Anal fistula

“ 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 anal and rectal mucous membrane is of a firm and tough structure, similar to the integument at the bottom of a boy's heel. After many years' observation of diseases of the anus and rectum I am forced to conclude that as a rule inflammation exists in the tissues twenty or more years before the severe symptoms, such as piles, fissure, anal pockets, pruritus, hypertrophy, atrophy, tabs, abscesses, and fistula, are sufficiently annoying to compel the sufferer to seek medical aid. ”

“ The muscle of the bowel is in a state of fatty degeneration, and atony and dilatation of the gut follow.
10. Painful affections about the rectum and anus deter persons from yielding to the desire for defecation. Fissure of the anus is the principal one of these, but fistula, hemorrhoids, and local eczema have a similar influence. A simple rigidity or spasmodic stricture of the anal sphincter creates constipation.4
4 Kunemann, De la Constipation compliqués de Contraction du Sphincter anal, et de son Traitement par la Dilatation de l'Anus, Paris, 1851. ”

“ 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. ”

“ Occasionally the urethra communicates with the rectum in consequence of ulceration, escape of urine into the cellular tissue, and formation of matter. The symptoms of stricture are often much relieved after the formation of fistulous openings; and the cure can then be much more easily accomplished than formerly, the passage being less irritable. When the fistula is free and open, allowing the urine to escape readily, the natural passage contracts, and will become almost entirely obliterated, unless means are taken to dilate it, and to diminish the unnatural opening. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ For, having become putrid, it spreads to the soft parts (the breech being of a humid nature, and the flesh in which it spreads being soft) , until the tubercle break and corrupt below at the anus. When this happens, a fistula is formed, having an ichorous discharge, and faeces pass by it, with flatus and much and abomination. It is produced, then, by contusions when any of the parts about the anus are bruised by a blow, or a fall, or a wound, or by riding, or rowing, or any such cause. For blood is collected, and it, becoming corrupted, suppurates ”

“ 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 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. ”

“ 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. ”

“ Syringe the fistula by means of a quill attached to a bladder, so that the injection may distend the fistula. But it does not heal unless it be cut open.
Part VI If the anus gets inflamed, and there is pain, fever, a frequent desire of going to stool without passing anything, and the anus appears to protrude, owing to the inflammation, and if at times strangury come on, this disease is formed, when phlegm, collected from the whole body, is determined to the rectum. Warm things are beneficial in this case ”

“ 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. ”

“ 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. ”

“ Fistulæ resulting from suppuration usually occur near the natural openings of mucous canals—for example, on the cheek, as a salivary fistula; beside the inner angle of the eye, as a lacrymal fistula; near the ear, as a mastoid fistula; or close to the anus, as a fistula-in-ano. Intestinal fistulæ are sometimes met with in the abdominal wall after strangulated hernia, operations for appendicitis, tuberculous peritonitis, and other conditions. In the perineum, fistulæ frequently complicate stricture of the urethra. ”

“ 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.) ”

“ 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. ”

“ Fistulae may be caused by an obstruction of the normal channel, the result of disease or injury, which prevents, for example, the tears, saliva or urine, as the case may be, from escaping; their retention gives rise to inflammation and ulceration in order that an exit may be obtained by the formation of an abscess, which bursts, for example, into the gut or through the skin; the cavity does not close, and a fistula is the result. ”

“ The rectum and anus are frequently subject to attacks, by contiguity, from diseases in neighboring organs. The most frequent of these is doubtless that form of ischio-rectal abscess which invades the bowel, causing fistula in ano. Various neoplasms having their seat in the tissues or organs near the bowel may obstruct it by simple mechanical pressure, or may cause inflammation, infiltration, and ulcerative erosion. Mechanical encroachment by the pressure of a foreign body in the vagina may cause grave interference with the normal functions of the lower bowel. ”

“ 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 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. ”

“ 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. ”

“ Indeed, other means will succeed in cases in which the knife fails or is for any reason inapplicable. One great objection to the knife is not only the [pg 585] dread which patients entertain of it, but the great liability of its use to result in paralysis of the sphincters of the anus, the consequence of which is loss of control over the bowels; and another is that it sometimes entirely fails to result in cure. By the means which we employ, these objections are entirely overcome, and, while the general system is being renovated, the fistula is healed, without any complications. ”

“ In complete fistula there may be more than one external opening, and this is in the majority of cases not far from the anus, but it may open in the perineum or upon any part of the gluteal region. When the openings are multiple they usually converge to form a common tract or sinus. The external opening presents nothing to the untutored eye to lead to the suspicion of grave internal trouble: frequently the vent is so minute and valvular or shielded by a thin pellicle as to be entirely overlooked ”

“ An internal fistula is more difficult of detection. The symptoms leading to a suspicion of its existence are—puriform discharge from the bowel, increased on going to stool, and then accompanied with tenesmus; pressure on the side of the anus, causing pain, and sometimes an augmentation of discharge; and in many instances hardness, deeply seated, is felt. On introducing the finger into the rectum, the aper450ture in the coats of the bowel is perceived, or a part of the bowel feels more boggy and tender than the rest ”