CAUSES AND TREATMENT OF - k Rectal Fistulae CHAS. C. ALLISON, M. D., Professor of Rectal and Genito-Urinary Surgery Omaha Medical College. Reprint from The Omaha Clinic, September, 1893. Causes and Treatment of Rectal Fistulae. By Charles C. Allison, M. D. Professor of Rectal and Genito-Urinary Surgery, Omaha Medical College. The anatomical relations of rectal fistulae depend largely upon the location of the preliminary abscess. The marginal abscess is the most frequent of the three varieties, and when not seen early and managed carefully, it results in a subcutaneous fis- tula, which, when complete, usually enters the bowel below the external sphincter. The ischio-rectal abscess proper takes origin in the space surrounding the rectum, limited above by the levator ani muscle, and laterally by the pelvic bones. The internal opening, when the resulting fis- tulse is complete enters the bowel above the sphincter muscles. The superior-pelvic-rectal abscess origi- nates in the space contained between the superior aponeurosis of the levator ani muscle below, the rectum internally, the peritoneum above, and the pelvic walls laterally. This region as well as the ischio-rectal space contains an abundance of cellular tissue and fat, by which the blood vessels 2 are supported, and the movements and expansion of the rectum facilitated. It communicates with the glutial region through the sciatic notch, and is con- tinuous with the sub-peritoneal cellular tissue, lining the pelvic cavity, while run- ning through the space are the hemor- rhoidal and vesical arteries and veins, branches of sacral plexus of nerves and inferior hypogastric plexus of the sym- pathetic. In this dependent position, circulation is sluggish, the vessels, are not supported by muscular planes as in other regions of the body, and in the plethoric subject with an abundance of effete material in the blood, seeking elimination through clog- ged excretory organs, we have the predis- posing cause of an abscess. Add to this constipation with improperly administered enemas, or an abrasion of marginal epithelium by an illy chosen de- tergent, and we can at once discover a pathway for the germ which finds a splen- did field for the formation of an abscess. Moreover, in the individual with a con- stitutional dyscrasia, faulty nutrition and emaciation, we find absorption of the fat which supports the vessels, and a com- paratively small trauma will produce rapid cell death, and form the nucleus of an abscess. 3 Diagnosis :-The marginal and ischio- rectal abscesses present the usual symp- toms of inflamation and will be recognized in their incipiency, but the superior-pelvic- rectal abscess is attended by atypical symp- toms in its early history, although prompt interpretation of the primary signs of the trouble is desirable on account of the grave effects produced by extensive disease in this space. The early symptoms are more easily recognized where we bear in mind the landmarks and contents of the space. Lumbar and femoral pain are caused by pressure upon sacral plexus. Vesical symptoms follow direct pressure upon, or the involvement of nerves supplying the bladder. Pain in the region of the anterior superior spine of the ilium, or at the um- bilicus accounted for by pressure upon the inferior hypogastric plexus of the sym- pathetic. Add to this rigor, fever, and probably oedema of the perineum, bowel disturbance with pain intensified by deep pressure, and if interference is not permitted, fluctuation completes the picture of this disease. There is one more symptom which I do not see mentioned by writers on this sub- ject, and that is the significance of small, cutaneous abscesses or feruncles in the perineum. 4 These frequently precede extensive breaking down of tissue in the pelvis, and are caused by the imperfect circulation and mal nutrition which accompany the pre- disposing causes mentioned above. Treatment :-Prompt and free evacua- tion with thorough irrigation (bi-choloride 1:2000 followed by hot water) the estab- lishment of drainage, rest to the part with good nutrition and tonics, will in many cases avert the fistula. The same rule applies to all these cases with reference to evacuation and irrigation, although drainage must be established in the marginal and ischio-rectal abscesses by very loose packing, the reason being that prompt repair is sought ; but in the superior-pelvic-rectal abscess burrowing is so dangerous and the discharge usually so free, that after very free incision, drain- age must be maintained by large tubes or by frequent packing at the hazard of pro- ducing a fistulous tract with a firm in- dolent lining. When a fistula of this character is en- countered it will be of the variety termed external, which means the upper end of the tract is separated from the bowel by a layer of healthy tissue, and in all recent cases the tract will be single, in which case free division of the lining membrane by a long narrow knife or by the fistulatome will encourage the development of granulation tissue, with an occlusion of the tract. 5 This treatment may appropriately be applied to all single and incomplete ex- ternal fistulous tracts and permanent relief will be attained in the vast majority of cases. The tract of the subcutaneous fistula which follows the marginal abscess and presents an internal opening low down in the bowel, should be followed to its in- ternal opening by a flexible grooved dir- ector ; the director should then be brought through the anal orifice and the over-lying tissues divided, the base curretted, ad- ditional sinuses dilligently sought and laid open, when the entire wound may be carefully apposed by catgut sutures and and primary union gained. A valuable aid in this procedure is the tampon-canula, or gauze-covered rubber tube in the rectum, which aids in securing rest to the parts and affords an aseptic dressing for the wound in the bowel. We have remaining the fistula with multiple tracts complete or incomplete, originating in the ischio-rectal or superior- pelvic-rectal regions, and attended by every variety of constitutional dyscrasia. As a rule it is wise to follow the main channel to the bowel, completing the tract if the internal opening cannot be found. In the absence of pus in the rectum which strongly suggests an internal open- ing, the injection of milk or any colored 6 fluid should be done while the sphincter is at rest - since stretching the orifice so changes the relation of the parts that the tract will be occluded ; freely incising all tissue tunneled by the probe, making the cut perpendicular to the sphincter, locating and incising all lateral tracts. When this is done the wound should be irrigated, detached shreds removed, over- lying cutaneous edges cut away, and the cavity loosely packed. The after treatment is highly important, in that small pockets of pus may accumu- late near the extremities of the wound or in the irregular base, and a failure ensue. The preventive means are loose packing to the bottom with daily irrigation and examination of the base of the wound. A blunt instrument through the wound at each dressing will avert the disaster and will not retard repair. When the reparative power of the pa- tient or the extensive inroads of the disease do not warrant such a radical procedure, a wise course to adopt is to pack the main sinus or stretch, if necessary, the chief tract, and freely irrigate with a stim- ulating or antiseptic solution until the lat- eral sinuses are healed or the inroads of the disease so abridged that a radical opera- tion may be confidently counseled. Indeed this palliative plan will often prove very gratifying when the patient's 7 fancy or physical condition absolutely for- bid operative measures. In the horse-shoe fistula the branching tracts should as far as possible be opened into one main tract, even though more than one operation is necessary, then the main passage may be repaired by a single incision of the sphincter. Upon the management of the patient after an operation about the rectum de- pends largely the success of the under- taking. Rest in bed is imperative in all cases except in advanced tubercular subjects who require some exercise to maintain the reparative power. Firm dressing should be used to aid in controlling muscular spasm, and the value of sulphonal in this indication I find, has not disappointed my claims put forth over three years ago for this drug.. Cough should be controlled on account of its disturbance of the levator ani, appro- priate tonics used, the bowels kept free after the second day, and every surgical detail be accompanied by scrupulous asep- tic management. The following cases seen within the last twelve months illustrate some of the points in the history of superior-pelvic-rectal abscess. T. F., aet. 20, single ; history, tuber- cular. Presented with a large abscess 8 showing some perineal oedema and fullness, and some induration over Poupart's liga- ment on the left side and in the lumbar regions. Temperature ioi °, expiration prolonged on left side apex ; no cough. Free incision revealed a small amount of pus; irrigation and packing was followed by some improvement. A chill, high tem- perature, and a rapid development of a painful induration in left inguinal region was noted, and the perineum was freely laid open and explored, the superior abscess cavity drained, and uninterrupted recovery followed. The deep packing and frequent irriga- tions during convalesence left a straight sinus with a hard lining membrane which was incised with fistulatome, prompt and complete repair following. T. P., aet. 34, married, negative history. Presented with a deep pelvic abscess which developed six months after a suc- cessful appendectomy. The abscess was freely opened and curetted, tubercle bacilli being found in the soft tissue removed by the curette. Copious discharge followed although good drainage and frequent irrigation was kept up. When repair had progressed suffi- ciently the patient was sent to the coast for a few months, returning entirely well. When these abscesses are large and show a tendency to burrow above Poupart's ligament or through the sciatic notch, they should be evacuated at these points, al- though the perineum generally allows of freer drainage, and promises a more rapid repair.