On Fistulae

by Hippocrates

Part I

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 II

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 III

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 IV

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 V

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 VI

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 VII

The strangury comes on in this way:-The bladder being heated from the rectum, phlegm is attracted by the heat, and by the phlegm (inflammation?) the strangury is occasioned. If, then, as is frequently the case, it cease with the disease, well; but, not withstanding, if not, give any of the medicines for strangury.

Part VIII

If procidentia ani take place, having fomented the part with a soft sponge, and anointed it with a snail, bind the man's hands together, and suspend him for a short time, and the gut will return. But if it still prolapse, and will not remain up, fasten a girdle round his loins and attach a shawl behind, and having pushed up the anus, apply to it a soft sponge, moistened with hot water in which the shavings of lotus have been boiled; pour of this decoction upon the anus by squeezing the sponge, then, bringing the shawl below between the legs, fasten it at the navel. But if he wish to evacuate the bowels, let him do so upon a very narrow night-stool. Or, if the patient be a child, let him be placed on the feet of a woman, with his back reclined to her knees, and when the bowels are evacuated, let the legs be extended. In this way the anus will be the least disposed to fall out. When a watery and ichorous discharge flows from the rectum, wash it out with burnt lees of wine, and water from myrtle, and having dried maiden-hair, pound and sift it, and apply as a cataplasm. But if there be a discharge of blood, having washed with the same, and pounded chalcitis, and the shavings of cypress, or of juniper, or of stone-pine, or of turpentine, the in equal proportions the apply as a cataplasm. Anoint the external parts with thick cerate.

Part IX

When the gut protrudes and will not remain in its place, scrape the finest and most compact silphium (assafoetida?) into small pieces and apply as a cataplasm, and apply a sternutatory medicine to the nose and provoke sneezing, and having moistened pomegranate rind with hot water, and having powdered alum in white wine, pour it on the gut, then apply rags, bind the thighs together for three days, and let the patient fast, only he may drink sweet wine. If even thus matters do not proceed properly, having mixed vermillion with honey, anoint.

Part X

If procidentia ani be attended with a discharge of blood, pare off the rind of the root of wakerobin, then pound and mix flour with it, and apply it warm as a cataplasm. Another: Having scraped off the rind of the most tender roots of the wild vine, which some call psilothrion, boil in a dark austere wine undiluted; then having pounded, apply as a tepid cataplasm; but mix also flour and stir it up with white wine and oil in a tepid state. Another:-Having pounded the seed of hemlock, pour on it a fragrant white wine, and then apply in a tepid state as a cataplasm.

Part XI

But if it be inflamed, having boiled in water the root of me ivy, finely powdered, and mixing the finest flour, and stirring it up with white wine, apply as a cataplasm, and mix up some fat with these things. Another:-Take the root of the mandrake, especially the green (fresh) root, but otherwise the dried, and having cleaned the green root and cut it down, boil in diluted wine, and apply as a cataplasm; but the dry may be pounded and applied as a cataplasm in the manner. Another:-Having bruised the inner part of a ripe cucumber to a soft state, apply as a cataplasm.

Part XII

If there be pain without inflammation, having roasted red natron, and pounded it to a fine powder, and added alum and roasted salts, finely triturated, mix together in equal proportions; then having mixed it up with the best pitch and spread upon a rag, apply, and bind. Another:-Having pounded the green leaves of capers, put into a bag and bind on the part; and when it appears to burn, take it away and apply it afterward; or, if you have not the leaves of capers, pound the rind of its roots, and having mixed it up with dark-colored wine, bind on the part in the same manner. This is a good application also for pains of the spleen. Of these poultices, those which are cooling, stop the discharge; those which are emollient and heating, discuss; and those which are attractive, dry up and attenuate. This disease is formed when bile and phlegm become seated in the parts. When the anus is inflamed, it should be anointed with the ointment, the ingredients of which are resin, oil, wax, plumbago, and suet, these being all melted and applied quite hot as a cataplasm.