These possibilities have caused surgeons to busy themselves, for long, in attempts at overcoming them. On the one hand, in order to get rid of contact with the contents of the intestine, and to control the move ments of the rectum, protracted constipation has been advocated, the bowels having been thoroughly cleansed before operation. Recent authors, Simon, and later Hegar and Kaltenbach, have objected to this constipa. tion-method. Without question the first movement from the bowels after ten to twelve days constipation, and the pressure on the line of union by the hard fzecal masses, are strong reasons for objecting to the method. On the other hand, the maintainance of diarrhceal discharges is not to be advocated, on account of the ease with which fluid fiecal mat ter may penotrate into the wound. Hegar and Kaltenbach recommend the following procedure: Before the operation the bowels shonld be thoroughly emptied; for the first three days after operation the diet should be milk and soups. On the evening of the fourth day, about one and a half grains of calomel should be given, and on the next morning a glass of bitterwasser. As soon as the bowels begin to move the rectum should be explored, and hard scybala are to be removed by the finger or else soft ened by an enzerna. On the following days a glass of bitterwasser in the morning generally suffices to move the bowels without difficulty. In order to prevent pressure and traction on the fistula by collection of gas and fwces in the rectum, and in order to control the movements of the lower rectum, R. Liston and Copeland have advocated incision of the sphincter ani, a procedure which has found advocates in Baker Brown, Richet, and Demarquay, while Dieffenbach and Simon have rejected it. Simon stated that the same aim could be attained by dilata tion of the sphincter, and that incision was therefore unnecessary, and in an instance which he has recorded where the sphincter was incised, he noticed that twelve hours after both gas and water were retained. Al though in this instance it is apparent that the incision may not have been properly clone, it follows from Simon's results that dilatation will suffice.
As far as I know, no one has treated of the operation for the repair of rectal fistuke better than G. Simon, and I follow his description. The opera tion may be performed either from the vagina in a similar manner to that for the repair of vesical fistula, or else after incision of the perineum by the rectal suture, or finally from the rectum.
1. Denudation and Suture from the Vagina.—To expose the fistula Simon recommended. a fenestrated speculum, but this instrument narrows the space and makes the vaginal wall too tense, and for these reasons it has not been generally used. The depression of the anterior vaginal wall by an elevator, and similarly the lateral walls by retractors, and the pulling down of the posterior vaginal wall by forceps or tenaculum, or by the finger of an assistant in the rectum, these measures suffice for expos ing the fistula except where it is fixed by cicatrices or there exists stenosis.
When the shape of the fistula allows, the attempt should be made to cause transverse union, since thus we may expect less traction on the united edges. The d.enudation is funnel-shaped, and many interrupted sutures are inserted, or else a number of superficial and deep. Either fine silk or wire should be used, and results have been obtained with catgu t.
2. Incision of the Perineunt from the Fistula and Trtangular Union. —This method, which has been resorted to in case of large fistulEe, such as those which exist from incomplete union of a laceration of the perineum extending into the rectum, Simon has also used and recommended in ease of small fistula3 when they are in the perineum and in its immediate neighborhood. In such instances obtaining union by simple denudation is often a very difficult matter, while after incision of the perineum it is far easier to denude, and traction from the perineum is done away with. This traction must be carefully guarded. against, further, by not inserting the perineal sutures too deeply. Dieffenbach's objection that incision of the perineum caused a large wound with consequent greater risk of non union, and with increase in the size of the fistula, has been proved un tenable by Simon's results, and the everyday good results from plastic operations speak in favor of this method in case of fistulm which occupy this locality 3. Operation from the Rectum —Failures in operations from the vagina, and in order to cure a transverse fistula in the upper third of the recto-vaginal septum, led Simon to attack the fistula from the rectum where the posterior rectal wall is readily accessible. This aim is readily
attained under deep amesthesia, the rectum being exposed by Simon's large spoon-shaped speculum and lateral retractors, and the anterior wall being pulled down by two double tenacula. (Fig. 35.) With the patient in the dorsal position the anterior rectal wall appears transversely and pos teriorly across the anus. Careful denudation may be controlled by the vagina. The sutures are inserted from within outwards, from the vaginal surface towards the rectal, about I cm. from the border of the wound on the vaginal side, and issuing at the edge of the border on the rectal side. In this way prolapse of the rectal mucous membrane between the edges of the wounded surface is prevented. The sutures are knotted in the rectum, and Simon removed them from the vagina owing to the difficulty of so doing from the rectum. Herein I cannot agree with him, and I question if the advice is acceptable. Simon claims that this method is the only one which assures exact union in case of fistulm in the upper third of the recto-vaginal wall.
According to Emmet the operation per rectum is only applicable to small fistula3 where the defect is greatest in the vagina and the edges can not be approximated from the vaginal side. In these instances an inci sion may be made into the mucous membrane on each side of the fistula, and parallel to the axis of the canal, in order to overcome tension, and then the operation from the vagina is the simplest method and most likely to be followed by good results, the hemorrhage being less and the sutures not tearing out so readily. Emmet notos a further indication for the operation from the rectum. When, as the result of sloughing after pro tracted labor, a vesico- and a recto-vaginal fistula exist in the midst of con tracted cicatricial masses, it may happen that the vesical fistula can be well exposed and operated upon, while the rectal fistula is concealed behind the cicatricial masa This mass should not be incised in order to expose the fis tula, since it answers the purpose of assisting in causing retention of urine by keeping the urethral walls in contact. In such instances the fistula must be closed from the rectum, or else, when this is not possible, froni the vagina, without eyesight, however, but under the guidance of the finger. This is a difficult procedure, of course, but Emmet has succeeded in a number of instances.
In my opinion Simon is deserving of our thanks chiefly for pointing out the methods after which it is possible to cure these recto-vaginal fis tuke. The choice of method will vary with the case, and it will be differ ent according to the locality and form of the fistula. Strict rules for each case cannot be formulated. Winckel's case, to which we have referred, proves that under circumstances even large fistulie, deep-seated, can only be attacked and even cured from the vagina. In case of small fistulal the median division of the septum it is advisable to attempt cure by sim ple denudation before incising the perineum, and the same holds for fis ttil near the perineum. Ordinarily one or another of the methods advo cated by Simon will be followed. Oce,asionally, in case of fistulw with thin edges in the median division, it may be advisable to attempt to cover them by a plastic operation with folds from the vagina, as Kidd did in case of vesico-vaginal fistula. Matirer records a case of cure by trans plantation of a fla,p of rectal mucous membrane over the denuded fistula after having split the sphincter. In other instances cicatrices must be divided in the rectum or in the vagina before resorting to operation. Further, the sutures may be passed from both sides, those towards the rectum being of very fine carbolized silk or catgut, and those towards the vagina being stronger, more numerous, and including more tissue. The sutures should always be removed from the side where they are knotted or twisted. The time for removal depends on the material, according to ordinary surgical rules. In addition to the methods of treatment which we have mentioned, there are others which are largely of historical inter est, such as compression with metallic plates or compresses from the rec tum and vagina (Cullerier, N6laton, Duparque).