Fissure of the Anus and Fistula in Ano

by Jr. Lewis H. Adler

Incontinence of feces is an unpleasant sequela to the operation for fistula. It is, happily, of rare occurrence, and follows only extensive operations, such as those in which the sphincter has been divided more than once, etc. When it exists to any extent it is productive of great annoyance to the patient, possibly more so than the original fistula. The application of the old-fashioned cautery-iron (Fig. 44), heated to the proper degree, or the small point of Paquelin's thermo-cautery (Fig. 45), applied 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.

Mr. H. W. Allingham, Jr.,[^[48]] recommends for this condition 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.

Dr. Chas. B. Kelsey[^[49]] advocates in these cases the complete excision of such a cicatrix, exposing freely the divided ends of the sphincter and bringing them together by deep sutures, exactly as in cases of lacerated perineum.

In dealing with a fistula situated anteriorly in a female subject, Messrs. Cooper and Edwards[^[50]] recommend that after a free division of the sinus the track be scraped thoroughly with a Volkmann's spoon, and then deep sutures inserted as in the case of rupture of the perineum, in the hope by this means of getting union by first intention.

Treatment by Immediate Suture.—In otherwise healthy subjects, affected with fistula in ano, a method of operating which has met with success, especially in this country, consists in the immediate suture of the wound after the fistula has been excised. The steps of the operation are as follows. The septum between the fistula and the bowel is divided; the entire fistulous channel, and all lateral sinuses, are excised; buried sutures of catgut or of silk are then passed around the wound, at intervals of a quarter of an inch, and tied so as to bring the deep tissues together. The sutures are inserted very much in the same manner as in the ordinary operation for ruptured perineum. The advantage of this plan of treatment is that primary union is secured and the patient recovers in a shorter time than would have been the case after one of the operations which aims to secure union by granulation.

Treatment by Ligature.—There are two methods of using the ligature, which we may term the immediate and the mediate.

The IMMEDIATE OPERATION has little to recommend it. It consists in passing a silk thread through the fistula and drawing it backward and forward so as to cut its way through. The same object may be accomplished by the use of the galvanic écraseur, or of the wire écraseur of Chassaignac.

Mediate Operation by Ligature.—In this method either the silk ligature or an elastic one may be employed.

Silk Ligature.—If silk be used, it may be employed in one of two ways. In both methods a short piece of silk is threaded to a silver probe bent to a curve, which is passed through the fistula and drawn out at the anus. The thread is passed through the track, so that one end hangs out of the bowel and the other at the external orifice of the fistula. It is at this point that the methods diverge. One plan consists in knotting the ends loosely together and allowing the patient to go about. After a time, ranging from two to four weeks, the ligature comes away, having slowly cut through the included tissue. According to Mr. Harrison Cripps,[^[51]] the pathological process by which this is accomplished appears to be a gradual destruction or disintegration of the included tissue, due to the ulcerative action of the thread. The other plan is to tie the silk so tightly that it will completely cut its way through and strangulate all the tissue requiring division in an ordinary case of fistula. This method causes considerable suffering to the patient, and has therefore been discarded in favor of the operation next to be described.

Operation by Elastic Ligature.—The advocates for the use of the elastic ligature maintain that with it there is no hemorrhage. This is a matter of considerable importance when the fistula penetrates deeply, and also in those rare cases of hemorrhagic diathesis where severe bleeding is apt to follow a trivial incision.