The fistula originated from a small abscess, with its internal opening between the sphincters, the external scarcely an inch outside the anus, and was not of long standing. The operation consisted in a division of the external muscle with the greater portion of the internal; he was put on a liquid diet, bowels confined for fifteen days and kept in a recumbent posture.
The incision was slow in healing, between three and four months; his health, which was formerly good, has been greatly impaired ever since the operation. The external sphincter has lost its power altogether and the internal muscle greatly weakened, which necessitate the wearing of a clout whenever the bowels become a trifle loose, and he lives in constant fear of soiling himself by allowing the escapement of the least quantity of flatus. The time lost, the money expended, and the unfortunate condition in which he finds himself eight months after the operation, have so thoroughly embittered him against the cutting process, that he spares no pains and loses no opportunity to influence every one with whom he comes in contact, against all such heroic and uncertain measures.
For the purpose of obviating these very unsatisfactory and highly objectionable results, we have a choice of any one, or all of three different methods, viz: treatment by injection, treatment with the fistulatome, and treatment by the galvano-cautery as practiced by Dr. Shotwell; who, fully appreciating the dangers of muscular section, has hit upon a plan both new and commendable.
Fig. 14.—Varieties of Fistula. (Gosselin.)
The sub-cutaneous, or sub-mucous fistula can be cocainized and slit up with a pair of scissors, and the tract cleansed and cauterized with a solution of carbolic acid, a comparatively trivial affair; but the external blind, the internal blind, the complete, the complete with diverticula etc., are varieties which call forth a decidedly greater amount of ingenuity and thought in bringing them to a successful issue.
The treatment by injection, sometimes classified as a “non-operative method,” has been so successful in the hands of many, that it is stoutly affirmed that any case curable by the usual heroic methods is equally curable by this method. Different preparations have been used, chief of all being carbolic acid, ranging in strength from 50 per cent. up.
In adopting the carbolic acid treatment, probably the better way after preparing the sinus, will be to use a 95 per cent. the first time and subsequently a 50 per cent. solution; protecting the parts from excoriation by any suitable unguent and absorbent cotton. Hot water compresses to relieve pain and reduce swelling. Iodoform, Eucalyptol, etc., in the interim. Judgment will be required in not making too many irritant applications and granulation thus hindered for want of rest.
The object is to destroy the pyogenic membrane by the cauterizing effects of the acid and get up a granulating carbolic acid sore. It may be necessary to evacuate the bowels and constipate for several days to give the muscles rest, or resort in extreme cases to divulsion. The sinus must have constant, free external drainage until the healing process is complete. Allingham recommends the introduction of the small end of a bone collar button to keep the orifice open, with a hole drilled through its centre for drainage.
As a preliminary step the external orifice should be dilated with a laminaria tent or other appropriate means. The fistulous tract explored with a common probe and thoroughly cleansed with hot water introduced through a flexible silver canula; which is also used for the injection of a 5 or 10 per cent. solution of cocaine to obtund the sensibility.