Treatment.
—Could every perirectal abscess be distinctly recognized and properly treated in its comparatively early and localized stage there would be few cases of residual trouble. This treatment consists of early and extensive incision, made externally and directed to the centre of the phlegmonous mass, sufficiently deeply also to reach it. The evacuation of even a small amount of pus, followed by more or less blood, will give prompt and immediate relief, and bleeding may be encouraged rather than checked for purposes of local depletion. Such incision may be in most instances made with freezing spray or local anesthesia. In children and exceedingly nervous patients it would be better done under general anesthesia, in order that it be done thoroughly. It is in patients who decline such early relief, or who, from ignorance or inattention have not received it, that ischiorectal abscesses sometimes assume serious proportions and become extensive phlegmons, breaking down anatomical partitions in the pelvis, burrowing extensively in various directions, since there is considerable fatty and cellular tissue both inside and outside of the pelvis in this region. Thus the surgeon may not see such a case until the entire buttock is involved, or until the process has gone perhaps even farther. Relief now must come from radical application of the same principles, by the aid of general anesthesia, multiple incisions with counteropenings, use of drainage tubes, etc. The patient now is fortunate if perforation into the rectum has not already occurred so that no pus is discharged from the bowel. If this has not yet happened it will probably be prevented by the above measures; but when it has, and a fistulous communication has already been established, it may be sufficient to thoroughly cleanse the infected cavity to see both it and the fistula close by granulation in the course of time. Wide external incisions are necessary in these cases, for complete access to the deep fossæ must be made. In more pronounced cases the pus evacuated will be extremely offensive, and there will be found masses of necrotic tissue, sloughs of fascia, and evidence of extensive local gangrene. Such putrid cavities must be thoroughly cleaned out, and will then be found to quickly resume a healthy aspect when treated by packing with gauze saturated in brewers’ yeast.
The more chronic and slower expressions of this condition are usually connected with local tuberculous disease. In fact every phlegmon which has passed the acute stage is favorably situated for tuberculous infection, and becomes in time a tuberculous lesion, which is to be treated on the general principles elsewhere enunciated. These fistulas are often seen in consumptive patients, and apprehension has widely prevailed that the pulmonary disease might be aggravated by radical attention to the fistula. This was only when such attention was made incomplete. To divide the fistulous passage and leave its raw surfaces unprotected and in contact with tuberculous tissue is to invite the spread of infection. To do the proper thing, on the other hand, i. e., to radically dispose of all tuberculous tissue and so treat both fresh and old surfaces that a new infection is not invited, is not to make a patient worse in any respect, but to relieve him of at least one focus of disease. There is, therefore, no reason why rectal fistulas should not be radically treated even when they occur in consumptive patients.
RECTAL FISTULAS.
Rectal fistulas are always the consequence of ischiorectal abscesses left to open spontaneously in either or both directions. They may occur also without the preëxistence of a distinct phlegmon, as, for instance, when a small ulcer in the rectum gives way and permits the gradual extension into the perirectal tissues of a mildly ulcerative or suppurative process.
Rectal or anal fistulas are classified as blind external, blind internal, or complete, according as they open and discharge themselves or show a complete passage-way from the rectum to the exterior. They may be small and single, or numerous and extensive. Old and especially chronic tuberculous cases are seen when the whole gluteal region is honeycombed and perforated by numerous fistulas, some of which probably connect with the interior of the bowel. I have seen such openings as low as the knee and as high as the dorsal spines, as the result of extremely insidious advance of tuberculous granulation and its subsequent breaking down. In such cases a history of an acute phlegmon occurring years previously may be obtained.
A blind external fistula, simple or complicated, naturally discharges its pus upon the exterior. It may be accompanied by little or no local tenderness or pain. A blind internal fistula makes itself known by a certain amount of rectal tenderness and by the discharge of pus with the stool, or at other times of pus which may possibly be blood-stained. Here there may be a history of old trouble, with external evidences of it, which suggests that exterior communication has been shut off while that with the bowel remains. In complete fistulas there is discharge not only of purulent material, but of more or less of that which is distinctly fecal, while gas sometimes escapes through them. Such a statement made by a patient is of itself significant. A fistulous passage may be surrounded by more or less infiltrated and inflamed tissue, or it may appear much like a duct. While always causing more or less annoyance, it may produce symptoms which seriously disturb. (See [Plate LIII].)
Treatment.
—The treatment of rectal fistula in any of its forms is distinctly surgical and should always be radical. A blind internal fistula can be discovered only with the speculum.
Every such fistulous passage should be split up and its tubular portion thoroughly excised or destroyed with a sharp spoon or caustic. Furthermore it should be followed to its ultimate ramifications. For this purpose it is of great assistance to first inject it with methyl-blue solution, or something else which shall stain it and make it recognizable wherever it may extend. To incise a superficial and external fistula is a simple matter, for which local anesthesia alone may suffice; but to deal radically with an extensive fistulous tract requires dilatation of the anal sphincter and such thorough investigation, with complete relaxation of the patient, that general anesthesia is needed. Now with a probe identifying the tract, and the knife and spoon made to follow it, or by identification of the stained tissues colored as above mentioned, the surgeon should proceed to the extreme of every morbid passage-way, dilating, cutting, trimming, scraping, as may be needed; while after the work is done every particle of disturbed raw surface should be cauterized with some reliable caustic (such as pure carbolic followed by alcohol) so as to sear the surface and prevent the possibility of reinfection.