To do this operation thoroughly necessitates sometimes multiple and extensive incisions, with a fierceness of action which may cause surprise. It is, however, the only effective way in which to proceed.
PLATE LIII
Illustrating Various Forms of Rectal and Anal Fistulas, and the Conventional Methods of Dealing with Them. (Bernard and Huette.)
One source of doubt and disappointment is met occasionally in the radical treatment which requires division of the sphincter, for to completely divide this muscle is to practically paralyze it and leave the patient thereafter with fecal incontinence more or less marked. Such accidents leave more or less disabling consequences. Usually they are avoidable, for it is rarely necessary to cut completely through a sphincter muscle, it being possible to avoid the necessity by partial division, with perhaps more complete exposure above and below. Even in those instances where it seems unavoidable if the muscle be first vigorously stretched, and thus temporarily paralyzed, it may then be safely divided, provided it be neatly and completely sutured at once, and the parts kept at rest for a few days, the intent in stretching the muscle being partly to so weaken it that it shall be temporarily disabled. It was suggested years ago by Jenks, of Detroit, and later by Kelly and others, to make a complete excision of the entire fistulous tract and then to treat this as any other fresh wound, closing it completely with sutures. The method is good in theory and occasionally applicable, and should not be neglected when circumstances favor its practice.
Every fistulous tract, simple or complicated, not promptly and neatly closed, should be dressed with gauze, with or without yeast, balsam, or some one of the other local applications recommended elsewhere in this work.
PROLAPSE, PROCIDENTIA, AND INVAGINATION OF THE RECTUM.
Prolapse of the rectum is observed in two degrees, either as a mere eversion of its mucosa, which, however, may be profuse and extreme, or as an actual escape by process of invagination through the anus of some portion of the rectal tube, with all its coats, including in well-marked cases even its peritoneal covering. The former is more common in children as the result of diarrhea, colitis, the presence of pin-worms, or other parasites, or any other cause which produces tenesmus and frequent straining, with consequent relaxation of the anal sphincter. It is amenable to treatment and is usually of insignificant proportion. It is also frequently seen in adults in connection with internal hemorrhoids, which are extruded with every stool, carrying with them more or less mucosa, and which are usually returned within the rectum by the patient at the conclusion of the act of defecation.