CHAPTER IT. (Part 2)

already described, for the reason that it affects the subcutaneous tissue and not the skin, and is diffuse and not circumscribed. The causes of this variety of abscess are the same as of those ali^ady mentioned, though traumatism plays, perhaps, a mor& important role. Falls, kicks, horse-back exercise, and violence in the ABBCBSS AND FISTULA. 78 use of the syringe are its most frequent antecedents. Surgical inter- ference with the rectum^ as in the removal of a haemorrhoids may also he followed hy this form of abscess^ and it may arise from the perforation of the wall of the bowel just above the sphincter, by an ulceration of any kind, generally, however, that due to a foreign body. It has also been known to follow the suppuration of an internal hsemorrhoid. The symptoms of this form of disease vary greatly in different cases. In cachectic persons, pus may form in large quantity, and break into the bowel without the knowledge of the patient, and a blind internal fistula may result. The diagnosis is generally easy. There will be the usual pain, tenderness, and swelling; and if the pain bo not too severe to admit of the attempt, fluctuation may be obtained by introducing one finger into the rectum, and making counter-pressure with the other hand outside. There is little use in hoping for resolution in an abscess of this kind, and all active attempts to cause it will be found to do harm, rather than good. The proper treatment is an early free incision. If the incision be made early, it may in itself have an abortive action, and under such circumstances it need not be very large. If pus has already formed, or the skin has begun to grow thin over the abscess cavity, the incision should be free enough to allow of the easy escape of the contents, for in this way only can the formation of a fistula be avoided. In such a case, drainage should be resorted to after the incision, and every effort should be made to secure healing from the bottom of the cavity. When the incision is made in the early stage of such a tumor as this, while the skin is yet hard and infiltrated, a free hsBmorrhage from cutaneous vessels is not uncommon, nor on account of its antiphlogistic action is it to be deprecated. Only when it has passed the bounds of safety need any steps be taken to arrest it, and this may always be done by a careful stuffing of the incision with picked lint. A word of caution against opening such abscesses as these in the surgeon's office, and allow- ing the patient to walk home, may not be out of place; for a small artery may commence spurting at any moment during the active exercise. Deep Abscess. — The deep abscesses of this region differ greatly from those already described, in their location, extent, and gravity. They may with advantage be divided into those of the ischio-rectal fossa and those of the superior pelvi-rectal space.' An abscess of tho ischio-rectal fossa is generally bounded by the levator ani muscle superiorly, and by the skin below, with the rectum on one side, and the adjacent portion of the pelvis on the other. An abscess of the superior pelvi-rectal space, on the other hand, originates in the lax connective tissue around the upper portion of the rectum above the levator ani muscle. It may assume vast proportions, blending ■ » Richet: Trait6 d'Anat. M6d. Chir. 74 DIBBiLSBS OF THE BECTUM AND ANUS. laterally with the subperitoneal connective tissue of the iliac fossa, and burrowing in almost any direction in the true pelvis. The causes of deep rectal abscesses are various. Traumatism is per- haps the most frequent, and the injury is generally internal, rather than external, and is caused by the point of a syringe or a foreign body, rather than by kicks and falls. Foreign bodies, such as fish-bones, may pass entirely through the rectal wall, and be found loose in the cavity of the abscess they have caused. Such an abscess may also be due to the injury inflicted by the foetal head in parturition, and in such a case, the diagnosis may be difficult to make from a puerperal inflammation, due to blood poisoning and involvement of the lymphatics. They may also be secondary to diseases of the urinary organs, such as acute inflamma- tion of the prostate, or a rupture of the urethra, and extravasation of urine; and they may result from rupture, ulceration, or perforation of the rectal wall, in connection with stricture. This explains partly, though not completely, the frequent coexistence of stricture and numerous flstulsB; for a stricture may act as the exciting cause of a deep abscess by the impairment of vitality and nutrition which it causes, as well as by producing a perforating ulcer above, as is proven by the fact that a great many fistulas have their internal openings below, and not above the constriction. Again, these abscesses may be due to a submucous inflammation, and production of pus, which first breaks into the rectum, and forms an internal fistula, and subsequently extends outwards, forming a large abscess; or they may be due to an acute phlebitis, or to faulty nutrition And a generally vitiated state. Finally, they may be in their origin entirely disconnected with the rectum, and due to disease of some neighboring part, or to necrosis of some adjacent bone of the pelvis or spine. Symptoms. — In an abscess of the superior pel vi-rectal space the symp- toms are often obscure and far from characteristic. There is more or less Tague pain in the pelvis and lumbar region, which is seldom intense and IS generally increased in defecation. Fever may be entirely absent, is sel- dom continuous, and chills are only occasionally met with when pus is iormed. In addition there is more or less headache and general malaise. An abscess of the ischio-rectal fossa may at its commencement be ac- companied by the same symptoms, but, later, the skin becomes hard, red, s.nd oedematous sometimes over a large portion of the corresponding but- tock, the pain is very severe, and rectal touch impossible. The general symptoms are those of any acute inflammation. In abscess of the superior pelvi-rectal *space, when the disease has extended to the cellular tissue of the iliac fossa, immense collections of pus may form, and this may burrow in any direction. In men it generally follows the course of the bowel, in- volves secondarily the ischio-rectal fossa, and makes its way through the skin at some distance f rotn the anus. In women it is more apt to pursue ABSCESS AKD FISTULA.. 75 a oontrary direction and may appear on the surface in the region of the crest of the ilium or in the groin. An abscess of the ischio-rectal fossa may tend to discharge its contents upwards toward the superior perineal region, being less confined by fascia and muscle in this direction. In this way the prostate and urethra may be implicated, and the signs of re- tention of urine may be joined with those which point more directly to the rectum. The pus from such an abscess, in time, generally breaks on the cuta- neous surface and forms one or several permanent fistulous tracks. The pus from a pelvi-rectal abscess not infrequently makes its way into the rectum and is discharged with each act of defecation; before the faeces when the opening is near the anus, after them when it is above the rectal pouch. It may, however, rupture into the vagina, bladder, uterus, or per- itoneum, but these internal openings are not the rule, but the exception, for the pus generally finds its way to the cutaneous surface, and fistulas result as with ischio-rectal abscesses. Either variety may cause fistu- lous tracks upwards into the true pelvis, downwards into the perineum, or outwards into the thigh. When the pus reaches the rectum it may bur- row for a considerable distance in the submucous connective tissue of the bowel, and separate the mucous membrane from its attachment before perforating it. In this way two large abscess cavities may be formed communicating with each other by a narrow orifice. What is now generally known as the horse-shoe abscess or fistula is due to the formation of an abscess in each fossa and the communication of the two behind the rectum through the substance of the sphincter muscle at its attachment to the coccyx. Such an abscess generally has one opening into the bowel and two on the cutaneous surface, though the latter may. be single also. By manipulation the pus may be made to cross from one fossa, to the other imparting a characteristic sense of fluctuation. There is a form of gangrenous cellulitis which sometimes affects the ischio-rectal region. It is a rare disease, and is generally idiopathic. In it there is no pus formed, but the cellular tissue and the skin over it become necrosed and slough in large, black masses. The adjacent por- tion of the rectal wall may be involved and the rectum be laid open for a considerable extent. The disease is attended with fever and great pros- tration; the tendency to relapse and extension is marked, and the cavity left after separation of the slough closes very slowly. * This form of dis- ease may be fatal. The reasons why abscesses in this region so seldom heal spontaneously are to be found in the anatomy of the part, and the fixedness or mobility of the walls of the abscess cavity. In the ischio-rectal variety the skin is * A Clinical Lecture on Idiopathic Gangrenous Cellulitis around the Rectum. Fumeaux Jordan, Brit. Med. Jour., Jan. 18th, 1879. Also, Jackson, Brit. Med. Jour., Feb. 8th, 1879. 76 DI8BABBS OF THE BEOTUM AND ANUS. hardy thickened and lardaceous; and from its rigidity cannot yield its position to sl\oyr of healing. The walls of the abscess higher np in the pelvi-rectal space, on the contrary, move with the varying fulness of the abdominal or pelvic organs with the incessant action of the levator ani, and with the f nlness or vacuity of the abscess cavity, which depends on the intermittent discharge of pus through its small opening. Diagnosis. — The diagnosis of these conditions should be made with great care, for on a correct appreciation of the extent of the disease will depend the prognosis and treatment; and this class of fistulas are not always proper cases for operation. A fistulous track communicating with a pelvi-rectal abscess may gene- rally be recognized by its length and by the amount of tissue between it and the bowel, which may easily be estimated with one finger in the rec- tum and a probe in the track. The probe does not approach the rectum, but either runs parallel with it, or recedes from it. The flow of pus from the opening is also apt to be intermittent and to occur at the time of defecation, being caused by the same muscular effort. Sometimes, when the cavity has not been recently emptied, a soft tumor may be felt by rectal touch, and pressure upon it may cause a flow of pus. With the pus bubbles of gas may also appear, but in a large abscess in the neighbor- hood of the bowel this is not a proof of an internal opening, but may be due merely to the proximity of the intestine. Prognosis, — ^The prognosis is necessarily grave. In the beginning the patient is exposed to all the dangers of pyaemia, peritonitis, and phlebitis; and should the abscess go on to a favorable termination in an external opening, there is still the dread that it may at any time seek . another opening toward the peritoneum with a fatal result. The imnie- diate results being favorable, the ultimate ones may still be disastrous; being those which always attend upon prolonged suppuration — ^visceral complications, amyloid degeneration of the liver and kidneys, and tuber- cular deposits. In the comparatively small number of cases of pelvi-rec- tal abscess in which healing occurs, the patient still has to meet the results of extensive cicatricial contraction. These may be stricture on the one hand, or incontinence on the other; with the subacute inflammatory tendency which is always apt to attend upon a cicatrix at the anus and cause pain and uneasiness. In females especially, such a cicatrix may be the cause of grave trouble with the genito-urinary canal. Treatment. — It may be considered as a rule to which there are few exceptions, that an acute inflammation in this region will go on to sup- pupM^ion; and hence that antiphlogistic measures adopted with a view resolution are useless. Early incision is, therefore, the only ^treatment, and, where properly performed, this may result in mt the formation of fistula. Allingham * goes so far as to say » Op. cit , p. 16. ABSCESS AND FISTULA. 77 that by this means he can almost guarantee that there shall be no fistula. The incision should radiate from the anus to avoid as far as possible the section of nerves; and should be free enough to secure the escape of pus, not only at the time, but while the abscess is healing. If there be bur- rowing in any direction, the incision should be prolonged to correspond; and the finger should be passed as far as possible into all parts of the cavity to break down all partitions. The wounS should then be stuffed with lint wet with carbolized oil, and a drainage tube inserted. The secret of success will be found to lie in securing a free outlet for pus, and thus preventing burrowing. These abscesses should not be laid open into the rectum — a point which is generally misunderstood in practice, because of the confounding of an abscess which which may ultimately result in a fistula with fistula itself. The treatment is that of abscess, and not that of fistula, and is especially directed toward the prevention of fistula. Even should the abscess have already opened into the bowel, healing may still be secured by following this line of treatment, with suitable means for keeping the rectum empty, and a laying open of the lower end of the rectum may be avoided. After a fistula is fully formed and all attempts at closure have failed, the usual operation of dividing the track into the bowel may be necessary, but it should always be undertaken with the expectation of disastrous consequences to the retentive powers of the sphincters. Incontinence to a greater or less extent is almost sure to follow such a free division of both sphincters and of the bowel above them. Incontinence depends more upon division of the internal than of the external sphincter, and is more apt to follow a double division of the fibres than a single one. For this reason the surgeon should always en- deavor to leave a few fibres at least of the internal muscle in any opera- tion, and the incision should always be directly and not obliquely across the fibres of the muscle. It is also well to remember that incontinence is always more apt to result from division of the muscles in the female than in the male. Even when incontinence has resulted, the case may be capable of re- lief in this regard by an operation with the cautery, which will be described in speaking of prolapse. I have seen marked benefit in this «ad condition result from this simple operation combined with the per- sistent use of a rectal bougie and such other measures as are calculated to increase the power of the sphincter, and I am much less inclined to despair of giving relief in these cases than formerly. In one case sent me by Dr. McOready, of New York, in which a considerable degree of incontinence resulted from an ischio-rectal abscess, this mode of treat- ment patiently followed for some months has almost entirely relieved the <iondition; so that where solid fsBces at first escaped him there is now a 78 DISSA8E3 OF THK lUXTTUM AND ANDB. good degree of oontraotile power, and the patient is only troubled with an occasional discharge of the rectal macuB in small qaantity. FCatula. — A fistula which is not due to a perforation of the rectal wall from within is the result of a previous abscess, and, therefore, in enumerating the causes of abscess those of fistulse have also been given. Like the abscesses from which they arise, they may well be divided into superficial and deep; or^nto those of the anus, which are subontaaeoos, and involre at the most only a few fibres of the external sphincter, and those of the rectum and pelvis, which open into the bowel at a higher point Both the superficial and deep may also be divided into the com- plete, or those which open both on the skin and into the bowel; the ex- ternal, which open only on the skin, and the internal, which have an. opening only within the bowel (Pig. 37). . complete fistula: C, blind in- Superficial FislulcB.'^On account of the special laxity of the submu- cous connective tissue in this region, already noticed, abscesses show little tendency to spontaneous cloanre, and fistula is the common result when left to their own coarse. In the subcutaneous fistula, the external orifice may be at some distance from the anus, or in the radiating folds. It may be so small as to escape the eye in a cursory examination, unless a drop of pua chance to be squeezed out of if; by the pressure of the fingers - in pnlliug open the parts; and when discovered, it may not admit the end of an ordinary probe. The surgeon should, therefore, always be provided with a probe of small size and of pure silver, whicK