FISTULA IN ANO.
Anal fistula is a fistula or track leading from the integument near the anus to the rectum, and may be complete or incomplete, the latter being called blind, internal or external fistula according to circumstances. A complete fistula is one in which there is an opening in the rectum, communicating with an opening in the integument by a sinus. A blind external fistula is one in which the canal dose not open into the rectum, but terminates at at the outer surface. A blind internal fistula is one in which the track extends from the rectum to the integument, but the latter remains intact. Gross thinks both of these latter conditions are very infrequent, if not impossible in the case of the blind internal fistula. He thinks that awkwardness, or some unusual tortuousity of the fistula often prevents detections of the internal opening, and mentions cases occurring in his own practice in which he has only succeeded after frequent attempts. That such cases do exist, however, every surgeon of experience knows very well, but we must at the same time admit their infrequency.
The causes of fistula are various and may be either constitutional or local. In all cases, however, the commencement of the trouble will be an abscess, either in the rectum or integument, which determines the character of the fistula by its manner of discharge. When the discharge is external, it may be either a complete or blind external fistula; when internal, either complete or blind internal.
At first the walls of the sinus will remain raw, but soon they become covered with a plastic deposit which may gradually assume the character of mucous tissue, or more that of the ordinary pyogenic membrane.
There is much variation in number, size, tortuousity, length, and number of openings in fistula. Usually they are single, with a single opening at each extremity, but Gross mentions a case in which there were seven external openings. The length of the track is usually a few lines, less than half an inch, while some cases occur in which it has reached two inches, owing to extreme tortuousity, the internal opening being at the usual distance from the anus, viz. from three to five lines. The capacity of the canal is usually just sufficient to admit an ordinary probe. While all these variations occur, the chief symptoms of fistula are quite constant, and vary only in prominence.
After the subsidence of an anal or rectal abscess, should there remain for days or months a slight discharge faecal in odour, and an occasional emission of flatus, an examination must be instituted at once. Should a fistula exist, the integument will be found discoloured, thickened, and quite painful to pressure. On close examination a small puncture will be observed, usually within the folds of the anus, exuding on pressure a small amount of fluid, more or less purulent, which has a decidedly faecal odour. At other times the opening will be indicated by a slight elevation of a bright colour as in the case of fistula in caries. On passing the forefinger of the left hand within the sphincter, and inserting a well oiled probe within the fistula, the location of the internal orifice can usually be quickly detected. In the case of blind external fistula, in addition to the absence of any internal orifice, the fistula will be found quite frequently dilated into a pouch like process. In internal blind fistula, the diagnosis must be very obscure, and can only be made out by using a speculum, and narrowly inspecting every portion of the lower rectum. The swelling, tenderness, and discolouration are the same in each case, and will cause a suspicion of internal fistula when no opening exists externally. The subjective symptoms are few and unreliable, and are to a certain extent objective as well. They are chiefly a sensation of escaping gas, put or faeces at unnatural points with a constant moisture of the anus and perineum. Pain is either insignificant or entirely wanting, and there is no irritation, as a rule, except from direct pressure.
The constitutional symptoms are not diagnostic, being for the most part a continuance of those existing prior to the formation of the fistula. Some writers have sought to connect tuberculosis of the lungs and anal fistula, in relation to cause and effect. Cases are known to all of us, in which marked cases of tuberculosis have suffered from anal fistula and others in which the cure of a fistula, by operative measures, has been followed by rapid phthisis, even when the graver malady had been hitherto unsuspected. The very uncertainty that surrounds this subject, at present, should teach us caution in instrumental interference.
As to the prevalence of this condition at different ages, and in the two sexes, it appears to be almost unknown in childhood and old age, being more frequent between the ages of twenty-five and forty. Some few cases have been observed in children under a year old, but none, as yet, as far as my knowledge goes, have been recorded as originating in persons past fifty years of age. Men are more frequently affected than women.
Treatment.-In chronic cases, with a fully-formed pyogenic membrane, I do not believe a cure is possible by remedies alone. We will be compelled to resort to some treatment which will destroy the lining membrane, and if adhesion does not occur, remedies may complete a cure.
In acute cases medicine will do very much, and even when chronic, if the fistula is incomplete a cure has sometimes followed. It is almost impossible to give indications for remedies that will be constant, and in lieu thereof I offer the following report of cases:
Aloes.-A case is reported cured by Dr. Boyd (Medorrhinum Invest. Vol. VI., p. 122) complicated with piles, in which the fistula was found cured, when the piles had disappeared.
Berberis vulg.-Dr. Adams gives a case cured with the following symptoms: Great soreness and pain throughout the entire back, from the sacrum to the shoulders, greatly increased from exercise. The fistula would close up and inflammation and suppuration follow. Acrid leucorrhoeal discharge, very prostrating.
Lachesis.-A case was cured, in which, with other symptoms of the remedy, there was a full feeling of the rectum and a sensation of little hammers beating.’
Thuja.-The same gentleman reports a case cured with this remedy, in which the condylomatous condition was present.
Arsenic.-A case of ten years standing was cured, in which the symptoms were: Great despondency;’ chills running up and down the back; relief from heat; large purple swelling in the right gluteal region.
Causticum.-I cured one case of fistula of one years standing in an old man, very corpulent, acrid discharge, and intense pruritus ani. The cure was radical and speedy.
Other remedies may be useful, but they will require selection in accordance with general or local symptoms, as given under Haemorrhoids, etc.
OF IOWA, CHICAGO. Author of - The homoeopathic treatment of surgical diseases, Published 1873. Surgical emergencies and accidents, Published 1884. The elements of surgical pathology : with therapeutic hints, Published 1896. Surgical diseases and their homoeopathic therapeutics, Published 1880.