SECT. LXXVII.—ON FISTULÆ AND FAVI.
The present occasion requiring us to treat of fistula in ano, it will not be improper to give an account in the first place of fistulæ in general. A fistula then is a callous sinus, attended with little or no pain, and forming in most parts of the body. It generally originates in abscesses not properly healed. The callus is compact and white, the flesh dry, and therefore insensible, neither vein nor nerve passing to it. Sometimes the sinus is dry and sometimes filled with a discharge. The discharge is sometimes constant, and sometimes at intervals, the mouth of it being at one time shut up, and at another time open. Sometimes the fistula terminates on a bone, sometimes on a nerve, or some other important part; and it is either straight or crooked; has either one orifice or many. Those therefore that terminate upon large arteries, or nerves, or tendons of considerable size, or the pleura, or any important part, are either not to be meddled with at all, or with great and skilful caution; but the others may be operated upon in this manner. We first examine them if they be straight with a sound (specillum), or if crooked with a double-headed specillum of a very flexible nature, such as those made of tin, and the smallest of those made of copper. When there are two or more orifices, we must not trust to the examination with a specillum, but injecting the sinus by one of its openings we ascertain from the manner in which the injection comes out whether it be one fistula with many orifices, or if there be several fistulæ. After the examination, if the sinus be superficial and narrow, it is to be distended by the introduction of a specillum, and the callus is to be cut off with a properly-shaped scalpel, or pared with the nails or the point of a scalpel. If it is also broad the redundant parts are to be dissected away. If it is not superficial, but deep and straight, we must cut off the callus all around as far as we can make incisions, and if any part remain, destroy it with a caustic medicine; or if the callus be large, and do not yield to medicine, we must form a slough by burning it with hot irons. If the fistula terminate with a bone, and if it is not diseased, we need only scrape it, but if it is carious, or otherwise corrupted, the whole diseased portion is to be cut out with counter perforators, and if necessary we may bore a hole with a wimble (trephine?) whether the bone be diseased only to the diploe or as far as the marrow. If a bone project, as after a transverse fracture, we must saw it off. Taking, therefore, two bandages, we apply the middle of the one to the projecting bone itself, and get it kept stretched by an assistant; the other being thicker, or formed of wool, we are to take in like manner, and apply the middle of it to the flesh under the bone, and taking its ends below, we give directions that the flesh below be retracted by this band lest it be torn by the teeth of the saw, and in this manner we accomplish the sawing. When any vital part is situated below, such as the pleura, spinal marrow, or the like, in cutting or sawing the bone, we must use the instrument called meningophylax for protecting them. If the bone is not diseased, but is denuded of flesh all around, it is to be sawn in the same manner, for bones which are disengaged from the other parts all around cannot possibly incarnate. In like manner, the extremity of a bone near a joint, if diseased, is to be sawn off; and often, if the whole of a bone, such as the ulna, radius, tibia, or the like, be diseased, it is to be taken out entire. But if the head of the thigh-bone, or pelvis, or a vertebra of the spine be diseased, we must not attempt to operate upon them for fear of the adjoining arteries. We must proceed in this manner in every particular case, attention being paid to the situation, proximity, and connexions of the affected parts, the extent of the disease, the strength and powers of the patient. The favus being a fistulous sinus with a milky discharge must be subjected to the same operation and treatment as fistula.
Commentary. For an account of the practice of Hippocrates we refer to our notes on [the 49th section of the Fourth Book].
Celsus states that if fistulæ spread deep, are crooked, or are numerous, they are to be cured by an operation rather than by medicines. Wherefore, if it spread transversely, he recommends us to introduce a specillum, or sound, and cut down upon it. But if it is crooked, its bendings are to be followed out and cut open in the same manner. When the operator has reached the end of the fistula, all the callus is to be cut out, and the lips of the wound secured by clasps and agglutinative applications. When the fistula terminates with a rib he directs us to saw out a piece of it lest it affect the adjoining parts. Fistulous sores about the abdomen he pronounces to be highly dangerous. He recommends us, however, to attempt a cure by making an incision, and uniting the edges of the wound by sutures. (vii, 4.)
Aëtius lays down nearly the same rules for the treatment of fistulæ as our author. When the sinus runs transversely along the skin, he directs us to lay it open. When it penetrates downwards he advises us to cut off the callus; and when the ulcer terminates with a bone to remove the diseased lamina of it. (xiv, 55.)
Albucasis delivers the surgical treatment of fistulæ at great length. He is very particular in inculcating the necessity of making free incisions, and of removing any pieces of diseased bone which may happen to be found at the bottom of the sore. He relates a case of fistulous ulcer in the thigh, to cure which he removed large pieces of bone, sawing it down as far as the marrow. Some of his saws are very ingeniously constructed, and one of them is not unlike the saw introduced into the practice of surgery by the late Mr. Hey, of Leeds. He enumerates nine causes which prevent sores from healing; and as they appear to be of some practical utility we shall briefly mention what they are: 1, a deficiency of blood in the body; 2, cachexy, or bad condition thereof; 3, fungous flesh, which prevents the union of the edges of the sore; 4, much sordes in the ulcer; 5, putridity, or any other bad quality of the fluids; 6, improper applications; 7 and 8, the pestilential state of the atmosphere and the insalubrity of the place where the patient resides; 9, a diseased bone. When none of these causes are present, the restorative principle of nature will of itself effect the cure of any solution of continuity. (Chirurg. ii, 88.)
Rhases gives extracts from Antyllus, and many other authors, on this subject, but as their principles of treatment are much the same as those delivered by Paulus, we need not occupy much room with an abstract of them. Antyllus forbids us to use the knife when the fistula is situated in the groin or fundament. When it is not judged expedient to have recourse to an operation, one of his Arabian authorities, Aaron, recommends a powder composed of equal parts of quicklime, cantharides, arsenic, sandarach, sal ammoniac, and ginger. (Cont. xxviii.)
SECT. LXXVIII.—ON FISTULÆ IN ANO.
Fistulæ in ano are discovered, if they are blind, from their being attended with pain, although no orifice appears; from there being a purulent moisture about the anus, and in most cases from their being preceded by symptoms of abscess; or, if they are open, by the introduction of a sound or swine’s bristle; for the instrument will pass down into a cavity and meet the index-finger introduced into the anus if the fistula has penetrated to the inside; but if it has not penetrated, the instrument does not come in contact with the finger but the intermediate substance between them remains imperforated. The fistula is known to be crooked and winding from the instrument’s passing down but a short way, while a great quantity of pus is discharged in proportion. Those near the intestines are known by an abdominal worm or fæces sometimes passing through the mouth of them. In almost all cases some callus appears about the orifice of the fistula. A fistula is incurable that perforates the neck of the bladder, or extends to the joint of the thigh, or to the rectum. A fistula is difficult to cure when it has no orifice, is blind, ends with a bone, and has many windings. All the rest are, in general, easily cured. We proceed with them thus: having placed the patient in a supine posture, with the legs elevated, so that the thighs may be bent upon the belly, as when an injection of the bowels is administered, if the fistula terminate superficially, having introduced a sound or ear-specillum through the orifice of it, we cut the skin which covers it at one incision. But if the fistula terminate deeply in the anus, having introduced a specillum into the mouth of it, and if we find that it has perforated the gut, by introducing the finger into the anus opposite the affected buttock, we take hold of the head of the specillum, and bending it, bring it to the outside, and with one simple division cut asunder the parts which lie over the sound. If the fistula is found not to have as yet perforated the gut, and to have terminated only deeply in the fundament, and if upon examination we find that a scaly or membranous substance intervenes between the index-finger and the extremity of the sound, we must perforate it violently with the head of the sound, and forcing the sound through the rectum, we must again, as formerly described, cut asunder the intervening parts with a scalpel; or, having perforated the bottom of the fistula in ano with the sharp part of a falciform instrument for operating upon fistulæ, we bring the instrument out at the anus, and so divide all the intermediate space with the edge of the instrument; and after the incision, having taken hold of the surrounding parts, which mostly consist of callus, with a common forceps, or one called staphylagra, we cut them out all around, avoiding the sphincter muscle; for some cutting deep in an unskilful manner, have wounded it, from which the patient has had an involuntary discharge of fæces. Those who from timidity, avoid a surgical operation may be treated with the ligature, as recommended by Hippocrates. For Hippocrates directs us to pass a raw thread, consisting of five pieces, through the fistula by means of a probe having a perforation, or a double-headed specillum, and to tie the ends of the thread and tighten it every day until the whole intermediate substance between the orifice be divided and the ligature fall out. If it remain long, the thread may be sprinkled with the detergent powder called psarum, or some such powder, and drawn in. Some insert a thread into the opening of the falciform instrument for operations on fistulæ, and pass it through in the manner described, which I think ought not to be done. For by avoiding an operation, in addition they incur the inconvenience of a slow recovery. With regard to blind fistulæ, Leonides says: “When the fistula is deep, and penetrates the sphincter, whether beginning in the fundament, or arising from a distance and terminating in the sphincter, after the examination which has been described, we dilate the anus as we do the female vagina, with the instrument for that purpose, or the small specillum. When the orifice of the fistula is discovered, the end of an ear-specillum is to be passed through it, and pushed deep into it, and cutting down upon it where it presents, the whole fistula is to be divided with a semispathula or a spathula for operating upon fistulæ.” We having met with this state of the disease, have found it impossible to practise this mode of operating, because we could not discover the cavity of the fistula. For it was situated between the anus and sphincter towards the right side, and the dilator rather obscured the operation. But having dilated the wrinkles about the anus a certain fissure appeared among them, being as it were the defluxion of the fistula, for the pus passed out by it we saw to pass the head of the specillum into the fistula by it, which served as a director; and having passed the index-finger of the right hand to the sphincter, and having found a certain thin substance intervening between the finger and the sound, by pressing the sound violently to the finger, we perforated the bottom of the fistula, which was turned upwards; and passing with the finger the head of the instrument outwards, the whole of the substance between the mouths of the fistula, (I mean the one so situated as to favour the defluxion, and that now made by us,) we divided with a scalpel and cut out the sound.