Elements of Surgery

by Robert Liston

Owing to the loose nature of the texture surrounding the gut, abscesses near the anus often attain a great size, and extend deeply before there is much external indication of their existence; a hardness is felt on pressing the fingers deeply by the side of the tuberosity of the ischium; this is at first obscure, but gradually becomes more developed; and at last a small dark red spot appears, indicating that the matter has approached the surface, and is most superficial at that part. But the surgeon should not wait for the pointing here, as the matter may burrow much previously, and abscess form in the substance of the sphincter, or exterior to it. If the matter does not cause ulceration of the coats of the intestine, and escape into its cavity, pointing takes place, and the pus is discharged externally, in general through a small opening. The matter is of a very offensive odour. The external aperture, and even the whole cavity of the abscess, may be at a distance from the gut, but in most cases the matter is close to it: its coats are denuded, and often ulcerated through. The surrounding degree of induration, the quantity of contained matter, the extent of the cavity, and the situation of the opening, vary almost in every instance.

Cases occur of induration, often very extensive, in the neighbourhood of the anus, on one or both sides, with dark discoloration of the integuments, and burning pain. The affection resembles carbuncle. The precursory symptoms are soon followed by partial suppuration, and extensive sloughing of the cellular tissue. At first there is excitement of the system, but symptoms of debility, and flagging of the vital powers, soon present themselves—irregular pulse, delirium, disordered stomach, hiccough, vomiting, and cold extremities. The disease is one of great danger, and the patient can be saved only by free and early incision, and the judicious employment of stimulants.

In some instances the inflammation is merely superficial, seated merely in the integuments, and followed by slow collection of matter.

It is indeed seldom that a cavity formed by abscess near the anus fills up entirely, however large and free the opening into it may have been. The parietes contract, but the hardness around is not entirely dissipated; the opening may close for a little while, but is soon found again discharging, and may continue to do so for months or years. A sinus is thus formed. Fresh collections and openings, either externally or internally, are apt to occur, with extensive induration of the cellular tissue, and disease of the gut. Instead of a single sinus, a number of collateral ones are formed, all running into the main canal, like branches to a common-sewer, or by-lanes opening into one spacious street. The disease is one of frequent occurrence amongst females; and often from a false sense of delicacy its existence is not declared till it has advanced to a state of truly horrible perfection.

Fistula is generally the consequence of abscess in the cellular substance near the anus. By the term is understood a sinus or track, with narrow orifice and hard parietes, discharging thin gleety matter. If the track extends from the cavity of the gut to the surface, flatus must often pass through the narrow and tortuous canal, and, from a peculiar noise being produced by its passage, the name of Fistula has probably been adopted. The term cannot be properly applied to recent cavities of abscesses, but only when their sacs have contracted, their lining has become callous, and their discharge thin and almost colourless.

The fistula may be one of three varieties—blind external, blind internal, complete. The first denoting that the sinus opens externally, but does not communicate, either at its origin or elsewhere, with the cavity of the bowel. The second, that it communicates with the bowel, but does not open externally. The last, that it both communicates with the bowel and opens externally. Some contend that fistulæ are always complete, that they commence from within, and that the internal opening is always at one particular point; but such, according to my experience, is far from being the case.

Fistulæ occur in children, though rarely; generally in people advanced in life. The cavity of the sinus, after long continuance, becomes coated with an expansion resembling mucous membrane, and secretes a discharge of mucous character.

In every case, it is necessary that the surgeon should ascertain, as accurately as possible, the extent and nature of the fistula; and, with this view, examination with the probe is requisite. The probe is introduced into the canal, when the fistula is an external one, and directed through its windings, so as to discover its direction, length, and divarications; the guidance of the instrument is facilitated, and the information augmented, by the forefinger being placed in the rectum. Sometimes all the by-paths cannot be detected, until the orifice of the canal is enlarged. When the fistula is complete, the probe, entered at the external extremity, can be passed into the bowel so as to be felt by the finger in the rectum; but it must be remembered that the internal opening is not always at the inner termination of the sinus, but often seated more externally—the cellular tissue being destroyed to a considerable extent above it, so as to form a large unhealthy abscess, communicating with the main track of the fistula. But the gut may not be opened into, though denuded to a large extent, and forming part of the walls of the sinus; and in some instances, the sinus may not come within a considerable distance of the bowel.

An internal fistula is more difficult of detection. The symptoms leading to a suspicion of its existence are—puriform discharge from the bowel, increased on going to stool, and then accompanied with tenesmus; pressure on the side of the anus, causing pain, and sometimes an augmentation of discharge; and in many instances hardness, deeply seated, is felt. On introducing the finger into the rectum, the aperture in the coats of the bowel is perceived, or a part of the bowel feels more boggy and tender than the rest; through this point a curved probe, introduced along the finger, may be passed into the sinus, and being then directed downwards, reaches the outer extremity of the canal, causes the integuments to project, or is readily felt from the surface. The internal opening is usually immediately within the sphincter, seldom higher.[49] The discharge, in general, is rather profuse, the bowel is very irritable, desire to evacuate it is frequent, and the feces are often tinged with blood. There is a sensation of itching about the fundament, the heat of the parts is felt by the patient to be increased, he is unable to bear pressure there, and sits on one buttock: in most cases the bladder sympathises considerably. The giving way of the bowel may be produced by ulceration commencing in the mucous membrane, but is more frequently the result of inflammatory action in the surrounding cellular tissue. The aperture is the seat of acute pain when pressed upon, and during evacuation of the bowel. Great light is thrown on such cases by the use of a proper speculum. But its introduction can seldom be borne in cases of inflammation, abscess, or recent fistula. In ulceration of the coats within the sphincter it is useful. Considerable information can certainly be obtained by the finger; but to the sense of touch, however acute, it is better, when admissible, to add that of vision. The speculum, made of silver or steel, and having its internal surface highly polished, is introduced gently into the anus, and expanded fully; and by changing the situation of the instrument, and holding a light so as to illuminate the interior, the surface of the bowel for five or six inches above the anus can be examined accurately, as if it were an external part of the body.

Simple indurations and contractions of the lower part of the bowel follow long-continued irritation and inflammation of its parietes. The part is not an uncommon seat of stricture, and sometimes the bowel is constricted at two or more points near each other; frequently the stricture is extensive and firm, in other cases it is narrow, consisting merely of a thin band. It is often complicated with fistula; if so, the internal aperture is immediately above the stricture, and is caused by ulceration; abscess sometimes forms above the stricture, destroys the coats of the bowel at that point, burrows around, and not unfrequently points at a great distance from its origin; or sloughing and ulceration may take place in the coats of the bowel, and feculent matter be discharged through the opening of the abscess. In females, the vagina may be opened into in consequence of unhealthy suppuration in the cellular tissue, between that organ and the gut.