he had experienced with the ligature, which did not come
away for nine days, during which time the patient was in
incessant pain. So he would have none of it. I dilated the
external opening with the tangle, and then put in a drainage
tube, but did not use carbolic acid or any strong applica-
tion, as the patient feared pain. For some time this case
did not do well, and I was on the point of giving it up,
when I persuaded him to take an anaesthetic and allow me
to dilate his sphincter muscles (which were very spasmodi-
cally contracted), and apply the carbolic acid. He con-
sented; and the result of this combined attack, and keeping
him in bed a week, conquered the sinus, and it healed
rapidly. I fancy this patient has remained well.

A difficulty in these cases is to keep the external orifice
very large without irritating too much ; and my friend Mr.
Clover, with his usual ingenuity, effected that object wonder-
fully well in a case I saw with him, by inserting a bone col-
lar stud into the opening. When this was slipped in, it
remained fixed, and the patient wore it and went about
without complaining even of discomfort; since seeing this
case I have tried the collar stud on many occasions, but have
had a small hold drilled through from end to end, in order
that no pus might be retained in the sinus, and it has ans-
wered the purpose I desired, viz., to keep the external ori-
fice large.



28 FISTULA AND THE TREATMENT BY ELASTIC LIGATURE.

A lady came to me from the country, in the beginning of
1879, with a small abscess, which had been opened, and a
sinus running up the bowel for quite an inch. She was most
desirous to be cured, but would not have the knife, and
feared the elastic ligature. I was able, after a little dilatation
of the orifice, to get the bone stud in, and in ten days the
sinus had healed. To give her every chance she kept her
soia, and I confined the bowels for seven days. I saw this
patient recently, and she kept quite well.

Since the publication of my last edition I have cured
many patients by dilatation of the sphincters and the use of
the bone stud and carbolic acid. I do not think anything
would be gained by relating more cases. One practical
point I would mention. The further the external aperture
is from the sphincter the more likelihood is that the sinus
may heal. This is shown as well in the cases of spontane-
ous cure as in my own successes. It. is very important, in
these attempts, not to do any harm. You must always
enjoin rest after a strong application, and watch that not
too much inflammation be set up.



CHAPTER IV.

FISTULA AND THE TREATMENT BY ELASTIC LIGATURE.

As I have been considering the treatment of fistula with-
out cutting, I think before describing the usual methods of
operating, I had better relate my experience of the use of the
elastic ligature, describe its mode of application, and endea-
vor to point out what really it can do and what it cannot be
expected to do. And at once I will fully confess that when
I read a paper before the Medical Society of London, in
February, 1875, on the treatment of fistula and other sinuses
by the elastic ligature, I anticipated a wider use for it than
I have found. Still, I must assert that the ligature is most
valuable in many cases, and frequently invaluable as an
auxiliary to the knife.

Professor ] >ittel, of Vienna, may certainly be called the
apostle of the elastic ligature, but he was not the discoverer,
as Mr Henry Lee and also Mr, Holthouse had previously



FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. 29

used it for the removal of naevi and in anal fistulas. When
I read Professor Dittel's paper I came to the conclusion that
the indian-rubber ligature might be found very useful in the
brance of surgery to which I had paid special attention. I
therefore determined to make a fair trial of it, and have now
employed it in more than 150 varied cases. I can truly say
I have over and over again been very glad that the utility
of the elastic ligature had been brought forward by Profes-
sor Dittel after it had quite fallen into oblivion.

Ligatures of thread have been employed for a great many
years, even, we may say, from the time of Ambrose Pare, for
cutting through certain structures, mainly arteries ; but
haemorrhoids, naevi, warty and pedunculated growths have
constantly been removed by the application of a ligature,
and the reason it has not been removed by the application
of a ligature, and the reason it has not been more extensively
available has arisen from the fact that only a comparatively
limited thickness of tissue can be cut through by one appli-
cation of the ligature, which, as suppuration takes place,
becomes loose, and then does not penetrate further unless it
be re-tightened; it is therefore only small and soft growths
that can be safely and advantageously treated by the inelastic
thread ligature.

Various means have been devised to overcome this
inherent defect, and make the thread ligature cut, by con-
stantly Oi frequently tightening the thread; such means are
shown in Ricord's instrument for the treatment of varicocele;
Mr. Luke's double screw, which he invented for cutting
through rectal fistulse which ran so high up the bowel as to
be considered dangerous of division with the knife. A
variety of methods, of which a spiral spring is the essential
have also been employed, from a wooden spiral-spring letter-
clip up to the very ingenious sarcotome of Dr. Ainslie
Hollis.

To all these methods, comparatively good as they may be,
some very strong objections may be raised. From consider-
able experience, I know that Mr. Luke's double screw,
advantageous as it has proved, causea very intense pain; the
daily or frequent necessity for tightening the ligature inflicts
upon the patient a torture often unendurable, and on many
occasions the knife has had to complete what the ligature
began, the patient being unable to endure the long-continued
suffering. Another very grave objection to the intermitting
application of pressure is the frequency with which secondary



30 FISTULA AND THE TREATMENT BY ELASTIC LIGATURE.

abscesses result. I have noticed this result in my own practice,
and seen it also in that of other surgeons.

Dr. Hollis's sarcotome is very superior to the others in
action, but even this requires tightening or re-setting from
time to time ; it acts likewise only in one direction, and
therefore lacks the even, circular pressure exerted by the
india-rubber. Another important objection is its size and
weight, which render it under many conditions inapplicable.

It must be evident, on reflection, that the pressure of the
india-rubber band or loop is not always the same during all
the progress of the cutting, in fact, it diminishes gradually
as the loop of the ligature becomes less in circumference ;
but practically the pressure up the moment of separation,
if the loop be properly adjusted at first, is sufficient for its
work.

The greatest pressure exerted by a solid india-rubber liga-
ture of the thickness of yV^b of an inch, stretched to the
utmost, only equals 2^ lbs. weight; for example, 6 inches of
india-rubber, when stretched to its utmost, /. e. 3 feet, exer-
cises a power of 2^ lbs.; when stretched to 2 feet only a
little more than i;^ lbs.; and when stretched only i foot, or
double its length, -|- lb.; and even this power is quite suffi-
cient, as shown by experiment, to pass through any ordinary
tissue, in consequence of its unremitting and even pressure
in every direction.

I have for a long time now used only solid india-rubber,
so strong that I cannot break it ; and I put it on as tightly
as I can and fasten it by means of a small pewter clip pressed
together by strong forceps. The ligature cuts through in
about six days, z. e. that was the average time in ninety cases
of fistula. The shortest time has been three days, and the
longest fourteen days, and in the latter case a solid portion
of flesh, three inches in length and two inches in thickness,
was cut through without any tightening of the ligature. You
may be assured that those who find a difficulty in getting the
ligature to cut quickly and painlessly are ignorant of the
proper method of applying it.

What are the advantages of the ligature ? Briefly these,
that in simple cases there is little or no pain inflicted by the
operation ; the patient can walk about without danger. I
have had many cases proving that nervous persons will often
submit to the ligature when they will not to the knife. There
is no bleeding — a manifest advantage in dealing with patients
whose tissues bleed copiously on incision. I have found it



FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. 3I

useful in several such cases. In phthisical cases it is, in my
opinion^ the best means of dividing a sinus. In very deep
bad fistulae the elastic ligature is most valuable as an auxil-
iary to the knife. I now most frequently use it in this way,
avoiding haemorrhage, in sinuses running high up the bowel,
where large vessels are inevitably met with. I have recently
had many examples of this, and have readily and painlessly
divided vascular structures without any danger of bleeding.
In an unusually bad case sent me by Dr. Wm. Price, of Mar-
gate, a timid lady did not know the ligature had been used
until it came away, on the seventh day, as she had absolutely
suffered no pain worth complaining about, and certainly not
more than when the knife is used alone. I have now oper-
ated on eight medical men, and they all have told me that
there had been no pain, and even very little discomfort, from
the ligature, and it had been a great advantage to them, as
they were able to get about in a moderate way and see their
patients. One mistake committed by those who oppose the
use of the ligature is this : they think the wound does not
commence healing unt 1 the ligature has come away; nothing
is further from the truth. When the ligature, if it has been
well applied, has cut its way out, the wound is often very
nearly healed. I beg to refer my readers to a monograph
by Professor Courty, of Montpellier, in corroboration of my
statement. This gentleman has used the elastic ligature fre-
quently, and has been most successful. Now, what is the
great objection to the general use of the ligature in fistula ?
It is this. It is very difficult, or even impossible in many
instances, to be absolutely sure that only one sinus exists.
If there are lateral sinuses, or a sinus burrovv'ing beneath or
higher up the rectum than the main trunk through which
you pass your ligature, the patient will not get well at one
operation. In these complicated cases the knife alone, or
conjoined with the ligature, is the only trustworthy remedy.
So it comes about that surgeons not very au fait in the diag-
nosis of fistula soon get into trouble, and at once condemn
and throw aside the ligature.

I had employed the india-rubber ligature in only a very
few cases before I came to the conclusion that if I intended
operating frequently, or if ever the method were to become
popular, other and better means than those recommended
and used by Professor Dittel must be devised for the intro-
duction of the ligature through the fistula. Professor Dittel
has described several ways of accomplishing the end in view;



32 FISTULA AND THE TREATMENT BY ELASTIC LIGATURE.



all of them appeared to be theoretically imperfect, and I
found them in practice difficult of performance, tedious, and
exceedingly painful to the patient. For complete fistula he
Fig 3. used a probe with an eye near its point,

which was to be passed from without to
within, carrying the india-rubber and a
strong thread, so that if the india-rubber
•5 broke in tying, another ligature could be
•| drawn by the thread through the sinus.
rt Another method was to pass a tubular
â– |j probe ; through the tube a fine wire was
J to be introduced, and the end hooked
^ down by the finger passed into the bowel;
J the probe was then to be withdrawn so
2 that the wire traversed the fistula, one
â– -3 end hanging from the outer opening, the
^ other emerging from the anus ; the India-
's -rubber was then to be fastened to the
,s'i wire and drawn through the fistula. This
^ I was really a very difficult task to accom-
•70 plish; sometimes the wire broke and the
•£J probe had to be reintroduced, it was
o-;^ therefore found better to attach to the
= c wire a piece of strong, thin cord, and
|J draw that through the probe, and then
y> attach to it the india-rubber, which, in
i its turn, was at last got into the desired
^ position. I need scarcely say that this
^ is a very lengthy, as well as painful,
c mode of procedure, as the thin wire or
^ cord cuts the inner opening of the fistula.
•| For cases of incomplete fistula Professor
i Dittel recommends a director to be
- passed as far as possible up the sinus,
•0 and along the groove a sharp needle
^ armed with the india-rubber is to be
carried and the bowel perforated, the
ligature drawn from the eye of the needle
by the finger, and the needle removed.
This, I may remark, if the sinus runs far
up the bowel, is by no means so simple of accomplishment
as it may appear. Being, then, very dissatisfied with these
methods of operating, I set myself to find some better and
simpler plan, and on reflection I came to the conclusion



FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. 33

that the india-rubber could be drawn much more readily
from within the rectum, through the internal opening (or
through an anificial i^erforation in the bowel), than by com-
mencing to pass it from the external opening. This con-
viction led me to devise this simple instrument (which is
shown in the wood-cut) for drawing a ligature through a
fistulous sinus or beneath a tumor, and Messrs. Krohne and
Sesemann have with much care and pains rendered it, in my
opinion, practically, quite perfect.

It consists, as will be seen, in the combination of a con-
cealed hook or notch, with a blunt or sharp-pointed probe,
as the case may require. A shows the curved probe with
the hook concealed by the sliding canula, ready to be passed
through a fistula, or, if a sharp point be substituted for a
blunt one, under a tumor. B exhibits the instrument with
the canula drawn back, and the previously concealed notch
exposed ready to receive the loop of India-rubber; when
this is placed in the notch, the canula is pushed home, and
the ligature is held so firmly that it cannot escape. Thus a
double ligature can be readily drawn through a fistula or
beneath a tumor. It is not necessary, in fistula, to see the
hook, for if the finger, with a loop of India-rubber around
it, be passed up the rectum, the loop can, with perfect
facility, and without the aid of vision, be directed over the
end of the probe and caught in the notch. C shows the
sharp-pointed instrument adapted to the same canula, so
that only one handle and one canula are required to com-
plete the double instrument. It is obvious that with my
instrument a double ligature is carried through the sinus;
this is an advantage, for if the india-rubber breaks as it is
being tied, there is a second ligature to fall back upon. I
ceased, however, to use the knot very soon after making
trial of the ligature, and I now use only a small oval ring of
soft metal; the two ends of the ligature are threaded through
this, the india-rubber is pulled as tight as is required, and
the metal ring is then closed by a strong pair of forceps.
The ring holds perfectly tight, it never breaks the ligature,
never gives way> and the closure is effected in a moment.



34 OPERATIONS ON FISTULA IN ANO.

CHAPTER V.

OPERATIONS ON FISTULA IN ANO.

Before proceeding to operate upon a case of fistula, it is
highly important that the bowels should be well cleared out,
and I preter, whenever possible, to administer a purge three
days prior to operating, and again the night before; an
injection may also be given in the morning.

The patient should be placed on a hard mattress, on the
side on which the fistula exists, the buttocks being brought
quite to the edge, or rather overhanging the edge of the
couch, and the knees well drawn up to the abdomen. I have
no hesitation in saying that, for the majority of rectal oper-
ations, this position is by far the most convenient, both
for the surgeon and the patient, but occasionally the litho-
tomy posture is preferable, as, for example, in performing
excision of the rectum. Now, take a Brodie's probe direc-
tor, made of steel, with a small probe point; oil it and pass
it into the external opening, through the sinus and the
internal opening, if possible; then insert your finger into the
rectum, and on feeling the point of the director in the
bowel, if the patient be not anaesthetized, tell him to strain
down; yon will then be able, without any difficulty, to turn
the point out of the anus. Tins done, the tissues forming a
bridge over the director are to be divided with a curved
bistoury.

If the fistula be deep, running beneath the sphincters, you
will not be able to get the point of the probe out at the
anus, even if the patient be anaesthetized; in such a case
you must pass the director well through the sinus, then
insert your left forefinger into the rectum, steady the
director, and run a straight knife along the groove, catting
carefully toward the bowel until the parts are severed. This
is by no means an easy operation, and requires much prac-
tice and experience to accomplish quickly and without
bungling. To the inexpert surgeon, in such a case, I recom-
mend my deeply grooved director and scissors, which I shall
describe furthtr on ; I may add that gentle dilatation
of the sphincters, under these difficulties, gives the surgeon
an immense advantage, of which I now constantly avail
myself.

If there be no interrial opening, you will almost alw^ays



OPERATIONS ON FISTULA IN ANO. 35

find some part where only mucous membrane intervenes
between the point of the probe and your finger. At this
spot work the director through, and bring down the point as
before. You must not rashly thrust the point of the probe
through the mucous membrane, or you will wound your own
finger; this accident may always be avoided by a little gentle
and patient manipulation, even when the tissues are indur-
ated. When you have divided the fistula from the external
to the internal opening, search higher with the probe for any
sinus running up beyond the internal opening; if this exists
you should lay it open.

I know many authorities have stated that it is only neces-
sary to incise the fistula between its external and internal
openings, and that the sinus above the internal opening will
spontaneously close; my experience is most decidedly
opposed to this statement.

In the great majority of cases you will not cure your
patient unless you lay the whole sinus open, from end to
end. Over and over again I have left the sinus above the
internal opening uninterfered with, and almost invariably
have had to regret having done so, and to perform a second
operation. It constantly occurs to me, at St. Mark's, to
treat cases which have been operated on at other hospitals,
the upper part of the sinus having been left and the patient
not being cured. In such cases fresh or continued burrowing
takes place from the upper track, and a second operation,
often more severe than the first, is rendered necessary. It
needs scarcely be said that in private practice this is very
damagmg to the surgeon's reputation.

Having, then, opened the fistula in its whole length upward,
search for lateral sinuses extending from the outer opening;
also see if there be any burrowing outward beyond the outer
opening. A fistulous orifice is only not at either end of the
sinus, but somewhere in its course. Examine carefully to
see if there be a secondary sinus running from and beneath
the track of the main sinus. Frequently, in fact nearly
always, in old standing cases, the deeper sinus does exist,
and unless it is incised with the rest the patient will not get
well.

Here, again, some surgeons have asserted that it is unnec-
essary to divide any but the principal sinus, for that if this
is done the rest will heal. On this point I cannot speak
too strongly. I am certain you can never guarantee the
healing of a fistula so long as any lateral or deep sinuses



36 OPERATIONS ON FISTULA IN ANO.

remain; and so long as they do remain fresh sinuses are apt
to form. As a rule, the best plan is to lay open the original
sinus first and the tributary ones afterwards.

It is impossible, in any work, to do more than lay down
general rules; every case will call more or less upon the
surgeon's knowledge, dexterity, and prudence; but in thus
strongly expressing my opinion, contrary to the dicta of
many eminent men, I can only say that I am stating what
I see almost every day to be the truth.

When all the sinuses are slit up, with a pair of scissors
take off a portion of the overlapping edges of skin; they
are often thin and livid, having very little vitality. If not
removed, they will fall down into the wound and materially
retard the healing process. I have frequently induced
healing in a fistulous track which had been only laid open,
by paring off the edges of the skin which were undermined.
It must be observed that I am not advocating ''the cutting
out of a fistula," as it used to be called; I am only recom-
mending the removal of any overhanging, undermined,
degenerate skin. When several sinuses have to be laid open,
I am in the habit of carefully preserving islets of skin from
the edges of which granulations will take place, and by which
cicatrization is materially hastened. Indeed, I have in many
cases practiced skin-grafting with good results, though fail-
ures have not been infrequent. In old-standing cases, where
there is much induration, it is very good practice to draw a
straight knife through the dense track of the fistula, and out-
ward beyond the external opening; it is wonderful how rap-
idly quite cartilaginous hardness passes away after this has
been done. This incision was commonly practiced by the
late Mr. Salmon. He called it his "back cut," and although
if carried to excess incontinence of faeces may result, I have
no hesitation in saying that Mr. Salmon cured many cases
by this means where other surgeons had failed.

Having completed your operation, take some finely carded
cotton wool, and with a probe pack it well into the bottom
of the wound, packing it into every part, and being the more
particular about this if your incisions have been extensive,
or pass high up the bowel, or if the parts are very dense
and gristly, as they are in old fistulae, and especially in cases
operated upon for the second time. A good, firm pad of
wool should then be placed between the buttocks, over the
wounds, and a T-bandage firmly applied. With these pre-
cautions you need never fear haemorrhage, for if the bleed-



OPERATIONS ON FISTULA IN ANO.



37



Fig. 4.



ing be thus arrested by pressure at first all will be well;
if, however, the wool be carelessly stuffed into the bowel
without method, it will not be placed evenly at the bottom
of the wound, and then, as soon as the patient rallies from
the shock of the operation bleeding will recommence, and
both patient and surgeon will be put to much annoyance,

and probably some anxiety.
Of course, if you see a large
vessel spurting at the bot-
tom of a wound it is best to
close it by torsion ; when,
however, the track of the
fistula is very callous you
cannot twist the vessel, and
a ligature may then be ap-
plied. By careful atten-
tion to the details above
given, a sinus may be open-
ed to any possible distance
up the bowel, or in any
direction or depth, without
positive danger, but on the
whole, for very deep, bad
fistulae, the elastic ligature
is, as I have before said,
generally to be preferred.

If the rectal sinus runs
up so high and the parts
are so dense that you can-
not get the point of your
probe-director out of the
anus, and you prefer to cut,
the safest and easiest way

It should be observed that the scissors can ^f operating is with the
only be removed from the groove by drawing 10 ^ '-'^^^

them out towards the handle of the director.

At the side is shown the strong spring scissors
sed. at St. Mark's Hospital in the operation

upon internal hemorrhoids. and first made by Ferguson,

of Giltspur street, London; with this instrument you can
divide fistulae high up the bowel, however dense they may