property, and is to be prudently used: but is, in truth none of the worser means.

LXXVIII. The Orifice being thus widened, we may proceed to the removing of the Callus, as directed

at Sect. 70. above, with this Ointment. ℞ Juices of Smal∣lage ℥ii, of Celandine ʒii. of Onions ʒi. Honey of Roses ℥ii. Turpentiue, q.s. mix, and make an Ointment.

LXXIX. ℞ Our Ung. Nico∣tianae ℥i. Turpethum Minerale ʒi. mix them: and in some very tender Bodies, Ʋng. Nicotianae may do it alone: if you have not Turpethum Minerale, you may use instead thereof so much red Precipitate.

LXXX. And of this nature are, Ashes of Fig-branches, mixt with Goose-fat; Pot-ashes or Salt of Tartar, mixt with Veal-fat; decoction of Fern-roots, deco∣ction and pouder of Tobacco, and Euphorbium, Diachylon mixt with Precipitate, Ʋnguen∣tum Apostolorum.

LXXXI. Amongst the Emol∣lients and Digestives, for resolving and dissipating a Callus, Wiseman enumerates these, viz. roots of Althea, of Lillies, of Elecam∣pane, of Solomons-seal, wild Cucumbers, seeds•• of Line and Fenugreek, all sorts of Marrows, Fats of Hogs, Geese, Cocks and Hens, Mans-grease, Ʋng. Althaeae cum Ammoniaco & Galbano; of which, says he, you may make Fomentations, Cataplasms, Oint∣ments, Cerats, &c.

LXXXII. To this purpose also, he recommends Empl. de Ranis, fine, & cum Mercurio, (for Mer∣cury has a mighty power in softning Bones, and Ivory it self) Empl. è Mucilaginibus, Dia∣chylon cum Gummi.

LXXXIII. But for the most part, stronger Medicaments, to consume and remove the Callus, are requisite: as, the Roots of Spon∣dylium, viz. Meadow or Cow Parsnip, roots of Asphodel, Snakeweed, Briony, decoction of Lupins; but the best of all, are the lesser Centory, and the roots of black Hellebor, put in for 3 days into the Sinus: yet this last will be dangerous, if the Fistula be in any part of the Tho∣rax, or Abdomen.

LXXXIV. Or, ℞ Honey ℥iv. juice of blue Flower-de-luce roots, Red-wine, A. ℥i. juice of Celan∣dine ℥ss. boil a little; then add Scammony in pouder, Litharge, A. ʒii. white Vitriol, Tobacco in pouder, Aloes, Myrrh, A.ʒi. Turpentine ℥ss. mix them.

LXXXV. Take Frankincense, Myrrh, Scammony, A.ʒii. roots of Briony, of round Birthwort, To∣bacco, A. ʒi. Verdigrise ʒss. Sal Armoniack ℈ i. Hogs-lard, Oil-Olives, A.q.s. mix them.

LXXXVI. If the Callus is somewhat hard, and the Patient in years, you must use things more harsh, and which mundify strongly: as, Take Ung. Apo∣stolorum ℥i. red Precipitate ʒi. burnt Alum ℈ii. or instead of red Precipitate, you may use Turbith Mineral, in the same quantity; mix them well together.

LXXXVII. Or you may use Ʋnguent. Aegyptiacum, with the Precipitate and Alum: as it is stronger, so it causes more pain than the Ʋng. Apostolorum, but it procures not so good a kind of Pus.

LXXXVIII. Aegineta, lib. 4. cap. 49. commends the juice of the roots of Laserpitium,

or Elaterium mixed with Tur∣pentine.

LXXXIX. Ʋng. Fuscum Wur∣tzii is a famous thing in this case, if it is reduced by boiling into the form of a Suppository or Tent, and so put into the Fistula.

XC. Or this of Barbett. Take Agrimony Mss. Scordium, flowers of Hypericon, A. P.ii. French Bar∣ley ℥i. White-wine q.s. boil, and strain; add Virgin-Honey ℥iv. boil to a thickness, then add Sarcocol ʒiii. Olibanum, Mastich, A.ʒii. Myrrh ʒiss. white Vitriol ʒi. mix them: of this make Supposito∣ries or Tents; he says it is pre∣valent also against Fistula in Ano.

XCI. But if the Callus is inve∣terate, and grown to a very great hardness, so that the former things will do nothing, you must then come to the stronger Remedies, and such as are Caustick; of which also, some are more gentle, others more vehemently fierce.

XCII. The more gentle are these. ℞ Strong Vinegar ℥vi. white Vitriol ℥iv. Alum, Verdigrise, A. ℥ss. boil, and calcine in a luted Vessel; then make it into a fine pouder, and mix it with Ung. Aegyptiacum, with which arm the Tents. Barbett.

XCIII. The Aqua Viridis, or Green Water, (which we have formerly described) is an excel∣lent thing; being oftentimes cast into the Fistula, with a Syringe.

XCIV. Aegineta, lib. 4. cap. 49. has this: Take Verdigrise ʒxii. Ammoniacum ʒii. dissolve the Ammoniacum in Vinegar, and then mix the Verdigrise with it.

XCV. Wiseman says, he com∣monly uses Lapis Causticus, Tro∣chisci de Minio, Arsenick, and Oil of Vitriol: or this: Take Wax, Rosin, A. ℥i. corrosive Sub∣limate ℈ii. more or less; mix them upon a Fire, and dip a Spunge in it, but not too hot, lest you burn it; then press it out, and cut it out into such a form as may serve your purpose.

XCVI. Guido commends Aqua fortis, some Spirit of Nitre, which is better than A••. fortis, because A.F. is apt to black and foul the Bones, if it should touch them: others commend Oil of Vitriol, others Oil of Sulphur, and some Spirit of Salt.

XCVII. If you desire rather an Injection, Wiseman says you may make this, or some such∣like. Take Ung. Aegyptiacum ℥ss. Soap-lees ℥i. Rose-water ℥ii. Plantane-water ℥iv. Sublimate ʒss, Arsenick ℈i. mix, and boil to the consumption, of a third part; of which cast a little of it in with a Syringe for three days toge∣ther, shutting the Orifice up with Wax, of some Emplaster; so shall you consume all the Callus.

XCVIII. But, says he, you must consider well the situation of the Fistula; lest by its too far pene∣trating, it should hurt the Bone, or parts underneath.

XCIX. Take strong Lye ℥iv. Honey of Roses strained ℥jss. De∣coction of Lupins ℥i. Alum ℥ss. mix them: if you would have it yet stronger, you may add thereto red Precipitate ʒss.

C. Or, Take Orpiment, Sulphur

vive and Calx vive, Ana; make them into a fine pouder, and mix them. Or, Take burnt Alum ℥ii. Vitriol calcin'd ℥i. Orpiment, Ver∣digrise, A. ℥ss. make all into a fine pouder. Or, Take Turbith Mine∣ral not washed, Vitriol calcin'd, fine Bole, Ana; make all into a fine pouder.

CI. The strongest of all are these. Take corrosive Sublimate, Vitriol calcin'd, fine Bole, Ana; make them into a fine pouder. Or, Take white Arsenick, Orpiment, Calx vive, Ana; make them into a fine pouder: or, (if the Fistula is laid open, so that you can easily come to the Callus) you may with a Feather touch it gently with the Butter of An∣timony.

CII. As to the use of the sormer Pouders: if you have dilated the Fistula by Incision, you may sprinkle the Callus with them; but if it is dilated by any other means, then you may mix the Pouders with Ʋnguent. Populeum, wherewith a Tent may be armed, and so applied: or you may make Troches of those Pouders, which being made into form and dried, may be put in.

CIII. But this you must observe, that you must not force out either the armed Tent, or Troches, before they force out of their own accord: for so they will bring out the Callus with them whole, the Tent being within the Callus.

CIV. If there are many Sinuo∣sities, so as that no Tent can pierce to their bottoms: it will be best then to mix these Pouders with some Liquor, as Aqua Calcis, a small Lixivium, Alum-water, Vitriol-water, or White-wine, and so inject with a Syringe.

CV. But by reason of the Ap∣plication of these Medicaments, there is usually much pain, and sometimes Inflammation; it will be good to provide against it by some proper Defensative: as, Take Oil of Roses, Whites of Eggs, Ana; mix them well together, and apply it over the Part affected.

CVI. Or, Take Cows-milk lbi. crums of White-bread ℥vi. boil to thickness of a Pultiss; then add Ung. Populeon ℥ii. Henbane-seeds, ℥ss. Saffron in pouder ʒjss. Opium in pouder ʒss. mix, and make a Cataplasm, which apply Mor∣ning and Evening.

CVII. And round the adjacent parts, you may apply this cor∣roborating Emplaster. ℞ Pou∣ders of Red-roses, of Myrtle∣berries, A.ʒi. Mastich, Olibanum, Pomgranate-peels, A. ʒii. Orrice∣root ʒiii. yellow Wax, Pine-rosin, Oil of Hypericon, A. ℥i. mix, and make an Emplaster.

CVIII. Wiseman, to ease the Pain, and defend the Part, uses these Lenients; Decoctions of Mallows, Marsh-mallows, Violet-leaves, Mullein, Henbane, Quince-seeds, Barley; or Oil of Eggs, fresh Butter, Lard, Ʋng. Basili∣con, with Oil of Lillies, Dial∣thaea, &c. and over them he applies Refrigerants, as Empl. è Bolo, Oxylaeum, Emplast. Album, with Juices.

CVIX. But if notwithstanding all that has been said, the Fistula will give place to no Reme∣medies, that have or can be applied; we must betake our selves to the Incision-knife,

or the Actual Cautery it self.

CX. The whole Sinus is to be laid open; (unless it be in those Fistula's which reach unto the great Arteries, Nerves, Tendons, Membranes, which gird in the Ribs, or other parts of like nature:) which is to be done with the Incision-knife, ac∣cording to its position and form; or else with the Syringo∣tomus of Fabricius Aquapendens, which is very useful in this cause.

CXI. The Fistula being laid open, the Callus is to be removed by some of the Medicaments before de∣scribed; or with the edge of a Pen-knife or Razor; cutting so far, 'till you come to the good and sound Flesh; which you may perceive, not only by the colour, but by the Blood, and sense of Pain.

CXII. If the Callus is extraor∣dinary hard, it will be the best way to remove it with the Actual Cautery, or red-hot Iron; which is done, not only with most speed, but also with least pain, or sense of feeling; yet this Remedy, by reason of the ter∣ror thereof, few People will admit of it.

CXIII. In the mean while that these things are doing, whether by Caustick Medicaments, the Knife, or red-hot Iron) the Part it self is to be well guarded with some cooling Defenfative and Repel∣ler; lest the great pain should cause an Inflammation.

CXVI. The Callus being thus burnt throughly, you must then apply things to remove the Eschar or Crust; as Oily things, fresh Butter, Hogs-lard, Palm-Oil, Ʋng. Populeon mixed with Ʋng. Basilicon; to which you may if you please add a little Precipitate.

CXV. If the Fistula ends in a Bone, you must (so soon as it is discovered by Section) diligently scrape and pare away whatever is black and corrupted in the Bone, which must be in the surface there∣of. If the rottenness has cor∣rupted farther, then the scaly part is to be cut forth with some proper Instrument, unless it comes forth of its own accord.

CXVI. If the rottenness has pe∣netrated to the Marrow, then that which is corrupted is to be taken forth; but if the Bone is wholly putrified, it must be all of it taken out; which may be well enough done in small Bones, but not so in others.

CXVII. The Bone being now cleansed, you are immediately to apply Incarnatives, and then to heal it after the manner of a simple Ʋlcer: if the Fistula does not give place to healing, it is a certain sign, that all the cor∣rupted part was not taken away: for which reason, the Fistula is to be opened, and the Bone to be farther scraped and cleansed with all the care imagi∣nable.

CXVIII. If yet after all this, it will not heal, you may then con∣clude, that it has penetrated so deep, as it will be scarcely possible to find out its end and bottom; and is then to be left unto Na∣ture, whom we are yet to assist and help with Medicaments: and for this purpose, this Pouder of

Nicholas the Florentine, is much commended.

CXIX. ℞ Salt decrepitated, Tartar, Agarick, A. q.s. let them be made into fine pouder: this is said to draw forth the Bones which are broken and corrupted, cats thro' the putrified Flesh, and heals the Ulcer.

CXX. But this following Pouder is better. ℞ Salt de∣crepitated, Tartar calcined, Scam∣mony, Tobacco, all in fine pouder, A.℥i. Euphorbium ℥ss. mix them.

CXXI. The Callus being remo∣ved and quite taken away, if there be any thing sordid and foul yet remaining, you must make use of detersive and sarcotick Medica∣ments, such as that at Sect. 53. aforegoing: and for which pur∣pose Centory the less, Birthwort-roots, Golden-rod, Pimpernel, and the like are to be used: and then lastly, with Sarcoticks and Epuloticks you must com∣pleat the Cure.

III. The Palliative Cure of a Fistula.

CXXII. When the Palliative Cure is to be used, we have partly shewed at Sect. 65. aforegoing: to which we add, that in what part soever it be, and how simple soever, if it proves re∣bellious, and resists all sorts of Medicaments, as it oftentimes does, in scorbutick, strumatick, and cacochymick Bodies, you must then apply your self to this Method, as the ultimate of all that is to be done.

CXXIII. For it drys, and shuts it up for a time with a thin Skin, which so remains, 'till more Humors are generated, and heaped up in the Part affected, and then it breaks out again.

CXXIV. The Body is to be well cleansed and evacuated (at due intervals of time) with pro∣per Emeticks and Catharticks, such as we have enumerated be∣fore at Sect. 40 and 41. above: but as the Purging must be con∣tinual, it may be for many Months, or some Years: so a Purging-drink may be thought more expedient; such as this following.

CXXV. Take fine soft Ra∣spings of Guajacum, mealy Sarfa bruised, choice Sena, Mechoacan bruised, Hermodacts, Carthamus-seeds, A. ℥vi. Rhubarb, Liquorice, Fennel and Coriander seeds, A. ℥iii. Scammony, Anniseeds, Winters Ci∣namon, Virginian Snake-root, A.℥i. Agrimony, Angelica, Avens, Bawm, Ladies-mantle, Sanicle, Winter∣green, A. M. i. all being grossly bruised, put them into a Bag, with a Stone in it, which put into three gallons of new Ale; of which after the second or third day, the Pa∣tient may begin to drink; half a Pint fasting every day, and if it is a Body hard to work upon, as much at 4 in the Afternoon.

CXXVI. And for his constant Drink, he may take this. Take Guajacum rasped, Sassafros ra∣sped, mealy Sarsa, China, Juniper-berries, Burdock-roots, A. ℥x. round Birthwort root, Zedoary, Winters Cinamon, A. ℥v. Aniseed, Coriander and Fennel seed, Ginger. A. ℥ii. Agrimony, Angelica, Avens, Bawm, Clowns-woundwort, Albeal, Betony, Sage, Hyssop, A. M. i. all

being grossly bruised, put them into a Bag with a Stone in it; which put into four gallons of new Ale, letting them work together for two days: after which, the Pa∣tient may drink it as his ordi∣nary Drink.

CXXVII. Let his Diet be drying, and very strengthning; because this continual running of the Ʋlcer will drain the whole Body, and be in danger to induce a Consumption: white Ship-bisket is good, and ought to be his only Bread; his Meat ought to be roasted; and for Restoratives, strong Broths and Gellies are often to be given him.

CXXVIII. Let the Orifice of the Fistula be open downwards; if it is not so, let it be made by Inci∣sion or Cautery, or by the help of the Syringotomos, so that the Humors may freely pass out.

CXXIX. Then as for Topicks, Lime-water is good to wash, or inject withal, and sometimes Red-wine, or Red-wine mixed with S.V. or Lime-water with S.V.

CXXX. ℞ Aqua Calcis (in which Litharge has been boiled) ℥i. Spirit of dried Roses, or of Myrtle-berries ℥ii. mix them. Or, Take Plantane or Rose water ℥vi. Spirit of Wine ℥ii. Roman Vitriol in fine pouder ʒii. mix, and dis∣solve. Or, you may inject and and wash daily with the Water of the Griffin, which exceeds all other things in Nature; for that by long using of it, it has many times dissolved the Callus it self.

CXXXI. In some of these Li∣quors a Pledget of Lint, or a new Spunge may be dipt, or throughly soaked, and applied to the Fistula, and bound to the place: and over the Lint or Spunge Empl. Album, or Diapalma may be put, to keep it fast on: and it needs to be drest but every other day only, unless very much Matter flows forth; for then it will require a daily dressing and looking after.