Book 7
4
Special consideration is required in the case of those in the anus. In these, where a probe has been passed up to its end, the skin should be cut through, next through this new orifice the probe is to be drawn out, followed by a linen thread which has been passed through the eye made for the purpose in the other end of the probe. Then the two ends of the linen thread are taken and knotted together so as to grip loosely the skin overlying the fistula. The linen thread should be made up of two or three strands of raw flax, twisted up so as to make one. Meanwhile the patient can do his business, walk, bathe, and take food as if in the best of health. Only this thread is to be moved twice a day, but without undoing the knot, the part of the thread outside being drawn within the fistula, and the thread must not be left until it becomes foul, but every third day the knot is to be undone, and to one end that of another fresh thread is tied, and the old thread being withdrawn the new one is to be left in the fistula after being similarly knotted. For thus the thread cuts through the skin overlying the fistula slowly, and whilst the skin released from the thread undergoes healing, that which is still gripped is being cut through. This method of treatment is lengthy but causes no pain. Those in a hurry should constrict the skin with the thread, so that they may continue through more quickly; and at night they should insert into the fistula some fine pledglets of wool, in order that its overlying skin, being put on the stretch, may be thinned out; but these measures cause pain. More speed may be added, but more pain as well, if both the thread and the pledglets are smeared with some one of the medicaments, which I have noted for the eating away of callus. Even here, however, the knife must be used, if the fistula extends inwards, of is multiple. In these kinds of fistulae, therefore, when the probe has been inserted, the skin is to be cut through along two lines so that between them a very fine strip of skin may be taken out, in order that the margins may not unite at once, and that there may be room for the smallest possible quantity of lint to be inserted; all the rest is done in the way described for abscesses. If, however, from one orifice several sinuses lead off, the straight part of the fistula is to be laid open with the scalpel, and the others branching from it, which are now exposed, are to be gripped by a thread. Should any fistula extend so far inwards that it cannot be safely laid open by the knife, a medicated bougie is to be put in. But in all such cases, whether treated surgically or by medicaments, the food should be moist, the drink abundant, and for a while water: when flesh begins to grow up, then at length the patient is to make use of the bath occasionally, and of flesh-making food.
