Kitap 5
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Sometimes, again, fistulae arise, both from abscesses of this kind and from other sorts of ulceration. A fistula occurs in almost any part of the body, but in each place it has some peculiarities. I shall speak first of its general characteristics. There are many kinds of fistulae, then, and whilst some are short, others penetrate deeper; some run straight inwards, others, and by far the most numerous, crosswise; some are simple, others beginning by one opening form two or three branches inside or even divide into several passages; some go straight, others are curved and tortuous. Some end in the flesh, others penetrate to bone or to cartilage, or, when neither of these is underneath, reach to the inner parts; some, therefore, are treated easily, others with difficulty; and some are even found to be incurable. The treatment is speedy when the fistula is simple, recent and only involving the flesh, and the body itself helps, when it is youthful and sound: contrary conditions are inimical; also if the fistula has damaged bone or cartilage or sinew or muscles; if it has involved a joint; or if it has penetrated either to the bladder of lung or womb or to large veins or arteries or to hollow regions, which as the throat, gullet or thorax. When too the fistula goes towards the intestines it is always dangerous, often deadly. When the body is either sick or aged or in bad condition, the case is much worse. First of all, however, it is prisoner to pass a probe into the fistula, that we may learn both its direction and depth, and at the same time whether it is moist or rather dry. This is known when the probe is withdrawn. But if there is bone in the neighbourhood, we can also learn whether the fistula has reached and penetrated the bone or not, and how far the damage has gone. For if what is touched by the end of the probe is soft, the disease is still limited to the flesh; if it meets with more resistance, the fistula has reached bone. But when the probe slides smoothly, there is not yet decay; if it does not so slide, but meets with an even surface, there is some decay although still slight; if what underlies is uneven also and rough, the bone has become more seriously eaten away. But the position of the fistula shows where there is underlying cartilage, and resistance to the probe shows when this has been reached. And from these signs we may gather the situation, extent and harmfulness of fistulae; whether too they are simple, or have several branches, can be estimated from the amount of pus; for it there is more than one opening will account for, it is clear that there are several branches; and since generally flesh and sinew and sinewy tissue such as sheaths and membranes are near the fistula, the character of the pus also will show whether the several branches have eaten into other parts of the body. For pus derived from flesh is smooth, white and fairly plentiful; from sinewy structures it is of the same colour but thinner and less in quantity; from sinews it is fatty and not unlike oil. Further also, the bending of the body indicates whether the fistulae have penetrated in several directions, because often when a patient has changed his recumbent posture, or held a limb in a different position, pus which had previously ceased, begins to discharge again; and it then becomes evident, not only that there is another branch from which pus is being discharged, but also that it is tending into another part of the body. But if the fistula is in the flesh, and is recent and simple, and is not tortuous or in a cavity or joint, but in a part which remains still unless moved with the body generally, a sufficiently effective application is a plaster such as is applied to recent wounds, so long as it is composed of either salt or of alum or of copper scales or of verdigris or some other metallic substances; and from this a tent should be made, thinner at one end, a little thicker at the other. This should be passed into the fistula with the pointed end forwards, and be kept until pure blood shows itself. Such are the general rules for the use of all tents for fistulae. Next, the same plaster spread on lint is put over the place, and over that is applied a sponge dipped in vinegar; it is sufficient to change the dressing on the fifth day. The class of food to be used is that which I have prescribed for making flesh. And if the fistula is at some distance from the praecordia, the patient should eat radishes at intervals on an empty stomach, and then vomit. A fistula of long standing becomes callous. Now no one can mistake callus, for it is hard and either white or pallid. But there is then need for stronger medicines: such as that which has of poppy tears 4 grams, gum 12·66 grams, cadmia 16 grams, blacking 32 grams, worked up water to form a tent. Or else there is the composition containing galls 1 gram, verdigris, sandarach, Egyptian alum, 1·16 gram each, roasted blacking 2·32 grams. Or that which is compose of copper ore and limestone, with half as much orpiment as of each of the other two; and these are taken up in boiled honey. But the quickest remedy is that prescribed by meges; rub up verdigris scrapings 8 grams, then dissolve ammoniacum for incense 1·16 gram in vinegar, and work the verdigris into this infusion; and this is one of the best remedies. But whilst the above remedies are the most efficacious, when they are not at hand it is easy to eat away the callus with any of the caustic medicaments; it is enough to smear one of them on rolled papyrus, or upon a pledget of wool twisted into the shape of a tent. Squills boiled and mixed with quicklime also eat away callus. If, however, the fistula is longer but runs crosswise, it is best to insert a probe and to cut down upon its end; then a tent is passed into each opening. But if we deem the fistula to be double or multiple, yet only short and confined to flesh, we should not make use of a tent, because it treats one part and omits the rest; but the same medicaments, dry, are put into a writing-quill, and that having been placed against the orifice of the fistula is to be blown through, in order that these medicaments may be forced in; or the same materials dissolved in wine, or, if the fistula is more foul, in honey wine, or, if more callous, in vinegar, are to be poured in. Whatever is introduced, refrigerants and repressants must be put on over the wound; for generally the parts surrounding the fistula are somewhat inflamed. It is not inappropriate, when changing the dressing and again before inserting fresh medicaments, to wash out the fistula, using an ear syringe; with wine if there is much pus; with vinegar if there is hard callus; if it is already clean, with honey wine or a decoction of vetch, to which also a little honey should be added. Thus it generally happens that that covering which is between the opening and the sound flesh is destroyed by the medicaments and comes quite away, and underneath is a clean ulceration; when this has occurred, agglutinants are applied, especially a sponge steeped in boiled honey. I am not unaware that many favour the insertion of lint formed into a tent and dipped in honey; but this agglutinates more quickly than flesh is formed. There need be no fear that clean flesh in contact with clean flesh will fail to unite: we see that there is often no need to add medicaments as well to effect this, since often when there is ulceration of the fingers, unless we have taken careful precautions, they become joined together whilst healing.
