De Medicina

4 Again, for fistulae which penetrate so deeply that a medicated bougie cannot be passed down to the ends, or those which are tortuous or multiple, surgery has the advantage over medicine; and there is less trouble if the fistula runs horizontally under the skin, than when it tends directly inwards. Therefore if it lies horizontally under the skin, a probe should be introduced and cut down upon. When there are bends, these are followed up in

the same way with the probe and knife; so also when they present multiple branchings. When the end of the fistula is reached, all the callus should be cut out, then pins are inserted through the skin margin, and agglutinating medicaments spread over all. But if it runs straight inwards, after its chief direction has been explored by means of the probe, that cavity ought to be excised, then a pin is to be inserted through the skin opening, and agglutinating medicaments applied as above; or if there is more corrupt ulceration, which is at time the case when there is disease of bone, after the bone has been treated, suppuratives are put on.

Now it is common for fistulae to have their exit between ribs; when this is the case the rib must be cut across on either side at that spot, and the segment removed lest anything diseased be left within. Fistulae which have passed between the ribs often involve the transverse septum separating the viscera above from the intestine. This can be recognized by the position of the fistula and the severity of the pain, and because at times, air with frothy humour escapes from the fistula, especially when the patient has held his breath. In that case there is no opportunity for the medical art. But in the case of other fistulae near the ribs which are curable, greasy medicaments are objectionable but anything else which suits wounds may be used; the best, however, is lint put on dry, or after soaking in honey if anything has to be cleaned.

There is no bone in the abdomen, but all the same fistulae there are so dangerous that Sostratus thought them incurable. Experience, however, shows that this is not always the case. Indeed — and this may

seem very remarkable — a fistula which forms over the liver, spleen, or stomach, is safer than one right over the intestine, not because a fistula there is more harmful, but because it opens the way to another danger. Some writers who have had experience of this have shown little perception of the true facts. For often the abdomen is actually penetrated by a weapon, and sutures bring the margins of the wound together and how this is done I will presently point out. Therefore also when a fine fistula breaks through the abdominal wall, it is possible to cut it out, and to join its margins by suture. But if such a fistula widens out inside, this excision necessarily leaves a wide gap which cannot be sutured without applying great force especially in the deeper part where the abdomen is enclosed by a kind of membrane which the Greeks call peritoneum. Therefore, when the patient begins to get up and move about, the sutures break, and intestines prolapse; which causes his death. But these cases are not altogether desperate, and so for the finer fistulae, treatment is to be adopted.

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.

5 Missiles too, which have entered the body and become fixed within, are often very troublesome to extract. And some of the difficulties arise from their shape, some owing to the positions to which they have penetrated. Whatever the missile may be, it is extracted, either by the wound of entry, or through the spot towards which it is pointing. In the former case, the missile has already made a way for its withdrawal; in the latter the way out is made with the scalpel; for the flesh is cut through upon its point. But if the missile is not deeply seated, and lies in superficial tissue, or if it is certain that it has not crossed the line of large blood vessels or sinews, there is nothing better than to pull it out by the way it entered. But if the distance it has to be withdrawn is greater than that which remains to be forced through, or if it has crossed the line of blood vessels and sinews, it is more convenient to lay open the rest of its course and so draw it out. For it will be more easily got at and more safely pulled out. And in the case of one of the larger limbs, if the point has passed beyond the middle, a through and through wound

heals more easily because it can be dressed with a medicament at both ends. But if the missile is to be drawn back, the wound should be enlarged with a scalpel, for then the missile comes away more easily, also less inflammation is caused; for this becomes more severe if the missile itself lacerates the tissues while being withdrawn. So also when a counter opening is made, this ought to be too wide for the missile to fill as it is passing out. In either case, the greatest care should be taken that no vein, nor one of the larger sinews, nor an artery, is cut. When any one of these is observed, it is to be caught by a blunt hook and held away from the scalpel. Than the incision has been made large enough, the missile is to be drawn out, proceeding in the same way, and taking the same care, lest that which is being extracted should injure one of those structures which I have said are to be protected.

The foregoing are general rules; there are some rules which apply to special missiles, and these I will at once set out. Nothing penetrates so easy into the body as an arrow, and it also becomes very deeply fixed. And this happens both because it is propelled with great force and because it is sharply pointed. Hence it is more often to be extracted through a counter opening than through the wound of entry, and especially so because it is generally furnished with barbs which lacerate more when drawn backwards than if pushed through a counter opening. When a passage out has been laid open, the flesh ought to be stretched apart by an instrument like a Greek letter; next when the point has come into view, if the shaft is still attached, it is to be pushed on until the point can be seized from

the counter opening and drawn out: if the shaft has already become detached, and only the arrowhead is within, the point should be seized by the fingers or by forceps, and so drawn out. Nor is the method of extraction different when it is preferred to withdraw the arrow by the wound of entry; the wound having been enlarged, either the shaft, if it is still attached, or, if not, the arrowhead itself, is pulled upon. When the barbs come into view, if they are short and fine, they should be nipped off on the spot by forceps, and the missile drawn out without them. If the barbs are too large and resistant for this, they must be covered by reed pens which have been split, and thus pulled out carefully so as not to tear the flesh. This is what is to be done in the case of arrows.

But if it is a broad weapon which has been embedded, it is not expedient to extract it through a counter opening, lest we add a second large wound to one already large. It is therefore to be pulled out by the aid of some such instrument as that which the Greeks call the Dioclean cyathiscus, because invented by Diocles, whom I have said already to have been among the greatest of the ancient medical men. The instrument consists of two iron or even copper blades, one blade has at each angle of its end a hook, turned downwards; the other blade has its sides turned up so that it forms a groove, also its end is turned up somewhat, and perforated by a hole. The latter blade is first passed up to the weapon, and then underneath it, until the point is reached, the blade is then rotated somewhat until the point becomes engaged in the perforation. After the point has entered the perforation, the

hooks of the first mentioned blade are fitted by the aid of the fingers over the upturned end of the blade already passed, after which simultaneously the cyathiscus and the weapon are withdrawn.

There is a third kind of missile which at times has to be extracted such as a lead ball, or a pebble, or such like, which has penetrated the skin and become fixed within unbroken. In all such cases the wound should be laid open freely, and the retained object pulled out by forceps the way it entered. But some difficulty is added in the case of any injury in which a missile has become fixed in bone, or in a joint between the ends of two bones. When in a bone, the missile is swayed until the place which grips the point yields, after which it is extracted by the hand, or by forceps; this is the method also used in extracting teeth. In this way the missile nearly always comes out, but if it resists, it can be dislodged by striking it with some instrument. The last resort when it cannot be pulled out, is to bore into the bone with a trepan close by the missile, and from that hole to cut away the bone in the shape of the letter V, so that the lines of the letter which diverge to either side face the missile; after that it is necessarily loosened and easily removed. If the missile has forced its way actually into a joint between the ends of two bones, the limbs above and below are encircled by bandages or straps, by means of which they are pulled in opposite directions, so that the sinews are put on the stretch; the space between the ends of the bone is widened by these extensions, so that the missile is without difficulty withdrawn. In doing this care must be taken, as mentioned elsewhere, to avoid injury to a sinew, vein or artery

while the weapon is being extracted by the same method which was described above.

But if the missile is also poisoned, after doing all the same things, even more promptly, if possible, in addition that treatment is to be applied which is given for one who has drunk poison, or has been bitten by a snake. The care of the wound itself after the extraction of the missile does not differ from that of a wound in which nothing has lodged and on which I have said enough elsewhere.