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

Date:
1907
    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
    thoroughly stretched and paralysed. The patient is kept in bed on a light diet for a few days, the bowels being opened by an aperient on the fourth day. If it is decided to divide the sphincter, it should be cut through in the track of the fissure; the whole thickness of the external sphincter must be divided, but the internal sphincter must not be touched. The dressings and after-treatment are similar to those employed after an operation for haemorrhoids. A fissure is occasionally associ- ated with a torn down valve at the lower end, called a ‘ sentinel pile ’. In such a case the pile can be cut off with scissors under eucaine and adrenalin, but it is extremely doubtful if such treatment will always succeed in curing the fissure. It is a bad plan to lay down a rule of thumb for treating fissures, each case requiring some difference both in its medical and surgical treatment. After any operation for fissure it is necessary to regulate the habits of the patient with a view to pi'eventing a recurrence of the condition ; in other words, the constipation which is nearly always present in these cases must be treated, or the patient will be disappointed with the result of the operation. PRURITUS ANI Pruritus ani is a most distressing affection, and should be combated by every means short of operative treatment, unless there is some such condition present as haemorrhoids, fistula, &c., which require to be treated surgically. But if in spite of palliative treatment the pruritus still persists, and it has been ascertained that the symptoms are not due to gout or diabetes, there remains only one form of treatment, and this rarely fails. The patient is prepared, &c., as for the operation for haemorrhoids. The anaesthetic having been administered, the sphincters stretched and the region carefully inspected for any cause for the pruritus, such as a fistula, fissure, haemorrhoids, &c.; if anything is found it should be dealt with. But if no such cause is detected, the anaesthetist’s drugs are removed to a safe distance and a Paquelin’s cautery, heated to a dull red B b C.
    heat, is drawn lightly over the skin from the mucocutaneous junction outwards in a radial direction for a short distance. This is done at intervals all round the margin of the anus, care being taken not to destroy the whole thickness of the skin, and to leave gaps of skin between the radial scars. If it is necessary to repeat the operation, these gaps of skin and any spots insufficiently treated before, are cauterized. If any mistake is made, let it be on the side of doing too little rather Fio 97. Perineum. The black lines radiating from the anus indicate the method of applying the cautery for the relief of pruritus ani. than loo much. The part should be dressed with boracic ointment on lint, covered with wool, and secured in position with a T-bandage. A hypodermic injection of morphia will be required when the patient comes round from the anaesthetic. The bowels should be opened on the third day and care taken to secure a daily motion afterwards. The part should be kept covered with some mild unirritating ointment for some time afterwards.