admits of being readily bent, for using in these examinations. The presence of more than one external orifice is rare in subcutaneous fistulie; and an internal opening will be found in the great majority of cases, if properly searched for. The only way to settle the question of the presence or absence of an internal opening in any doubtful ease is by opening the anus with a specaliim and injecting milk through the external orifice. In the vast majority of eases the milk will be found in the rectum, and the internal orifice will be found just within the external sphincter. <Callout type="important" title="Important">This method can help confirm the presence of an internal opening.</Callout> AB8C£BB AND FISTDI.A. 7& It may sometimes be felt in this location by the educated finger as a small tubercle, and in other cases it is marked by a distinct loss of substance. In some the internal opening will be found in the radiating folds entirely below the fibres of the sphincter, and in others it may be much higher up the bowel.* The internal orifice does not in all cases mark the superior limit of the fistullooB track. This may run several inches up the bowel under the mucous membrane, when the internal orifice is just within the external sphincter (Pigs. 28, 29). <Callout type="risk" title="Risk">Failure to locate the internal opening can lead to ineffective treatment.</Callout> Fig. 28, Fia. as. Fig. 16.— AB, deep muscular track resulting from an Ischiorectal abscess. AI. Mucous tube running up and down the bowel. Fig. 29.— DE, Subtegmenatary and submucous fistula with lateral and external opening. DF, deep Muscular Crack, having same internal, but separate external opening. The track of a fistula is sometimes straight, extending directly from one orifice to the other; in other cases a track, properly speaking, does not exist and both orifices open directly into the original abscess cavity. If the external orifice be very small, the cavity may at any time become distended with pus and give rise to all the symptoms of a fresh abscess, till the pus finds an exit either through the old opening or a new one. The external orifice of a true, straight fistulous track is generally large and sometimes free enough to allow of the escape of gas. The track is lined with lardaceous tissue the result of chronic inflammation, and in this may be found numerous blood-vessels of new formation. This tissue, by preventing all contact of the walls, necessarily prevents healing. On the other hand, the track is sometimes lined with healthy granulations which are capable of being formed into new tissue^ and for this reason a fistula will sometimes heal spontaneously. The history will sometimes afford valuable information as to the general character of the case. The history of a slight abscess and the escape of a small amount of pus generally means an insignificant fistula with external and internal openings near the margin of the anus; while, on the other hand, the history of a prolonged inflammation and a free discharge of pus means a large abscess cavity mounting to a considerable height^ and with its internal orifice at a correspondingly high point. The symptoms caused by this class of fistulas vary greatly. At first they are those of the abscess in which they originate. After that the one great symptom is the incessant discharge, sometimes slight, at others abundant; sometimes purulent, at others serous; always foetid; sometimes containing faeces and gas. It is generally the stoppage of the discharge and the consequent filling of the track or abscess cavity which induces the patient to seek the surgeon. Besides the discharge there may be no symptoms at all, or there may be more or less uneasiness in the part, and pain on defecation, with the constipation which arises from the fear of a passage, and the symptoms to which it gives rise. Such a state of affairs may exist for many years without aggravation, or without causing the patient to seek relief. Deep Fistulas. — Deep or submuscular fistulas differ greatly in their extent and gravity from those last described. In them the track is large and often double or branching, and the external opening may be far away from the anus. The whole perineum and gluteal region will sometimes be found to be perforated by openings. In a case sent to me by Dr. B. W. Taylor, of New York, I easily counted between twenty and thirty of these discharging points, and the whole perineum and surrounding region were hard, brawny, and infiltrated. The man, under the pressure of his sufferings probably, had become a confirmed opium eater and was in a deplorable plight. The track in some of these cases has been known to take a remarkably irregular course. Sir A. Cooper* mentions an autopsy where a fistula opened in the groin, followed the course of the spermatic cord, and ended in what seemed like an ordinary^ fistula in ano; and cases in which the pus has burrowed under the gluteal muscles and finally opened in the thigh or even nearly at the popliteal space, are not uncommon. Blind Internal Fistula. — Fistulas with internal openings alone have a somewhat special pathology. When caused by an abscess it is generally by one of the deep variety which has opened into the rectum high up and continues to discharge in this way. The abscess causing such a fistula may, however, be a small submucous one, and the symptoms will then be pain, spontaneous discharge of pus from the bowel, and subsequently pain after defecation resembling that of a fissure. There is another, and perhaps more common class of internal fistulae in which the opening is not the result of the breaking of an abscess, but in which the opening is first formed by ulceration and the track is a secondary consequence. This pathological fact was proved by the well-known investigations of Eibes, who believed that the internal orifice was always the first formed, but here he was undoubtedly in error. A circumscribed ulcer which shall perforate the mucous membrane and result in internal fistula may be due to several causes: to the inflammation of one of the lacunae just above the sphincter from the lodgment within it of a particle of hard faeces; to rupture of an inflamed internal haemorrhoid; to the application of strong acids to haemorrhoids; to operations upon the rectum generally for haemorrhoids; and to the peculiar ulceration met with in tubercular patients, but not necessarily tubercular in its nature. Such a condition is a very painful one. The opening which may be large enough to show a distinct loss of substance to the touch, catches and retains particles of faeces, causing a burning pain which may last many hours after defecation. As a result of the opening an abscess forms after a time with the usual symptoms, the induration of which may be felt externally. When the abscess is small and the induration not extensive a speculum examination may reveal the ulcer; but the fistulous track and abscess may escape — a mistake which will render all treatment directed toward the cure of the ulcer of no avail. There may indeed be several ulcers, only one of which has a fistula connected with it. Treatment. — A fistula may heal spontaneously or after a very slight excitement to reparative action, such as the mere passage of a probe in making an examination. It has been mentioned that the track is sometimes lined with healthy granulations, and that these may result in new tissue which shall close it; but this can never occur after the usual infiltrated tissue has once been formed, which is seen in all old cases. Allinghain^ relates several cases of spontaneous cure, and estimates the proportion in which it may occur as about one per cent. Setting aside these cases, we are at once brought to the question which will often be asked by the patient, and which the surgeon may not always be able to answer to his own satisfaction, whether or not it is always best, or even safe to try and cure a fistula. In certain cases of Bright's disease, cancer, cardiac and hepatic affections, etc., all surgical interference may be plainly contra-indicated; but the question is most apt to arise in connection with pulmonary affections. There can be little doubt that phthisical patients are especially predisposed to this affection, and the reason is probably in great measure a mechanical one, depending upon a loss of fat in the ischio-rectal fossa and a resulting 'loss of support to the haemorrhoidal veins. From this there results a venous congestion and final dilatation or rupture of the vessels^ which, with the cough and concussion, leads eventually to abscess. I believe it to be a safe rule to operate upon phthisical patients as upon others, being led by the idea that one exhausting disease — phthisis — is better than two — phthisis and fistula. I have many times followed this rule with happy results as to improved general health after the cure of the fistula. Once only has it happened to me to see the cure of a fistula followed by a marked increase of the lung trouble, and even in such a case the relation between cause and effect cannot be established. I have also yet to meet the first case which, under suitable and careful general and local treatment, refused to heal after the operation. There are several rules which should be carefully regarded in this class of cases, however. No cautious practitioner would think of operating either in a very advanced or a rapidly advancing lung trouble. Cough, when violent and frequent, is also a decided contra-indication, interfering, as it does very certainly, with the healing of the wound. The following case will perhaps illustrate the line of treatment to be followed in a general way. Case* V. — A theological student, aged twenty-eight, applied to me from a neighboring city for relief from a large subcutaneous abscess with an internal opening within the sphincter, and an external one at some distance from the anus. The probe could easily be passed a considerable distance in every direction beneath the undermined skin. The discharge was very profuse. This condition had existed for several months; the patient was much reduced in weight, there was consolidation in the apex of one lung, with a history of phthisis and haemorrhages. The internal and external orifices were connected by an incision involving the external sphincter, and the abscess cavity was laid open for a distance of four inches along the perineum, and dressed with picked lint. After a fortnight's rest in his room, the patient being partially dressed most of the time, and spending his days on the lounge or easy chair rather than in bed, reparative action seemed to come to a standstill, and with careful directions as to dressing the wound, I sent him off into the mountains. He reported at my office after an interval of three months spent in the woods, during which time he had frequently been on horse-back several hours at a time. The change in his general condition was very remarkable, he having gained nearly twenty pounds in weight. The abscess cavity was nearly, but not quite closed, and again he returned to the country, with the understanding that he should report in the city every fortnight. In just six months from the operation the wound was entirely healed, there had been no exacerbation in the lung troubles, and the patient was in better general condition than for years previously. In cases of fistula in phthisical patients, the sphincters should be interfered with as little as possible, as they are apt to be weak at the best. The internal orifice is apt to be large and raggedy and the external may be the same. The tendency to undermine the skin is always marked, and the discharge is generally thin and watery. Cauterization. — It is not necessary even to enumerate the various substances which from time out of date have been advocated for this purpose. Among those for which good results have been claimed, iodine holds the first rank. There is no doubt that that by its use certain fistulas and abscesses may be made to heal, but the plan is uncertain and not very reliable. The operation consists in closing the internal opening with a finger in the rectum and then injecting the fluid with a small syringe through the external orifice, using pressure enough on the track to bring the fluid into contact with every part. In the place of iodine, nitrate of silver either in solution or fused upon a probe; the tincture of iron; or carbolic acid, may be used. The galano-cautery wire, or a simple hot iron may also be employed to modify the track; and a fine sea-tangle tent carefully introduced will sometimes set up reparative action. By any of these means failure will be the rule, but success may occasionally be secured after faithful trial. The ligature. — Under the head of the ligature may also be included its different modifications — Scrasement lineaire, elastic ligature, and the galano-cautery wire. The method of cure by the simple ligature consists in passing a strong cord through the fistula from the external opening, through the internal, and out at the anus, then in tying the two ends, and tightening the loop from day to day till the tissue included is divided. The operation is generally effectual, but it is also painful, tedious, and uncertain. It is a substitute for the knife, a concession to the fear of being cut, and it is free from haemorrhage; but it only accomplishes in the end, and sometimes after weeks of suffering, what the knife accomplishes in a moment; and except for the single fact that by its use haemorrhage may be avoided it would bear no comparison with the latter. If this mode of treatment is for any reason decided upon, there are certain modifications of the operation which are much to be preferred to the simple cord. The method of immediately cutting through the tissues by attaching the ends of the cord to the handle of an Scraseur (ecrasement linSaire) is a much better way of attaining the same end which is due to Ghassaignac There are, however, two methods of dividing the tissues which are still better than this — one by the galano-cautery wire, the other by the elastic ligature. The galano-cautery wire has the same advantage over the knife as the ligature in preventing haemorrhage; and it is not particularly painful in its application. In using it, as little heat should be used as is possible to slowly divide the tissue, or haemorrhage may occur and all its advantages be lost. On account of the expense of the apparatus, and the skill required for its management, this method has never become very popular with the general practitioner, but it is very successful in the hands of a few. Probably the best of all methods next to the knife is that of the elastic ligature. The cord in this case is of solid rubber which is drawn as tightly as possible — the tighter the better — and then held on the stretch by slipping a soft metal ring over the ends and squeezing its two sides together close up against the tissues. In the course of a few days the ligature will be found to have cut its way through the included tissues, the time depending on the quantity and quality of the mass to be cut. Various devices have been recommended for facilitating the passage of the ligature. The best known is Allingham's, Fig. 30. In using it, remember that it is intended to draw the cord from the rectum out of the external orifice, and not vice versa, Helmuth, of New York has modified the instrument and I think with advantage, Fig. 31, but the least elaborate and most effective instrument for the purpose in my own hands is a simple silver, eyed probe which is threaded with the elastic cord and then passed from the external orifice through the track and out at the anus. I once had an awkward accident with Allingham's instrument which broke in my hand in a moderately deep and hard track. After the ligature is in place, the patient is allowed to go about his ordinary pursuits, and this is claimed as one great advantage of this method. I have never been able to understand why cutting*with a string should permit of any more liberty than cutting with a knife. The patient, it is true, will generally get well if he goes about while the string is doing its work, and so he will after the operation with the knife; but in both cases the healing will be facilitated by rest. The operation is said to be painless. I have not found it so. Both the passing of the cord, and its tension for the first forty-eight hours have been bitterly complained of in some of my own cases. The healing has already begun before the ligature comes away; but with the dropping out of the cord there will sometimes be found a considerable slough in the line of strangulation which may require some days for its separation.
Key Takeaways
- Use milk injection to confirm internal opening presence
- Deep fistulas can be extensive and dangerous
- Spontaneous healing is rare, surgery often necessary
Practical Tips
- Regularly check for signs of infection or unusual discharge in the rectal area.
- Seek medical attention if you notice persistent symptoms like pain, bleeding, or foul-smelling discharge.
- Maintain good hygiene to prevent infections from developing.
Warnings & Risks
- Ignoring symptoms can lead to severe complications and prolonged suffering.
- Incorrect diagnosis may result in ineffective treatment and worsening of the condition.
Modern Application
While the techniques described here are outdated, understanding the importance of proper sanitation and recognizing signs of infection remains crucial. Modern medical practices have improved diagnostic tools and treatments, but this historical knowledge can still provide valuable context for understanding and managing rectal issues.
Frequently Asked Questions
Q: How can I confirm if there is an internal opening in a suspected fistula?
The chapter suggests injecting milk through the external orifice to check for an internal opening. If the milk appears in the rectum, it indicates the presence of an internal opening.
Q: What are some signs that a fistula might be deep and dangerous?
Deep fistulas can have large, double, or branching tracks, with external openings far from the anus. They may also perforate the perineum and gluteal region, leading to multiple discharging points.
Q: Can a fistula heal on its own without surgery?
The chapter states that spontaneous healing is rare, especially in older cases. Surgery is often necessary for effective treatment, as the usual infiltrated tissue cannot be reversed once formed.