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. XXIV. Of a FISTƲLA of the EYE.

I. WHat the Greeks call 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Fistula Lachry∣malis: we in English call the Weeping Fistula, or Fistula of the Eye. I know some will have this Ulcer to be called 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉 Aegilops, because it is a hollow or cavernous Ʋlcer in the Fleshy, or great Corner of the Eye; but Aegilops is no more Fistula La∣chrymalis, than a cavernous Ʋlcer not callous, is a Fistula.

II. The Place. It is seated in the great or innercorner of the Eye, near the Nose: or according to to Barbett, in the Punctum La∣chrymale, from which (a hollow Ulcer therein becoming callous) comes the Name of Fistula La∣chrymalis.

III. The Causes. It sometimes is caused from Anchylops, or Aegylops, or what produces the like Tumors in other places: some∣times it is made by Fluxion, and appears at first very small, like a Phlegmon or Inflammation.

IV. Sometimes, and that fre∣quently, it is caused by the French-Pox; and many times from a strumous Humor, in such as are affected with the Kings-Evil. Barbett says, it becomes callous, or degenerates into a Fistula, from a continual flux of Hu∣mors.

V. The Signs. It is manifest at sight: for first, the Orifice offers it self to view; then, by com∣pression of the Finger upon the Canthus, the matter issues out; sometimes a mixt matter is discharged, sometimes in a smal∣ler quanrity, and sometimes in a larger; and sometimes it is not unlike to the white of an Egg: also, you may run a Probe to the bottom of the Sinus.

VI. If it is from a Strumous Cause, it is made by Congestion, and the Tubercle is round, without dis∣colouring the Skin: if it is made by Fluxion, there is pain and redness accompanying it, and inflammation all over the Eye.

VII. The Prognosticks, Some∣times this Matter will be so sharp and malign, as to penetrate, rot, and eat quite thro' the Bone; so that it will discarge it self down∣wards thro' the Nose, with a fetid smell.

VIII. All these kinds of Fistu∣la's of the Eye, are of difficult cure, let them be from what cause soever: for the Part being loose and spungy, the Eye very sensi∣ble, and the Part very lax, it makes the Humors apt to soak into it, and penetrate even the Bone it self.

IX. That which is recent, if it is well opened, is easiest of cure; that which is inveterate, or of long continuance, is for the most part accompanied with an Ul∣ceration of the Gland, and a Caries in the Bone, which makes them subject to a weeping, after they are cured.

X. The sensibility of the Eye, makes it subject to pain and fluxion; and also unfit to be drest with sharp Medicaments, such as a Fistula usually requires.

XI. And if the Ʋlcer is accom∣panied with Erosion, it will be apt to terminate Cancerous; (as I once saw one) in which case, the Patient is deplorable.

XII. If it is become Cancerous, (known by its hard and livid lips, sharp pain, and fetid virulent mat∣ter) you are only to use a Palliative Cure, (as in Cancerous Ulcers) for an Absolute Cure will never succeed.

XIII. If the acrimonious mat∣ter has penetrated the Nose, to make a way thro' the Bone of the Nose from the corner; then the upper Orifice is only to be shut up, without scaling of the Bone; which will be a

abour both very painful, and fruitless.

XIV. If the Fistula continues long, as a Year, &c. and the Pus passes thro' the Bone to the Nos∣tril, it will cause 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Oculi Atrophia, a Consumption of the Eye, which will be incurable.

XV. The Cure. The Indications of Cure are threefold: 1. To cause an evacuation, alteration, diversion, or revulsion of the Humor. 2. To remove the Cal∣lus, without which the Cure cannot succeed. 3. To heal up the Ulcer, by Incarnatives and Epuloticks.

XVI. Due Purging ought to pre∣cede, by such things as are most universal, and least apt to cause Vomiting; Syrupus Catharticus, an Infusion of Sena, and Pulvis Cornachini are commendable: to which you may add, Pilulae Catharticae, Tinctura Purgans, and Pulvis Catharticus.

XVII. An alteration of the Hu∣mor is to be endeavoured, by such Alteratives as are prescribed in the Cure of Strumae, French-Pox, Scurvy, &c. using a Decoction of Guajacum, Sarsa, &c. for many days, with other Altera∣tive and Vulnerary Diets.

XVIII. The Matter also ought to be derived from the Head by Errhins, applied to the Nostrils: as, Take Scammony, Guttae Gam∣bae, A. ʒii. Confectio Hamech q.s. mix, and make long Rolls for Errhines.

XIX. And a diversion of the Humor is to be made, by applying Cupping-glasses, Vesicatories, and Causticks to their proper places: Fabricius Hildanus, Cent. 1. Obs. 41. says, that instead of a Cautery, he applied a Seton to the Neck, by which means alone he has performed the Cure.

XX. And some Authors will have a Revulsion to be made by Bleeding; where there is (as they say) a Plethory, or platitude of Blood.

XXI. Externally, Repellents (says Wiseman) are to be applied to the diseased Part, to prevent Fluxion; made of distilled Wa∣ters, or Juices of Horstail, Let∣tice, Plantane, Purslane, Night∣shade, Frog-spawn, &c. with whites of Eggs, Bole-Armeny, Sealed-Earth, &c.

XXII. And to intercept the Matter, (says he) we apply to the Temples Gum-mastich, Ta∣camahacca, Empl. ad Herniam.

XXIII. But if the Tumor in∣creases with tension and pain, it will then be fit to endeavour a Discussion, by such things as are prescribed in an Ophthalmia; as Elder-flowers, Hypericon, Len∣tils, Orobus, Rue, Southernwood, Wormwood, Melilot-flowers, Camomil, &c. boiled in Wme, or some weak Lixivium.

XXIV. The second Indication is, to remove the Callus; in order to which, the Orifice (because it is generally narrow) ought to be dilated with a Tent made of Elder-pith, Gentian-roots, Rope-root, Spunge pressed, &c. ac∣cording to the proportion of the sinuosity in the beginning.

XXV. Then you shall yet more enlarge it, by Spunge prepared with Melilot-Emplaster, or Glair of Eggs; as we have formerly

taught; by which means you will discern all the corners of the sinuosity.

XXVI. The Fistula being thus dilated, we must now apply our selves to the removing of the Cal∣lus: Barbett has Phlegm and Spirit of Vitriol, Aqua fortis, Mercury-water, Ʋng. Aegyptia∣cum, burnt Alum, blue Vitriol, Verdigrise; but Ʋng. Fuscum Wurtzii, boiled to the consisten∣cy of a Suppository, to be put into the Fistula, he commends above all.

XXVII. Riverius advises to wash the Ʋlcer every day with Rue-water, applying after Ung. Apostolorum, which is to be con∣tinued for three Weeks; laying over it some convenient Em∣plaster, and defending the Eye with Rose-water. ℞ Rue-water ℥iv. Honey ℥ii. Verdigrise ʒi. mix them. Inject it warm, with a Syringe.

XXVIII. If the Callus does not yet waste, use this following Injection. ℞ Rue, Pilewort, Agrimony, A. M. ss. S.V. lbss. juice of Tobacco ℥iv. infuse twenty-four Hours, then strain out.

XXIX. After the use of which, apply this following upon Dos∣sels. ℞ Wine-Vinegar ℥iv. Ho∣ney of Roses strained ℥iij. Ginger ʒii. Verdigrise ℈ii. mix, and boil to a thickness.

XXX. But in application of Medicaments this Part, you have not so great a liberty, as in other Fistula's: for fluid and running things, having a great acrimony, are not safe; for passing unto the Adnata, and from thence to the Cornea, they may possibly erode it, whence a new Ulcer may be made, and so the Grief may be doubled.

XXXI. And even solid things themselves, must be very carefully applied; that they go no farther, nor spread beyond the sinuosity, lest horrible Symptoms be in∣duced, by means of a fluxion, and increase of the acrimony of the Humor, which may hurt the Membranes of the Eye, ad∣jacent to the Part affected.

XXXII. Some use this. Take water of Elder, or Dwarf-elder flowers lbj. corrosive Sublimate ʒii. or better; according to the hardness of the Callus: the proportion you must guess at by the continuance of the Fi∣stula, Habit of Body, and Age of the Patient, making it either weaker or stronger.

XXXIII. Others use this. Take Plantane or Rose water ℥vi. Spirit of Nitre ℥iii. mix them. This they account excellent, but 'tis very sharp, and must be used with caution, and sparingly applied to the sinuosity, so that no part of them touch the Membranes, lest they should excite vehement Accidents.

XXXIV. Others like solid Me∣dicaments better; because the force of their operation is more durable, and they are more secure, as being not so apt to spread. In a young, tender, and delicate Body use this. Take red Precipi∣tate, or Turbith-mineral ʒii. burnt, Alum ℥i. mix them very well.

XXXV. Afterwards, take Ung. Populeon ℥i. of the former Pouder more or less, mix them: with this Mixture arm a Tent, which put

into the dilated Fistula, which let remain 'till it slips out of it self; and continue the use of it, 'till the Callus is removed: which you may know, if the sinuosity appears soft, and the Pus sticking upon the Tent be laudable.

XXXVI. If there is a Caries, Wiseman proposes this. Take Vi∣triol calcin'd, Cantharides (their heads and wings cut off) Quick∣lime, Sal Armoniack, R•…•…-alum, Ana: mix, and bring them to a body with Boys Ʋrine.

XXXVII. In applying of these things, the parts about must be defended, and the Fluxion hin∣dred by application of Refrige∣rants; yet after all, it is a most painful and tedious ways.

XXXVIII Wiseman proposes the use of the Actual Cautery, which being applied thro' a Can∣nula will with one touch waste the Callosity, and destroy the Caries: after which, it is to be drest up with a Dossel dipt in a mixture of Oil of Roses and the white of an Egg, and a Compress in the same over all: then it is to be digested, and deterged with milder Prescriptions, keeping the Orifice dilated with a Dossel dipt in Tinctura Myrrhae, &c. 'till the Bone exfoliates.

XXXIX. And so Barbett: If (says he) the Os lachrymale, or Zygomaticum be foul, the Skin being divided, an Actual (or Po∣tential) Cautery must be applied, that the Caries may be removed; otherwise, (if that be not ta∣ken away) it will be impossi∣ble to cure the Fistula.

XL. All Authors, as with one Voice, subscribe to the Actual Cautery, which must represent in figure an Olive-stone: the parts adjacent must be defended from the Fire, by a Cannula, or hollow Pipe, as Aquapendens and Wise∣man direct: you must effectually impress it, to dry the humidity, the sooner to procure the sca∣ling of the Bone.

XLI. 'Tis true, some Authors prescribe fatty things, to hasten the separation of the Eschar; yet it is better not to use them, be∣cause the Part is moist of it self; and so the application of such Medicaments might induce a sordid Ulcer.

XLII. What I shall advise to, is a Tent dipt into Red-wine, or Tincture of Euphorbium; or a Pledget dipt in the same, lay∣ing above all Empl. Album, or Diapalma, or Empl. de Minio simplex, or cum Sapone; the use of these things is to be conti∣nued, 'till the Scaling of the Bone.

XLIII. But because many People (by reason of the terror) will not admit of the Actual Cautery, it may be performed be Incision, &c. after this manner: first, with a bended Probe, find out the cavity every way, both upwards and downwards; and draw a Line with Ink, between the Glandule of the Eye, and the Trochlea or Pulley; thro' which the first oblique Muscle, called superior or major, passes, ending obliquely in the uppermost part of the Cornea.

XLIV. Then divide the fleshy or membranous parts, making In∣cision to the Os lachrymale or

Zygomaticum: the Part incised divide with the Nails of your Forefingers, until the Incision is so much dilated, that it may without any difficulty admit of an indifferent Pledget or Tent.

XLV. This done, put in a Tent made of Ʋng. Fuscum Wurtzii; or a small Pastil made of unwashed Turbith-mineral, Vitriol cal∣cin'd, Sealed-earth, and Ʋng. Populeon; mixt, and wrought up into a stiff Paste, and dried.

XLVI. About the Tent or Pastil, apply a Pledget armed with Populeon, over which lay Empl. Album, or Diapalma malaxed with Oil of Poppies or of Hen∣bane, or of Hypericon; then defend the orbit of the Eye with little Bolsters or Pledgets, wet in Frogspawn-water camphora∣ted, and so bind it up; dressing it twice a day with the Tents or Pastils, viz. Morning and Eve∣ning, 'till the Callus falls out of its own accord.

XLVII. Then view the Bone, and see how much is carious; and thereto apply this, or some such like. Take roots of round Birth∣wort, of Orrice, of Hog-fennel, Myrrh, Euphorbium, A. ℥ss. make all into a fine pouder, and apply it: this may serve in such as are young, and of a tender habit of Body.

XLVIII. But if they be of good years, or middle-aged, and of a strong constitution, you may apply the pouder of Euphorbium; after the application of which, or of the former Pouder, you may fill up the cavity of the Part incised with prepared Sponge, as aforesaid; and about it apply a Pledget armed with Ʋng. Po∣puleon, which hold fast down with Empl. Album, Bolsters, and Bandage.

XLIX. This manner of Dressing you must continue 'till the Scale falls off, or the carious part is separated, which will be in about 20 days, or very little more: then mundify with Mel Rosatum, or Mel Rutaceum, or Syrup of dried Roses, or with this. Take Spirit of Wine ℥ iv. Honey ℥ ii. Verdigrise ʒi. boil to the consum∣ption of a third part.

L. Then endeavour the Consoli∣dation, with Syrup of Myrtles, or Syrup of Comfrey: or with this. Take roots of round Birthwort, of Orrice, bark of Frankincense, A. ʒiss. Aloes, Cadmia fossilis, Ma∣stich, Myrrh, Sarcocol, A. ʒi. Honey q.s. mix, and make a Li∣niment. Or: Take Alum, Anti∣mony, Aloes, Balaustians, Frank∣incense, Dragons-blood, A ʒi. Verdi∣grise ℈ ss. make a fine pouder, which mix with Rue-water q.s. and make a Collyrium, to drop into the Eye, thrice a day, &c. and last of all, cicatrize with some Epulotick Ointment, Cerat, or Emplaster.

LI. If it so chance, that the whole substance of the Bone of the Nose subjacent to the Fistula is carious or corrupted, and a Catarrh be also attending, so that it seems to be often cured, and breaks out again. In this case, you must first dilate again the sinuosity, 'till the corrupt Bone appears; then you must pierce the Bone of the Nose with a Gimblet, that so the Pus or Matter may flow inward, to the Nostrils; and

then cure up the Ulcer or Fi∣stula, as we have taught in other places.

LII. This, tho' it is no real Cure, yet outwardly no deformity can be seen, nor shall the Patient himself be able to discern the turning of the Pus, from the out∣ward Glandule to the Nostril in∣wardly; nor shall he himself perceive any smell which shall offend him: as he who smells continually to a Damask-Rose, shall in a little time perceive no smell at all in it.

LIII. If you perceive the Fi∣stula to be malign, or seems to degenerate into a Cancer, (known by the Signs at Sect. 12. afore∣going) you must only use a pal∣liative Cure: for which purpose, apply this Medicament of Heur∣nius. ℞ Lapis Calaminaris thrice heated red-hot, and quenched in Vinegar ℥i. burnt Brass ℥iv. burnt Lead washed, Myrrh, A. ℥ss. Saffron ʒii. Opium ʒi. mucilage of Fenugreek ℥xxiv. mix them well by grinding together.

LIV. If you intend to keep it for any time, it will be best to mix it with Sheeps-suet, Oil of Ben, A. ℥xii. instead of the Mucilage of Fenugreek, because thereby it will be better preserved. It is an excellent Eye-salve, in all Ulcers and Fistula's of the Eyes, whether simple, malign, or can∣cerous.

LV. Fabricius Hildanus, Cen∣tur. 5. Obs. 23. has this notable Example. A Boy 13 years of age had a Fistula lachrymalis 4 years together in his left Eye, the Bone being carious; the Gland was so eroded, that when he cried, tears trickled out of the Fistula. The Actual Cautery was the best Re∣medy, yet the Boy refused it: therefore having ordered his Diet, he was Purged, and a Seton was made in his Neck: when the Seton ran, the Poten∣tial Cautery was applied, which causes no pain: when the Eschar was fallen, the Fistula was dila∣ted to the Bone, with an esca∣rotick Ointment and prepared Sponge: afterwards good store of Euphorbium in pouder was strewed upon it; and upon that a Plaster of Gum Elemi was applied. When these things had been used for some Weeks, the Bone scaled; after the Scale was taken away, half a drop of Balsam of Tolu was applied once a day to the Ulcer, which soon healed up, and continued per∣fectly well; and a little after the Seton was removed, and the Fistula healed up. In this Cure, Hildanus ascribed most to the E p or bium.