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. XXXVII. Of a FISTƲLA of the ANUS.

I. WHAT the Greeks call 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Fistula in Ano; we in English call, A Fistula in the Funda∣ment.

II. The Causes. They mostly proceed from Phlegmons, Phymata, and Hemorrhoids, broken, and ill cured, or not cured in a long time; as also from the Wounds made with Horsleeches, not well cu∣red, or leaving some Venom behind in them; which creating a malign and corrosive Juice, insinuates its self farther and farther, making a long Sinus, which in process of time be∣comes callous.

III. The Signs. Those which are caused by the inward Piles, are made gradually, and pass their Matter, (says Wiseman) which is a thin Gleet, between the Tu∣nicles of the Intestinum rectum, making their way out, near the Verge of the Anus, thro' a small Pin-hole, as it were.

IV. These are discovered by the issuing out of a thin Humor, staining the Shirt or Shift, rather than by any Pain they cause; which Discharge is thought to be ra∣ther a kind of Sweating than otherwise; yet it is not a sweating, but a real issue of thin Matter.

V. This in process of time is accompanied with itching, and is subject to excoriation or galling; from whence sometimes several kinds of Pimples or Pustles do break out; and sometimes Rha∣gades, Fissurae, or Chaps; and at length the Sinus spreads out∣wards, and grows callous, and the Orifice hard, and so con∣tracted, that a small Probe will hardly go in.

VI. Those Ʋlcers which are caused by Phymata, cause their Matter to pass deep among the Interstitia of the Muscles, (as other Abscesses in fleshy parts do) according as they can make their way: sometimes they pe∣netrate through the Intestinum rectum, to the very neck of the Bladder, yea into the Pelvis; or at best, insinuate their Gleet amongst the Musculi glutaei, &c.

VII. These are very painful, and send forth a sanious or purulent Matter, proportionable to their hollowness: and in length of time, they make as it were Coney-burrows, and grow cal∣lous; being of the worst sort of these Fistula's.

VIII. If a search is made with a Probe into the Sinus which comes from the Piles, and the while you press your Finger into the Anus, you may feel the Probe run all along between the Tuni∣cles of the Intestine; and it may pass thro' the Pile which gave it its original.

IX. Whereas the Sinus's which proceed from another root or spring, have outwardly no external Ori∣fice, but an Orifice inwardly, and discharge their Pus or Matter by Stool: yet possibly in length of time they may make a way ex∣ternally, and pass their Matter thro' one or more Orifices out∣wardly, at a farther or nearer distance from the Anus, ac∣cording as the Apostem lay in the Intestine.

X. You may easily find out, whe∣ther the Fistula does pass thro' the Intestinum rectum, or not: for, the Intestine or Gut is penetrated, if an Injection being made by the outward Orifice of the Fistula, it passes within the Anus: or, if after breaking of Wind, part of it makes its way thro' the Sinus: or, if putting your Forefinger into the Anus, you feel the naked Probe, it being thrust thro' the Sinus of the Fistula, by the outward Orifice: or, lastly, if the Excrements appear to be mingled with the Pus or Quit∣tor, or if the Quittor smells like the Excrements.

XI. The Prognosticks. No Fi∣stula in Ano is easy to be cured, because this place is as it were the Sink of the Body; and so abounds with plenty of impurities, and much superfluous moisture, which alwas hinder the Cure.

XII. Those Fistula's which pe∣netrates deep, beyond the Musculi Ani, if they be cured by laying open, the Patient will scarcely after retain their Excrements, but with much difficulty; and if they reach beyond the Sphin∣cter, the retention will be im∣possible.

XIII. Simous Ʋlcers arising from Phymata, if they have been of long continuance, are dangerous, and of difficult cure: Ulcers in Ano, are also hard to be cured, if they discharge a large quantity of Pus, by an opening so far distant, that you cannot safely lay it open; but the nearer to the Anus, the more easy the Cure.

XIV. If it proceeds from a Ca∣cochymical Constitution, where the Lungs or any Viscera are weak; it ought never to be healed, but kept open as a Fontanel or Issue, for discharge of Morbifick Hu∣mors.

XV. But if it cannot be kept open, with ease to the Patient, a good and sparing Diet is to be pre∣scribed; and the Humors are to be carried off some other way, before the absolute Cure is at∣tempted.

XVI. In like manner, sinuous Ʋlcers arising from the Piles, ought to be kept open, so long as they can be continued without pain trouble, or disturbance to the Pa∣tient: for by this means the Body will be discharged of ma∣ny superfluous Humors, and the whole Man kept in health.

XVII. Sinuous Ʋlcers in length of time grow callous, and so be∣come Fistulae; and they only differ from sinuous Ʋlcers as they are callous, which being in the Fundament, are more te∣dious than in other parts.

XVIII. If the Fistula does run superficially upwards by the Inte∣stinum rectum, whether it pene∣trates the Anus, or not, it is without danger, and may easily be cured.

XIX. But if the Fistula runs higher up, than you can reach it with your Fingers, it will be of difficult cure, because you can∣not lay it open the whole length: and if the Humor issues from the remaining Sinus, upon the Part which is opened, it will hinder cicatrizing.

XX. If the Fistula is become inveterate, runs much, and the Patient is much extenuated, strength decayed, Stomach lost, or debilitated, with faintness, and faint cold Sweats; let the state and condition of the Fistula be what it will, pierce the Intestine, or pierce it not, runs deep or superficial, it signifies not much; for it is to be feared, the hopes of Cure are past.

XXI. The Cure. It is twofold, viz. 1. Real. 2. Palliative. As to the Real Cure: a good Diet being instituted, and Universals prescribed, as in other Fistula's, we shall come immediately to the Chirurgick Part, which is performed by Deligation, or In∣cision, and the application of Topicks.

I. By Deligation.

XXII. The Cure by Deligation or Ligature, which was the Opera∣tion of the Ancients: but here is to be noted, that Deligation and Incision have place only when the Fistula is shallow; if it be deep, it cannot well be attem∣pted by any of these means.

XXIII. If therefore the Fistula penetrates into the Intestinum rectum, first, dilate it with a Fistula-Tent or Sponge, and remove the external callus as we have formerly taught; for so the Part which is to be bound will be more thin, and so more easily cut asunder by the Ligature.

XXIV. Let the Ligature be made of twisted brown Thread, or fine stitching-Silk, to which some put a Horse-hair, whereby they are made to do the work the quicker; a twist of three Threads of stitching-Silk may be enough; for if the Ligature is made too thick, it will too much bruise the Flesh in cutting it.

XXV. Others make it of fine sealing-Thread, which is made of the best Hemp, unboiled and un∣whitened; which is exceeding strong, and will not rot before it has done the work a either of these may do, you need not be very curious about the choice.

XXVI. Where the Fistula has penetrated put one end of the Thread or Ligature into the eye of a small and flexible Probe, made of sina and pliant Silver, or of Lead; then thrust the eye with the Thread thro' the Sinus into the Intestinum rectum; which done, put into the Anus your Finger, and with it pull the Thread out of the eye of the Probe, and draw it out at the Anus: or having bent the eye of the Probe, bring it without the Anus, and then putting the Thread into the eye, draw that end thro' the narrow Orifice of the Fistula.

XXVII. If the Sinus is not very thick and long, you may by one strong deligation bind up all the Sinus: but if the Sinus is thick and long •• you must use several

constrictions, tying the ends of the Thread with a running∣knot, that it may be the more easily loosed: but some, after one deligation only, more and more draw in the ends of the Thread, with a round piece of a Stick turned about.

XXVIII. Where the Fistula has not penetrated the Gut, you may make use of a short Probe, making the point sharp, to pass thro' the Intestine; but it must be very pliant, that it may be the fitter for the work.

XXIX. And in some cases, where the Fistula lies high, and the Sinus is crooked, you may make use of a fit Cannula, for the con∣veying the Needle up; and to strengthen it in its work, that it does not bend in perforating of the Intestine.

XXX. When all the Sinus after division by deligatiou, lies open, go forwards in the Cure, as if it had been opened by Incision; by removing the Callus, Abs∣tersion, Incarnating, &c.

II. The Method by Incision.

XXXI. The laying it open by Incision is thus. The Mouth of the Sinus is to be dilated by a Tent of Sponge, &c. and the exterior Callus is to be removed; if it be troublesom: otherwise immo∣diately go to the Work, and divide the Sinus with a pair of Scissars; which some Artists approve of, for the speedy division it makes; and indeed, if the Sinus is short, it is the Best way.

XXXII. But in doing this, you must be careful, lest the folds of the rugous Coat should fall between; for so you may chance to make two Wounds of one.

XXXIII. But if the Fistula penetrates the Intestine very deep, the work will be more difficult and bazardous, not only in the cutting, but in the progress of the Cure: for the newly-divided lips will be apt to fall one upon another, and so unite again; which if they do, the Fistula is renewed: and a Dossel or Tent put up the Sinus, will not continue in it, but lye as a Suppository, conti∣nually stimulating the Intestine to thrust it forth.

XXXIV. Whereas the Ligature contuses in some measure the lips, in cutting them; so that they re∣quire to be digested before they can unite, in which the Sinus fills up with Flesh, and heals within; so that the Fistula seems to heal, or be cured above, as the Liga∣ture divides below.

XXXV. The Fistula being thus opened, whether by Deligation or Incision, the Callus is to be removed by Cathereticks, as we have taught in the Cure of a Fistula in general, then to be digested, cleansed, incarnated, and cicatrized.

III. The Application of Topicks.

XXXVI. The Callus being re∣moved by Cathereticks, or Incision, or Canteries, fill up the hollowness with Dossels armed with an astrin∣gent Pouder, and the white of an Egg, to keep the lips of the in∣cised parts asunder: for if you should endeavour an unition too

soon, the cavity may possibly still remain, and induce a Reci∣divation.

XXXVII. For which reason, it is necessary that with Incarnatives (not fat or greasy) you should en∣deavour to engender good and sound Flesh in the bottom: if it is fatty it will generate loose and spon∣gy Flesh, which will put you to more trouble.

XXXVIII. For this purpose you may make use of this. Take Syrup of dry'd red Roses, or Syrup of Myrtles, or some other Ʋulne∣rary and Sanative Syrup ℥iv. Pulvis Cephalicus ℥i. mix them.

XXXIX. In opening the Fistu∣la by Ligature, there is wont to be sometimes heat and Inflammation: in this case, it is usual to apply a Stuph of Tow dipt in austere Red-wine, and Oil of Roses to al∣lay the heat of the Part.

XL. And every day (whilst the Ligature is doing its work) after going to Stool, it may be drest: and if need requires, you may inject a Decoction of hull'd Bar∣ley with Quince or Fleawort∣seeds, and then apply some Lenient or Auodyn, as Ʋng. Populeon, Rosatum, &c.

XLI, It is also to be noted, that in opening it by Ligature, the third or fourth day, the knot is to be ty'd streighter: and so in twice or thrice tying the Liga∣ture, it will cut its way out: or when it is almost through, the remaming part may be cut with a pair of Probe Scissurs.

XLII. If you use the Cannula, you must first pass it up the Orifice of the Fistula, and place the end of it against your Finger, which (be∣ing first anointed with a little fresh Butter) you have put into the Intestinum Rectum; then ano∣ther holding the Cannula, you may pass your Needle thro' it into the Gut; and as it is brought out by your Finger there, slip off the Cannula, and hasten the Needle forwards on its way, till you have brought it out with the Ligature: then cutting off the Needle, make the knot upon a bit of Emplaster, to prevent the Ligatures cutting the oute side, tying it as strait as the Patient can bear it, and making the second knot with a bow, and place the ends thereof so, as it may not be fouled in going to Stool.

XLIII. If there are shrivell a Piles or Condylomata, &c. about the Verge of the Anus, cut them off at the same time, or before you make the Ligature or Inci∣sion, to prevent the Inflamma∣tion, they might be subject to from the pain, which may be caused by the Operation.

XLIV. If the Sinus runs deep under the Verge of the Anus, so that the Lips are like to lie high, to make as it were a Gutter; it will be best to take them down by application of a Caustick, for it will much hasten the Cure, and make the Cicatrice smooth.

XLV. But if the Fistula goes so deep inwardly that you cannot con∣venlently open it, neither by Liga∣ture, nor Incision, you must in this case, dilate the Fistula with a Fistula Tent, and the Sponge: then remove the Callus with some proper Catheretick, as the Fistula Trochisk; the Trochisk

being come out, and the Callus wasted away, deterge it with Mel Rosatum mixed with Aqua Calcis, &c.

XLVI. When it is well digested, and cleansed, and a good Pus comes forth, you must incarnate with some choice Sarcoticks, or with that at Sect. 38. above; which you must put into the Sinus up∣on Tents, which Tents you are day by day to shorten, till at last the whole Sinus of the Fi∣stula is closed; then cicatrize with Ʋng. de Minio, Empl. Al∣bum, &c.

IV. The Palliative Cure.

XLVII. Where Fistulae in Ano cannot be Cured, or are not safe to be Cured, but it is more health∣ful to keep them open, to help Na∣ture in the discharge of the Morbisick or Superfluous Humors, descending by the Haemorrhoidal Vessels, espe∣cially when they are without pain, or any great trouble, are small, and terminate in the Orisice of the Anus; in all these Cases, the Palliative Cure is to be chosen.

XLVIII. If you see that the Orifice of the Fistula swells, and will not keep open; or that by rea∣son of the Contraction of the Callus, the Matter may be straightned; so that it may be in danger of insinuating it self deeper, and make the evacuation trouble∣som; it will be good to apply a small Caustick upon the Orifice, to remove the Callus.

XLIX. And after the separa∣tion of the Slough, the Orifice may be kept open with much ease, as if it were a Fontanel or Issue: And for receiving the Matter, and preventing Excoriation, the Patient may wear a Pledget of fine Tow, which will sit close without Bandage.

L. Or it may be spread thin with some softning Ointment, as the ne∣cessity may require, and be kept clean without any very great trou∣ble, till some ensuing Symptom shall indicate what is more to be done in it; or till length of time may happily Cureit.

LI. An Observation. A recent Fistula in Ano, coming upon Piles ill Cured, I perfectly Cured by a good Diet drink made of Guajacum, Sarsa, &c. and sitting many times on a Close-stool over the Fumes of Amber.

LII. Another Patient I had who had a Fistula in Ano, which proceeded from the applying of Leeches; it was a young Woman who had it above Five Years, and was very troublesom to her. I Cured her by a Salivation of 24 days, and a Guajacum Diet-drink, causing her for a considerable time to sit every day on a Close∣stool over the Fumes of Am∣ber.

LIII. Another Patient I had, which I Cured only by sitting for some days, half an Hour, and fometimes an Hour in a day, on a Close-stool, and receiving up his Fundament the Fumes of Cin∣nabar Artificial, made up into Troches in this manner. Take Winters Cinnamon in pouder, Am∣ber in fine pouder, A. ℥iss. Gum of Juniper, Mastich, Myrrh, A. ℥i. Artificial Cinnabar ʒvi. all being in fine pouder, with Mucilage of Gum Tragacanth, make Troches,

each weighing ʒss. of which he used 4 or 5 at a time. See the Third Edition of Our Synopsis Medicinae, lib. 5. cap. 57.