AN OPERATION FOR THE RADI- CAL CURE OF FISTULA IN ANO BY AN IMPROVED METHOD. BY AUGUSTIN H. GOELET, M.D., GynmcMogist t6 the West Side German Clinic, etc., New York. KBPRINT FROM American Medico-Surgical Bulletin, July i, 1894. TO CONTRIBUTORS. Contributions of Original Thought and Experiences, on Medical and Surgical Topics, are desired uy the AMERICAN MEDICO-SURGICAL BULLETIN on the following condition^: 1.-Authors of Scientific Papers or Clinical Reports accepted by us will receive-according to their own preference ex] rcased with each communication, either: a .--A number of Reprints of their article in neat pamphlet form (pocket size); or, b:- Instead of the above, an Equivalent value therefor in Cash. 2.-All contributions are received only on the express understanding: a;-That they have not been printed anywhere, nor communicated to any other journal. I;- That, if they have been read anywhere to an audience, this fact be stated in full detail by a note on the manuscript. 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AN OPERATION FOR THE RADICAL CURE OF FISTULA IN ANO BY AN IMPROVED METHOD, WHICH SECURES PRIMARY UNION, AND COMPLETE RETENTIVE POWER, EVEN WHEN TWO INCISIONS THROUGH THE SPHINCTERS ARE NEC- ESSARY. By AUGUSTIN H. GOELET, M.D., Gynecologist to the West Side German Clinic, etc.. New York. HISTORY : The patient, Mrs. I., aged 33 years, applied to me for the treatment of uterine disease, having a retroflexion with chronic granu- lar endometritis. She had also two anal fistulae, resulting from abscesses seven or eight years before, and had declined opera- tion because complete retentive power could not be promised her. One fistula opened externally, posterior to the anal orifice, and about an inch from it, the internal opening being between the internal and external sphincters. The external opening of the other was on the perineum, anterior to the anus, and an inch and a half from it, being almost directly opposite the external open- ing of the other fistula. This anterior fis- tula passed up, outside of both sphincters, and opened into the rectum two inches and a half from the orifice. It had also a pouch extending upward for half an inch beyond along the rectal wall. The extent and re- lative position of the fistulae are well shown in Fig. I. After curing the endometritis and displace- ment, and building up her general health, 1 which had been very much impaired, I obtained her consent to an operation upon the promise of a satisfactory result. My favorable experience with the operation about to be described, where only one fistula existed, led me to believe that it could be done with equal success, even where two incisions through the muscles were neces- sary. Two days before the operation, the bowels were thoroughly evacuated, and she was placed upon a restricted diet. On the Fig. I. morning of the operation, the bowels were again cleared out, and, in addition, the rec- tum and colon were washed out with copious enemata of hot water. Technique of the Operation: After the patient had been anaesthetized, the anus and surrounding integument, including the peri- neum, were scrubbed and shaved, and after- ward rendered aseptic with a solution of bichloride. The patient was then placed upon her side, and the sphincters were di- vulsed. This was done to paralyze the muscle temporarily, and thus insure in- activity for the first few days, while the heal- 2 ing process was going on. The rectum was again washed out, and a large tampon well vaselined, was inserted high up into the rec- tum to protect the field of operation from the possible escape of any fluid from the bowel beyond. The entire operative field, includ- ing the rectum below the tampon, was then rendered aseptic by a hot solution of bichloride. With one finger in the rectum as a guide, a grooved director was passed through the posterior fistula into the rectum, and, by means of a bistoury, the intervening structures were divided by an incision pass- ing toward the anus at right angles to the fibers of the sphincter muscle, thus opening the fistula into the rectum. The same pro- cedure was followed out with the anterior fistula, the whole intervening structures be- tween the external and internal openings including both sphincters being severed. Then the fistulous tracts were thoroughly curetted with a sharp curette and made raw and healthy, care being taken to trim off with the scissors all unhealthy tissue. The edges of the rectal opening of each fistula were carefully trimmed to favor prompt union. We come now to the most important step in the operation, viz: uniting these raw sur- faces by suture so as to secure perfect pri- mary union of the divided muscles, as well as of all of the other structures included in the incisions. To obtain this, it is necessary to approximate closely and accurately all opposing surfaces so that no pockets will be left, and the sutures introduced upon the mucous membrane of the rectum shall not extend into the deeper structures. I am satis- fied that unless this latter precaution is 3 strictly observed in suturing the rectal wall above the anal orifice, leakage of septic matter from the bowel will often occur along the track of the sutures, and failure will result. For a similar reason cat-gut is to be preferred to silk for suture material. At the orifice and on the external sur- face in general, deep sutures are not objec- tionable, but in this operation deep su- tures which include all the structures would obstruct the circulation, increase the oedema, and thus interfere with primary union. Therefore, in this operation. I have em- ployed a buried suture of fine cat-gut for uniting the deeper stuctures, and have united the mucous membrane by interrupted sutures, which include the rectal wall only. In the present instance, the more exten- sive anterior wound was brought together by three rows of buried sutures of fine cat- gut, the first row beginning at the upper angle of the incision beneath the mucous membrane and running continuously along its base, terminating just inside of the integ- ument. The second row commenced also at rhe upper angle, just below the point where the first was inserted, and continued along the base of the wound, as it then existed, completely burying the first row. This terminated likewise just inside of the integument of the perineum. A third row, also of fine cat-gut, and continuous, superfi- cial to the others, covered up the second row, and united all of the raw surfaces except the mucous membrane of the rectum and the integument of the perineum. These parts were then united by interrupted su- tures of chromic cat-gut, beginning at the upper angle of the wound, where formerly the fistula opened into the rectum. The 4 Fig. II. 5 ends ot the divided muscle were carefully united. The posterior wound was sutured in a Fig. III. similar manner, but required only one row of buried sutures, and the superficial inter- 6 rupted sutures of chromic cat-gut. After- ward the rectum was again irrigated with hot bichloride solution, and the rectal plug was removed. A flexible rubber drainage tube wrapped with iodoform gauze, and covered with vaselin, was inserted, through the anus, well up into the rectum to allow the escape of gas, and to serve as a dress- ing. Finally, a loose iodoform gauze dressing, held in place by a napkin, was placed over this. The patient was confined to bed for ten days, and was kept on a liquid diet for the first five days. The external dressing was renewed every day, and the anal plug was removed at the end of forty eight hours. The bowels were emptied by enema on the fifth day after the operation at which time the sphincter had completely regained its power. Result : Both wounds healed by primary union, and, although the external sphincter had been cut in two places at opposite points, and the internal sphincter at one point, the patient had full retentive power. Two weeks after the operation, three quarts of water were injected into the rectum for the purpose of evacuating the bowel, and it was easily retained without the slightest leakage. Any one who has operated by the old method of simple incision and packing of the wound with gauze, to allow it to heal from the bottom, with all its annoyances to both patient and operator, will readily ap- preciate the advantages and the immense saving of time afforded by tne new method, to say nothing of the prompt and more satisfactory result. In conclusion, I would emphasize partic- ularly the following essential details, viz : i) Complete divulsion of the sphincter. 7 2) Perfect asepsis. 3) Incision of the muscles at right angles to the fibers. 4) Thorough curettage of all fistulous tracts. 5) The use of buried sutures of fine cat- gut for the deeper structures, and inter- rupted chromic cat-gut for the mucous mem- brane and the integument. 6) The rectal tube and dressing. 7) Absolute inactivity of the bowel and a liquid diet for five days following the ope- ration. New York ; 351 West 57th Street. 8 seventh YEAH. $2.00 per year. American Medico=Surgical Bulletin A SEMI-MONTHLY JOURNAL OF PRACTICE AND SCIENCE. Issued on the 1st and 15th of each month. THE BULLETIN PUBLISHING COMPANY, 73 William Street, N. Y. EDITORIAL STAFF. v. 11 1 1AM HENRY POR 1ER, M.D., FREDERICK PETERSON, M.D., Chiei Editor. Associate Editor. SAMUEL LLOYD, M D., j. RIDDLE GOFFE, M.D., Department of Surgery. Department of Obstetrics, Gynaecology WILLIAM FANKHAUSF.R, M.D., and Pae liatrics. Department of ^Materm Medipa and GEORGE R SW|NBURNE> M D ADOLPH ZEH, M.D., Genito-Urinary Surgery. Pathology and General Medicine. HENRY T. BROOKS. M.D., WILLIAM C. GUTH, M.D., Bacteriology. Pathology and General Medicine. JOHN WINTERS BRANNAN, M.D., GEORGE G. VAN SCHAICK, M.D , Neurology and Psychiatry. Pathology and Clinical Medicine. IRA VAN GIESON, M.D., W. TRAVIS GIBB, M.D., Pathology of Nervous System. Gynaecology. LEWIS A. CONNER, M.D., r. S. St )UTH WORTH, M.D., Neurology. Paediatrics. ALBERT WARREN FERRIS, M.D., WILLIAM OLIVER MOORE, M.D., Neurology. Ophthalmology and Otology. PEARCE M D ADOLPH BARON, MD., Neurology. Diseases of Children MORTON R. PECK, M.D., HENRY F. QUACKENBOS, M.D., xt 1 Neurology. General Medicine. „ , ' VENTURA FUENTES, M.D., P. HA1.STED MYERS, M.D, ... . , . ... ~ Clinical Medicine. < Irthopaedic Surgery. GEORGE THOMAS JACKSON. M.D., LOUIS HEITZMANN, M.D.. Dermatology General Medicine and Pathology. WILLIAM B. COLEY, M.D.. DANIEL B. HARDENBERGH, M.D, ,. , .. Obstetrics and Gynaecology. < .•■neral Surgery. J ' JAMES E. NEWCOMB, M.D.. O ITO H. SCHULTZE, M.D., Laryngology. Obstetrics and Gynaecology.