Jr. Lewis H. Adler

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 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. ”

“ 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 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ I have used it for several years, not only in my practice, but in my own individual case, and consider it under all circumstances one of the best nerve tonics that we possess. For mental exhaustion or overwork it gives renewed strength and vigor to the entire system. ”

“ 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. ”