On Fistulas — First Draft Translation

ON FISTULAS. Fistulas arise from bruising and from swellings; they also arise from rowing and from horse-riding, when blood collects in the buttock close to the rectum; for as it putrefies it spreads into the soft parts, inasmuch as the rectum is moist and the flesh in which it spreads is soft, until the swelling bursts and rots its way downward into the rectum. 1. When this has happened, a fistula forms, and ichor flows, and excrement flows through it, and wind, and great foulness. From bruisings, fistulas form whenever any of the regions around the rectum is bruised by a blow, or by a fall, or by a wound, or by horse-riding, or by rowing, or by anything of that sort; for blood collects and, as it putrefies, suppurates; and from the suppuration the part suffers what has been described in the case of swellings. First, then, whenever you perceive some such swelling forming, cut it as quickly as possible while still unripe, before it suppurates into the rectum. 3. But if you receive the fistula when it is already diseased, take a fresh garlic sheath; lay the person on his back with the legs spread apart, one to each side; lower the sheath in until it strikes the end, and measure the depth of the fistula with the sheath. Also, pound the root of hartwort as fine as possible, pour water over it, and soak it for four days; and after preliminary fasting, let the patient drink it mixed with honey, at a measure of three kyathoi; during this time, purge also the ascarids. Those who are left untreated die. Next, soak a linen bandage of fine byssus cloth with the juice of great spurge, dust over it roasted copper flower ground fine, form it into a plug equal in length to the fistula, thread a suture through the tip of the plug and back through the garlic sheath so as to join them, lay the person on his back, and with a speculum observe where the rectum has been eaten through; there pass the sheath through, and when it protrudes into the rectum, take hold of it and draw it through until the plug is pushed through and made level both above and below. When it has been worked in, insert a keratin suppository into the rectum, smear it over with fuller's earth, and leave the rectum alone; when the patient defecates, remove it and apply it again, until the fifth day comes; on the sixth day remove it, drawing the plug out of the flesh; then grind alum after this, fill the suppository with it, and having inserted it into the rectum leave it until the alum becomes moist; anoint the rectum with myrrh until it appears to have grown together. Another treatment: take raw linen as fine as possible, fold it to a span's length five times over, and bind a horse-hair around it; then make a tin probe perforated at the tip, thread the end of the folded raw linen through the probe, lower the probe into the fistula, and at the same time lower the index finger of the left hand into the anus; when the probe touches the finger, draw it out by means of the finger, having bent back the tip of the probe and the end of the linen held in it; then withdraw the probe again, and tie the ends of the raw linen two or three times; twist the remaining length of the raw linen back on itself, and bind it to the thread; then tell the patient to go away and attend to his own affairs. 4. Whatever of the raw linen slackens as the fistula putrefies, tighten and twist it again each day; and if your raw linen rots away before the fistula has been eaten through, attach another piece of raw linen to the hair and thread it through and tie it (for the hair is included with the raw linen for this reason: it does not rot); when the fistula has rotted through, a soft sponge cut as thin as possible must be applied; then insert a good quantity of roasted copper flower into the fistula with the probe, smear the sponge with honey, push it forward by inserting it under the middle of the index finger of the left hand, and apply another sponge on top and bind it in the same way as for haemorrhoids; the next day, undo it, rinse around with warm water, and try to clean out the fistula with a sponge on the index finger of the left hand, then bind on the copper flower again; do this for seven days, for in these days above all the lining of the fistula rots away; for the remainder, until healing is complete, bind it in this way; for in this manner, the fistula being forcibly held open and unfolded by the sponge, it will neither collapse again nor will part of it be healed while another part refills, but the whole of it will be healthy in itself. During the treatment, foment frequently with plenty of warm water, and starve the patient. But if the fistula has not eaten through, probe it with the probe, then cut until it opens all the way through, dust on copper flower, and leave for five days; pour warm water over it; knead barley-meal with water and dust it on top, and bind on beet leaves; when the copper flower falls away and the wound of the fistula is clean, treat it as the former one. 6. But if it is in a location where cutting is not possible, and the fistula is deep, mix copper flower, myrrh, and natron with urine and wash it out; and insert a small lead piece into the mouth of the fistula so that it does not grow together; for the washing, attach a bird's quill tube to a bladder, lower it into the fistula, and direct the washing through it. It does not heal unless it is cut. If the rectum is inflamed, and there is pain and fever, and the patient sits down frequently to pass stool but nothing comes away, and the phlegm causes the rectum to appear to protrude, and sometimes strangury takes hold: this condition arises when phlegm settles into the rectum from the body. 7. Warm things are beneficial; for, when applied, they are able to thin and melt the phlegm, and together with the sharp, the salt draws out the moisture, so that there is no burning or any biting in the gut. One must treat as follows: have the patient sit in warm water; grind sixty grains of Cnidian berry, dissolve in a kotyle of wine and a half-kotyle of oil, warm slightly, and give as an enema. These drive out phlegm and excrement. If the patient is not sitting in water, boil eggs in dark fragrant wine and apply them to the anus, spreading something warm underneath, or fill a bladder with warm water; or pound roasted linseed, grind it and mix an equal amount of flour, in dark fragrant wine and oil, and poultice as hot as possible; or mix in barley, or ground Egyptian alum, and poultice and steam; then mold a long suppository and warming it at the fire, shape it with the fingers; then, making it lukewarm, insert it into the anus; anoint the outer parts with wax ointment (κηρωτή), and poultice with garlic boiled in diluted dark wine. When you remove it, have the patient sit in warm water; then mix juice of nightshade, and goose and pig fat, and chrysocolla, and resin, and white wax, then melt them together in the same vessel and mix them, and anoint with this; and as long as there is inflammation, poultice with hot garlic. And if with these treatments the patient is relieved of the pain, let that suffice; but if not, give the white poppy juice to drink; if not, give some other thing that purges phlegm; and prescribe diaita (regimen) of light gruels for as long as the inflammation persists. Strangury comes on in the following way: the bladder, being heated from the rectum, draws phlegm to itself by the heat; and from the phlegm strangury arises. 8. If the strangury ceases together with the disease — as it generally tends to happen — well; but if not, give the remedies for strangury. If the rectum prolapses, push it back up with a soft sponge, smear it with snail-juice, bind the hands, and hang the patient upside down for a short time, and it will go back in. 9. If a larger prolapse occurs and it does not stay inside, put a girdle around the loins and pass a band behind from the girdle; push the rectum inside, apply a soft sponge soaked in warm water in which shavings of lotus-wood have been boiled; pour also some of that same water over the rectum, and squeeze out the sponge; then pass the band between the legs and bind it around the navel. When the patient wants to defecate, let him do so on a privy seat as narrow as possible; if it is a child, let him lean forward against a woman's knees. When he defecates, let him stretch out his legs; for in this way the rectum would least prolapse. If the rectum becomes moist and ichor drains off, wash around with burnt lees and water from myrtle, and dry and pound maidenhair fern, sift it, and dust it on. If there is bleeding from the rectum, wash around with the same, then grind chalcitis and shavings of cypress, or cedar, or pine, or terebinth wood, mix an equal amount with the chalcitis, and poultice; anoint the outer parts with a thick wax ointment (κηρωτή). When the rectum prolapses and will not stay in place, shave the best and densest silphium thin and poultice. Also hold a sneezing medicament to the nose and provoke sneezing in the patient. Or wash around pomegranate rind with warm water, and grind alum in white wine, pour it over the rectum, then apply rags, bind the thighs together for three days, and let the patient fast, but drink sweet wine. But if it still does not stay in even so, mix red ochre together with honey and anoint. If the rectum prolapses and bleeds: peel the bark from arum root and boil it in water; then grind it, mixing in flour, and poultice hot. Another: scrape the tenderest roots of the wild vine — which some call the hair-remover — and boil them in undiluted dark astringent wine; then grind and poultice lukewarm; mix in flour too, and knead in white wine and oil, lukewarm. Another: grind the fruit of hemlock, dripping in fragrant white wine, then poultice lukewarm. If there is inflammation, boil the root of ivy in water, grind it smooth, mix in the best flour, knead in white wine, poultice, and mix in fat as well. Another: root of mandrake — preferably fresh, but if not, dry — the fresh root rinse off and cut it and boil in diluted wine, and poultice; the dry root grind and poultice in the same way. Another: grind the interior of ripe cucumber smooth and poultice. If there is pain without inflammation, roast red natron and grind it smooth, and alum, and roast salt and grind it smooth; mix an equal amount of each; then mix with the best pitch, spread on a rag, insert and bind up. 10. Another: grind fresh caper leaves, put into a pouch, and bind on; and when it seems to burn, remove and apply again. If there are no caper leaves, pound the bark of the root, knead with dark wine, and bind on in the same way. This is also good for pain of the spleen. Of these poultices, some have power to cool and stop flowing; others, softening and warming, to disperse; others, drawing into themselves, to dry and shrink. This condition arises when bile and phlegm settle into the affected places. When the rectum is inflamed, anoint with the medicament composed of resin, oil, wax, litharge, and fat; these were prescribed to be applied as hot as possible.