The operations of general practice / by Edred M. Corner and H. Irving Pinches.

Date:
1907
    practically free from danger, whilst the risk of recurrence is very small. It is a common practice to leave the stout liga- tures long and not to sew up the mucous membrane. The long ligatures, however, have to be removed by traction, and this is a painful process, whilst they are very uncleanly. Dr. G. R. F. Stillwell, of Beckenham, has urged that the ligatures should not be left at all, the pile being cut away so close to the ligature that it slips off. This is often followed by haemorrhage which must be stopped, otherwise the method is excellent. We would strongly recommend this operation to the practitioner. Its results are excellent and amply repay him. Often in a few days the patient can return to his work. As the operation for haemorrhoids is undergone for definite troubles, such as pain, bleeding, or dirtiness ; and not because of any possible or hypothetical trouble in the future; a patient who has been relieved is truly grateful. Recently, the authors have made a great change in their practice by giving salts, magnesium and sodium sulphates within twenty-four hours of the operation, as suggested by Dr. Stillwell. It is found that such patients can get up earlier and attend to their office or business letters. This is a great advantage to business men and quite compensates them for any slight risk of recurrence. Finally, let the practitioner be on the look-out and guard against the formation of a fissure after the operation, which will mar his results. THROMBOSIS OP HAEMORRHOIDS People will go about with haemorrhoids for years until something like thrombosis, a fissure or strangulation, compels them to submit to operation. In this section we are only concerned with the first of these incidents. It has been contended that what is ordinarily called a thrombosed pile is a small haemorrhage into the tissues. Whichever it is, the pain can be relieved. The patient is given gas whilst lying in the left lateral position, the part quickly washed, the
    thrombosed pile seized, incised, and held open with torceps, the clot removed and replaced by a small plug of cotton wool soaked in 1-2,000 perchloride of mercury. This little plug comes out of itself and gives no trouble. See to the diet and keep the bowels relaxed for the next few days. The operation for the cure of haemorrhoids should not be under- taken whilst the parts are inflamed. The question of its advisability at a later date can be placed before the patient. FISTULA IN ANO The true fistula in ano is a suppurating track which extends from an external opening on the skin around the anus, to an Fig. 94. Sectiou of anal canal showing supex-ficial (b) and deep (a) complete fistulae. internal opening within the bowel. Sinuses having but one opening, either on the skin or within the bowel, are frequently called blind external or blind internal fistulae, in distinction to the complete fistula. Before deciding upon operation the question of the fistula being secondary to advanced phthisis, stricture or carcinoma of the rectum, must be considered. If it is decided to operate, the patient must be prepared both generally and locally, anaesthetized, &c., as described under the operation for haemorrhoids. Though not usually recom- mended, it is best to thoroughly stretch and paralyse the
    sphincter (see p. 178). A director is passed through the ex- ternal opening and along the fistula, the canal being carefully and gently probed until the opening into the rectum is found ; while doing this considerable help is obtained if a finger is passed into the rectum, the internal opening may be felt, when the finger will serve as a guide to the probe. The end of the director, passing through the internal opening and projecting into the rectum, is hooked down by the finger and brought outside the anus, so that the portion of tissue between the two ends of the director is exposed. A cut is then made through this tissue down to the director, opening up the fistula from Fig. 95. Section of anal canal showing blind external (a) and internal (b) fistulae. end to end; as a rule this cut will divide only the external sphincter. The next step is one of the most important in the operation, but is one which is frequently omitted; it consists of exploring the fistulous track and thoroughly laying open every branch and pit leading from it, but the sphinctci must be divided only once. In order to deal with all the diseased tissues in this manner, the main track of the fistula is care- fully examined with the aid of a probe, for side openings ; if one is found a director is passed down it, if it has an external opening the director is pushed through and the tissues div ided down to the director; if there is no external opening, the
    point of the director is pushed through the skin and the bridge of tissue divided as before. All side branches are dealt with in this manner, and all projecting tags of skin cut away. The various tracks are thoroughly scraped so as to remove all unhealthy granulations. The whole success of the operation depends on the thoroughness with which the diseased tissues are exposed; so that, even when no side tracks are discovered, it is a good plan to make an incision at right angles to the original one, in order to completely open up the affected area. All bleeding points are ligatured, but the wounds are not sewn up. It is useless to attempt to pack the cavity as the plugs are displaced as soon as the patient’s legs are straightened, but the wound is covered with gauze, a large pad of wool placed over this, the whole being supported with a T-bandage; the dressings should be changed at least twice daily. After the first or second day the patient obtains considerable relief by sitting for a quarter of an hour, half an hour or even longer, night and morning, in a warm bath ; this helps to keep the wound
    clean, and if the dressing is adherent it can be allowed to soak off in the bath. The bowels should be opened on the third day, and after that a daily motion must be secured. The wound heals from the bottom by granulation, and in doing so a considerable amount of contraction occurs, to such an extent that a lai’ge, gaping cavity becomes converted into a small, puckered scar. Blind externcd fistula. A probe is passed down the track, and if the end of the probe projects beneath the mucous mem- brane in the rectum, it is pushed through, converting the blind into a complete fistula, which is then treated as above. If however, the probe enters the ischiorectal fossa, the external opening is enlarged by making a deep triradiate incision, and the wound is allowed to heal from the bottom by granulation. The after-treatment is the same as for the complete fistula. Blind internal fistula. A probe with the end bent is passed into the rectum, and the tip of the probe inserted in the mouth of the fistula, and passed gently down the track. The tip of the probe projects beneath the skin at the anal margin, and is cut down upon, and a triradiate incision made. The incom- plete fistula is thus converted into the complete one, and is treated as such. The old operation of simply ‘ slitting ’ the fistula is not sufficient and should never be done, for the external wound closes before the deeper parts have healed, the condition will therefore recur and the patient be disappointed. It is desir- able to remove the skin edges to prevent this; or to use the triradiate incision. FISSURE IN ANO A fissure in ano can frequently be cured by palliative treat- ment, but if this fails recourse must be had to operation, either stretching the external sphincter or dividing it. The patient is prepared in the same manner as for any other rectal operation, and is placed in the lithotomy position. The anaesthetic having been administered, the sphincter is