The disease is sometimes so violent and obstinate, that the parts in the vicinity, and sometimes the rectum itself, are separated from the organs around. Various methods of peculiar severity have been adopted on this occasion. It is, however, sufficient to lay a detached portion of the gut open on the side most affected, as in common fistulae; and sometimes another portion on the opposite side. If the bones are sound, these operations will usually succeed.
When the matter insinuates itself into the perinaeum, or down the hip, the sinuses should be laid completely open. When the matter has been long confined, the parts become hard and apparently scirrhous. In this case the sinus must not only be laid open, but the scir-rhositics removed by the knife. It has been common to apply caustics for the latter purpose; but this mode of relief is tedious, and much more severe than the knife.
When the operation is finished, it has been the general practice to stuff the cavities with lint; but this occasions great irritation, and often induces diarrhoea. After cleaning the wound, pledgets are to be gently introduced, so as to cause no uneasiness. The sore, however, often assumes an unhealthy appearance, and the discharge is thin. Though this may arise from the sinus not being completely opened, it is more commonly owing to the weak state of the constitution. Bark, wine, and cold bathing, country air,and milk diet, have been recommended. Balsam of Peru and of capivi, turpentine, and other stimulating applications, have been used often with little success. Unfortunately, when thewound has healed, worse symptoms have come on. Patients are, however, often impatient, and the surgeon must cure the wound which he has made, if he wishes to preserve his credit. It is melancholy to reflect, that we cannot always, at the same time, do our duty, and satisfy those under our care. We have sometimes succeeded in inducing patients to "bear the ills they have," rather than "fly to others that they know not of," and our best success has been obtained-by delay.
D. Mudge's "experienced and successful method of treating fistula in ano"consists in employing a speculum to dilate the rectum, and bring the parts more completely within the view. The callous edges of the wound are touched with butter of antimony; and when the surface appears preternaturally smooth, the precipitate ointment is applied.
See Heister's Surgery; Le Dran's Operations; Sharp's Operations; Pott's Treatise on Fistulas; Bell's Surgery, vol. ii. p. 282; Kirkland's Medical Surgery, vol. i. p. 201, 235; London Medical Journal, vol. v. p. 392; White's Surgery, p. 386.
Iistula in the epididymis. In the London Medical Observations and Inquiries, vol. ii. p. 273, is an instance of a fistula in this part being cured. A man of thirty-five years of age hurt his testicles by a fall; a suppuration followed, and the matter was discharged externally. When the swelling was reduced by means of an emollient cataplasm, a fistula was discovered in each epididymis: a probe director was then introduced into the left sinus, which was cut open its whole length; after which all the indurated parts and the diseased skin were dissected; the same was done on both sides, and a part of the epididymis on the right side was cut away. The dressings, as in common wounds, finished the cure; and the functions of the testes were afterwards said to be fully executed.
' Fistu.'la lachrymalis, (see AEgylops,) is a disorder of the canals leading from the eye to the nose, which obstructs the natural passage of the tears, so that they trickle down the cheeks. In its first and mildest stage, an inflammation on the part is alone observed: in the next, matter is discharged from the puncta lachrymalia, which flows with the tears; the matter may proceed from an orifice through the skin, between the nose and the angle of the eye. The last and worst degree is, when the matter of the abscess has corroded the subjacent bone.
If the skin between the angle of the eye and the nose is not perforated, it is called imperfect; if corroded, a perfect; and if the subjacent bones are affected, a compound, fistula lachrymalis.
Other disorders near the seat of the fistula lachryma-lis are confounded with it; but properly this kind of fistula is an erosion of the ducts of the lachrymal sac; in consequence of which, pus flows from them into the great angle of the eye; when the clear lachrymal fluid alone flows out, the disorder is an epiphora, q. v. The matter of a proper fistula generally flows through the upper puncta, but sometimes through the lower only, or in a few instances through both.
The symptoms are, frequent dropping of tears, and of purulent matter, especially in the morning, without any manifest external inflammation. By pressing with the finger upon the lachrymal sac, a discharge of pus follows through the puncta lachrymalia; and it"this pus be offensive to the smell, or of a green or blackish colour, though not offensive, the adjacent bones are generally carious. When the matter is of a bad smell or colour, the probe will readily determine the state of the bone; for sometimes it is not injured, notwithstanding the attendance of the usual signs; and it is sometimes carious, when the pus is laudable. If, however, the discharge continues to be faulty, a caries will, for the most part, be formed in the lachrymal bone, the os planum, or in the jaw bone. If the nasal duct is obstructed, it is known by injecting some fluid into it, when, instead of passing into the nose, it returns by the puncta lachrymalia: if there is an encysted tumour, the exterior parts swell, and the tumour will not yield to the pressure of the finger, though there is no inflammation. When it does yield, there is a lachrymal hernia. Instances have occurred of a fistula lachrymalis not discharging pus with the tears, but alone when the patient was asleep; and this hath happened when the adjacent bones have been carious.
If the complaint is recent, the habit of body not remarkably diseased, the external skin not corroded, the nasal duct unobstructed, the matter of a good colour and consistence, incision and the cautery are unnecessary; for compression and mild astringent collyriums will be sufficient: the matter should be occasionally pressed out with the finger, to prevent its acquiring an acrimony. But if the duct into the nose is stopped, nothing will succeed but the operation. In performing it, the loose skin of the under eye lid must be pressed upon the globe of the eye, and a passage into the lachrymal groove cut: this is known by the crackling of the os unguis under the pressure of the knife; a probe must then be introduced to perforate into the nose. It is necessary to guard against cutting on the upper part of the maxillary bone, which will be discovered from the resistance. In that case the incision must be made further back. If, in perforating the os unguis, you press upon it too forwards, you will be obtructed by a part of the maxilla superior, which forms a portion of the canal in which the sac is lodged; if you press inwards, there will be danger of injuring the os, or septum nasi, or the os ethmoides: but if the instrument is passed backwards and downwards towards the uvula, no obstruction will occur.
For compressing instruments with which to cure the slighter cases, see Sharp's Operations, and Gooch's Cases. On the Fistula Lachrymalis, see Sharp's Operations; Le Drun's Operations; Edinburgh Medical Essays, vols. ii. and iii; Pott's Treatise on the Fistula Lachrymalis; St. Yves on Disorders of the Eyes; Heis-ter's Surgery; Bell's Surgery, vol. iii. p. 469; Kirk-land's Medical Surgery, vol. ii. p. 134; London Medical Journal, vol. i. p. 62, vol. ii. p. 77, 245; Nosology of the Eyes, p. 77, 83; White's Surgery, p. 256.
Fistula in perinaeo consists in an opening in the skin, corresponding with one in the urethra. It sometimes happens that one opening from the side of the urethra corresponds with several through the skin; but it rarely happens that there is more than one opening from the urethra.
After lithotomy, a puncture of the perinaeum, an abscess in the same part near the urethra, a scirrhus in the prostate, etc. a fistula is sometimes formed, through which the urine partly passes, while the rest is conveyed through the natural passage.
A fistula proceeding from the urethra runs in various directions before it reaches the external opening of the skin; so that when the latter is near the anus, it may be taken for a fistula in that part; but the discharge of urine through the fistula at once distinguishes its nature.
Besides the callosities on the external orifice of these fistulas, there are sometimes calculous concretions lodged in their cavities; indeed, so various are the circumstances attending different cases of this kind, that only general rules can be laid down for their treatment.
In general the outward opening must be enlarged by cutting away the callous lips, or destroying them by caustic; but it sometimes happens that the same end may be attained by distending the urethra with a bougie. Le Dran observes, that though there are several fistulous orifices, and several callosities in the perinaeum, when the water passes off in a small stream through the natural passage, the chief remedy will be the introduction of bougies; for as this canal is enlarged, the external orifices are diminished and healed, and the callosities consequently softened. Mr. Bell prefers the cure of this fistula by the introduction of a seton. See Fistula. Le Dran's Operations. Bell's Surgery, vol. ii. p. 226. London Medical Journal, vol i. p. 379. White's Surgery, p. 395.
On fistulas in general, see Celsus, Boerhaave's Aphorisms, and Pott's Treatise on Fistulas.