FISTULA.
Fistula in the recto anal region so far exceeds that in any other locality, that its overwhelming predominence here almost entitles it to the exclusive right of the term; while, to those who have given this part of the physical organism special study, the word itself, calls to mind a local condition of disease that is anything but an easy one to manage.
In point of frequency fistula is next akin to hemorrhoids, but a much less desirable complaint to treat. Allingham states that the number of cases occurring in hospital practice is greater. That two-thirds of all the cases operated upon of the in patients at St. Mark’s Hospital, London, were fistula. The most frequent cause assigned being abscess. A failure of the abscess to heal, leaving a sinus or sinuses, is explained by the presence of loose areolar tissue and fat, excessive mobility of the parts by the action of the sphincters, respiration, coughing and sneezing, and a strumous diathesis.
In consequence of an occasional failure of the muscles to regain their power after division by the knife, elastic ligature or galvano-cautery wire in the treatment of fistula, leaving the subject in a pitiable state of incontinence of feces, which has resulted in several well authenticated cases in suicide, new and rational methods have been devised for the relief of this very troublesome and unpleasant affection.
Kelsey says: “A permanent incontinence of feces is always considered by the patient a very poor exchange for fistula, which was causing comparatively little suffering and annoyance.”
The fact that such a deplorable condition does sometimes follow complete section of the sphincters, and that we have no means of knowing previously when it may or may not occur, I submit the question to all thinking, conscientious and painstaking physicians: Should we not seek the adoption of any efficient means of treatment, whereby such risk is wholly avoided?
About the first of March, 1890, Daniel Mc., aged 35, who a few months before had been operated upon by a reputable surgeon for a simple, uncomplicated fistula, sought my acquaintance, exhibited his condition and related his experiences.
The fistula originated from a small abscess, with its internal opening between the sphincters, the external scarcely an inch outside the anus, and was not of long standing. The operation consisted in a division of the external muscle with the greater portion of the internal; he was put on a liquid diet, bowels confined for fifteen days and kept in a recumbent posture.
The incision was slow in healing, between three and four months; his health, which was formerly good, has been greatly impaired ever since the operation. The external sphincter has lost its power altogether and the internal muscle greatly weakened, which necessitate the wearing of a clout whenever the bowels become a trifle loose, and he lives in constant fear of soiling himself by allowing the escapement of the least quantity of flatus. The time lost, the money expended, and the unfortunate condition in which he finds himself eight months after the operation, have so thoroughly embittered him against the cutting process, that he spares no pains and loses no opportunity to influence every one with whom he comes in contact, against all such heroic and uncertain measures.
For the purpose of obviating these very unsatisfactory and highly objectionable results, we have a choice of any one, or all of three different methods, viz: treatment by injection, treatment with the fistulatome, and treatment by the galvano-cautery as practiced by Dr. Shotwell; who, fully appreciating the dangers of muscular section, has hit upon a plan both new and commendable.
Fig. 14.—Varieties of Fistula. (Gosselin.)
The sub-cutaneous, or sub-mucous fistula can be cocainized and slit up with a pair of scissors, and the tract cleansed and cauterized with a solution of carbolic acid, a comparatively trivial affair; but the external blind, the internal blind, the complete, the complete with diverticula etc., are varieties which call forth a decidedly greater amount of ingenuity and thought in bringing them to a successful issue.
The treatment by injection, sometimes classified as a “non-operative method,” has been so successful in the hands of many, that it is stoutly affirmed that any case curable by the usual heroic methods is equally curable by this method. Different preparations have been used, chief of all being carbolic acid, ranging in strength from 50 per cent. up.
In adopting the carbolic acid treatment, probably the better way after preparing the sinus, will be to use a 95 per cent. the first time and subsequently a 50 per cent. solution; protecting the parts from excoriation by any suitable unguent and absorbent cotton. Hot water compresses to relieve pain and reduce swelling. Iodoform, Eucalyptol, etc., in the interim. Judgment will be required in not making too many irritant applications and granulation thus hindered for want of rest.
The object is to destroy the pyogenic membrane by the cauterizing effects of the acid and get up a granulating carbolic acid sore. It may be necessary to evacuate the bowels and constipate for several days to give the muscles rest, or resort in extreme cases to divulsion. The sinus must have constant, free external drainage until the healing process is complete. Allingham recommends the introduction of the small end of a bone collar button to keep the orifice open, with a hole drilled through its centre for drainage.
As a preliminary step the external orifice should be dilated with a laminaria tent or other appropriate means. The fistulous tract explored with a common probe and thoroughly cleansed with hot water introduced through a flexible silver canula; which is also used for the injection of a 5 or 10 per cent. solution of cocaine to obtund the sensibility.
Fig. 15.—Bone Stud
Concerning the carbolic acid treatment Allingham says: “Since the publication of my last edition I have cured many patients by dilitation of the sphincters and the use of the bone stud and carbolic acid. One practical point I would mention. The further the external aperture is from the sphincter the more likelihood is there that the sinus will heal. This is shown as well in the cases of spontaneous cure as in my own successes. You must always enjoin rest after a strong application, and watch that not too much inflammation be set up.”
The fistulatome shown in [fig. 16], is a contrivance which is perhaps destined to take the lead in the treatment of fistula generally. It is so constructed that the fine cutting blades close on themselves, while the instrument, which is probe pointed, is being introduced, but immediately open on withdrawal, and thus catch up and cut through the fistulous membrane.
Fig. 16.—Fistulatome with blades extended.
Who the inventor of this clever device is, I have been unable to ascertain, having seen it claimed by three different physicians, one of whom speaks of curing 76 per cent. of all cases treated by one operation. That is by drawing the fistulatome through the tract once. Cases of long standing require that the instrument should be turned at right angles and drawn through the second time and possibly repeated later on, or a tenotome employed to scarify any remaining indolent sinus.
It will be readily seen, however, that a fistula with a side pocket, branch or diverticulum, would hardly be reached by this method; although the blades are so formed that they draw the membrane of a dilatable pouch to them from the sides. In such cases a little ingenuity would be required in finding these diverticula, for the purpose of scarifying them with a tenotome.
The preparation of the sinus and the after-treatment are the same as already mentioned. Also evacuation of the bowels and constipation by the use of an opium suppository, even to the dilitation of the sphincters, if thought necessary to bring about a cure. In rare instances, where divulsion has been practiced and while yet under the influence of anæsthesia, it might be advisable to lay open the cavity by cutting from the sphincters, pockets traced, scarified and partitions divided.
Fig. 17.—Flexible Silver Canula.
In relation to treatment, Andrews says: “The truth is, that anal fistulæ have a natural tendency to recovery, and are held back from it mainly by two things.
1. “The unfavorable effect of the undrained septic fluids within the sac.
2. “The tightness of the external opening, which prevents free drainage, and keeps the sac distended with this putrid pus.
“It is demonstrated by Dr. Mathews on the one hand and by the experiments of quacks on the other, that by controlling these two conditions, many cases will heal spontaneously. It follows that among the thousands of patients subjected to cutting operations by surgeons for this disease, there are many who might be cured by much milder means.”
Shotwell’s operation consists in straitening out of the fistulous tract with a steel probe, having an eye at its distal end, which is carried entirely within the bowel whether the fistula is complete or not. He next pierces the solid structure about three-eighths of an inch farther from the anus with a lance-pointed probe also having an eye near its end, parallel with the first probe, until its end is seen penetrating the bowel a little beyond.
The eyes of the probes are then threaded with the opposite ends of a No. 24 platinum wire about ten inches in length, and both probes withdrawn, leaving the wire in situ forming a loop; both ends are now secured to an electrode, the current turned on and the loop drawn through the partition. Little, if any, dressing is required, but the bowels must be kept locked up for at least a week. This of course involves the use of general anæsthesia.
A word to the beginner, in the prevention and detection of fistula. Since abscess is the most prolific source, proper attention to the abscess by poulticing, early lancing, the sinus washed with hot, heavily carbolized water, allowed free drainage, the bowels evacuated, constipated and the muscles put at rest for a few days, will doubtless be successful in forestalling its almost certain fistulous sequence.
Dr. Hoyt strongly recommends divulsion of the sphincters, immediately after opening the abscess, as an unfailing remedy in preventing fistula.
Annoyance by itching, a slight discharge and soreness at times in a circumscribed spot, with previous history of abscess, might be considered a sure sign of fistula. But the patient may give the same symptoms with no knowledge of previous abscess, or other cause pointing to the formation of a fistula. Yet, on inspection, a small opening with pouty lips, or a closed cicatricial depression not much larger than a pin-head, will be found. This is the external ring or opening of a fistula, and if closed, may resist the introduction of a probe sufficiently to create the belief that no sinus exists.