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                          FISSURE OF THE ANUS

                                  AND

                            FISTULA IN ANO.

                             --------------



                                   BY

                       LEWIS H. ADLER, JR., M.D.,
       _Instructor in Diseases of the Rectum, in the Philadelphia
           Polyclinic and College for Graduates in Medicine._






                                 1892.
                            GEORGE S. DAVIS,
                             DETROIT, MICH.



------------------------------------------------------------------------




                             Copyrighted by
                            GEORGE S. DAVIS.
                                 1892.




------------------------------------------------------------------------

                           TABLE OF CONTENTS.


                             --------------

                 FIRST PART.—ANAL FISSURE, OR IRRITABLE
                          ULCER OF THE RECTUM.

                               CHAPTER I.
           Definition—Location—Age and Sex Affected—Etiology

                              CHAPTER II.
        Symptomatology—Physical Exploration—Diagnosis—Prognosis

                              CHAPTER III.
                  Treatment, Palliative and Operative


                      SECOND PART.—FISTULA IN ANO.

                               CHAPTER I.
    Relative Frequency—Age and Sex Affected—Etiology—Classification

                              CHAPTER II.
        Symptomatology—Physical Exploration—Diagnosis—Prognosis

                              CHAPTER III.
                        The Palliative Treatment

                              CHAPTER IV.
                        The Operative Treatment

------------------------------------------------------------------------




                                PREFACE.


In the following pages I have endeavored to give a concise yet thorough
account of the two affections Fissure of the Anus and Fistula in Ano,
in respect to their etiology, symptomatology, diagnosis, and treatment.
It has not been my object to write upon rectal fistulæ in general.

While the two subjects treated in this volume have been ably written on
at various times and by different authorities, it is undeniable that no
organ of the body is more neglected by both the laity and the
profession than is the rectum.

The neglect upon the part of the laity is largely attributable to
carelessness in regard to regularity of habit and to want of
cleanliness in this portion of the body. This neglect is the prime
factor in the causation of many of the rectal maladies frequently
encountered by the specialist. Furthermore, patients suffering from
rectal diseases, especially women, often from a false sense of modesty
defer their visit to a physician as long as possible, allowing their
trouble to proceed from bad to worse, and when their suffering finally
becomes almost unbearable and a doctor is consulted they refuse to
allow him to make a rectal examination; in this way error in diagnosis
occurs, and consequently relief is not obtained. The use of improper
paper for toilet purposes often occasions the production of rectal
diseases.

The profession as a body find other fields of labor more inviting than
the study and treatment of rectal diseases, the diagnosis of which to
be complete and satisfactory must in every case be based upon an ocular
and thorough digital examination. As a result of this unattractiveness,
even amounting to repulsiveness, to the general practitioner, most of
the affections of the lower bowel are treated by him as "piles," the
diagnosis being usually made by the patient, and accepted by the
physician without question or personal examination. Such being the
case, it is no wonder that when the surgeon prescribes equal parts of
_ung. acid. tannici et ung. belladonnæ_, or a similar salve, to every
patient complaining of rectal trouble, a cure does not often result.

A knowledge of these facts has led me to hope that a brochure upon the
subjects herein treated might excite a deeper professional interest in
rectal maladies if issued as a volume of the Physician's Leisure
Library Series, which by its moderate price permits of a wide
circulation.

I desire to express my obligations to the publisher, Mr. George S.
Davis, for the attractive style in which the work has been issued, and
to Dr. B. W. Palmer, of Detroit, Mich., for valuable suggestions while
the work was passing through the press; also to my friend Dr. G. G.
Davis, of Philadelphia, for the original drawings furnished, from which
a number of the illustrations have been executed, and to Messrs. Chas.
Lentz & Sons, surgical cutlers of Philadelphia, for the use of various
cuts of instruments.

                                                     LEWIS H. ADLER, JR.

    1610 Arch Street, Philadelphia, Pa.

------------------------------------------------------------------------




                 Part 1.—Irritable Ulcer of the Rectum,
                        or Fissure of the Anus.

                  *       *       *       *       *


                               CHAPTER I.

           DEFINITION—LOCATION—AGE AND SEX AFFECTED—ETIOLOGY.


FISSURE.—The domain of surgery includes few diseases which produce
such intense suffering to the patient as does the affection under
consideration, and none in which proper treatment is followed by more
prompt relief and more certain ultimate success.

Fissure, although so simple in extent and character and so readily
curable, exercises a most potent influence in undermining the patient's
health and strength, the constant pain and irritation to the nervous
system being more than the majority of persons can endure.

DEFINITION.—We may define a fissure, or irritable ulcer of the rectum,
as a superficial breach of the mucous membrane in the anal region, of a
highly sensitive nature, giving rise to spasmodic contraction and
paroxysmal pain of a peculiar character. According to Bodenhamer,[1]
its shape may be linear, oblong, or circular.

LOCATION.—Its position is usually just within the verge of the anus,
beginning at the muco-cutaneous junction or Hilton's line, and
extending upward toward the rectum for a distance seldom exceeding half
an inch. It may occupy any portion of the circumference of the anal
region, but its usual site is at its posterior or coccygeal side.

MULTIPLE CHARACTER.—Although this lesion is usually solitary, we
sometimes find it multiple, especially when it is of syphilitic origin.

AGE AND SEX AFFECTED.—Anal fissure is a disease of adult life, and is
said to be more common among women than among men. Very young children,
however, are not exempt, as many reported cases show. The late Dr. D.
Hayes Agnew[2] mentions having seen it occur in infants not over two
months old. Dr. A. Jacobi[3] is of the opinion that this affection is a
more common one than is generally supposed, and believes that many of
the fretful children who sleep badly and cry constantly, and often
present symptoms simulating those of vesical calculus, suffer from
fissure of the anus. He quotes Kjellberg, who at the Dispensary at
Stockholm among 9098 children found 128 cases of fissure of the anus,
of which number 60 were boys and 68 were girls; the majority were less
than one year old, and in 73 cases the age was less than four months.

ETIOLOGY.—The explanation of the very intense pain by which this
disease is characterized is to be found upon study of the structural
arrangement of the termination of the bowel, with especial attention to
the nerve-supply of the part. Therefore it will be in order to review
at this point the more important anatomical features of the lower
portion of the rectum.

The outlet of the intestine is closed by two sphincter muscles, the
external being immediately beneath the skin surrounding the margin of
the anus. It is elliptical in form, about half an inch in breadth on
each side of the anus, and is attached posteriorly by a small tendon to
the tip and back of the coccyx; anteriorly it becomes blended with the
transverse and bulbo-cavernosus muscles at the central point of the
perineum. The internal sphincter consists of the normal circular fibers
of the rectum, considerably increased in number; its thickness is about
two lines, and its vertical measurement from half an inch to an inch.
It is situated immediately above and partly within the deeper portion
of the external sphincter, being separated from it by a layer of fatty
connective tissue.

These muscles—the two sphincters—are separated on the outer side by
the attachment of the levator ani, some of the fibers of which are
internally connected with the external sphincter; on the inner side the
muscles are in contact, the line of union corresponding accurately with
the junction of the skin and the mucous membrane. In most cases this
junction of the sphincters is marked by a line of condensed connective
tissue.[4] This line is known as "Hilton's white line."

Hilton has pointed out an important anatomical fact in connection with
this line—to wit, that it is the point of exit of the nerves,
principally branches of the pudic, which descend between the two
sphincter muscles, becoming superficial in this situation, and are
there distributed to the papillæ and mucous membrane of the anus (Fig.
1).

[Illustration:  Fig. 1—Nervous Supply of the Anus (Hilton). _a_,
mucous membrane of the rectum; _b_, skin near the anus; _c_,
external sphincter muscle; _d_, internal sphincter muscle; _e_, line
of separation of the two sphincters; _f_, the overlying white
line marking the junction of the two sphincters; _g_, nerve
supplying the skin near the anus, which it reaches by passing
first externally to the rectum and then through the interval
between the two sphincters; _h_, flap of mucous membrane and skin
reflected back.]

These nerves are very numerous, which accounts not only for the extreme
sensitiveness of the part, but also, as stated by Andrews,[5] for its
very abundant reflex communications with other organs. They play a very
important part in the etiology of irritable ulcers. The exposure of one
of their filaments, either in the floor or at the edge of the ulcer, is
an essential condition of its existence.[6]

The upper portion of the rectum possesses very little sensibility, as
the chief nerve-supply of the organ is at its termination and around
the anus; hence it is that such grave diseases as cancer or ulceration
may exist in the higher parts of the bowel and not manifest their
presence by pain.

[Illustration:  Fig. 2—Diagram of the Nervous Relations of Irritable
Ulcer of the Anus (Hilton). _a_, ulcer on sphincter ani; _b_,
filaments of two nerves are exposed on the ulcer, the one a nerve of
sensation, the other of motion, both attached to the spinal cord, thus
constituting an excito-motor apparatus; _c_, levator ani muscle; _d_,
transversus perinæi muscle.]

Andrews[7] directs attention to Hilton's diagram (Fig. 2), as showing
that impressions from a fissure are carried to that part of the cord
which supplies the pudic nerves and the ilio-lumbar, lumbar, and
sciatics, which include the motor supply of the external sphincters as
well as of the bladder and the lower extremities.

From these general considerations we can understand why reflex spasm of
the sphincter is so constant and important a sign of this malady, and
how other and more general reflexes are to be accounted for,—such as
symptoms of bladder and urethral diseases, radiating pains, etc.

We also find in the nervous mechanism of the part an explanation of the
predisposing causes, important symptoms, and pathology of this peculiar
affection.

As to the immediate origin of this lesion, it may be said to arise from
a variety of causes, such as atony of the rectum, or other conditions
leading to constipated habits. In these cases the bowel becomes
impacted with hardened feces, which when discharged overstretch the
delicate mucous membrane, and thus, either by irritation or by direct
abrasion, the ulcer is formed.[8]

In consequence of spasmodic or organic contraction of the external
sphincter ani, fecal matter or some other foreign body lodges in the
fossa between the two anal sphincters, and by its long-continued
presence in this pent-up situation becomes highly irritating and gives
rise to an obstinate fissure.[9]

Anal fissure sometimes results from the excoriations produced by
vitiated and acrid discharges, such as occur in dysentery, chronic
diarrhœa, cholera, leucorrhœa, etc. Hemorrhoids are frequently a
predisposing cause and a complication of this affection.[10] They
narrow the outlet of the bowel, and through the successive inflammatory
attacks to which they are subject the neighboring tissue loses its
elasticity, is rendered brittle, and is easily lacerated.

Polypi are not uncommon causes of this lesion.[11] The polypus is
usually situated at the upper or internal end of the fissure, but it
may be on the opposite side of the rectum, as in several cases coming
under the author's observation.

Allingham[12] states that ulcer of the rectum may result from a
congenital narrowness of the anal orifice, being then usually seen in
children; or it may be caused by an hypertrophied condition of the
sphincters, which has arisen from severe constipation or some rectal
affection.

Anal fissure is sometimes produced by a superficial excoriation or
ulceration of the outlet of the bowel, analogous to that so frequently
observed upon the inside of the lips, the tongue, and other parts of
the mouth. Bodenhamer[13] mentions having seen several severe cases of
this disease produced by a kind of _aphthous ulceration_ in nursing
mothers, and one in a child. They were attended with extreme burning
pain and more or less anal spasm. He also states that in these cases
the ulcerations of the anus were contemporaneous with similar
ulcerations of the mouth; their coexistence and the exact similarity of
their appearance left little doubt as to their identity.

Harrison Cripps[14] states that a source from which these ulcers
sometimes take their origin is a little marginal abscess which has led
to the destruction of the portion of the muco-cutaneous surface lying
over it.

The anus is liable to a species of chapping resembling that of the lips
in winter, which sometimes results in extremely painful fissures. Such
a condition is supposed to be induced by the influence of a dry
atmosphere or by some slight disturbance in the general health,
rendering the parts friable and liable to crack from the slightest
violence.

Fissure is sometimes of syphilitic origin. Finally, it may be due to
mechanical injuries, such as uterine displacement, the severe straining
efforts made in parturition, the careless use of the enema syringe, the
awkward employment of instruments by the surgeon in the diagnosis and
treatment of rectal diseases, etc.

-----

Footnote 1:

  "Anal Fissure," 1868, p. 45.

Footnote 2:

  "Principles and Practice of Surgery," vol. i, p. 416.

Footnote 3:

  "Intestinal Diseases of Children," p. 295.

Footnote 4:

  Andrews, "Rectal and Anal Surgery," Chicago, 1889, p. 69.

Footnote 5:

  _Op. cit._, p. 69.

Footnote 6:

  Ball, "The Rectum and Anus," Philadelphia, 1887, pp. 128-129.

Footnote 7:

  _Op. cit._, pp. 69-70.

Footnote 8:

  Bodendamer (_op. cit._, p. 58) calls attention to a fact of some
  importance as bearing upon this point—to wit, that in some cases of
  constipation, while the diaphragm and other abdominal muscles act
  with considerable energy, the anal sphincters remain more or less
  contracted, and yield but slowly, so that the indurated feces contuse
  and abrade the surface of one or more points of the mucous membrane,
  which abrasions, if they do not heal, lay the foundation of the
  disease.

Footnote 9:

  Instances of this condition as the cause of anal fissures are
  mentioned by T. B. Curling in his "Observations on the Diseases of
  the Rectum," second edition, London, 1855.

Footnote 10:

  T. J. Ashton, "Diseases of the Rectum," second American from the
  fourth English edition, 1865, p. 46.

Footnote 11:

  Allingham, "Diseases of the Rectum," fifth edition, London, 1888, p.
  208.

Footnote 12:

   _Op. cit._, p. 209.

Footnote 13:

  _Op. cit._, p. 59.

Footnote 14:

  "Diseases of the Rectum and Anus," second edition, London, 1890, p.
  185.




                              CHAPTER II.

        SYMPTOMATOLOGY—PHYSICAL EXPLORATION—DIAGNOSIS—PROGNOSIS.


SYMPTOMS.—The symptoms in the early stage of this disease are not
usually severe, and are generally experienced during defecation, when
at some point or other there will be an uneasy sensation, consisting of
an itching, pricking, slight smarting, or a feeling of heat about the
circumference of the anus. As the disease progresses, the discomfort
attending the movements of the bowel is greatly augmented, and at a
variable period of time gives place to a severe pain, of a burning or
lancinating character, which is followed by throbbing and excruciating
aching, attended by violent spasmodic contraction of the sphincter
muscles, continuing from half an hour to several hours.

From reflex irritation, pains are often experienced in other parts,
simulating sciatica or rheumatism; the urinary organs, as has already
been mentioned, are liable to be sympathetically deranged, causing
attention to be diverted from the real seat of the disease.

The ulcer being fully established, the suffering usually comes on with
intensity shortly after the actual passage of the motion, and
frequently it lasts for many hours, completely incapacitating the
patient for work while it continues. I have known persons affected with
this malady who for hours were obliged to maintain one position, or to
assume the recumbent posture, for fear that the slightest movement
would aggravate the pain.

After an indefinite period the pain subsides or entirely disappears,
the patient feeling fairly comfortable, or even perfectly well, and to
all outward appearance he would continue so were it not for the
knowledge that the subsequent passage of fecal matter will bring with
it a recurrence of agony. In consequence of this dread, the act of
defecation is postponed as long as possible, with the result that when
the evacuation does take place the pain is greatly increased.

The feces, when solid, will be passed streaked with purulent
matter,—possibly also with blood,—and when more soft will be figured
and of small size; sometimes they are flattened and tape-like, due to
the incomplete relaxation of the sphincters during defecation. Not
infrequently the appearance of such a stool leads the inexperienced to
make a diagnosis of stricture of the rectum. In this connection it may
be well to state that a fissure is sometimes found associated with a
stricture, which latter is due to a congenital contracted state of the
anus. Serremone, quoted by Ball,[15] believes that the stricture is the
cause and not the result of the fissure, the narrow outlet being more
liable to injury from over-stretching.

When a fissure is of long duration, the constitution becomes greatly
impaired as a result of the constant pain, the constipation, and the
frequent resort to narcotics, and the patient is liable to fall into a
state of melancholy and extreme nervous irritability; the countenance,
expressive of pain, grows care-worn and sallow; the appetite is poor;
and there is more or less emaciation, associated with the general
appearance of a person suffering from serious organic disease.

Flatulence is another annoying symptom that generally attends severe
cases of anal fissure.[16] It is not only troublesome, but also
painful, the disengagement of gas being almost certain to bring on a
paroxysm of pain.

Such are the rational symptoms of anal fissure. If, then, a patient
comes to a physician, complaining of severe pain lasting for some time
after defecation, the presumption is strong that a fissure exists,
since no other rectal disease produces this characteristic distress.
But in this as in all other affections of the inferior extremity of the
intestinal tract we must supplement our investigation by an actual
exploration of the parts, in order to determine the true character of
the trouble and to exclude the presence of coexisting lesions.

OCULAR AND DIGITAL EXAMINATION.—Previous to making the rectal
examination, the bowels should be thoroughly emptied by an enema,—the
subsequent pain and anal spasm being prevented by a preliminary local
application of a four-per-cent. solution of the hydrochlorate of
cocaine to the mucous membrane of the anus, the drug being applied on a
pledget of cotton and left _in situ_ for five or ten minutes. Care must
be exercised not to use the solution too freely, as otherwise toxic
symptoms are apt to ensue when the drug is employed in this region. The
rich lymphatic and vascular supply of the part probably accounts for
this fact.

[Illustration:  Fig. 3—Head Mirror.]

The rectum and the bladder being completely evacuated, the patient
should be placed on the side in a good light, with the knees drawn up
and one hand supporting the uppermost buttock. To condense the light on
the parts to be examined the head mirror may be employed (Fig. 3).

Upon inspection, the first thing that attracts our notice, frequently,
is a red, somewhat edematous prominence (Fig. 4) close to the verge of
the anus, looking not unlike a small hemorrhoid. This excrescence has
been termed the "sentinel pile." Upon placing a finger on each side of
the tumor and pressing down and out, as recommended by Bodenhamer,[17]
the fissure will be seen.

[Illustration:  Fig. 4—Anal Fissure associated with the so-called
"sentinel pile" (Bodenhamer).]

An important point, to which Bodenhamer calls attention, is the
external appearance of the anus itself, which in these cases is usually
in a highly contracted state and more or less infundibuliform; the
observer being struck by the very considerable depth to which the anus
is retracted, and its unnatural look.

The fissure is sometimes difficult to find, and must be searched for in
the folds of the anus. This can be accomplished by drawing the mucous
membrane away on each side, by which means we shall usually be able to
see just within the orifice an elongated, club-shaped ulcer, the floor
of which may be very red and inflamed, or, if the disease is of long
standing, of a grayish color, with the edges well defined and
indurated. Sometimes the ulcer is quite superficial, while in other
instances it extends completely through the muco-cutaneous surface,
exposing the subjacent muscular coat. Cripps[18] states that these
ulcers are sometimes undermined, so that a probe may be passed for a
short distance beneath them, while occasionally a little fistulous
channel will run some distance up the anus.

A fact to which special attention should be directed here is that small
ulcerations may exist in the sinuses of Morgagni. Kelsey[19] and
Vance[20] have met with such cases, the ulceration being completely
hidden from sight, and detectable only by the sharp pain caused by the
introduction of a small bent probe. This condition is no doubt a rare
one, but is none the less important on this account, for its situation
is such that it may be readily overlooked.

The next step in the examination of a case of fissure is the
introduction of the finger into the rectum,[21] and it should be
conducted in the following manner.[22] If the lesion be situated
dorsally, pressure should be made by the finger toward the perineum,
thus avoiding the fissure and rendering the introduction of the digit
as painless as possible. If the fissure be situated anteriorly or
laterally, the finger should be pressed toward the opposite side of the
bowel.

In cases of fissure the speculum ani is seldom required by those
accustomed to making rectal examinations. In the majority of instances
the possession of the _tactus eruditus_—education of the sense of
touch—will enable the surgeon to form a correct diagnosis without the
aid of this instrument, and thus save the patient much pain. If a
speculum should be required, the instrument of Aloe (Fig. 5) or of Sims
(Fig. 6) may be employed.

[Illustration:  Fig. 5—Aloe's Speculum.]

[Illustration:  Fig. 6—Sims' Speculum (detachable handle).]

It is not an uncommon occurrence, according to Allingham,[23] to find a
polypus associated with fissure, it being situated at the upper end of
the ulcer, or lying against it on the opposite side of the wall of the
rectum. I have met with several such instances. If the polypus be
undiscovered, treatment of the fissure will prove useless, for it will
not heal until the polypoid growth is removed. In searching for a
polypus, it is important to remember that the investigation should be
conducted by passing the finger from above downward, as otherwise the
tumor may be pushed up out of reach, the pedicle in these cases often
being of considerable length.

DIAGNOSIS.—The manifestations of this disease are so characteristic of
the lesion that it seems almost impossible for an error to be made in
its diagnosis. The peculiar nature of the pain, the time of its
occurrence (either during or some time after an evacuation of the
bowels), its continued increase until it becomes almost unbearable, and
its gradual decline and entire subsidence until the next evacuation,
are symptoms clearly pointing to fissure, and in most instances should
be sufficient evidence to establish a diagnosis; yet in a number of
well-authenticated cases mistakes have been made, and patients
suffering from this disease have been treated for neuralgia, uterine or
vesical trouble, stricture, and even hemorrhoids.

Anal fissure is very readily distinguished from neuralgia by the
absence in the latter of any breach of surface or of any other disease
of the mucous membrane of the rectum; by the entire want of connection
between the pain and the alvine evacuations; and by the constant
suffering. In neuralgia the pain caused by pressure with the finger in
the anus is not confined to one spot, as it is in fissure, but all
portions of the bowel are alike tender. It is true that the morbid
sensibility of the rectum and anus caused by a fissure and that caused
by neuralgia are often so intimately blended that it is sometimes no
easy matter to distinguish between them; nothing but the detection
itself, in some cases, of the fissure, which can always be discovered
by a thorough examination, will clear up the diagnosis.[24]

The symptoms of anal fissure often simulate so closely those of uterine
disease and bladder affections that the surgeon is led astray and
overlooks the real seat and true nature of the malady. Occasionally the
spasmodic condition of the sphincter in these cases simulates the
symptoms of stricture; but a thorough examination will dispel all
uncertainty by revealing the presence of the ulcer.

Frequently uterine trouble or hemorrhoids are found associated with the
fissure, and in this event the case is treated for either one or the
other of the first two complaints, the presence of the other lesion
being unsuspected and consequently neglected. In all such instances a
careful inspection of all the parts concerned will at once remove all
errors in diagnosis and dispel all doubts.

In children, the fact must always be borne in mind that fissures and
other erosions about the anal orifice may be due to the scratching
induced by the irritation of pin-worms.

COURSE AND PROGNOSIS.—Anal fissure is not an immediately dangerous
disease; nor can it be said that it has any tendency toward recovery if
let alone. An indefinite time may elapse without any other change than
the gradual wearing down of the patient's vitality from continued
suffering and nervous strain. With proper treatment, however, this
disease can be promptly cured, and practically without risk, the
operation usually practiced being one of the simplest of surgical
procedures.

-----

Footnote 15:

  _Op. cit._, p. 132.

Footnote 16:

  Bodenhamer, _op. cit._, p. 81.

Footnote 17:

  _Op. cit._, p. 92.

Footnote 18:

  _Op. cit._, p. 187.

Footnote 19:

  "Diseases of the Rectum and Anus," third edition, New York, 1890, p.
  294.

Footnote 20:

  Medical and Surgical Reporter, August 14, 1880.

Footnote 21:

  In some cases of fissure the irritable condition of the sphincter
  will cause such contraction of the anus when an examination is
  attempted that it will be impossible for the surgeon to pass his
  finger into the rectum without etherization of the patient. In these
  instances it is best to advise the patient to submit to such
  operative measures as may be deemed necessary at the same time that
  the examination is made under ether.

Footnote 22:

  Allingham, _op. cit._, p. 212.

Footnote 23:

  _Op. cit._, p. 212.

Footnote 24:

  Bodenhamer, _op. cit._, p. 100.




                              CHAPTER III.

                  TREATMENT, PALLIATIVE AND OPERATIVE.


It is highly important to the success of any plan of treatment directed
toward the cure of anal fissure, that attention be paid to the
condition of the bowels. Regularity of habit should be established, and
the evacuations rendered semi-fluid—as figured or hard stools
generally aggravate the symptoms.

To accomplish these purposes, enemata or mild aperients should be
employed, and the diet must be regulated, the use of bland and
unirritating food being enjoined.

All drastic purges should be avoided, as they are more or less
irritating to the extremity of the rectum.

In order to establish a daily evacuation of the bowels and to render
the movement as painless as possible, I am in the habit of ordering an
enema of warm water, or one of rich flaxseed tea, say from half a pint
to a pint, to be administered every evening; preference being given to
the night-time, as then the patient can assume the recumbent posture,
which, combined with the rest, affords the most relief from subsequent
pain.

If the first enema should prove ineffective, it should be repeated in
half an hour. In order to relieve the pain and spasm of the sphincters
attending the evacuation, it is well to use a suppository about half an
hour before the enema is employed, consisting of:

       ℞       Ext. belladonnæ                   gr. 1/8 ad 1/2.
               Cocain. hydrochloratis            gr. 1/4 ad 1/2.
               Ol. theobromæ                     gr. x.
       Misce,  et fiat suppositoria j.

Or an ointment of extract of conium may be used, as recommended by
Harrison Cripps:[25]

          ℞     Ext. conii                          ℨ ij.
                Olei ricini                         ℨ iij.
                Ung. lanolini            ad         ℥ ij.

A small quantity of this ointment should be smeared on the part five
minutes before expecting a motion, and again after the motion has
passed.

All ointments used in the treatment of rectal disease may be applied by
means of a hard-rubber pipe (Fig. 7).

[Illustration:  Fig. 7—Hard-rubber Ointment-Applicator.]

The various methods of treating anal fissure may be divided, for the
sake of convenience, into the _palliative_ and the _operative_.

PALLIATIVE MEASURES.—Palliative treatment will meet with success in a
considerable proportion of cases, especially when there is no great
hypertrophy of the sphincter muscles. Allingham[26] states that the
curability of this lesion does not depend upon the length of time
during which it has existed, but rather upon the pathological changes
it has wrought. He asserts that he has cured fissures of months'
standing by means of local applications, where the ulcers were
uncomplicated with polypi or hemorrhoids, and where there was not very
marked spasm or thickening of the sphincters.

It is essential to the success of the treatment of fissure, especially
by local applications, that rigid cleanliness of the parts be
maintained; for this purpose the anus and the adjacent portions of the
body should be carefully sponged night and morning and after each stool
with hot or cold water, the temperature being regulated to suit the
patient's comfort.

An excellent instrument for irrigating the rectum is the one devised by
Dr. Edward Martin, of Philadelphia (Fig. 8). I have also employed
Bodenhamer's instrument for this purpose (Fig. 9).

In applying the various local remedies it is necessary first to expose
the ulcer to view, and to anæsthetize its surface with a four-per-cent.
solution of hydrochlorate of cocaine, well brushed in with a
camel's-hair pencil. The application of the cocaine may have to be
repeated once or twice, at intervals of three or four minutes, in order
to obtain the desired anæsthetic effect.

[Illustration:  Fig. 8—Martin's Rectal Irrigator.]

[Illustration:  Fig. 9—Bodenhamer's Irrigator.]

If any ointment has been used about the fissure, the anus should be
subjected to a hot-water douche before using the cocaine, as cocaine
will not exert its anæsthetic influence on a greasy surface.[27] For
this purpose Martin's irrigator (Fig. 8) answers admirably. The parts
should subsequently be dried thoroughly with cotton or a sponge. A
convenient sponge or cotton mop holder is shown in Fig. 10.

[Illustration:  Fig. 10—Rectal Sponge-Mop Holder.]

Among the different remedies that have been used for the local
treatment of fissure of the anus may be mentioned the following:
Nitrate of silver; acid nitrate of mercury; fuming nitric acid;
carbolic acid; sulphate of copper; the actual cautery, etc.

Of these topical applications, the _nitrate of silver_ is the best. Its
effects are various: it lessens or entirely calms the nervous
irritation which is so important a factor in producing spasmodic
contraction of the sphincters; it shields the raw and exposed mucous
surface, by forming an insoluble albuminate of silver; it destroys the
hard and callous edges of the ulcer, and tends to remove the diseased
and morbid action of the parts.

The form in which I usually employ this salt is in solution (from ten
to thirty grains to the ounce). To attain the best results, the
solution should be used once in twenty-four or forty-eight hours,
according to circumstances. It may be applied by means of cotton
attached to a silver applicator or cotton-holder (Fig. 11), or to a
piece of wood. The application is made by separating the margins of the
anal orifice with the thumb and index finger of the left hand, and
introducing into the anus the probe charged with the solution.

[Illustration:  Fig. 11—Cotton-Applicator.]

According to Bodenhamer,[28] if the ulcer is more than one-third of an
inch above the margin of the anus it will be necessary to use the
speculum.

The solution is to be applied to the fissure only; a few drops are all
that will be required. If thorough local anæsthesia has been induced by
the use of cocaine, the application of the silver salt produces little
if any suffering; for by the time the anæsthetic has lost its effect
the acute pain caused by the nitrate of silver will have passed away.

After each application the part should be well smeared with an ointment
of iodoform (thirty grains to the ounce). The odor of the iodoform may
be disguised by the addition of a few drops of otto of roses. Iodol may
be used instead of iodoform, and in the same way.

After the ulcer has been touched once or twice with the silver
solution, the effect will be, in those cases which are benefited by
this treatment, a considerable mitigation of the severe pain which has
troubled the patient when at the closet and afterwards; and the sore
will present a healthy granulating appearance, and slowly contract in
size.

In children and in young persons, unless the fissure be complicated
with some other affection, this lesion is almost always curable by
adopting the foregoing mode of treatment.

Some authorities speak highly of the use of the _acid nitrate of
mercury_, _fuming nitric acid_, _carbolic acid_, _the actual cautery_,
etc., but in my experience their employment is attended with more
suffering than follows the employment of the nitrate of silver or the
simple operative treatment which will presently be described.
Furthermore, the application of these remedies is not so certain to
effect a cure as either of the two procedures just mentioned, so that I
rarely resort to their use.

The daily introduction of a _full-sized bougie_, made of wax or tallow,
will sometimes act beneficially in cases of fissure, by distending the
sphincter and producing such an amount of irritation as will set up a
healing process in the ulcer. An application of cocaine or of
belladonna ointment should be made to the part prior to the employment
of the bougie.

Allingham[29] strongly advocates the local use of the following
ointment:

          ℞     Hydrarg. subchlor                   gr. iv.
                Pulv. opii                          gr. ij.
                Ext. belladonnæ                     gr. ij.
                Ung. sambuci                        ℨ j.
          M.    Sig.: To be applied frequently.

This authority states that he has cured many cases with this ointment
alone.

Another excellent ointment recommended by Mr. Allingham[30] is the
following:

          ℞     Plumbi acetatis } __
                Zinci oxidi     } aa                gr. x.
                Pulv. calaminæ                      gr. xx.
                Adipis benzoatis                    ℥ ss.
          M.

An ointment of red oxide of mercury, thirty grains to the ounce, has
also cured many cases.

The "Brinkerhoff System," as applied to fissures of the anus, is thus
described by Dr. Edmund Andrews:[31]

"Once or twice a month, as the itinerant doctor comes around on his
circuit, he inserts his little speculum, cleans out the ulcer, and
applies to it a solution of nitrate of silver, forty grains to the
ounce. Between the applications the patient uses a morning and evening
treatment himself. Each morning he is to evacuate the bowels, then
inject the rectum with lukewarm water, and finally insert into it a
little ointment, consisting of three grains of carbolic acid and eight
grains of sulphur to the ounce of vaseline or lard.

"For evening treatment he uses 'Brinkerhoff's Ulcer Remedy,' having the
following composition:

          ℞     Extract of hamamelis dist           f ℨ v.
                Solution of persulph. of iron       f ℨ j.
                Cryst. carbolic acid                gr. ij.
                Glycerine                           f ℨ ij.

          M.  Sig.: Add half a teaspoonful of this to the
          same quantity of starch, and about an ounce and
          a half of water. Inject into the rectum every
          evening."

OPERATIVE TREATMENT.—In the more severe cases local treatment will
fail to effect a cure, and operative interference will be necessary.
There are three methods of repute to be considered in this connection:
(1) _forcible dilatation_; (2) _incision_; (3) _a combination of these
two procedures_, dilatation and incision.

FORCIBLE DILATATION.—This is the operation recommended by Récamier,
Van Buren, and others. It consists in introducing the two thumbs into
the bowel, back to back, and then forcibly separating them from each
other until the sides of the bowel can be stretched as far out as the
tuberosities of the ischia. It is essential to place the ball of one
thumb over the fissure, and that of the other directly opposite to it,
in order to prevent the fissure from being torn through and the mucous
membrane being stripped off. As pointed out by Allingham,[32] it is
well to repeat the stretching in other directions until the entire
circumference of the anus has been gone over. In this manner, by
careful and thorough kneading and pulling of the muscles, the
sphincters will be made to give way, and will be rendered soft and
pliable. This procedure should always be done with the patient
thoroughly under the influence of an anæsthetic, and should occupy at
least five or six minutes.

This operation is perfectly safe, but, as it is no less severe than the
operation by incision, and as in some cases it fails to effect a cure,
I can see no advantage in adopting it instead of the more satisfactory
and always successful plan of treatment by combined dilatation and
incision. It may be found preferable in some cases on account of the
prejudice of patients against the use of the knife.

INCISION.—A fissure can be cured by this method, by making an incision
through the base of the ulcer and a little longer than the fissure
itself, so as to make sure of severing all the exposed nerve-filaments.
The cut should divide the muscular fibers along the floor of the ulcer.

In a fair proportion of cases this operation will meet with success,
but it is not so certain and radical as the operation next to be
described.

It has the advantage over the other operations, however, of being
nearly or entirely painless under local anæsthesia produced by cocaine,
and therefore, when general anæsthesia is contra-indicated, or is
refused by the patient, this method is worthy of a trial.

DILATATION AND INCISION.—This operation, if skillfully and carefully
performed, I believe to be a radical and unfailing cure for the
disease. The bowels should be cleared out by a dose of castor-oil and
an injection; after which, under ether-anæsthesia, the sphincters
should be dilated in the manner previously described. This being
accomplished, and the ulcer properly exposed, a straight blunt-pointed
bistoury (Fig. 12) should be drawn deeply across the surface, making a
cut about an inch in length and a third of an inch in depth. Instead of
the blunt bistoury, a sharp-pointed scalpel may be used (Fig. 13). It
should be entered at the margin of the anus, passed under the ulcer,
and made to protrude above the ulcer, the overlying structure being
then divided from without inward.

[Illustration:  Fig. 12—Blunt-pointed Bistoury.]

[Illustration:  Fig. 13—Sharp-pointed Scalpels.]

The subsequent treatment consists in keeping the patient in the
recumbent position, and in the use of a little opium to confine the
bowels. After three or four days a laxative may be given, from which
time daily alvine movements should be secured. In seven or eight days
the patient can begin to move about; but for at least two weeks he
should avoid standing long on the feet. No dressing is required further
than bathing the parts with a little warm water and carbolic acid soap,
to remove any offensive discharges. For the same purpose, peroxide of
hydrogen may be employed.

THE SUBCUTANEOUS DIVISION OF THE SPHINCTERS, as recommended by some
authors for the cure of fissure, is not a satisfactory method, and is
mentioned here solely to condemn it. It is not only uncertain in its
results, but is also painful, and in more than one instance has been
followed by abscesses.

-----

Footnote 25:

  _Op. cit._, p. 189.

Footnote 26:

  _Op. cit._, p. 215.

Footnote 27:

  W. P. Agnew, M.D., "Diagnosis and Treatment of Rectal Diseases,"
  second edition, 1891, p. 97.

Footnote 28:

  _Op. cit._, p. 111.

Footnote 29:

  _Op. cit._, p. 214.

Footnote 30:

  _Op. cit._, p. 215.

Footnote 31:

  _Op. cit._, pp. 75-76.

Footnote 32:

  _Op. cit._, p. 221.

------------------------------------------------------------------------




                        Part 2.—Fistula in Ano.

                  *       *       *       *       *


                               CHAPTER I.

    RELATIVE FREQUENCY—AGE AND SEX AFFECTED—ETIOLOGY—CLASSIFICATION.


FISTULA IN ANO which is not due to ulceration and perforation of the
rectal wall from within is the result of a previous abscess. Such an
abscess forms in the ischio-rectal fossa, and, although opened early by
a free incision even before the cavity becomes distended with pus, it
frequently fails to heal. It may fill up and contract to a certain
extent, but it does not become entirely obliterated; a narrow track
remains, which constitutes the affection designated fistula in ano.

There are several reasons why rectal abscesses so frequently degenerate
into fistulæ. One is, that, owing to an internal opening within the
bowel, small particles of fecal matter find their way into the sinus,
and, acting as foreign bodies, prevent the healing; another, that,
owing to the frequent movement of the parts by the sphincter muscles,
sufficient rest is not obtained for the completion of the reparative
process; and, finally, the vessels near the rectum are not well
supported, and the veins have no valves, hence there is a tendency to
stasis, which is unfavorable to rapid granulation.

According to the authority of Mr. Harrison Cripps,[33] if the fistula
be divided its surface will be seen to be lined with a smooth,
gelatinous membrane, which when examined under the microscope is found
to consist of granulation-tissue exactly analogous to that which lines
the interior of a chronic abscess. The leucocytes constituting the
outer wall of this membrane are but loosely adherent, and constantly
becoming free they form the chief part of the pus which drains from the
fistula.

RELATIVE FREQUENCY OF THIS AFFECTION.—In point of frequency, compared
with other rectal diseases, fistula is next to hemorrhoids. This
statement is contrary to the showing made by the published statistics
of St. Mark's Hospital, as quoted by Allingham.[34] This table shows
that out of four thousand cases taken consecutively from the
out-patient department of the hospital there were one thousand and
fifty-seven persons suffering from fistula and one hundred and
ninety-six from abscess, of which latter number one hundred and
fifty-one subsequently became fistulæ, so that more than one-fourth of
the whole number of cases treated were fistulæ. Allingham also states
that a recent examination of the records of the in-patients of the same
institution, covering a period of several years, shows that two-thirds
of those operated upon were cases of fistula.

Mr. Allingham[35] justly calls attention to one source of error in
drawing conclusions from statistics—namely, the fact that many
patients suffer from more than one malady. He states that it constantly
happens that a fistula is found in connection with hemorrhoids, either
as the substantive disease or as a complication. Again, a fissure or
circular ulcer often has a sinus running from it, so that it may fairly
be considered as the opening of an internal fistula, and the case
called a fistula; or the sinus is not detected, and the case is called
ulcer or fissure.

Another fallacious element in the statistics of Mr. Allingham, which
should not be overlooked, is pointed out by Mr. Chas. B. Ball.[36] St.
Mark's has a special reputation for the cure of fistula, so that many
persons suffering from this disease go there, and in this way the
records show an apparent greater frequency of fistula. Mr. Ball also
states[37] that at the Dublin General Hospital, although fistula is
common, it is by no means the commonest of rectal diseases; and in his
own practice this affection has not furnished more than one-sixth of
rectal operative cases.

AGE AND SEX AFFECTED.—This disease is commonly met with during middle
age, but it is by no means restricted to that period of life. Allingham
states[38] that he has operated upon an infant in arms, and upon a man
over eighty years old. Dr. Henry R. Wharton[39] mentions having seen a
number of cases at the Children's Hospital, Philadelphia, among which
he records one of complete fistula in a child a few months old.

CAUSES.—Fistula in ano may originate in ulceration and perforation of
the mucous membrane of the bowel—the result of the irritation produced
by fecal accumulations (arising from any cause, such as atony of the
intestines, irregularity of habits, rectal stricture, etc.), or by
foreign bodies, such as fish- or rabbit-bones, grape- or fig-seeds,
etc.; more frequently it owes its origin to an abscess caused by
injuries, such as blows or kicks upon the anus, or by exposure to cold,
as from sitting upon damp seats—especially after exercise, when the
parts are hot and perspiring; it may also arise from excessive
irritation of the rectum occasioned by the presence of any of the forms
of parasites which infest the anus and its immediate neighborhood.
Other predisposing causes are thrombosed veins and suppurating
hemorrhoids. Abscess, and then fistula, may likewise supervene in
fevers and certain depressed conditions of the blood, such as
frequently give rise to boils or carbuncles.[40]

"The late Dr. W. E. Horner, Professor of Anatomy in the University of
Pennsylvania, used to describe an arrangement of pouches opening
upward, in the mucous membrane of the rectum, by which the entanglement
of seeds, bits of bone, etc., contained in the feces was favored. His
account may be found in his 'Special Anatomy and Histology,' vol. ii,
p. 46 (edition of 1851), where he quotes a paper on Fistula in Ano, by
Ribes. He says, also, that Glisson and Ruysch had described them as
valves, and that Winslow was acquainted with them. The latter author
(Douglas's Transl., 1743, vol. ii, p. 149) says, 'They form little bags
or semilunar lacunæ.' Another American writer, Bushe ('Malformations,
Diseases, and Injuries of the Rectum and Anus,' 1837, p. 15), speaks of
these pouches, and confirms Winslow's description. They are also
mentioned in the treatises of Leidy and S. G. Morton. Hyrtl (Handb. der
Topogr. Anatomie, 1871, bd. ii, p. 142) describes them quite fully, and
speaks of their agency in the development of fistulæ.

"Mr. W. T. Clegg, of Liverpool, says (Lancet, Feb. 5, 1881) that Mr.
Bickersteth has for four years been describing these anal pouches,
which 'are not mentioned in any of the books he has consulted.'

"It is certainly strange that this arrangement, so clearly pointed out,
should have been passed over in silence, not only by many anatomists,
but by late writers on rectal surgery; yet it is undoubtedly a frequent
cause of fistula. In Fig. 14 these pouches are shown, with a fistula,
probably formed by a foreign body lodging in one of them. Over the
fistula the mucous membrane has been removed, and a bougie has been
passed through the canal."[41]

[Illustration:  Fig. 14—Section of the Rectum, showing the
rectal pouches, and a fistula with a bougie passed through it,
the mucous membrane dissected off. At _a_ is a small external pile, cut
in half.—St. George's Hospital Museum, ser. ix, No. 42 (Holmes, Princ.
and Pract. of Surgery, vol. ii, p. 643).]

Finally, a tubercular or strumous diathesis seems to be as potent a
factor in the causation of fistula as it is in other suppurative
troubles. The appearance of a fistula in a tubercular subject is
characteristic of the constitutional malady. It is thus described by
Messrs. Alfred Cooper and F. Swinford Edwards:[42] "The part is, as a
rule, unusually hirsute; the ischio-rectal fossæ are drawn in, owing to
absence of fat; the sphincter is weak and offers no resistance to the
introduction of the finger. The skin around the orifice is bluish and
often considerably undermined, and the discharge is thin and watery.
The internal orifice is often large, and the mucous membrane around it
is also undermined."

The tendency to the occurrence of abscess and fistula in phthisical
patients has long been recognized, and has given rise to some doubts as
to the propriety of resorting to operative measures in such cases. This
point will be considered in the chapter on Treatment. According to
Messrs. Cooper and Edwards,[43] about five per cent. of phthisical
subjects also suffer from fistula, and about twelve per cent. of
fistulous patients are the subjects of tuberculosis.

VARIETIES.—For all practical purposes we may divide fistulæ into the
following four forms: (1) the _complete_ fistula, in which there are
two openings, one in the rectum and one on the skin more or less remote
from the anus (Fig. 15); (2) the _incomplete internal_ fistula, in
which there is a communication with the cavity of the rectum by means
of an opening in the mucous membrane, but none with the external
surface of the body (Fig. 16); (3) the _incomplete external_ fistula,
in which there is an external opening through the skin, but no
communication with the bowel (Fig. 17); and (4) the _complex_ fistula,
in which there are many sinuses and numerous external openings (Figs.
18 and 19). Some of these tracks run outward; some extend up the bowel
beneath the mucous membrane; whilst others travel round the bowel and
open in the other buttock, giving rise to the so-called _horseshoe_
fistula. The second and third varieties named are often spoken of as
_blind_ fistulæ.

[Illustration:  Fig. 15—Complete Fistula traversed by Probe (Esmarch).]

[Illustration:  Fig. 16—Internal Incomplete Fistula (Esmarch).]

[Illustration:  Fig. 17—External Incomplete Fistula (Esmarch).]

[Illustrations]

                 FISTULÆ WITH DOUBLE TRACKS (MOLLIÉRE).

       Fig. 18—A, B, deep submuscular track resulting from an
      ischio-rectal abscess; A, I, submucous track running up
      and down the bowel.

       Fig. 19—D, E, subtegumentary and submucous fistula with
      internal and external opening; D, F, deep submuscular
      track, having same internal but separate external opening.

-----

Footnote 33:

  _Op. cit._, p. 152.

Footnote 34:

  _Op. cit._, p. 13.

Footnote 35:

  _Op. cit._, p. 13.

Footnote 36:

  _Op. cit._, p. 66.

Footnote 37:

  _Op. cit._, p. 67.

Footnote 38:

  _Op. cit._, p. 13.

Footnote 39:

  Keating's "Cyclopædia of the Diseases of Children," vol. iii, p. 341.

Footnote 40:

  Allingham, _op. cit._, p. 14.

Footnote 41:

  Article on Diseases of the Rectum, by Henry Smith, Esq., revised by
  John H. Packard, M.D., in Holmes' "System of Surgery" (Packard,
  editor of American edition), vol. ii, pp. 643-644.

Footnote 42:

  "Diseases of the Rectum and Anus," second edition, London, 1892, p.
  126.

Footnote 43:

  _Op. cit._, p. 126.




                              CHAPTER II.

        SYMPTOMATOLOGY—PHYSICAL EXPLORATION—DIAGNOSIS—PROGNOSIS.


SYMPTOMS.—The symptoms of fistula are not easily overlooked.
Occasionally there is considerable pain present, but more frequently
only a feeling of uneasiness about the anus is experienced. When a
fistula originates, as I believe it most commonly does, from a
preëxisting abscess, there is a sensation of weight about the anus,
with swelling of the integument, considerable tenderness upon pressure,
pain in defecation, and a constitutional disturbance associated with
rigors. These symptoms are relieved after the matter is discharged. The
exploring needle (Fig. 20) is often useful in determining the presence
of pus in such abscesses in which it is impossible to obtain
fluctuation. In complete fistula in ano, and in the incomplete internal
variety, the evacuations are streaked or covered with pus and mucus,
perhaps also slightly tinged with blood.

[Illustration:  Fig. 20—Small Trocar and Acupuncture or Exploring
Needle (for testing the character of ambiguous swellings or fluid
collections about the rectum).]

The chief discomfort to a patient with fistula is the discharge, in
greater or less quantity, of purulent or muco-purulent matter which is
kept up from the sinus so long as it remains unhealed, soiling the
linen and making it wet and uncomfortable, and producing an excoriation
of the nates. The discharge is not of itself sufficient to be a source
of great exhaustion, and does not interfere with ordinary occupations,
so that many patients have had fistula for a considerable length of
time without being conscious of any serious ailment. The escape of
flatus and mucus from the bowel in complete fistula will often prove a
source of annoyance, as will also the passage of feculent matter which
will be expelled through the sinus should the fistulous channel be very
free.

An attack of secondary suppuration is always liable to complicate the
presence of a fistula, and is usually due to a stoppage of the track by
small particles of feces or by exuberant growth of the granulations.
Such a sequela, of course, is attended with pain, until a new opening
forms or one is made by the surgeon. In some cases the original
fistulous track becomes reëstablished. Fistula in some persons,
particularly those of a nervous temperament, produces an impression of
physical imperfection and weakness in their organization, which renders
them miserable. As in other affections of the rectum, various reflex or
sympathetic pains are experienced in cases of fistula; they are
referred to the back, to the loins, and to the bottom of the abdomen.
When such pains extend down the leg and to the foot, they are likely to
be attributed to sciatica unless the history of the case is carefully
studied and a critical examination made.

OCULAR AND DIGITAL EXAMINATION.—Immediately before an examination is
made in cases of fistula, as well as in all other investigations
connected with the diagnosis of rectal diseases, the bowels should be
emptied by an enema. This procedure not only renders the exploration of
the parts easier and cleaner, but also, in women especially, serves to
quiet the patient's fears of any untoward accident occurring, and
therefore facilitates the thoroughness of the surgeon's examination by
securing the coöperation of the patient, as in extruding the parts, etc.

In order to examine a patient with supposed fistula, he should be
placed in a recumbent position on a table or an examining-chair,
preferably on the side on which the external opening is situated, with
the legs well drawn up toward the abdomen, and the buttocks brought to
the edge of the couch.

[Illustration:  Fig. 21—Silver Probe attached to handle.]

The anus and the surrounding parts should be carefully examined to
detect any apparent lesion. If the external orifice of the sinus is
prominent, or if there is a sentinel granulation present, the outlet of
the fistula will be obvious; but when it is small and located between
folds of the skin, its situation may be demonstrated by making pressure
with the top of the finger in the suspected locality, which will
usually cause a little drop of matter to exude. The site of a fistula
may often be detected by feeling gently all around the anus with the
forefinger and finding an induration which feels like a pipe-stem
beneath the skin. A flexible silver probe (Fig. 21) should now be
passed along the fistulous track. In doing this, considerable care is
requisite, and the utmost gentleness should be observed, bearing in
mind that the probe is to be directed by its own weight through the
sinus, and not by force applied by the hand of the surgeon. If it does
not pass easily, bend it and see if it cannot be coaxed along the
channel. In many cases it will pass directly into the bowel. When the
probe has been passed as far as it will go without the use of any
force, introduce the finger gently into the rectum. This should be
subsequent to the passage of the probe, as otherwise the introduction
of the finger into the bowel will set up a spasm of the sphincter
muscles, which will greatly interfere with the passage of the probe.
When the finger is in the bowel it will frequently come in contact with
the probe, which fact demonstrates the presence of a complete fistulous
track; in other cases the mucous membrane is felt to intervene between
the digit and the probe. In such cases the internal opening generally
exists, but is difficult to discover,—sometimes because the examiner
searches for it too high in the bowel. Palpation with the sensitive tip
of the finger will often render the presence of the inner orifice
obvious, by coming in contact with an indurated mass of tissue. If such
a spot be felt, the finger should be placed upon it and the probe
passed toward the finger. Make sure that the fistula is a complete one,
by feeling the probe touch the finger. There may not be an internal
opening; if not, see how near the probe comes to the surface of the
bowel.

[Illustration:  Fig. 22—Pratt's Speculum.]

If a doubt still exists as to the completeness of the track, one of a
variety of specula (Figs. 22, 23, 24) may be introduced into the
rectum, and the outer orifice of the sinus injected with either milk or
a solution of iodine, when if there be an internal opening the
appearance of the colored fluid within the bowel will set the question
at rest.

If the inner opening be not discovered by these methods, the case must
be looked upon as one of external rectal fistula.

[Illustration:  Fig. 23—O'Neil's Speculum.]

[Illustration:  Fig. 24—Kelsey's Rectal Retractor.]

According to Ball,[44] in cases where the probe passes away from the
rectum and is directed along the anal fascia to the upper portion of
the ischio-rectal fossa, or where the entire substance of the rectal
wall separates the finger and the probe, the case is one either of
external rectal sinus, or of fistula originating in the superior
pelvi-rectal space. In such cases, Mr. Ball states, "we must go farther
and try and find the cause, such as diseased bone, etc.; and in the
female a vaginal examination may show us a uterine or ovarian origin.
Where there are numerous external openings it is necessary to carefully
probe all of them, so as to determine whether they are all connected,
and the direction which they take. The upper limit of the separation of
the mucous membrane should also be made out, and search should be made
for the presence of more than one internal orifice, if such is likely
to be present."

The presence of incomplete internal rectal fistula is more difficult to
determine than the other varieties of this lesion which have just been
considered. It is the most painful form, but, fortunately, it is of
infrequent occurrence. Its orifice may be located anywhere in the
rectum, but is generally found between the internal and external
sphincters. According to Allingham,[45] the circumference of this
opening is often as large as an English threepenny piece, its edges
being sometimes indurated, at other times undermined. The feces, when
liquid, pass into the sinus and create great suffering—a burning pain
often lasting all day after the bowels have acted.

In this variety of fistula the feces are coated more or less with pus
or blood, and a boggy swelling is noted at some portion of the
circumference of the anus. A peculiar feature of this swelling is often
noted—viz., its presence one day and its disappearance in a day or
two, followed by an increased discharge of pus from the bowel. This
fact is explainable by the closure of the outlet of the fistula, caused
either by a plug of feces or as a result of inflammatory swelling,
which allows the collection of a quantity of pus and the consequent
formation of a boggy tumor. The swelling disappears upon the
reëstablishment of the communication between the bowel and the sinus,
and is attended by the profuse discharge of matter previously
mentioned. This phenomenon is repeated over and over again, and
indicates the nature of the disease.

In other cases of blind internal fistula, if the orifice can be felt,
or if it can be seen through a speculum, a bent probe may be introduced
into it and made to protrude near to the cutaneous surface of the body,
where its point can be felt.

DIAGNOSIS.—The method of diagnosing fistula has already been
sufficiently detailed. A few words, however, as to differential
diagnosis may prove useful. Fistulæ frequently coexist with other
rectal diseases; it is therefore important that an examination should
be carefully made, so as to exclude such lesions—for instance, the
presence of stricture, malignant disease, hemorrhoids and other tumors,
etc. A thorough physical examination of the chest should also be made,
to ascertain the presence or absence of phthisis, which so frequently
complicates fistula in ano. Serious kidney disease should be excluded
before recommending operation, for obvious reasons. In cases of caries
of the vertebræ, of the sacrum, or of the pelvis, fistulous tracks may
form and simulate anal fistula. In such instances a careful
investigation will reveal the true origin of the trouble, and will show
that the case is not one of ordinary fistula in ano.

COURSE AND PROGNOSIS.—This disease untreated has a tendency to
increase. The longer its duration the more tortuous and complicated
does it become. Hence the earlier the patient submits to treatment the
more favorable will be the prognosis, and the time and extent of the
treatment necessary to effect a permanent cure will be correspondingly
diminished.

-----

Footnote 44:

  _Op. cit._, p. 77.

Footnote 45:

  _Op. cit._, p. 21.




                              CHAPTER III.

              THE PALLIATIVE TREATMENT OF FISTULA IN ANO.


TREATMENT OF ABSCESS.—Preliminary to a consideration of the treatment
for the disease when the fistulous track has been formed, some
attention must be devoted to the importance of dealing promptly with
the inflammatory and suppurative process which leads to abscess, and
which usually forms the first stage of the affection known as fistula
in ano.

When a patient presents the symptoms of a threatened abscess in the
vicinity of the rectum, he should be directed to go to bed, or at least
to avoid all undue exercise; the bowels should be thoroughly evacuated,
preferably by the use of a saline cathartic; the diet should be
nutritious; and, if the case be seen early, hot fomentations and
poultices may be applied to the parts. The early adoption of these
measures may abort the threatened abscess.

If, however, there be reason to suspect that matter has formed or is
forming, it will be advisable to make a free incision into the center
of the affected site with a sharp curved bistoury, if the trouble is
superficial, or, if it is deep, with a narrow straight knife. When pus
is present and is deeply seated, the evacuation of the abscess will be
aided by the introduction of the forefinger into the bowel, by which
means the swelling may be pushed forward, rendered tense, and hence
made more apparent.

In opening these abscesses, if possible, ether should be given. The
patient should lie on the side on which the threatened abscess is
situated; the upper leg should be bent forward upon the abdomen. When
pus is present, the operator should stand out of the line of its exit,
for when the cavity is opened it often squirts out a considerable
distance. After the matter has been discharged, the forefinger should
be introduced into the abscess-cavity for the purpose of breaking down
any secondary cavities or loculi that may exist. When this has been
accomplished, the abscess should be thoroughly washed out with peroxide
of hydrogen (Marchand's, undiluted, or some other reliable
preparation), after which a rubber drainage-tube should be inserted, or
a piece of iodoform gauze should be lightly placed between the lips of
the incision, to prevent its closing too rapidly, and also to allow
free drainage. Careful daily attention should be paid to the wound
while the cavity of the abscess is contracting, as it is important to
maintain a free and dependent outlet for the matter which continues to
be secreted; but stuffing and distention of the cavity should be
avoided. If a drainage-tube be used, it should be shortened from day to
day as the wall of the abscess contracts.

After an operation for rectal abscess, the patient should be kept quiet
for several days; and if great care be taken, both with the subsequent
drainage and in keeping the orifice open, the part may heal without the
formation of a fistula.

TREATMENT OF FISTULA IN ANO.—The treatment of fistula, like that of
fissure, may be either _palliative_ or _operative_.

PALLIATIVE TREATMENT.—This method of treatment will be required in
cases where there is a positive refusal on the part of the patient to
submit to an operation, and in persons whose constitutions are broken
down by disease and in whom the reparative powers of the body are not
equal to the task of restoring it to health. Chronic alcoholism,
albuminuria, diabetes, malignant diseases, etc., are conditions in
which operative procedures are attended with risk, and in which
palliative measures should be tried. Phthisis is not an absolute
contra-indication to operative measures. The rule which I observe is to
operate in those cases of tubercular subjects in which the disease is
quiescent, but to avoid such interference if the lung-mischief is at
all active.

Incomplete external fistulæ, and even complete fistulæ of somewhat
recent origin and not extensively indurated, may be cured by
non-operative measures; but such treatment requires constant attention
on the part of the practitioner, as well as a willingness on the part
of the patient to give sufficient time to the treatment. Even under
such circumstances the process of repair is slow, and in many cases the
result will not be perfectly satisfactory. It is true that fistulæ
sometimes recover spontaneously, or are cured by simple means, such as
the mere passage of a probe used in examining the fistulous track, but
instances of this kind are rare.

In certain selected cases of fistulæ I am in the habit of endeavoring
to effect a cure by stimulating the sinus and allowing free drainage of
the secretions, so as to avoid the use of the knife. To accomplish
satisfactory results with this mode of treatment, the following
indications should be borne in mind: 1, that the external orifice be
perfectly free; 2, that the sinus be kept clean, so as to prevent
putrefactive changes; 3, that an effort be made to excite a healthy
action in the fistulous channel; and 4, that the parts be kept as quiet
as possible.

To meet the first indication, it is necessary to dilate the outer
opening of the fistula with sponge or sea-tangle tents: but better
still for this purpose are the Lee's Antiseptic Slippery-Elm Tents
(Fig. 25).[46] These are made of selected slippery-elm bark, and
compressed under high pressure. Owing to their non-irritant and
demulcent properties, I find them superior to other tents.

[Illustration:  Fig. 25—Slippery-Elm Tent (large size).]

The second indication (that the sinus be kept clean, so as to prevent
putrefactive changes) is best carried out by the use of peroxide of
hydrogen. I have cured some cases of fistula in ano by means of
injections into the sinus of peroxide of hydrogen alone, being careful
to keep the external opening free, and treating the patient daily until
healing occurred. I am in the habit of using Marchand's preparation,
undiluted. It is injected into the sinus by means of a long, flexible
silver canula (Fig. 26) attached to a hypodermatic syringe.

[Illustration:  Fig. 26—Flexible Silver Canula.]

Other antiseptics may be employed for the same purpose, such as
bichloride of mercury (1 to 2000), or carbolic acid (1 to 80), but I
much prefer the peroxide of hydrogen.

The third indication (to excite a healthy action in the sinus) can be
met in one of a number of ways. In the first place, before applying
such remedies it will be well to obtund the sensibility of the channel
by an injection into the sinus of a four-per-cent. solution of cocaine.
This may be accomplished by using the same syringe and canula that are
used for cleansing the fistula.

If the wall of the sinus is somewhat indurated, it is better to insert
a small, flexible curette (Fig. 27) and scrape the wall of the fistula
along its entire length. The sinus is now prepared for some one of the
various stimulating substances which have been recommended for this
purpose. Among these may be mentioned peroxide of hydrogen; nitrate of
silver, fused, or in solution (thirty to sixty grains to the ounce);
sulphate of copper in solution (ten grains to the ounce); carbolic acid
mixed with equal parts of glycerine and water.

[Illustration:  Fig. 27—Flexible Curette.]

These substances may be applied to the fistulous track by means of
cotton attached to a silver probe or to an applicator (Fig. 11, p. 26);
or they may be injected into the sinus by means of the syringe and
silver canula (Fig. 26, p. 57).

If the fistula is a complete one and the substance used be applied as
an injection, the finger should be passed into the rectum and made to
cover the internal orifice of the sinus, so as to prevent the escape of
any of the fluid into the bowel.

Regarding the fourth point (keeping the parts at rest), the patient,
whilst under treatment, should be confined to the horizontal position,
either in bed or on a sofa. Congestion of the parts is thereby
lessened. A firm pad placed over the anus and well supported by a
T-bandage is useful in limiting the motions of the anus due to the
alternate contraction and relaxation of the levator ani muscle.

The chance of success in the palliative treatment of fistula in ano
will be greatly increased if due attention be paid to the general state
of health of the patient, and when circumstances render it possible he
should be advised to seek the benefits of a change of air.

-----

Footnote 46:

  Made by J. Elwood Lee Co., Conshohocken, Pa.

                              CHAPTER IV.

               THE OPERATIVE TREATMENT OF FISTULA IN ANO.


IN all cases of fistula in ano, before undertaking operative
interference it is essential for the surgeon to examine the patient
carefully, not only locally, but also as to the general state of
health; for this disease is not infrequently complicated with other
lesions—as has been previously mentioned—which may render operative
procedures inadvisable.

Thus, when a fistula is associated with a stricture of the rectum of a
malignant nature, any operative interference on the former lesion will
be out of the question. If it is a simple stricture and its existence
be not recognized, or if it be left untreated, any operation performed
on the fistula will fail to effect a cure.

TREATMENT BY INCISION.—In a large majority of cases of fistula in ano,
the operation which is sanctioned by experience as the most prompt and
certain at the same time that it is the safest in its results is to lay
open the sinus into the rectum, dividing with the knife all the tissues
intervening between its cavity and that of the bowel. Figs. 28, 29, 30
and 31 represent useful forms of knives for incising a fistula.

The preparation of the patient consists in having the bowels moved by
means of castor oil or some other mild cathartic on the day preceding
the operation, and on the morning of the operation the lower bowel
should be evacuated by means of an enema.

[Illustration:  Fig. 28—Blunt-pointed Knife.]

[Illustration:  Fig. 29—Curved Knife, useful in certain fistulous
cases.]

[Illustration:  Fig. 30—Gowlland's Bistouries.]

[Illustration:  Fig. 31—Kelsey's Fistula-Knife.]

After etherization the patient should be placed on the side on which
the fistula exists, the buttock being brought to the edge of the
operating-table. Occasionally the lithotomy posture is preferable, as
in cases in which there is a complex fistula.

The first step in the operation is to dilate the sphincter muscles,
which is to be done in a slow but steady manner by introducing the
thumbs into the rectum, back to back, and making gradual pressure
around the anal orifice until muscular contraction is overcome.

[Illustration:  Fig. 32—Probe-pointed Director.]

[Illustration:  Fig. 33—Kelsey's Fistula-Director.]

In dealing with COMPLETE FISTULÆ a flexible probe-pointed director
(Figs. 32, 33) is passed through the sinus, and is then brought out of
the anus by means of the forefinger of the left hand introduced into
the bowel. The tissues lying upon the director are then to be divided
with a sharp bistoury. A careful search is now to be made for any
diverticula, which if found should be divided. If none exist, the
granulations lining the track should be scraped away with a Volkmann's
spoon (Fig. 34). The healing process will be facilitated by removing
with scissors all overtopping edges of skin and mucous membrane.

[Illustration:  Fig. 34—Volkmann's Spoon.]

If the internal opening is more than an inch from the anus, a
probe-pointed bistoury (Figs. 28, 30, p. 61) should be introduced into
the fistula upon a director, and its point made to impinge upon a
finger in the rectum. As the finger and the instrument are withdrawn,
the necessary incision is made. Or the director can be passed through
the sinus, and a wooden gorget (Fig. 35) inserted into the bowel, after
which the track can be divided with an ordinary bistoury. The gorget
prevents the opposite side of the bowel from being injured should the
knife slip. (Fig. 36).

[Illustration:  Fig. 35—Gorget.]

[Illustration:  Fig. 36—Operation for Fistula with Gorget (Bernard and
Huette).]

When the track of the fistula is much indurated, and considerable force
is therefore required to make the incision, it will be better to
perform the operation by means of Mr. Allingham's spring-scissors and
special director (Fig. 37). With this instrument, fistulæ running high
up in the bowel may be divided, no matter how dense they may be. The
director is made with a deep groove, the transverse section of which is
more than three-quarters of a circle; in this the globe-shaped
probe-point of one blade of the scissors runs. When placed in the
groove the blade cannot slip out; so, the director having been passed
through the sinus, the forefinger of the left hand is introduced into
the bowel, and then the probe-pointed blade of the scissors is inserted
into the groove of the instrument, and run along it, cutting its way
through the diseased tissue as it goes, the finger in the bowel
preventing the healthy structure from being wounded.

[Illustration:  Fig. 37—Allingham's Spring-Scissors and Director.]

A frequent error in operating on fistulous cases consists in not
keeping to the sinus, the director being pushed through the track-wall,
and then being free to roam about in the cellular tissue of the part,
at the operator's will. In this manner a portion of the fistulous
channel is left, and an unnecessary amount of the tissues (skin and
subcutaneous structures) is divided. Such a mistake can always be
avoided by taking plenty of time in performing the operation, and by
careful sponging of the sinus as it is laid open, in order to follow
the track of the granulation-tissue lining it, which by this simple
means is freely exposed to view.

The method of treating EXTERNAL RECTAL FISTULÆ must vary according to
the direction and extent of the track. If the mucous membrane alone
intervenes between the finger introduced into the bowel and a probe
passed along the sinus, the channel should be transformed into a
complete fistula by perforating the mucous membrane with the probe, or
with a director, at the uppermost limits of the fistulous channel. The
regular operation for complete fistula is then to be performed by
dividing the intervening septum between the fistula and the bowel.

In cases in which the sinus is directed away from the rectum, the
proper course is not to divide the sphincters, but freely to enlarge
the external orifice and to maintain free drainage.

The treatment of INCOMPLETE INTERNAL RECTAL FISTULÆ invariably demands
operative interference at the earliest possible moment after a
diagnosis is made; for if left alone its tendency is to burrow.

The operation for a blind internal fistula consists in making it a
complete fistula and in dividing the intervening structures between the
bowel and the sinus. This is best performed by introducing a
probe-pointed director, bent at an acute angle, into the bowel, and
passing the bent portion through the internal opening. This done, the
point of the probe can be felt subcutaneously and cut down upon, and
the remainder of the operation completed.

In dealing with COMPLEX FISTULÆ the surgeon must be guided by the
peculiarities of each case. In operating upon a horseshoe fistula it is
essential to recognize the true condition of affairs; for a careless or
an inexperienced observer might think that he had two separate fistulæ
to deal with, and operate accordingly. Even were he to recognize that
he was dealing with a horseshoe fistula, if he followed the usual plan
he would slit up first one sinus and then the other, dividing the
sphincter in two places obliquely through its fibers, thus endangering
the patient's future power of controlling the movements of the bowel.
(Fig. 38.)

[Illustration: Fig. 38.—Diagram showing wrong method of operating in
horseshoe fistula.]

[Illustration: Fig. 39.—Diagram showing the method recommended in
operating upon horseshoe fistula.]

According to Messrs. Cooper and Edwards,[47] "If this fistula can be
laid open in such a way as to entail only one division of the
sphincter, and that at right angles to its fibers, there will be a
minimum amount of risk of subsequent incontinence." The operation can
be done in this way (Figs. 39, 41, 43). First pass a probe-pointed
director through the internal aperture, and on its point incise the
skin in the middle line behind; now push the director through, and slit
up. Secondly, slit up the lateral sinuses on directors passed in at the
external openings and brought out at the dorsal incision. These lateral
sinuses may take a straight, a curved, or even a rectangular direction.
Fistulæ taking these different courses are illustrated in Figs. 40 and
42.

[Illustration: Fig. 40—A diagram of one variety of horseshoe fistula.]

[Illustration: Fig. 41—Diagram of incisions necessary.]

"The first incision will have divided the sphincter, but the other two
will only have divided tissue external to it. Should the external
apertures be so placed that a straight line drawn from the one to the
other would pass behind the anus (Fig. 40), the steps of the operation
could be reversed, and a director be passed in at one external orifice
and out at the other, and the tissues divided. Now pass the director
from the wound in the middle line into the bowel, through the internal
opening, and slit up the tissue with the included sphincter. In this
way the incisions will be found to be more or less T-shaped, the stem
corresponding to the dorsal cut."

[Illustration:  Fig. 42—A diagram of severe horseshoe fistula, with
five external openings.]

[Illustration:  Fig. 43—Diagram showing incisions necessary for the
cure of foregoing with one division of sphincter.]

TREATMENT OF HEMORRHAGE.—There is seldom much hemorrhage after an
operation for fistula, but in some cases it may be necessary to ligate
a large vessel which has been divided. If there should be a profuse
general oozing, the sinus may be packed with iodoform gauze, or, if
necessary, the rectum may be plugged; for this purpose Allingham ties a
double string into the center of a large bell-shaped sponge, which is
passed into the bowel so as to prevent the blood from escaping upward
into the colon. He then firmly packs the parts below with cotton dusted
with powdered alum or persulphate of iron. In order to allow the escape
of flatus, a catheter may be passed through the sponge. As a rule, all
hemorrhages following rectal operations are easily controlled by mild
measures, such as the local application of hot water, of ice, or of
some mild astringent.

THE AFTER-TREATMENT.—After the operation for fistula in ano, the wound
should be packed with iodoform gauze, which is left undisturbed for
twenty-four hours. This is done to prevent subsequent hemorrhage. A pad
of gauze and cotton and a T-bandage are next applied.

The subsequent dressing of the case should be daily attended to by the
surgeon himself. The parts should be kept perfectly clean, and the
wound syringed with peroxide of hydrogen, carbolic acid solution, etc.,
after which a single piece of iodoform gauze laid between the cut
surfaces of the wound will be all the dressing required.

In the after-treatment of these cases I have seen the healing process
greatly retarded by excessive packing of the wound with the lint, or
delayed by the undue use of the probe. Such interference is to be
avoided.

If the granulations are sluggish, and the discharge is thin and serous,
it will be well to apply some stimulating lotion, such as peroxide of
hydrogen or a weak solution of copper sulphate (two grains to the
ounce).

The surgeon should be on the watch during the healing process to avoid
any burrowing or the formation of fresh sinuses. Should the discharge
from the surface of the wound suddenly become excessive, it is evidence
that a sinus has formed, and a careful search should be made for it.
Sometimes it begins under the edges of the wound, at other times at the
upper or lower ends of the cut surface, and occasionally it seems to
branch off from the base of the main fistula.

Pain in or near the seat of the healing fistula is another symptom of
burrowing, and when complained of the surgeon should carefully
investigate its cause.

After an operation for fistula, the patient's bowels should be confined
for three or four days, for which purpose opium is usually given. At
the end of this time the bowels may be opened by the administration of
a dose of castor-oil, and so soon as the patient feels a desire to go
to stool an enema of warm water should be injected, which will tend to
render the feces soft and fluid and hence make their passage easier.
The patient should be kept in a recumbent posture until the fistula is
healed; and until the bowels are moved the diet should be liquid—such
as milk, beef-tea, and broths. The time required for a patient to
recover after an operation for fistula in ano varies with the extent of
the disease. In an average case it will be necessary to keep the
patient in bed for two or three weeks, and confined to the house for a
couple of weeks longer.

[Illustration:  Fig. 44—Set of three Cautery Irons to fit one handle.]

[Illustration:  Fig. 45—Paquelin's Thermo-Cautery.]

INCONTINENCE OF FECES is an unpleasant sequela to the operation for
fistula. It is, happily, of rare occurrence, and follows only extensive
operations, such as those in which the sphincter has been divided more
than once, etc. When it exists to any extent it is productive of great
annoyance to the patient, possibly more so than the original fistula.
The application of the old-fashioned cautery-iron (Fig. 44), heated to
the proper degree, or the small point of Paquelin's thermo-cautery
(Fig. 45), applied to the cicatrix of the operation wound, will often
suffice to relieve this trouble, by causing contraction of the anal
outlet and giving tone and increased power to the sphincter muscle.

Mr. H. W. Allingham, Jr.,[48] recommends for this condition freeing the
ends of the muscle by a deep incision through the old cicatrix and
allowing the wound once more to heal from the bottom by granulation.

Dr. Chas. B. Kelsey[49] advocates in these cases the complete excision
of such a cicatrix, exposing freely the divided ends of the sphincter
and bringing them together by deep sutures, exactly as in cases of
lacerated perineum.

In dealing with a fistula situated anteriorly in a female subject,
Messrs. Cooper and Edwards[50] recommend that after a free division of
the sinus the track be scraped thoroughly with a Volkmann's spoon, and
then deep sutures inserted as in the case of rupture of the perineum,
in the hope by this means of getting union by first intention.

TREATMENT BY IMMEDIATE SUTURE.—In otherwise healthy subjects, affected
with fistula in ano, a method of operating which has met with success,
especially in this country, consists in the immediate suture of the
wound after the fistula has been excised. The steps of the operation
are as follows. The septum between the fistula and the bowel is
divided; the entire fistulous channel, and all lateral sinuses, are
excised; buried sutures of catgut or of silk are then passed around the
wound, at intervals of a quarter of an inch, and tied so as to bring
the deep tissues together. The sutures are inserted very much in the
same manner as in the ordinary operation for ruptured perineum. The
advantage of this plan of treatment is that primary union is secured
and the patient recovers in a shorter time than would have been the
case after one of the operations which aims to secure union by
granulation.

TREATMENT BY LIGATURE.—There are two methods of using the ligature,
which we may term the _immediate_ and the _mediate_.

The IMMEDIATE OPERATION has little to recommend it. It consists in
passing a silk thread through the fistula and drawing it backward and
forward so as to cut its way through. The same object may be
accomplished by the use of the galvanic écraseur, or of the wire
écraseur of Chassaignac.

MEDIATE OPERATION BY LIGATURE.—In this method either the silk ligature
or an elastic one may be employed.

SILK LIGATURE.—If silk be used, it may be employed in one of two ways.
In both methods a short piece of silk is threaded to a silver probe
bent to a curve, which is passed through the fistula and drawn out at
the anus. The thread is passed through the track, so that one end hangs
out of the bowel and the other at the external orifice of the fistula.
It is at this point that the methods diverge. One plan consists in
knotting the ends loosely together and allowing the patient to go
about. After a time, ranging from two to four weeks, the ligature comes
away, having slowly cut through the included tissue. According to Mr.
Harrison Cripps,[51] the pathological process by which this is
accomplished appears to be a gradual destruction or disintegration of
the included tissue, due to the ulcerative action of the thread. The
other plan is to tie the silk so tightly that it will completely cut
its way through and strangulate all the tissue requiring division in an
ordinary case of fistula. This method causes considerable suffering to
the patient, and has therefore been discarded in favor of the operation
next to be described.

OPERATION BY ELASTIC LIGATURE.—The advocates for the use of the
elastic ligature maintain that with it there is no hemorrhage. This is
a matter of considerable importance when the fistula penetrates deeply,
and also in those rare cases of hemorrhagic diathesis where severe
bleeding is apt to follow a trivial incision.

For the introduction of the elastic ligature we are indebted chiefly to
Dittel, of Vienna. This ligature causes strangulation of the parts by
the firm pressure it constantly exerts upon the included structures; it
cuts its way out in a week's time or less.

It is stated by those who have an extended experience with this plan of
treatment, that, contrary to what might be expected, the pain attending
the ulceration of the band through the tissues is slight, especially
after the first twelve hours. Consequently, this method would prove an
excellent way of treating fistula if it were always to be relied upon
to effect a cure. Unfortunately, this is not the case, for it often
happens that after the ligature has cut its way through, and the
superficial parts have healed, the fistula remains uncured. The reason
for this is to be found in the fact that the ligature has dealt with
the main track, only, of a fistula in which exist one or more secondary
channels and diverticula. I therefore resort to this method of
treatment only in that class of patients who have an insuperable dread
of any cutting operation; when the fistula is uncomplicated with
sinuses; in cases of deep fistula where there is danger of wounding
large vessels; in cases in which the patients are debilitated by means
of some chronic disease; and, finally, in patients of known hemorrhagic
tendency. It is a valuable adjunct to the use of the knife in dealing
with cases in which a sinus runs for some distance along the bowel.

The method of employing this ligature is as follows. A solid cord of
india-rubber, about one-tenth of an inch in diameter, may be threaded
to a probe having at one end a rounded opening, or eye, through which
the ligature is passed. The probe enters the fistula from the external
to the internal opening, and passes out through the anus. To facilitate
the passage of the cord, the rubber should be put on the stretch. After
the ligature is passed, a soft metallic ring is slipped over the two
ends of the cord; the cord is then tightly stretched and the ring
slipped up as high as possible and clamped.

[Illustration: FIG. 46.—Allingham's Ligature-Carrier.]

If the internal opening be any distance up the bowel, Allingham's
instrument (Fig. 46) facilitates the passage of the ligature. In using
it, remember that it is intended to draw the cord from the bowel out of
the external orifice, and not _vice versa_. This instrument has been
modified and improved by Helmuth, of New York. (Fig. 47.)

[Illustration:  Fig. 47—Helmuth's Ligature-Carrier.]

Little after-treatment is required when the elastic ligature has been
used. It will frequently be found that by the time the cord separates
the wound has become superficial.

-----

Footnote 47:

  _Op. cit._, p. 119.

Footnote 48:

  Medical Press and Circular, May 23d.

Footnote 49:

  Annual of the Universal Medical Sciences, 1889, vol. iii, p. 5, D.

Footnote 50:

  _Op. cit._, p. 124.

Footnote 51:

  _Op. cit._, p. 181.

------------------------------------------------------------------------




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                             --------------

                 Beware of Substitutes and Imitations.


   _CAUTION:—Be sure the word "Horsford's" is printed on the label._
              _All others are spurious. Never sold in bulk._


------------------------------------------------------------------------


                  Convenient Preparations for Surgeons

                             --------------

WE supply Antiseptic Liquid, Tablets of Bichloride of Mercury, for
easily preparing solutions of any desired strength; Labbaraque's
Solution, Solution Aluminium Acetate, Sulphur Bricks.

We furnish Cocaine in the following packages: Cocaine alkaloid, pure in
crystals; Cocaine citrate, 4 per cent. solution; Cocaine hydrobromate,
pure in crystals; Cocaine hydrobromate, 4 per cent. solution; Cocaine
muriate, pure in crystals; Cocaine muriate, 2 per cent. solution;
Cocaine muriate, 4 per cent. solution; Cocaine oleate, containing 5 per
cent. of the alkaloid; Cocaine salicylate, 4 per cent. solution;
Cocainized oil, 5 per cent.

Cascara Cordial and Glycerin Suppositories are eligible and
satisfactory laxatives after operations.

Mosquera's Beef-Meal, Beef-Cacao and Beef-Jelly are concentrated foods,
highly nutritious, perfectly palatable, and may be administered in a
variety of forms. They constitute ideal foods for those enfeebled by
operative procedures.

Pepsin Cordial is an agreeable and efficient digestive and tonic.

Descriptive literature of our products sent to physicians on request.

                             --------------

                                                     PARKE, DAVIS & CO.,

                                                   DETROIT and NEW YORK.


------------------------------------------------------------------------


                        BULLETIN OF PUBLICATIONS

                                 — OF —

                      GEORGE S. DAVIS, Publisher.

       ---------------------------------------------------------


                        THE THERAPEUTIC GAZETTE.

      A Monthly Journal of Physiological and Clinical Therapeutics

                               EDITED BY

 H. A. HARE, M. D.,    G. E. DeSCHWEINITZ, M. D.,    EDWARD MARTIN, M. D.

                  SUBSCRIPTION PRICE, $2.00 PER YEAR.


                           THE INDEX MEDICUS.

                      A Monthly Classified Record
            of the Current Medical Literature of the World.

                    COMPILED UNDER THE DIRECTION OF

DR. JOHN S. BILLINGS, Surgeon U.S.A.,

                              and DR. ROBERT FLETCHER, M. R. C. S., Eng.

                  SUBSCRIPTION PRICE, $10.00 PER YEAR.


                          THE AMERICAN LANCET.

                               EDITED BY

                         LEARTUS CONNOR., M. D.
             A MONTHLY JOURNAL DEVOTED TO REGULAR MEDICINE.

                  SUBSCRIPTION PRICE, $2.00 PER YEAR.


                            THE MEDICAL AGE.

                               EDITED BY

                       B. W. PALMER, A. M., M. D.

     A Semi-Monthly Journal of Practical Medicine and Medical News.

                  SUBSCRIPTION PRICE, $1.00 PER YEAR.


                     THE WESTERN MEDICAL REPORTER.

                               EDITED BY

                       J. E. HARPER, A. M., M. D.
                 A MONTHLY EPITOME OF MEDICAL PROGRESS.

                  SUBSCRIPTION PRICE, $1.00 PER YEAR.


                       THE BULLETIN OF PHARMACY.

                               EDITED BY

                       B. W. PALMER, A. M., M. D.
        A Monthly Exponent of Pharmaceutical Progress and News.

                   SUBSCRIPTION PRICE, $1.00 A YEAR.

                             --------------

New subscribers taking more than one journal, and accompanying
subscription by remittance, are entitled to the following special rates:

GAZETTE and AGE, $2.50; GAZETTE, AGE and LANCET, $4.00: LANCET and AGE,
$2.50; WESTERN MEDICAL REPORTER or BULLETIN with any of the above at 20
per cent. less than regular rates.

Combined, these journals furnish a complete working library of current
medical literature, all the medical news, and full reports of medical
progress.

                             --------------

                GEO. S. DAVIS, Publisher, Detroit, Mich.

------------------------------------------------------------------------


                           IN EXPLANATION OF

                    The Physicians' Leisure Library.

                             --------------

We have made a new departure in the publication of medical books. As
you no doubt know, many of the large treatises published, which sell
for four or five or more dollars, contain much irrelevant matter of no
practical value to the physician, and their high price makes it often
impossible for the average practitioner to purchase anything like a
complete library.

Believing that short practical treatises, prepared by well known
authors, containing the gist of what they had to say regarding the
treatment of diseases commonly met with, and of which they had made a
special study, sold at a small price, would be welcomed by the majority
of the profession, we have arranged for the publication of such a
series, calling it The Physicians' Leisure Library.

This series has met with the approval and appreciation of the medical
profession, and we shall continue to issue in it books by eminent
authors of this country and Europe, covering the best modern treatment
of prevalent diseases.

The series will certainly afford practitioners and students an
opportunity never before presented for obtaining a working library of
books by the best authors at a price which places them within the reach
of all. The books are amply illustrated, and issued in attractive form.

They may be had bound, either in durable paper covers at 25 Cts. per
copy, or in cloth at 50 Cts. per copy. Complete series of 12 books in
sets as announced, at $2.50, in paper, or cloth at $5.00, postage
prepaid. See complete list.

              -------------------------------------------

                      PHYSICIANS' LEISURE LIBRARY

             PRICE: PAPER, 25 CTS. PER COPY, $2,50 PER SET;
                CLOTH, 50 CTS. PER COPY, $5.00 PER SET.

                      ----------------------------

                               SERIES I.

 Inhalers, Inhalations and Inhalants.
       By Beverley Robinson, M. D.

 The Use of Electricity in the Removal of Superfluous Hair
     and the Treatment of Various Facial Blemishes.
       By Geo. Henry Fox, M. D.

 New Medications, Vol. I.
       By Dujardin-Beaumetz, M. D.

 New Medications, Vol. II.
       By Dujardin-Beaumetz, M. D.

 The Modern Treatment of Ear Diseases.
       By Samuel Sexton, M. D.

 The Modern Treatment of Eczema.
       By Henry G. Piffard, M. D.

 Antiseptic Midwifery.
       By Henry J. Garrigues, M. D.

 On the Determination of the Necessity for Wearing Glasses.
       By D. B. St. John Roosa, M. D.

 The Physiological, Pathological and Therapeutic Effects
     of Compressed Air.
       By Andrew H. Smith, M. D.

 Granular Lids and Contagious Ophthalmia.
       By W. F. Mittendorf, M.D.

 Practical Bacteriology.
       By Thomas E. Satterthwaite, M.D.

 Pregnancy, Parturition, the Puerperal State, and their Complications.
       By Paul F. Mundé, M. D.

                      ----------------------------

                               SERIES II.

            The Diagnosis and Treatment of Haemorrhoids.
                  By Chas. B. Kelsey, M. D.

            Diseases of the Heart, Vol. I.
                  By Dujardin-Beaumetz, M. D.

            Diseases of the Heart, Vol. II.
                  By Dujardin-Beaumetz, M. D.

            The Modern Treatment of Diarrhoea and Dysentery.
                  By A. B. Palmer, M. D.

            Intestinal Diseases of Children, Vol. I.
                  By A. Jacobi, M. D.

            Intestinal Diseases of Children, Vol. II.
                  By A. Jacobi. M. D.

            The Modern Treatment of Headaches.
                  By Allan McLane Hamilton, M. D.

            The Modern Treatment of Pleurisy and Pneumonia.
                  By G. M. Garland, M. D.

            Diseases of the Male Urethra.
                  By Fessenden N. Otis, M. D.

            The Disorders of Menstruation.
                  By Edward W. Jenks, M. D.

            The Infectious Diseases, Vol. I.
                  By Karl Liebermeister.

            The Infectious Diseases, Vol. II.
                  By Karl Liebermeister.

                      ----------------------------

                              SERIES III.

      Abdominal Surgery.
            By Hal C. Wyman, M. D.

      Diseases of the Liver.
            By Dujardin-Beaumetz, M. D.

      Hysteria and Epilepsy.
            By J. Leonard Corning, M. D.

      Diseases of the Kidney.
            By Dujardin-Beaumetz, M. D.

      The Theory and Practice of the Ophthalmoscope.
            By J. Herbert Claiborne, Jr., M. D.

      Modern Treatment of Bright's Disease.
            By Alfred L. Loomis, M. D.

      Clinical Lectures on Certain Diseases of the Nervous System.
            By Prof. J. M. Charcot, M. D.

      The Radical Cure of Hernia.
            By Henry O. Marcy, A. M., M. D., LL. D.

      Spinal Irritation.
            By William A. Hammond, M. D.

      Dyspepsia.
            By Frank Woodbury, M. D.

      The Treatment of the Morphia Habit.
            By Erlenmeyer.

      The Etiology, Diagnosis and Therapy of Tuberculosis.
            By Prof. H. von Ziemssen.

                      ----------------------------

                               SERIES IV.

      Nervous Syphilis.
            By H. C. Wood, M. D.

      Education and Culture as correlated to the
          Health and Diseases of Women.
            By A. J. C. Skene, M. D.

      Diabetes.
            By A. H. Smith, M. D.

      A Treatise on Fractures.
            By Armand Després, M. D.

      Some Major and Minor Fallacies concerning Syphilis.
            By E. L. Keyes, M. D.

      Hypodermic Medication.
            By Bourneville and Bricon.

      Practical Points in the Management of Diseases of Children.
            By I. N. Love, M. D.

      Neuralgia.
            By E. P. Hurd, M. D.

      Rheumatism and Gout.
            By F. Le Roy Satterlee, M. D.

      Electricity, Its Application in Medicine, Vol. I.
            By Wellington Adams, M. D.

      Electricity, Its Application In Medicine, Vol. II.
            By Wellington Adams, M. D.

      Auscultation and Percussion.
            By Frederick C. Shattuck, M. D.

                      ----------------------------

                               SERIES V.

     Taking Cold.
           By F. H. Bosworth, M. D.

     Practical Notes on Urinary Analysis.
           By William B. Canfield, M. D.

     Practical Intestinal Surgery, Vol. I.
           By F. B. Robinson, M. D.

     Practical Intestinal Surgery, Vol. II.
           By F. B. Robinson, M. D.

     Lectures on Tumors.
           By John B. Hamilton, M. D., LL. D.

     Pulmonary Consumption, a Nervous Disease.
           By Thomas J. Mays, M. D.

     Artificial Anaesthetics and Anaesthesia.
           By DeForest Willard, M. D., and Dr. Lewis H. Adler, Jr.

     Lessons in the Diagnosis and Treatment of Eye Diseases.
           By Casey A. Wood, M. D.

     The Modern Treatment of Hip Disease.
           By Charles F. Stillman, M. D.

     Diseases of the Bladder and Prostate.
           By Hal C. Wyman, M. D.

     Cancer.
           By Daniel Lewis, M. D.

     Insomnia and Hypnotics.
           By Germain Sée. Translated by E. P. Hurd, M. D.

                      ----------------------------

                             SERIES VI.(a)

    The Uses of Water in Modern Medicine, Vol. I.
          By Simon Baruch, M. D.

    The Uses of Water in Modern Medicine, Vol. II.
          By Simon Baruch, M. D.

    The Electro-Therapeutics of Gynaecology, Vol. I.
         By A. H. Goelet, M. D.

    The Electro-Therapeutics of Gynaecology, Vol. II.
          By A. H. Goelet, M. D.

    Cerebral Meningitis.
          By Martin W. Barr, M. D.

    Contributions of Physicians to English and American Literature.
          By Robert C. Kenner, M. D.

    Gonorrhoea and Its Treatment.
          By G. Frank Lydston, M. D.

    Acne and Alopecia.
          By L. Duncan Bulkley, M. D.

    Fissure of the Anus and Fistula in Ano.
          By Dr. Lewis H. Adler, Jr.

    Cholera.
          By G. Archie Stockwell, M. D., F.Z.S.

    Massage and the Swedish Movement Cure.
          By Baron Nils Posse.

    Sexual Weakness and Impotence.
           By Edward Martin, M. D.

(a) To be issued one a month during 1892.

                      ----------------------------

                      GEORGE S. DAVIS, Publisher,

               P. O. Box 470              Detroit, Mich.

------------------------------------------------------------------------


                       BOOKS BY LEADING AUTHORS.

                             --------------

      SEXUAL IMPOTENCE IN MALE AND FEMALE                   $3.00
      By Wm. A. Hammond, M. D.

      PHYSICIANS' PERFECT VISITING LIST                      1.50
      By G. Archie Stockwell, M. D.

      A NEW TREATMENT OF CHRONIC METRITIS                     .50
      By Dr. Georges Apostoli.

      CLINICAL THERAPEUTICS                                  4.00
      By Dujardin-Beaumetz, M. D.

      MICROSCOPICAL DIAGNOSIS                                4.00
      By Prof. Chas. H. Stowell, M. S.

      PALATABLE PRESCRIBING                                  1.00
      By B. W. Palmer, A. M., M. D.

      UNTOWARD EFFECTS OF DRUGS                              2.00
      By L. Lewin, M. D.

      SANITARY SUGGESTIONS (Paper)                            .25
      By B. W. Palmer, M. D.

      SELECT EXTRA-TROPICAL PLANTS                           3.00
      By Baron Ferd. von Müller.

      THE PRINCIPLES AND PRACTICE OF BANDAGING               3.00
      By Gwillym G. Davis, M. D., Universities
      of Pennsylvania and Göttingen.

                         ---------------------

                       GEO. S. DAVIS, Publisher,
                             P. O. Box 470,
                         DETROIT,  -  -  MICH.