The London practice of physick, or, The whole practical part of Physick contained in the works of Dr. Willis faithfully made English, and printed together for the publick good.

CHAP. IV. Of Issues.

VEsicatories differ from Issues in this, that these are ordered for longer continuance. Moreover the former for the most part being requisite in Acute Diseases and others, whose Mor∣bid matter requires a speedy removal, regard chiefly the taking away of the Conjunct cause of the Disease, and therefore are made of a good breadth, but superficial withal, that such run∣ning Sores being large may evacuate much Matter, and then be easily Cur'd: But on the contrary Issurs being chielfy in∣dicated for Preservation, are design'd for removing, or over∣coming the Procatarctick cause of the Distemper: Wherefore they consist of a narrower, but deeper Orifice, made through the whole thickness of the Skin, so that letting forth the Mor∣bifick matter still in less quantity, they derive it farther, and continue longer to empty it forth.

Concerning Issurs there are these three chief heads of enquirie viz. First what Humours chiefly those Emissaries evacuate, and whence they derive them. Secondly, in what Diseases and Constitutions they agree better, or worse; And Thirdly, in what places, after what Form, and with what Instruments they ought to be made.

1. As to the former, Issues in like manner as Vesicatories Purge forth all Humours within the Skin, though lying in a less compass, or such as are convey'd through it both from the Sangui-ferous and Nervous Vessels; nor do they only like Ve∣sicatories irritate and draw from the outward Superficies of the Skin, but perforating the whole Skin, convey forth what∣soever flows from the sides of the Orifice through the broken Vessels, and whatever comes from elsewhere under the hole: Wherefore not only the Humours gather'd together within the Pores and Glands of the Skin, or convey'd thither by the Ar∣teries and Nerves flow to Issues, but moreover the Serous Ex∣crements under the Skin, which are wont to be convey'd, or to pass from place to place through the Interstices of the Muscles and Membranes, tend to them from all parts, and there find their way forth. Again, an Issue made in a fit place antici∣pates Mothisick Humours, which are wont to be convey'd to

parts that are weak, and long afflicted, and so frees sometimes this part, sometimes that, from their Incursion: Hence the Gouty, or Nephritick, or Colick, nay sometimes the Paralitick, or Scorbutick matter is intercepted by Issues in its passages from its Sources to the Weakned places or Receptacles; and so the usual Fits of the Disease being evaded, is convey'd forth: And this Emissary even as Trenches cut for draining Fenny moi∣stures, empties forth by defrees Humours sticking in any part or region of the Body, and there doing hurt, and so it pre∣vents or cures a Morbid Disposition.

2. From these various ways of giving relief, with which Is∣sues are wont to do good in general its easily gathered for what affects chiefly they are required; for though there be in a man∣ner no Disease, in which this Remedy either does hurt, or proves useless, yet it seems more necessary in some cases than in others; it's prescrib'd even by the vulgar for almost every Distemper of the Head, both outward and inward: Every ordinary person advises an Issue above all things for the Convulsions of Infants and Children, for the Inflammation of their Eyes, their Swellings of the Kings-evil, and so for Head-aches, Sleepy, Vertigious, or Convulsive affects of Adult or Aged persons: Nor is this Re∣medy less extol'd against Diseases of the Brest; is there any one subject to a Cough, Bloody or Consumptive-spitting, or to an Orthopnaea, who has not an Issue made him? In like manner also Issues are commended for affects of the Belly, there is scarce any Hypochondriacal person, or Hysterical Woman, and no Gouty or Cahecttical person but have their Skin pierc't in more places than a Lamprey. It would be a tedious thing to re∣count here particulary all the Distempers for which Issues are good.

3. Nevertheless this Remedy, however good and useful of it self, does not agree with all persons, nor therefore must it be indifferently prescrib'd to all: For there are two sorts of Men, who thongh they happen to be sick, may be excus'd from Is∣sues; because this Emissary evacuates too much in some, and in others little, or less thanit ought, and in the mean time is mighty painful and intolerable.

An Issue sometimes does not agree well because it evacuates or spends too much the Humour, or Spirits: For I have ob∣serv'd in some that an Issue made in any part of the Body voids forth an Ichor in quantity immoderate, and in quantity vitious; for out of it at frequent times, if not continually, a Watery, thin, and faetid Latex, often making the Pea, and coverings black, flows in a great abundance, so that from its too great Efflux the Strength and Fiesh are consum'd.

An Issue sometimes vioding forth no very great quantity of Ichor spends the Spirits and Strength more than it ought, which is known by the effect, and sometimes not till afterward; to wit, because some upon keeping one or more Issues open, grow weak and lean, and upon their being stopt, become presently more Vigorous, and of a full habit: Moreover it's a common observation that many upon having an Issue made near the Head, have been soon after seiz'd with some defect and weak∣ness in their Sight, so that they were forc't presently to close it up, which seems to happen for this reason, because where the stock of Spirits is but small, and their consistency very thin, little spendings of them, or of the Juice out of which they are engendered, in case they are continual, are with difficulty endur'd.

Moreover in an other, and that a different respect, Issues, as also Vesicatories are forbidden to some, or are prescrib'd to them with great caution; because voiding little or scarce any thing at all, they mightily torment the place in which they are made: For those who being of a Cholerick, or otherwise hot Tem∣perament, have their Mass of Blood thicker, and of a closer Texture than it ought by reason of its being but little diluted with Serum, in these persons a Solution of continuity being made, and kept in being by an Issue, the Blood (not deposing Serum enough to keep it self free) sticks it self in the pas∣sage, adn so being extravased causes a mighty painful Infsam∣mation; and in the mean time such an Issue voiding such a very small quantity of Ichor proves as useless as trouble∣some.

As to the places where Issues are to be made, they are to be chosen according to the ends of Curing, or the intentions requir'd from them; which are chiefly these three, viz. First, a general Evacuation of Humours from the whole Body. Second∣ly, an Evacuation, and at the same time a Revulsion from some particulare Member. Thirdly, an Evacuation and at the same time a Derivation from some particular Member. In respect of the former it's proper to have an Issue cut in the left Arm; The Second intention requires it to be made far from the part affected, and the Third near it.

For these ends, viz. sometimes this, sometimes that, or the other Issues are wont to be made, and that either by Incision, or a Cautery, or Perforation, in every Region of the Body, viz. in the Head, Brest, and Abdomen, and in the Arms and Leggs, nay in most parts of each, and in their Orifices Peas or Wooden Peas, Pellets, or Pledgets are put, and there con∣tinued for keeping them open. By running through the Parts

and Members of the Body, we shall observe the chiefest places, and kinds of Issues.

Some order an Issue to be burnt by a Cautery in the Co∣ronal Suture, and recommend it for withdrawing the Humours and evacuating them from the Brain and its Envelopings: Though some make a common Practice of this, yet I have found it not to have succeeded well in many; so that I have ordered many Issues so made on the Crown of the Head to be clos'd up, And this not without being taught by reason and experience: For the Blood conveys much Filthy Matter towards the place where it uses to discharge its Excrements, and deposes it in the whole Neighbourhood, and especially in the part affected (as being weaker and more apt to receive them) whence it often happens that the Disease is rather in∣creas't than Cur'd: For the same reason, viz. to derive Hu∣mours from the inward part of the Head outwards, others make Issues in the Bregma on the Sagittal Suture, and others in the hinder part of the Head about the beginning of the Lambdoides: But the same exception lies against these as against the for∣mer. Certainly an Issue made in the Arm much better an∣ticipates the Morbifick matter which is wont to be depos'd about the inner parts of the Head, if made in the Legg it revulses it, and made a little beneath the Head it derives it thence. Hence for great affects of the Brain, and its Me∣ninges, in Infants and Children, we cut an Issue on the Nape of the Neck: To Adult or Aged Persons we apply a Cau∣tery on both sides the Spine betwixt the Shoulder-blades: And there we often make two Issues capable of containing many Peas with great success. As to Issues cut or burnt behind the Ears, or a Setaceum past through its carneous Lobe; I have observ'd these things to have been seldom advantageous, but often troublesome; because a Solution of continuity made in these places neither discharges much Ichor, nor lasTs long, for the Orifice though fill'd with a Pea, or Pill, will be covered with a thin Skin growing over it in despite of all we can do.

Issues in the Back do excellently well, not only in Diseases of the Head by evacuating and deriving the Morbifick matter, but likewise in the Gout, Stone, and all Colicks, by anticipaing the Matter that feeds the Disease, and intercepting it as it passes to its lurking holes, which is plainly made appear by Expe∣riments and Observations made in persons reliev'd by them.

Issues betwixt the Shoulder-blades are good for Diseases of the Brest; also in the Arm, or Legg to evacuate or anticipate Humours flowing towards the Lungs, and to withdraw the

same there depos'd; That an Issue in the Thorax cut betwixt the Ribbs sometimes derives immediately the Consumptive mat∣ter from the Lungs, we have shewn elsewhere.

The Region of the Abdomen seems unfit to have an Issue in any part of it: Nevertheless the Practice of some, though it be rare, is much cried up, which order that a large Issue ca∣pable of containing many Peas, be burnt on the Region of the Spleen for all hypochondriacal affects; I have known this done in some without any great good, certainly not enough to re∣compence the trouble of such a Remedy.

Some time since by an Issue in the Groin Isuccessfully Cur'd a mighty weakness and ache in the Loins, not yielding to any other Remedies, and in another person an inveterate Sciatica: For the Glandulous Emunctories seated in that place, imbibe a great store of Excrements of the Blood and Nervous Liquor, which if forthwith discharg'd from them, and that in a con∣tinued manner, it will conduce much to the freeing of the Neighbouring parts from any Morbifick Seminal Root.

The ••••ugh being a large Member seems fit enough for bear∣ing many and large Issues to evacuate Humours plentifully from the whole Body, yet it does not happen so in many, partly because having a Figure too much declining like an inverted Cone, there is no convenient place for binding to keep in the Pea; and partly because a Solution of continuity made amongst the meetings of many Tendons, proves frequently Inflaming and Painful; so that it has been found necessary sometimes when an Issue has been made there to cause it presently to be closed up again to free the Person from Pain, and the trou∣ble of Lameness: Though in some it does better, because an Inflammation does not always happen to the place perfor∣ated, and a Ligature apply'd to it, continues stedfast to those that use to Garter above the Knee.

Moreover we must not only make choice of a fit part of the Body for an Issue, but likewise of a fit place in the Mem∣ber where it is made, which particularly requires the Judg∣ment of a Physician, or skilful Chirurgion: For we must be very careful that a Cautery or Incision be not admitted over, or too near the Tendons or greater Vessels: Nor must an Issue be made in the very Body of a Muscle, but in the Space or Interstice betwixt the Muscles; where the hole must pass the whole Skin and so much farther till the little Membrane of the Muscle underneath be penetrated, wherefore this operation is not to be committedindiscreetly to Quacks and others ig∣norant of Anatomy; for upon an ill performance herein there ensues not only a Frustration of all good, but often great pre∣judices

thence arise, nay sometimes eve•• to the hazard of Life.

It's needless for me here to describe the way of preparing and compounding a Cautery, or the figure and uses of the In∣cision Instrument for making Issues, for these are commonly known, yet it will not be amiss to discourse somewhat here after what manner we must deal with the Symptoms which happen to those Emissaries after they are made, and hinder or pervert their Energies.

There being many and sundry sorts of affects hapening to Issues, a Cure is not requir'd for them all, but only for those of greatest moment: Therefore in the first place it is needed whenever an Inflammation happens to the part or place where it is. Secondly, if the Orifice voids more or less Ichor than it ought. Thirdly, if the Sore be apt to dry up of its own accord, and now and then to be covered with a little Skin, or to grow rank with a Spungy Flesh growing up in its Cir∣cumference. As to the lesser defaults, as when the Sore bleeds often, or if changing its place it gets by little and little into a worse, with many others in which it's wont to pre∣varicate, it will not be worth while to mind them here.

1. An Inflammation sometimes happens to an Issue, and that sometimes so great that it threatens a Spacelus or Mortifica∣tion of the part, nay and sometimes brings it: Now such an affect comes either upon the fresh making of the Orifice, or happens afterward by reason of the Blood and Humours being upon some occasion put in a Commotion, and rushing in a throng to that place.

When an Issue is first made, presently by reason of the So∣lution of continuity, and consequently the Blood's being some∣what letted in its Circulation in that part, some Inflammation and Soreness happen to all persons: But in some who have a very hot Blood, and little diluted with Serum, this proves much more violent, there hapening sometimes a Mortification of the part inducing a Spacelus: Or Secondly, the Blood there stagnating is chang'd into a Pus to be evacuated by an Abscess: Or Thirdly, which more frequently happens, and ought to be always procur'd in our case, the Blood causing an Inflamma∣tion is return'd again into the Vessels, and restord to its Cir∣culation by other Ductus's into which it is forc'd.

But that it be convey'd back these two things are necessarily re∣quir'd, viz. First, that it be much diluted with Serum there plentifully abounding, or rather protruded into the part; And then Se∣condly, that the emptied Vessels behind the Tumour Drink up

again the Blood diluted by the Serum, and driven back: For the Blood driven toward the Tumour, when it can go no far∣ther forward, yet at least that upon lessening its Bulk it may go back, discharges Serum plentifully from it self, and drives it into the places obstructed; which entring into the stagnating Blood, dilutes it, and getting into tis place drives it into the Ductus's of the Vessels; and that Serum in the mean time passing forward exhales through the Pores, and so the Blood which was extravasated being diluted, and sent back by the Serum, and the Serum it self evaporated, the Tumour with the Inflammation vanish by degrees: But in case (as it often happens in hot Temperaments) the Blood extravased and driven into the Pores be not diluted with a plentiful access of Serum, it will not only stick there with obstinacy, but will cause a violently Inflamed Tumour with a Fever, and sometimes other dreadful Symptoms. Not long since a great Divine whose Blood was thick and hot, having an Issue made in the inside of his Legg, though the Skin only was cut, an Inflammation shortly fol∣lowed, which grew so violent within a few Days that it could scarce be hindred from turning to a Gangreen by the use of any Remedies whatsoever. Wherefore when the Blood extra∣vasated through a Solution of Unity, and wanting an access of Serum for diluting it, and carrying it back, tends to a vio∣lent Inflammation, Fomentations, and Cataplasms of Emollient things outwardly apply'd often do much good, because the moist and mild Parricles parting from them, enter the stag∣nating Blood, and dilute it, and so giving it a gentle motion cause it to return more readily into its Vessels; so that those moist applications outwardly us'd supply the defect of the in∣ward Serum requir'd for diluting the Blood: Nevertheless that the Blood so diluted, and put in motion be restor'd to Cir∣culation, it's farther necessary that the Vessels which are to re∣ceive it be fufficiently emptied, for which end besides a slen∣der Diet, Bleeding and Purging are often of necessary use; and indeed it is usual to Purge and often to Bleed Cacochy∣mical, and Plethorical persons a little before, or after an Issue is made. Nor are these Remedies only proper to prevent or remove an Inflammation in case of a fresh Issue, but are like∣wise good whenever that affect happens to an Issue of a long standing: For if at any time the Blood being very impure, and withal Feverishly boiling enters upon an Excretory Tur∣gescency, it often falls out that it deposes its Excrements and Filthy Dreggs about the Issue, being hardly to be Purg'd else∣where, and that it being there hindred from its Circulation upon their being heapt together, is extravasated, and so causes

a violent Inflammation: Such an affect lately hapening in an Ancient Nobleman, and at first neglected, soon turn'd to a Gan∣green, from which nevertheless by the help of proper Medicines carefully administred both inwardly and outwardly, he escapt not without great danger of his Life.

2. If at any time an Issue discharges too much Ichor, which for the most part is thin, and of a very ill Smell, and some∣times discoloured, so that such vast Spendings of Humour, and withal it's intolerable Stench requires a Cure: In such case there are two chief Therapeutick intentions, viz. First, to strengthen the mixture of the Blood that its Texture be not too prone to a Dissolution, and Fusion of Serum: And Secondly, to pre∣serve the place Ulcerated by the Issue, and to keep it free from any Coruptive Ferment, so that no Noysome Filth there lodg'd may defile the Blood as it passes through in circulating, whereby being infected it may presently run into parts, and be forc't to depose the Serum there in such abundance.

The former scope of Curing orders scarce any thing but now and then a moderate Purge, and a good Diet, viz. that the person keep himself from all Surfeits, and irregularity as to the quantity, quality, and seasons of taking his Food; and parti∣cularly from thin Wines, Cider, and other Acid Liquors, with which the Blood is wont to be fus'd, and driven to flowings of Serum: For Persons so affected most surely pay for any er∣rour or irregularity committed in Diet, a Pain presently being rais'd about the Issue.

For the due Preservation of the Tone of the place where the Issue is made, and for keeping it free from Putrefaction, you must take a particular care that for avoiding all Nastiness, both the Solids to be put into the Orifice, and the Coverings, be they either Plaisters, Ivy Leaves, or Oyl-cloaths be chang'd twice a Day: For in some each of these soon gets an ill savour, and presently causes the Ulcer of the Issue to stink: In case this tends to Putrefaction, presently instead of a Pea, or Wooden∣pill, let a Pill of Virgin-wax incorporated with red Saunders and Verdigrease be put into it; and likewise let a Fomentation of the Decoction of St. John's Wort, Yarrow, Centory, &c. be apply'd Morning and Evening.

3. Sometimes it happens that an Issue even as a dryed Foun∣tain, discharges no Humour: The reason whereof usually is either because the hole being not deep enough does not pe∣netrate the whole Skin, which is easily Cur'd by making it deeper; or the Sore though large and deep enough, yet still continues dry because the Serum does not readily nor freely separate from the Mass of Blood, this having too close a Tex∣ture

and then the only Remedy is to wear within the Ori∣fice, Solids more irritating, and working more strongly on the Mouths of the Vessels: For which purpose Pills are made of the Wood of Ivy, of Box, or of the Roots of Gentian, or of Hermodacts, and are often us'd with good success.

4. It often falls out that the Orifice of an Issue being too small, and distilling forth little Ichor is covered over with a thin Skin with the Pea included in it, and that with the hole it is heal'd up: For which default there is scarce a proper Re∣medy to be apply'd; wherefore (rather than still to fret the Skin to no purpose) it's better to let such an Issue close up, or to transfer it to some other place.

5. The Sore of an Issue inclining to heal, and being hin∣dred from it, has very often about its edges, and sometimes in its Cavity a Spongy Flesh growing up; the reason whereof is that the Nutritive Juice convey'd to the ends of the Arteries, and Nervous Fibres, and not presently washt away by the Se∣rous ichor, sticks there, and beginning to be assimilated extend, both those Vessels to fill the Cavity with Flesh; and the Blood in the mean while brought thither Forms within that Mass little Sprouts of Veins for its return; nevertheless that Flesh, as yet rough and shapeless, being kept from the greatest part of the Orifice, grows up above its Brim, and when it is risen so high that it can be no longer veiled and covered with the Skin, it continues still Naked and Spongeous: This Excrescency is easily enough Cur'd by sprinkling on it Escharotick Powders, of burnt Allom, Colcothar, or Mercury Praecipitate; for these sorts of Medicines with their Acrimonious and Stiptick force eat away the Flesh thus Luxuriant, repel the Nutritive Juice, and shut close the Mouths of the Vessels. When that superfluous Flesh grows continually and increases about the edges of an Issue, it's a sign that the Nutritive Juice abounds more there than the Excrementitious Humour, and consequently that in persons so affected that Emissary is not so very beneficial, wherefore under the pretext of this reason many are mightily averse from that Remedy (which certainly is inoffensive in most, though it be not equally advantageous in all.)

There is now an unperswadable opinion which has taken foot∣ing amongst many here in England (I know not if it be so in other Countries) that an Issue or Issues dipose to Barrenness; wherefore to all married Women, and desirous of Children, this sort of Remedy, though otherwise never so conducing to their Health, is Religiously forbidden; though no reason is yet given for this strick Prohibition; only stories are told of certain Women having Issues who are Barren; when it is as easy to

shew more Barren Women without Issues, and many fertile with them: And truly I use to retort this as a chief Argu∣ment against that opinion, there being no need of any other.