The method of employing the ligature is as follows: A solid India-rubber cord about one-tenth of an inch in diameter is threaded to a probe having at one end a rounded opening or eye through which the ligature is passed. The probe enters the fistula from the external to the in ternal opening, and passes out through the anus. To facilitate the passage of the cord, the rubber should be put on the stretch. After the ligature is passed a soft metallic ring is slipped over the two ends of the cord; the cord is then tightly stretched and the ring slipped up as high as possible and clamped. If the internal opening be any distance up the bowel, the instrument devised by the Ailing hams facilitates the passage of the liga ture. It is intended to draw the cord from the bowel out of the external orifice, and not vice versa. Frequently by the time the cord separates the wound has become quite superficial.
-After the opera tion the wound should be packed with iodoform gauze and left undisturbed for twenty-four hours, to prevent subsequent hemorrhage. A pad of gauze, over which carbolized oil is spread, and cotton and a T-bandage are next applied. The subsequent dressing of the case should be daily attended to by the surgeon him self. The parts should be kept perfectly clean, and the wound syringed with peroxide of hydrogen; carbolic-acid solu tion, 1 to 80; or a 2-per-cent. solution of creolin. After this a single piece of iodoform gauze laid between the cut sur faces of the wound will be all the dress ing required. The healing process may be greatly retarded by excessive packing of the wound with lint, or delayed by the undue use of the probe. Such inter ference is to be avoided. If the granu lations be sluggish and the discharge be thin and serous, it will be well to apply some stimulating dressing such as resin cerate with 20 grains of iodoform to the ounce, or a weak solution of copper sul phate (2 grains to the ounce), etc.
The surgeon should be on the watch during the healing process to avoid any burrowing or the formation of fresh sinuses. Should the discharge from the surface of the wound suddenly become excessive it is evident that a sinus has formed, and a careful search should be made for it. Sometimes it begins under the edges of the wound, at other times at the upper or lower ends of the cut surface, and occasionally it seems to branch off from the base of the main fistula. Pain in or near the seat of the healing fistula is another symptom of burrowing; when complained of, the surgeon should carefully investigate its cause.
After an operation for fistula the pa tient's bowel should not be confined by the use of an opiate. The natural dread on the part of the patient, of experi encing pain, the result of a movement of the bowels, will be sufficient to in hibit any action, and the usual experi ence of the rectal surgeon is that a laxa tive will be required. The bowels should
be moved on the third or fourth. day. So soon as the patient feels a desire to go to stool an enema of linseed-oil (6 to 8 ounces) should be given, which will tend to render the faces soft and fluid and hence render their passage easier. The patient should be kept in a recum bent posture until the fistula is healed; and until the bowels are moved the diet should be liquid: milk, beef-tea, and broths. The time required for a patient to recover after an operation for fistula in ano varies with the extent of the dis ease. In an average case it will be neces sary to keep the patient in bed for two or three weeks and confined to the house for several weeks longer. Many cases may be operated on in the office under local anaesthesia; such cases may get well without being confined to the house.
3luch haemorrhage rarely follows an operation for fistula, but in some cases it may be necessary to ligate a large ves sel. If there should be a profuse general oozing, the sinus may be packed with iodoform gauze, or, if necessary, the rec tum may be plugged; for this purpose the Allinghams tie a string into the centre of a large, bell-shaped sponge, which is passed into the bowel so as to prevent the blood from escaping upward into the colon. They then firmly pack the parts below with cotton dusted with powdered alum or persulphate of iron. In order to allow the escape of flatus, a catheter may be passed through the centre of the sponge. As a rule, all haemorrhages following rectal operations are easily controlled by mild measures, such as the local application of hot water, of ice, or of some mild astringent.
Incontinence of forces is happily of rare occurrence, and follows only ex tensive operations, especially those in which the sphincter has been divided more than once. When it exists to any extent, it is productive of great annoy ance to the patient, possibly more so than the original fistula. The application of the small point of the Paquelin thermo cautery to the cicatrix of the operation wound will often suffice to relieve this trouble, by causing contraction of the anal outlet and giving tone and increased power to the sphincter-muscle. The Allinghams recommend for this condi tion freeing the ends of the muscle by a deep incision through the old cicatrix and allowing the wound once more to heal from the bottom by granulation. Kelsey advocates complete excision of the cicatrix, exposing freely the divided ends of the sphincter and bringing them together deep sutures, exactly as in cases of lacerated perineum.