400 BC
ON FISTULAE
by Hippocrates
translated by Francis Adams
Part 1
Fistulae are produced by contusions and tubercles, and
they are also
occasioned by rowing, on horseback, when blood accumulates in the
nates near the anus. For, having become putrid, it spreads
to the soft
parts (the breech being of a humid nature, and the flesh in which it
spreads being soft), until the tubercle break and corrupt
below at the
anus. When this happens, a fistula is formed, having an ichorous
discharge, and faeces pass by it, with flatus and much and
abomination. It is produced, then, by contusions when any of
the parts
about the anus are bruised by a blow, or a fall, or a wound, or by
riding, or rowing, or any such cause. For blood is collected, and
it, becoming corrupted, suppurates; and the from the the same
accidents happen, as have been described in the case of tubercles.
Part 2
In the first place, then, when you see any such tubercle
formed, you must cut it open while still unripe, before it suppurate
and burst into the rectum. But if a fistula be already
formed when you
undertake the case, take a stalk of fresh garlic, and having laid
the man on his back, and separated his thighs on both sides,
push down
the stalk as far as it will go, and thereby measure the depth of the
fistula. Then, having bruised the root of seseli to a very fine
powder, and poured in some water, let it macerate for four days,
and, mixing the water with honey, let the patient drink it, fasting,
to the amount of three cyathi, and at the same time purge away the
ascarides. Those who are left without treatment die.
Part 3
In the next place, having moistened the strip of cotton cloth,
with the juice of the great tithymallus, and sprinkling on
it the flos
aeris, roasted and triturated, and having made it into a
tent equal in
length to the fistula, and having passed a thread through the ends
of the tent again through the stalk, and having placed the patient
in a reclining position, and having examined the ulcerated parts of
the rectum with a speculum, pass the stalk by it, and when it
reaches the rectum, take hold of it and draw it out until the tent
be pushed through, and be brought on a level above and below. When
it (the tent?) has been pushed inward, introduce a ball of horn into
the rectum (the rectum having been previously smeared with Cimolian
chalk), and leave it there, and when the patient wants to go
to stool,
let it be taken out and again replaced, and let this practice be
continued for five days. On the sixth day let it be removed, and
drawing the tent out of the flesh, and afterwards pounding alum and
filling the ball (pessary) and introducing it into the rectum, leave
it until the alum melts. Anoint the rectum with myrrh until the
parts appear to be united.
Part 4
Another method of cure:-Taking a very slender thread of raw lint,
and uniting it into five folds of the length of a span, and wrapping
them round with a horse hair; then having made a director
(specillum) of tin, with an eye at its extremity, and having passed
through it the end of raw lint wrapped round as above described,
introduce the director into the fistula, and, at the same time,
introduce the index finger of the left hand per anum; and when the
director touches the finger, bring it out with the finger,
bending the
extremity of the director and the end of the threads in it, and the
director is to be withdrawn, but the ends of the threads are to be
knotted twice or thrice, and the rest of the raw threads is to be
twisted around and fastened into a knot. Then the patient is to be
told that he may go and attend to his matters. The rest of the
treatment:-Whenever any part of the thread gets loose owing to the
fistula becoming putrid, it is to be tightened and twisted every
day; and should the raw thread rot before the fistula is eaten
through, you must attach another piece of raw thread to the
hair, pass
it through, and tie it, for it was for this purpose that the hair
was rolled round the raw lint, as it is not liable to rot. When the
fistula has sloughed through, a soft sponge is to be cut into very
slender pieces and applied, and then the flowers of copper, roasted,
are to be frequently applied with a director; and the sponge smeared
with honey is to be introduced with the index finger of the
left hand,
and pushed forward; and another bit of added, it is to be bound on
in the same manner as in the operation for hemorrhoids. Next day,
having loosed the bandages, the fistula is to be washed with hot
water, and cleansed, as far as possible, with the finger of the left
hand by means of the sponge, and again the flos aeris is to be
applied. This is to be done for seven days, for generally the coat
of the fistula takes that time to fistula takes that time to slouch
through. The same mode of bandaging is to be persevered in
afterwards,
until the cure be completed. For in this way, the fistula being
forcibly expanded by the sponge will not fill up and heal unequally,
but it will all become whole together. During the treatment, the
part should be bathed with plenty of warm water, and the patient
kept on a spare diet.
Part 5
When the fistula does not get eaten through, having first
examined it with a sound, cut down as far as it passes, and sprinkle
with the flos aeris, and let it remain for five days. Then pour warm
water upon it, and above lay flour mixed with water, and bind on it
the leaves of beet. When the flos aeris comes away, and the
fistulous sore becomes clean, cure it as before described. But if
the fistula be in a part which does not admit of this treatment, and
if it be deep, syringe it with the flowers of copper, and myrrh, and
natron, diluted with urine, and introduce a piece of lead into the
orifice of the fistula so that it may not close. Syringe the fistula
by means of a quill attached to a bladder, so that the injection may
distend the fistula. But it does not heal unless it be cut open.
Part 6
If the anus gets inflamed, and there is pain, fever, a frequent
desire of going to stool without passing anything, and the anus
appears to protrude, owing to the inflammation, and if at times
strangury come on, this disease is formed, when phlegm,
collected from
the whole body, is determined to the rectum. Warm things are
beneficial in this case; for these, when applied, can attenuate and
dissolve the phlegm, and dilute the acrid and salt particles, so
that the heat subsides, and the irritation in the rectum is removed.
Wherefore it is to be treated thus: The patient is to be put into a
hip-bath of hot water, and sixty grains of the grana gnidia are to
be pounded and infused in a hemina of wine, with half a
hemina of oil,
and injected. This brings away phlegm and faeces. When the patient
does not take the hip-bath, boil eggs in dark-colored fragrant wine,
and apply to the anus, and spread to the anus, and spread something
warm below, either a bladder filled with warm water, or linseed
toasted and ground, and its meal stirred up and mixed equally with
dark, fragrant wine, and oil, and this applied very warm as a
cataplasm; or, having mixed barley and Egyptian alum pulverized,
form into an oblong ball (suppository?) and warming it gently at the
fire, make it into a cataplasm, foment, form it into shape with the
fingers, and then making it quite tepid, introduce it into the anus.
The external parts are to be anointed with cerate, and a cataplasm
of boiled garlic, with dark wine diluted, is to be applied.
But if you
remove these things, let him take the hip-bath of hot water, and
having mixed together the juice of srychnos, the grease of a goose,
swine's seam, chrysocolla, resin, and white wax, and then having
melted in the same and mixed together, anoint with these things, and
while the inflammation lasts, use the cataplasm of boiled garlic.
And if by these means he be freed from the pain, it is enough; but
if not, give him the white meconium (Euphorbia peplus?), or, if not
it, any other phlegmagogue medicine. While the inflammation
lasts, the
diet should be light.
Part 7
The strangury comes ...
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