ANUS, Fistula of.
In blind external fistula, an attempt may be made to induce healing before resorting to incision by applying a strong solution of Zinc Chloride on a probe coated with a thin layer of wool, or strong Carbolic Acid may be used in the same manner. Beck's warm Bismuth Paste may be injected. The writer has seen healing occur after repeated injections of undiluted Tinct. lienzoin. Co. When these fail, as they usually do, a free T-shaped incision may be made, and sometimes this is all that is necessary, though usually the sphincter will require division at the same time, and the thorough scraping of the tract, which must be exposed and dissected bit by bit in search of a hidden internal opening.
In complete fistula a probe-pointed director is inserted into the skin orifice, and gently made to enter the bowel through its internal opening. The po.nt is then hooked down by the finger in the rectum, and brought through the anus. The next step is to pass a curved bistoury along the groove, and divide at one stroke the intervening tissue—mucous mem brane, sphincter and skin. The cul-de-sac above its internal opening is next divided from the internal surface, after which the entire fistulous tract should be dissected out; and where this is not possible it must be thoroughly scraped, so as to completely destroy its internal lining. The incised surfaces should be minutely examined for evidences of secondary tracts or tunnels, and these must be excised or scraped, but the sphincter is only to be divided_by the one clean incision across the direction of its fibres. The wound is finally packed firmly with Iodoform or Sublimate gauze, over which a pad of absorbent tissue is bound by means of a T bandage. At each daily dressing the fresh gauze should be inserted to the
very bottom of the wound, so as to encourage granulation from below, and prevent union of the lips of the wound near the surface. It will be evident that upon this careful after-treatment, which often falls to the patient's ordinary medical attendant, depends the prevention of relapses or return of the fistula. The bowel should be empty at the time of operation, and a motion by the use of Castor Uil or enemata should be effected upon ate second day, and all through the rest in bed, in order to avoid hard scybala.
Blind internal fistula is treated in practically the same way as complete fistula. The inner opening being detected by the finger just inside the sphincter, a probe-pointed director is passed into it, and the point made to bulge or project through the attenuated cutaneous roof of the tunnel, after which all the tissues between the skin and the director are to be divided by a curved bistoury as just described, and the fistulous tract excised or scraped before the wound is packed with lodoform gauze.
Where any of the varieties of fistula are found in patients far advanced in debility by phthisis, diabetes, or hepatic cirrhosis, the use of the knife must be avoided, save to incise the boggy skin over the roof of a blind internal fistula; the best method of treatment will then lie in injecting Beck's Bismuth Paste (liquefied by heat) through a fine -nozzled syringe daily .nto the fistulous tract.