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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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
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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.
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The Modern Treatment of Headaches.
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The Modern Treatment of Pleurisy and Pneumonia.
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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.
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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.
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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.
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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.
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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.
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GEORGE S. DAVIS, Publisher,
P. O. Box 470 Detroit, Mich.
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BOOKS BY LEADING AUTHORS.
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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
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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.
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P. O. Box 470,
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