CHAPTER III.

THE PALLIATIVE TREATMENT OF FISTULA IN ANO.

TREATMENT OF ABSCESS.—Preliminary to a consideration of the treatment for the disease when the fistulous track has been formed, some attention must be devoted to the importance of dealing promptly with the inflammatory and suppurative process which leads to abscess, and which usually forms the first stage of the affection known as fistula in ano.

When a patient presents the symptoms of a threatened abscess in the vicinity of the rectum, he should be directed to go to bed, or at least to avoid all undue exercise; the bowels should be thoroughly evacuated, preferably by the use of a saline cathartic; the diet should be nutritious; and, if the case be seen early, hot fomentations and poultices may be applied to the parts. The early adoption of these measures may abort the threatened abscess.

If, however, there be reason to suspect that matter has formed or is forming, it will be advisable to make a free incision into the center of the affected site with a sharp curved bistoury, if the trouble is superficial, or, if it is deep, with a narrow straight knife. When pus is present and is deeply seated, the evacuation of the abscess will be aided by the introduction of the forefinger into the bowel, by which means the swelling may be pushed forward, rendered tense, and hence made more apparent.

In opening these abscesses, if possible, ether should be given. The patient should lie on the side on which the threatened abscess is situated; the upper leg should be bent forward upon the abdomen. When pus is present, the operator should stand out of the line of its exit, for when the cavity is opened it often squirts out a considerable distance. After the matter has been discharged, the forefinger should be introduced into the abscess-cavity for the purpose of breaking down any secondary cavities or loculi that may exist. When this has been accomplished, the abscess should be thoroughly washed out with peroxide of hydrogen (Marchand's, undiluted, or some other reliable preparation), after which a rubber drainage-tube should be inserted, or a piece of iodoform gauze should be lightly placed between the lips of the incision, to prevent its closing too rapidly, and also to allow free drainage. Careful daily attention should be paid to the wound while the cavity of the abscess is contracting, as it is important to maintain a free and dependent outlet for the matter which continues to be secreted; but stuffing and distention of the cavity should be avoided. If a drainage-tube be used, it should be shortened from day to day as the wall of the abscess contracts.

After an operation for rectal abscess, the patient should be kept quiet for several days; and if great care be taken, both with the subsequent drainage and in keeping the orifice open, the part may heal without the formation of a fistula.

TREATMENT OF FISTULA IN ANO.—The treatment of fistula, like that of fissure, may be either _palliative_ or _operative_.

PALLIATIVE TREATMENT.—This method of treatment will be required in cases where there is a positive refusal on the part of the patient to submit to an operation, and in persons whose constitutions are broken down by disease and in whom the reparative powers of the body are not equal to the task of restoring it to health. Chronic alcoholism, albuminuria, diabetes, malignant diseases, etc., are conditions in which operative procedures are attended with risk, and in which palliative measures should be tried. Phthisis is not an absolute contra-indication to operative measures. The rule which I observe is to operate in those cases of tubercular subjects in which the disease is quiescent, but to avoid such interference if the lung-mischief is at all active.

Incomplete external fistulæ, and even complete fistulæ of somewhat recent origin and not extensively indurated, may be cured by non-operative measures; but such treatment requires constant attention on the part of the practitioner, as well as a willingness on the part of the patient to give sufficient time to the treatment. Even under such circumstances the process of repair is slow, and in many cases the result will not be perfectly satisfactory. It is true that fistulæ sometimes recover spontaneously, or are cured by simple means, such as the mere passage of a probe used in examining the fistulous track, but instances of this kind are rare.

In certain selected cases of fistulæ I am in the habit of endeavoring to effect a cure by stimulating the sinus and allowing free drainage of the secretions, so as to avoid the use of the knife. To accomplish satisfactory results with this mode of treatment, the following indications should be borne in mind: 1, that the external orifice be perfectly free; 2, that the sinus be kept clean, so as to prevent putrefactive changes; 3, that an effort be made to excite a healthy action in the fistulous channel; and 4, that the parts be kept as quiet as possible.

To meet the first indication, it is necessary to dilate the outer opening of the fistula with sponge or sea-tangle tents: but better still for this purpose are the Lee's Antiseptic Slippery-Elm Tents (Fig. 25).[46] These are made of selected slippery-elm bark, and compressed under high pressure. Owing to their non-irritant and demulcent properties, I find them superior to other tents.

The second indication (that the sinus be kept clean, so as to prevent putrefactive changes) is best carried out by the use of peroxide of hydrogen. I have cured some cases of fistula in ano by means of injections into the sinus of peroxide of hydrogen alone, being careful to keep the external opening free, and treating the patient daily until healing occurred. I am in the habit of using Marchand's preparation, undiluted. It is injected into the sinus by means of a long, flexible silver canula (Fig. 26) attached to a hypodermatic syringe.

Other antiseptics may be employed for the same purpose, such as bichloride of mercury (1 to 2000), or carbolic acid (1 to 80), but I much prefer the peroxide of hydrogen.

The third indication (to excite a healthy action in the sinus) can be met in one of a number of ways. In the first place, before applying such remedies it will be well to obtund the sensibility of the channel by an injection into the sinus of a four-per-cent. solution of cocaine. This may be accomplished by using the same syringe and canula that are used for cleansing the fistula.

If the wall of the sinus is somewhat indurated, it is better to insert a small, flexible curette (Fig. 27) and scrape the wall of the fistula along its entire length. The sinus is now prepared for some one of the various stimulating substances which have been recommended for this purpose. Among these may be mentioned peroxide of hydrogen; nitrate of silver, fused, or in solution (thirty to sixty grains to the ounce); sulphate of copper in solution (ten grains to the ounce); carbolic acid mixed with equal parts of glycerine and water.

These substances may be applied to the fistulous track by means of cotton attached to a silver probe or to an applicator (Fig. 11, p. 26); or they may be injected into the sinus by means of the syringe and silver canula (Fig. 26, p. 57).

If the fistula is a complete one and the substance used be applied as an injection, the finger should be passed into the rectum and made to cover the internal orifice of the sinus, so as to prevent the escape of any of the fluid into the bowel.

Regarding the fourth point (keeping the parts at rest), the patient, whilst under treatment, should be confined to the horizontal position, either in bed or on a sofa. Congestion of the parts is thereby lessened. A firm pad placed over the anus and well supported by a T-bandage is useful in limiting the motions of the anus due to the alternate contraction and relaxation of the levator ani muscle.

The chance of success in the palliative treatment of fistula in ano will be greatly increased if due attention be paid to the general state of health of the patient, and when circumstances render it possible he should be advised to seek the benefits of a change of air.

Footnote 46:

Made by J. Elwood Lee Co., Conshohocken, Pa.