CHAPTER IX – RECTAL FISTULA PROMPTLY, COMPLETELY, AND PERMANENTLY CURED BY MEANS OF CARBON DIOXIDE APPLICATION
In January 1903, I published in the New York Medical Journal my first case of successful treatment of rectal fistula by means of carbon dioxide gas application:
CASE I. I. A, 34 years of age. Dancing master. Married; father of three children. Family history good. General condition fair. Active, industrious man; has, in spite of great suffering, worked very hard to support his family and aged and infirm relatives. He came to my office on December 29, 1902, to be treated for fistula in ano. Had been suffering from constipation for as long as he could remember. When twenty-two years of age he became afflicted with hemorrhoids and these have given him trouble ever since. When the piles protruded he used to reduce them by means of a damp, hot cloth. In June 1902, he noticed a discharge in the anal region. Before this discharge was noticed, and ever since, defecation was exceedingly painful, and there was always considerable straining. A bearing-down pain would sometimes last from six to seven hours, no matter what position he assumed—sitting, standing, or even lying down. There was also experienced a peculiar trouble on urinating; as soon as the desire to urinate made itself felt, the patient had to seek quickly a place of security, because with the desire to micturate ended all control over the sphincter vesicæ.
The patient was so nervous that he dreaded examination and I had to promise not to cause any pain. I found a fistulous opening posteriorly and within an inch from the anal margin near the median line, from which there was some discharge. As the opening was very small, I inserted a probe with great care, so as to cause as little pain as possible, but did not pass it through the whole length of the sinus, because I had promised to cause no pain. The history and the appearance, however, convinced me that I had to deal with a complete rectal, or if you prefer it, anal fistula. I advised operation, as some colleagues, who had seen the patient before me, had also done.
After the patient had left my office it came to my mind to try the application of carbon dioxide gas, first, to make sure that there was communication with the rectum; and secondly, to see what effect the gas would produce when passed through the sinus.
Twenty years ago I had demonstrated urbi et orbi that carbon dioxide gas applied to inflamed mucous surfaces of the rectum, vagina, or nose, was an ideal remedy, and all my experience during the two decades since passed has confirmed my observation more and more. Altho I have published all I have noticed in regard to this method of treatment from time to time in different journals, in different countries, and in different languages, and altho I have asked many professional friends personally to give the method a trial, I have as yet heard neither a single confirmation nor a single contradiction of my experience. I may, perhaps, be excused for this digression; it may serve to illustrate how difficult it is to introduce a novel idea.
An experience I had had in a case in which morphine injections had left numerous abscesses on the surface of the body where the needle had been used, and in which the carbon dioxide gas current, turned on or rather into these abscesses, had had a prompt curative effect, after ordinary antiseptic treatment had been rather unsatisfactory, suggested to me to try carbon dioxide gas in case of fistula.
On December 30, 1902, I passed a current of gas through the external opening. There was no other pain than that caused by the insertion of the nozzle of a common dropper which I had attached to the rubber tube conducting The irritation of the external orifice caused by the insertion of the dropper caused a slight hemorrhage—perhaps one drop of blood. Except for this, the application of the gas gave rather a pleasant sensation. It passed through the sinus into the rectum, filling the bowel up to its full capacity and causing thereby the agreeable sensation of warmth that is noticed when the gas is introduced directly into the rectum.
December 31. The patient spoke in the most enthusiastic terms of the relief experienced. He felt like a new man. There was no discharge; the parts around the fistulous opening were, indeed, perfectly dry, which they had never been since June. The bowels had moved freely and there had been no pain on defecation. From that time to the present there has never been any abnormal condition on micturition. The soreness of the tissues around the fistula had disappeared. Only a little blood from the granulations on inserting the nozzle.
January 1, 1903. Gas applied. There had been no pain or straining with defecation.
January 2. Gas applied. He had passed hard fecal matter, straining at the beginning of defecation; but by no means to be compared in severity with what he had experienced formerly. Before the gas treatment, he had been unable to clean himself after stool except by dashing water over the anus, the parts were so sensitive; now he could use toilet paper. No blood on inserting the nozzle. From the first application the sinus began to close, and with the third, very little, if any, gas passed into the rectum.
January 3. No discharge from fistula. The patient had had difficulty with piles. Feces had been hard. Piles protruding. Rectal cone, to reduce the hemorrhoids; compound licorice powder to soften feces.
January 5. The application of the gas current into what was left of the sinus brought away a plug of thick, yellow pus the size of half a pea, or less. It was demonstrated today that no gas entered the rectum.
January 6. Had had considerable pain on defecation. Bowels had been very loose, diarrhea-like, the result of the licorice powder. The pain was felt at the outlet of the former fistula. There was some thin matter and some thick, from the rest of the sinus. Absolutely no pain anymore, except during defecation.
January 7. No evacuation of bowels. Fistula closed.
January 8. Hard stools; great straining, but without pain.
January 9 and 10. Gas has been applied daily to the fistula since January 1, up to the present date, when it will no longer enter. The rectum is now to be inflated daily with carbon dioxide gas, to heal the internal ulceration, if such is present. Regulation of stool by means of compound licorice powder. Rectal cone to reduce the hemorrhoids.
I confess I have not had the opportunity to make a thorough examination of the rectum, either digitally or by means of the speculum or proctoscope, but for practical purposes, I may arrive at the exact diagnosis ex juvantibus. It appears to be a case in which hemorrhoids became ulcerated; this ulceration caused the abscess and the abscess caused the fistula.
January 12. I have today seen this patient, who describes his present condition as one of elysium compared with the past. Formerly, he was unable to sit down long enough for his meals; his agony was very great, and he had suffered thus for years. Now he has no pain whatsoever, on defecation or otherwise. His bowels move painlessly once or twice a day. He is still taking the licorice powder, and inflating the rectum, but the rectal cone has not been since applied, as the hemorrhoids have given him no further trouble. I advised him, however, to continue its use to reduce the hemorrhoids. The fistula is completely and entirely closed and healed.
January 22. All these days patient has been free from pain, bowels have moved regularly. Digital examination revealed a considerably enlarged but soft, almost fluctuating prostate. Upon inquiry, I learned of a gonorrhea that the patient had had twelve years ago. Ordered introduction of a rectal cone with warm water passing through it several times a day.
January 27. No more trace of fistula but cicatrix. The introduction of the rectal cone had been difficult, on account of a resistance (by the prostate), the bowels had been inclined to constipation, and defecation was sometimes painful. Urine passed into two glasses furnishes conclusive evidence of prostatitis; the one in the first glass being turbid to a high degree, the one in the second perfectly clear.
My second case was that of a tuberculous fistula, but here the carbon dioxide gas did not have a curative effect. The same negative results I had with complicated fistulas with multiple sinuses and numerous openings through the skin, mucous membrane, or both, where the sinuses extended for a considerable distance beneath the mucous membrane, partially or completely around the bowel or to distant organs, as it occurs most frequently in syphilitic or tuberculous subjects.
Only in cases of simple complete fistula with two openings, one upon the surface of the body in the neighborhood of the anus and the other in the rectum, that is, the most common form of rectal fistula, have I succeeded.
The last case I treated successfully is the following:
A.H. 59 years of age, tailor, father of a large family, came to my office on October 16, 1904. Complete rectal fistula, five centimeters to the right from the anus, discharging for one year pus and serum and causing much pain. The probe entered the rectum in a straight direction. Around the external orifice of the fistula, the tissues are very much indurated, almost callous. Carbon Dioxide gas introduced into the sinus entered the rectum. The patient lives at a great distance from my office and came only in intervals of three days to have the gas applied.
After the third application, no more gas entered the rectum. When he came the fourth time, the tissues around the external orifice had lost their induration almost completely, and the sinus was so shallow that hardly any gas could be introduced. Having been at my office six times, I dismissed him, perfectly cured of his trouble, and when I saw him last, during the month of December, I learned that the cure has been a permanent one.
As I have demonstrated as long as twenty-two years ago, carbon dioxide gas applied to inflamed mucous surfaces of the rectum, vagina, or nose is an ideal remedy, and all my experience during the two decades since passed has confirmed my observations more and more. The local effect of the carbon dioxide gas on ulcerated surfaces is twofold. By its anesthetic action it relieves pain and tenesmus, and by its stimulant action on the circulation, it is healing.
The only drawback which seems to be in the way of this treatment becoming favored by the great specialists on rectal diseases is that it is too simple, too rational, and its explanation too clear.
All that is required is the simple gas generator, a glass bottle with a wide neck and a rubber stopper perforated so as to admit a tube with a nozzle, in which the carbon dioxide gas is generated by means of a solution of bicarbonate of soda and crystallized tartaric or citric acid (see Fig. 2).
It may be of interest to those who are not familiar with the history of the treatment of rectal fistula to read the following little historical sketch:
Hippocrates taught to treat fistula in ano by means of ligature. Galenos and his pupils were opposed to this method and substituted extirpation. The surgeons of the seventeenth century considered the cure of a fistula a very difficult task because they were of the opinion that such a cure could be accomplished only when all pathological, that is, all indurated, tissue would be completely destroyed. The operation had become a very barbarous one, consisting in extirpation of the fistula and all the callosities of the rectal wall in its neighborhood, by means of the actual cautery or some chemical caustics. The consequence was, the patients thus operated on who survived the operation, who did not die in consequence of hemorrhage or pyemia, were either not cured or were left with incontinentia alvi, or anal stricture. They were in worse condition than before the operation. The after-treatment was as complicated as the operation itself.
For this reason, the operation of rectal fistula was much dreaded, and the physicians took all possible pains to cure fistula by other means of ointments, baths, and internal remedies—but, as a rule, without success.
This condition of things explains the fear of Louis XIV., who in the year 1686 was suffering from rectal fistula, and consented to the operation only after all other possible remedies had been tried in vain on many of his subjects suffering from the same evil. He was operated on by his first surgeon, Felix, who invented a new knife, which was afterward called the royal knife. The operation, performed November 21, 1687, was a success.
Dionis, who has reported all details of the case, tells us that afterward many people, not only of the royal court, imagined themselves suffering from the same affliction as their king, in order to have the honor of being cut with a knife which bore the royal name.
Only after Pott, in 1765, had taught that the callosities need not be destroyed and that a simple incision was sufficient to heal the difficulty, did the operation lose its danger and its horrors. Yet, Syme, in the year 1854, complains that there still existed surgeons in England who could not be persuaded to abandon the old method and that he had seen several cases of frightful destruction, which had been caused by rural surgeons operating for simple rectal fistula.
Again and again, have means been tried to cure fistula without operation. None has been successful, but here now is a problem solved which has vexed physicians for thousands of years.
The cases of complete cure of rectal fistula I demonstrated before the German Medical Society of New York, January 2, 1905. In the first case two years, and in the second two months, had elapsed since the complete closure of the fistula.
CHAPTER X – CARBON DIOXIDE IN CHRONIC SUPPURATIVE OTITIS AND DACRYOCYSTITIS
1. Otitis (inflammation or infection of the ear)
Knowing from history that carbon dioxide had been successfully employed in purulent otitis, I was anxious to see it tried in this affection. Dr. Duncan Macpherson, to whom I suggested such trial, had the courtesy to comply with my wishes, and I am indebted to him for the following notes of three cases which he has treated in the outdoor clinic of the New York Post-graduate Medical School. The apparatus used by Dr. Macpherson was the new cylinder of the Kny-Scheerer Company, which contains about two pounds of liquefied carbon dioxide and which works to perfection, as the current of gas can be accurately regulated. The gas is passed through a catheter introduced into the Eustachian tube.
The first case was that of a girl 9 years of age, who had a running ear for nine months following scarlet fever. The treatment consisted of sterile water syringing at home, at first every four hours, as the discharge became less profuse three times a day, then twice a day, and finally once a day. Carbon dioxide gas was employed in the clinic twice a week. The discharge was arrested in three months. She had not been treated before she came to the clinic.
The second case was in a girl 7 years of age. Discharge followed an attack of influenza six months before. Treatment was the same as in the first case; it lasted two months. Discharge lessened greatly, and, according to a recent report made by the mother, it has now ceased entirely.
The third case was in a boy. Discharge followed the opening of the mastoid process for the cure of empyema. The operation had not been successful. This case has been under treatment for about four months. Necrotic bone is present, and the carbon dioxide treatment has, as it appears, not done any good.
No microscopical examination of the pus has been made in any of these cases.
2. Dacryocystitis (inflammation of the tear sac)
During spring, 1905, I was attending some patients, man, and wife, who came to my office from some distance, from the State of New Jersey. They incidentally told me of their son, twelve years of age, as being afflicted with purulent dacryocystitis. He had been treated during eighteen months in some New York ear infirmary, had been operated upon, and frequently probed. The purulent discharge, however, had persisted. I induced the parents to bring the child to my office. Judging from the effect of carbon dioxide in cases of rectal and other fistulas I decided to try it in this instance, being convinced that no possible harm could be done thereby. I introduced it from my simple gas generator to the tube of which I had attached an ordinary dropper. The gas current directed into the lacrimal canal brought up a great amount of pus, but caused no discomfort to the patient. I entrusted the parents with this simple method of treatment. I saw the patient at weekly intervals twice again and convinced myself that the inflammatory symptoms had subsided, that there was no more pus. As the parents told me, there had been none since they had applied daily, according to my instruction, the carbon dioxide current.
I can not make a report of the final result as the parents, not appreciating perhaps the extraordinary interest I took in the case, did not give me any other information than that the improvement had been great, that altho there was some lacrimal humor occasionally, there had been no more pus.
Being anxious that this observation should be verified by an ophthalmologist, I addressed myself to Dr. Frank Newton Irwin, who, like Dr. Macpherson, had the courtesy to give the carbon dioxide treatment a trial in the clinic of the New York Post Graduate Medical School, and who also had the kindness to give me the following notes of two cases:
Mrs. F. D, aged 56, has had recurrent attacks of purulent dacryocystitis for ten years. Says she had been operated on and probed at irregular intervals during these ten years. Came to the clinic first two years ago. Dr. Irwin found the lacrimal canal closed; he could not introduce a fine probe. Pus could be squeezed out by making pressure upon the lacrimal sac. The canal was then opened into the nose with Bowman’s knife, and twice or thrice a week the canal was probed into the nose with large probes. Probing was frequently accompanied by the application of silver nitrate, argyrol, and other solutions. While drainage was kept free the purulent discharge persisted. Four months ago (i.e., in March 1905) Dr. Irwin commenced carbon dioxide treatment, introducing the gas from the Kny Scheerer cylinder, to which the tip of a lacrimal syringe had been attached, into the sac and He used the gas twice a week for three months, at the end of which time there was no more pus.
Miss S. H, aged 25. Says she had lacrimal abscess six years ago. Was treated by ordinary methods of probing. Pus always present. Treatment kept up for several months. Abscess would recur. When Dr. Iwrin first saw this case the lacrimal sac was full of pus, nose draining out through a fistula on the face, half an inch below the lacrimal opening. He treated this case for several months by probing, making irrigations, and applying astringents, but could not get rid of the pus. Commenced using carbon dioxide gas about three months ago (April 1905). The gas was introduced through the tip of a lacrimal syringe—into the fistula, into the sac, and into the nose twice a week for three months. Result, no more pus. Probing was continued in both cases.