Certain superficial or marginal fistulae following fissures, or slight trauma, or very small abscesses, may heal, and heal permanently, if left to themselves and kept perfectly clean. Such cleanliness, however, must be persistent and scrupu lous. Not only must the parts be washed at least once daily, a-nd more often in warm weather, but they must be cleaned carefully after each movement of the bowels, and should be irrigated with some mild antiseptic or astringent, such as myrrh-wash or dilute liquor plumbi subacetatis. After the washing they must be made and maintained perfectly dry. After wiping out the sinus, filling it with some inert powder or with powdered boric acid is at times of un doubted benefit. Blake (Boston Med. and Surg. Jour., Sept. 2, '97).
— The sur geon should examine the patient care fully, not only locally, but also as to the state of his general health, for fistula in ano is not infrequently complicated with other lesions which may render operative procedures inadvisable. Thus, when a fistula is associated with a stricture of the rectum of a malignant nature any operative interference on the former le sion will be out of the question. If it be a simple stricture and its existence be not recognized, or if it be not treated, any operation performed on the fistula will usually fail to effect a cure.
a number of instances the operation which is sanctioned by ex perience as the most prompt, certain, and safest in its results is to lay open the sinus into the rectum, dividing with the knife all the tissues intervening between its cavity and that of the bowel. The bowels should be moved by means of castor-oil or some other mild cathartic on the day preceding the operation, and on the morning of the latter the lower bowel should be evacuated by means of an enema.
After etherization the patient should be placed on the side on which the fistula exists, the buttocks being brought to the edge of the table. Occasionally the lithotomy posture is preferable, as in cases in which there is a complex fistula. The first step in the operation is to dilate the sphincter-muscles slowly, but steadily, by introducing the thumbs into the rectum, back to back, and mak ing gradual pressure around the anal ori fice until the muscular contraction is overcome.
In dealing with complete fistuhe flexible probe-pointed director is passed through the sinus, and is then brought out of the anus by means of the forefinger of the left hand introduced into the bowel. The tissues lying upon the di
rector are then to be divided with a sharp bistoury. A careful search is now to be made for any diverticula, which, if found, should be divided. If none exist, the granulations lining the track should be scraped or cut away. The healing process will be greatly facili tated by removing with scissors all over topping edges of skin and mucous mem brane. If the internal opening be more than an inch from the anus, a probe pointed bistoury should be introduced into the fistula upon a director and its point made to impinge upon a finger placed in the rectum. As the finger and the instrument are withdrawn, the neces sary incision is made. Or the director can be passed through the sinus and a wooden gorget inserted into the bowel, after which the track can be divided with an ordinary bistoury. The gorget pre vents the opposite side of the bowel from being injured should the knife slip.
When the track of the fistula is much indurated and considerable force is there fore required to make the incision, it will be better to perform the operation by means of Allingham's spring-scissors and special director. With these instru ments, fistuhe running high up in the bowel may be divided no matter how dense they may be. The director is made with a deep groove, the transverse sec tion of which is more than three-quar ters of a circle; in this the globe-shaped probe-point of one blade of the scissors runs. When placed in the groove the blade cannot slip out. The director hav ing been passed through the sinus, the forefinger of the left hand is introduced into the bowel, and the probe-pointed blade of the scissors is inserted into the groove of the instrument and runs along it, cutting its way out through the dis eased tissue as it advances, the finger in the bowel preventing healthy struct ure from being wounded.
A frequent error in operating on fistulous cases consists in not keeping to the sinus, the director being pushed through the track-wall, and then being free to roam about in the cellular tissue of the part, at the operator's will. In this manner a portion of the fistulous channel is left, and an unnecessary amount of the tissues is divided. Such a mistake can always be avoided by tak ing plenty of time in performing the op eration and by careful sponging of the sinus as it is laid open, in order to follow the track of the granulation-tissue En ing it, which by this simple means is freely exposed to view.