SECT. XLIX.—ON FISTULA.
Fistula is a callous sinus formed for the most part from abscesses, and deriving its appellation from the pipes of reeds (fistulæ). If, therefore, it terminate with a bone, it cannot be cured without a surgical operation, unless in process of time a scale of the bone come off spontaneously. But if it does not terminate with a bone, it is to be cured by the applications for removing callosities, and the agglutinative medicines. The applications for removing callosities are such as these: the root of spondylium scraped around and applied removes the callus of fistulæ. And in like manner black hellebore applied removes the callus in two or three days; also lees of oil boiled and injected; sori in a crude state, or burnt and injected with some diluted wine, or sori and crocomagma with hydromel. Or make collyria by mixing elaterium with turpentine, and apply. Or syringe with the juice of the root of laserwort. This melts down the callus: of verdigris, dr. xij; of ammoniac, dr. ij; mix with vinegar, and form into an oblong collyrium.
A collyrium which I use for removing the callosities of fistulæ. Mix with vinegar equal parts of ammoniac perfume, of copperas, of verdigris, of misy, of chalcitis, and of gum.—Another, from the surgical works of Heliodorus: Of calamine, of misy, of copperas, of burnt copper, of gum, of each, dr. iv; of crude chalcitis, dr. iij; mix with the urine of a young person not come to manhood, and form collyria. Put this collyrium into the fistula, and apply externally the inner part of bread soaked in water, changing it until the inflammation subside, and the eschar fall off.—Another, which I received in Alexandria: Of the roots of alkanet, of toasted misy, of chalcitis, of verdigris, of fissile alum, of copperas, of aloes, of each, oz. j; triturate along with fine cantharides in vinegar, and make collyria.—Another: Of copperas, dr. ij; of chalcitis, of verdigris, of each, dr. j; mix with ammoniac and use, and when the callus is thrown off, cleanse with verdigris and eight times the quantity of the purest honied water; but after the discharge of the callus, incarnants must be used. An incarnative collyrium: of aloes, of myrrh, of ammoniac, of the cinders of egg shells, equal parts; having triturated with water form collyria, and apply.—Another: Of myrrh, of aloes, of frankincense, of pomegranate rind, equal parts, mix with water; but some use bull’s gall. The oil of unripe olives is incarnative when injected. I knew a person who injected cedar-rosin into fistulæ, and succeeded surprisingly. After it is incarnated we must have recourse to the agglutinative medicine, according to the plan described for other sinuses. “When the fistula is narrow and long,” says Galen, “and does not appear to me to contain callus internally, but only sordes, I first inject lye into it, and then allowing it to remain in the fistula until I expect that the sordes has fallen completely off, I afterwards apply the medicine.” It was the one from the oil of palma Christi, mentioned above.
Commentary. We shall have occasion to refer to the Hippocratic treatise ‘De Fistulis,’ in the [Sixth Book].
Celsus treats of fistulæ with more than his wonted minuteness. This is his definition: “Id nomen est ulceri alto, angusto, calloso.” He has described all the complications of it with great accuracy. He directs us to commence by making an inspection with a probe or sound, so as to ascertain the state of the parts and of the discharge. If a soft body is felt at the bottom, we conclude that the fistula terminates in the flesh, but if a hard one is felt, we know that it ends with a bone. If the probe slide readily over the bone, it is free from caries, but if it does not so, and yet no inequalities are felt on it, caries has taken place, but it is still smooth: if it feel unequal and rough, the bone is eaten with caries. For a simple and recent fistula, not deep-seated or in a joint, the plaster for recent wounds will be sufficient, provided salt, or alum, or the scales of copper, or verdigris, or any of the other metals, be added to it. The application is to be made upon a piece of linen, and a sponge soaked in vinegar is to be put over it, and is to be removed on the fifth day. The patient must live upon nutritious food. If the fistula is at a distance from the præcordia, emetics with radishes are said by him to be proper. When the fistula is old it becomes callous, and requires stronger applications, containing such ingredients as calamine, atramentum sutorium, verdigris, galls, lime, orpiment, or realgur. He mentions as a very ready application a solution of ammoniac in vinegar, with some verdigris added to it. However, he remarks, any other caustic will accomplish the same purpose. If the fistula is long and transverse, an incision is to be made at its commencement, after which the collyrium may be applied. When the fistula is double, or consists of still more passages, he recommends us to blow in with a writing pen the medicines in the form of powder, or to apply them dissolved in wine, mulse, or vinegar. But whatever the internal dressing be, he recommends us to apply on the outside of it something of a refrigerant and repressing nature, as the parts around are generally affected with inflammation. When the dressings are removed the fistula is to be syringed with wine if the discharge of the pus is copious, with vinegar if its edges are callous, but with mulse, or a decoction of tares, if the passage be clean. By the means we have been describing it will generally happen, he says, that the inner coat of the fistula will slough off, and leave the ulcer in a clean state. Agglutinants are then to be applied, especially a sponge smeared with boiled honey. When the sides of the fistula are clean there need be no apprehension lest they do not adhere, since, he remarks, we often see in ulcerations of the fingers that without great care one finger is apt to adhere to another.
In the ‘Euporista’ of the Pseudo-Dioscorides, it is recommended first to dilate the fistula with a piece of sponge, and then to use a stimulant application containing verdigris, ammoniac, &c.
Aëtius gives an excellent account of fistula, but it is mostly borrowed from Galen. We can afford room only for a few extracts. When a fistula extends obliquely, nothing can be done without making a free incision, for which purpose he directs us to introduce a sound and cut along it. His directions for examining into the nature of a fistula are such as ample experience alone could have dictated. He seems to be decidedly of opinion that, except in cases of a recent fistula, or when it is not deep-seated, an incision ought always to be made at first; after which applications for removing the callus may be used. When, however, the patient refuses to submit to an operation, and the case is recent, the cure may be attempted by means of escharotics and incarnants, such as verdigris, misy, alum, &c., mixed with frankincense, aloes, and myrrh.
Oribasius briefly recommends white hellebore, a mixture of equal parts of verdigris and ammoniac, and a few other such articles, as applications for fistulæ.
Scribonius Largus mentions several compound applications containing misy, chalcitis, verdigris, alum, &c.
Marcellus gives one consisting of ceruse, ammoniac, and oil.
Actuarius gives a brief but distinct account of the nature and treatment of fistula, but it is taken almost entire from our author.
Avicenna inculcates that a fistula is only to be cured by a free incision, or by removing the callous sides of it by burning with fire or caustic medicines, such as arsenic, ammoniac, sulphur, the flour of copper, or mercury. This in fact is the sum of the medical practice in such cases. There is nothing particularly interesting in Haly Abbas. Alsaharavius truly states that a diseased bone is the common cause of fistulous ulcers not healing, and inculcates that in this case there can be no hope of recovery until the carious portion be removed. Rhases, upon the authority of the celebrated Antyllus, directs us to use corrosive applications when a fistula cannot be operated upon with the scalpel. He intimates that this is particularly the case when the disease is seated in the groins.
The earlier modern surgeons, such as Gulielmus de Saliceto, Arnoldus, Rogerius, Rolandus, and Guy of Cauliac, in imitation of the Arabians, direct fistula to be treated by the application of septics, the actual cautery, or incision. Rogerius recommends a tent spread with quicklime and soap, or with arsenic. Guy of Cauliac, like Avicenna, speaks favorably of sublimed quicksilver or corrosive sublimate.