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.
[Illustration: Fig. 25—Slippery-Elm Tent (large size).]
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.
[Illustration: Fig. 26—Flexible Silver Canula.]
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.
[Illustration: Fig. 27—Flexible Curette.]
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.
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Footnote 46:
Made by J. Elwood Lee Co., Conshohocken, Pa.