CHAPTER LXIX

RECTAL FISTULA

THIS condition originates from abscesses in the connective tissue surrounding the lower portion of the rectum. It usually results from neglect in the treatment of simple anal abscess or in that of a similar pus-collection in the ischiorectal fossa. Among tuberculous patients, however; a persisting indolent fistula may develop despite thoroughly efficient surgical treatment of the original abscess.

There are several types of fistula, one of which is the open variety, with a free communication to the external skin, as well as into the intestinal canal. Another is termed the blind internal fistula, in which the sinus opens into the bowel but has no external outlet. The blind external fistula opens upon the skin, but does not perforate the rectum. Irrespective of the type of fistula, the course of the sinus in almost every instance is tortuous and irregular. The point of internal perforation is frequently but a short distance above the anus, though in some cases the sinus extends upward a considerable distance before penetrating the bowel. The external opening may be situated in immediate proximity to the anus or at a distance of several inches. The discharge of pus or liquid feces from the sinus produces, as a rule, considerable discomfort and irritation. In most cases there is a comparative lack of pain and tenderness. The discharge varies according to the nature of the infection. When of tuberculous origin, the secretion is often scant and watery in character. In case of mixed infection it is usually more profuse, of greater density, and of a greenish-yellow appearance. Tuberculous fistulæ are apt to exhibit at the cutaneous orifice a reddened, irregular, and overhanging edge.

The method of origin of small abscesses arising from the anal diverticula is closely analogous to appendicitis with pus-formation. Opportunity is afforded in both conditions for the entrance of numerous different microorganisms. Their presence, together with the indefinite retention of fecal matter and foreign substances, gives rise to varying degrees of irritation and inflammatory change.

In reviewing the general etiology of tuberculous lesions of the intestinal tract attention was called to the mechanic facilities offered for the lodgment of tubercle bacilli in the tiny lacunæ existing in the mucous membrane above the anus. This explains the distinctly tuberculous origin of many cases of rectal fistula. While in a considerable number of cases the fistulous abscesses are in themselves tuberculous, a non-tuberculous fistula is not infrequent among pulmonary invalids. Although nearly 15 per cent. of all fistulæ occur among this class of people, the local condition is not invariably tuberculous.

The relation of fistula in ano to pulmonary tuberculosis has been the subject of much uncertainty and confusion for many years. The proportion of consumptives afflicted with anal fistula varies, according to different observers, from 2 to 5 per cent. The condition has existed in slightly over 2 per cent. of the cases coming under my personal observation. It was even thought at one time that the existence of fistula produced a degree of immunity to pulmonary tuberculosis. Among non-consumptives, therefore, it was considered rational to

prevent the healing of the sinus for fear lest a tuberculous infection of the lungs would subsequently develop. If the victim of the fistula was a consumptive, the chances for recovery from the pulmonary disease were believed to be enhanced by a continuance of the fistula, and materially diminished by its closure. According to Freeman, it was at one time considered good treatment to produce artificial fistulæ in consumptives as a means of cure of the original disease, upon the theory that injurious humors were thus drained from the system.

At present there exist considerable differences of opinion as to the true relation of these two affections, and especially as to the applicability of remedial measures under varying conditions. It is well to bear in mind, as stated, that tuberculous fistulæ may occur in individuals presenting no other evidence of similar infection, and that non-tuberculous fistulæ may sometimes develop in the midst of pulmonary phthisis. In this respect there is maintained a further resemblance between abscesses in the appendix and in the region of the anus. There is, however, in the two conditions a striking difference as to the practical construction to be placed upon these relations. In connection with appendicitis it was stated that a clinical distinction was unnecessary between tuberculous appendicitis and a simple inflammatory involvement among consumptives, as the indications for treatment were identical. The principles of management as applied to cases of rectal fistulæ, however, are not similarly uniform, for reasons that are perfectly obvious. Appendicitis, regardless of its origin, is recognized as a distinct menace to life, without immediate operation. Rectal fistula, however, at no time threatening the life of the individual, is embraced under an entirely different category, the results of surgical treatment being dependent upon the influence of the general health.

It is important to distinguish between fistula in themselves tuberculous without evidence of infection in other parts of the body, and fistulæ in consumptives irrespective of the origin. Among the latter the essential consideration is not the local condition of possible tuberculous origin, but the existence of an infection in remote parts, causing a diminished resistance of the tissues and retarding, if not preventing, complete union after operation. In this event surgical interference may become non-effective and may even react to the disadvantage of the patient through the refusal of the wound to heal, the increased area of broken-down tissue, the occasional impaired function of the sphincter, and the not infrequent mental depression.

The decision as to therapeutic management must be based upon certain prognostic considerations which relate directly to the extent of pulmonary tuberculosis and the general vitality. Tuberculous fistulæ in otherwise healthy individuals are subject to the same principles of radical surgical management as simple fistulæ among the same class of patients. In consumptives the special indications for the operation relate to the supposed ability of the tissues to heal promptly after thorough excision. Surgical interference among pulmonary invalids as a class has fallen into considerable disrepute because of the frequent unsatisfactory results of the operation. It must be admitted that among these patients it is notoriously unsuccessful in a large proportion of cases. It is well known that the course of the pulmonary disease is not influenced either for better or worse by the complicating fistula, save for the unfavorable results sometimes noted after ill

considered and untimely surgical procedures. The alleged development of pulmonary tuberculosis following operation for rectal fistula is probably explained by the previous latency of the pulmonary infection and its delayed clinical recognition. On the other hand, the influence of advanced pulmonary phthisis upon the local fistulous condition is beyond question.

The unfortunate results of operation upon consumptives are frequently traceable to the lack of proper discrimination exercised as to the selection of cases. The operation is often performed upon invalids with advanced pulmonary disease, or at a time when the infection, though of recent development, is associated with greatly impaired nutrition and lessened individual resistance. The essential consideration as to the propriety of the operation attaches not to the extent or duration of the tuberculous change in the lung, but rather to its comparatively slight activity and the existence of an excellent nutrition as indicative of general vitality. It is my custom to deny this operation to patients until the pulmonary infection has undergone almost if not complete arrest, with the restoration of at least a normal body weight. Until such time patients are quieted with the assurance that the persisting fistula exercises no possible influence upon the disease, and that a fortunate result of operation is permitted only by an increased general resistance. A significant commentary as to the frequency of ill-advised operation is the fact, that in nearly every instance of rectal fistula among pulmonary invalids at the time of coming under my observation. an operation had previously been performed with unsatisfactory result.

In

The surgical management, aside from ordinary drainage operations which are indicated in all cases of abscess formation in this vicinity, consists of simple incision with curetment, or of total extirpation of the fistulous tract. Incision is the less formidable and more usual method of procedure, and is sometimes attended by satisfactory results. case of a complete open fistula a grooved director is passed from the external opening into the rectum, and the intervening tissues divided with a sharp curved bistoury. This is preceded by thorough stretching of the sphincter. If the fistula is incomplete, a connection must be established from the skin to the interior of the bowel by the director. After the entire sinus has been laid open, the infected area is forcibly scraped and sterilized with pure phenol. The wound is packed with iodoform gauze, the healing taking place by granulation.

The process of excision, which is more likely to be attended by a speedy and gratifying result among tuberculous cases, consists of the dissection of the entire fistulous canal. Great care must be taken to remove, if possible, a considerable area of apparently non-infected tissue. This procedure is even advisable in chronic cases exhibiting dense fibrous tissue formation along the wall of the sinus. After cleansing and sterilization, the wound is closed with silkworm-gut sutures in an effort to secure accurate coaptation of the walls. Especial care should be taken to bring the parts in perfect apposition at the anal end of the sinus. For this purpose the ends of the sphincter muscle should be united by a suture encircling and passing through the muscle. Primary union takes place in a large proportion of cases. If asepsis is imperfect and suppuration ensues, the stitches should be immediately removed. and the reopened wound packed with gauze, thus permitting healing to take place by granulation.

SECTION VII

TUBERCULOSIS OF THE GENITO-URINARY TRACT

CHAPTER LXX

GENERAL ETIOLOGIC CONSIDERATIONS

TUBERCULOUS infection of either the genital or urinary system is almost always secondary to a preexisting focus in some other portion of the body. It is difficult, however, to deny absolutely the possible existence of primary tuberculosis in these parts. Isolated cases of such an infection are found in the literature of the subject, but the evidence is frequently insufficient to sustain the assertion that the reported condition is one of genuine primary infection of the genitourinary system. The term primary is often used in connection with tuberculosis of this region, not as denoting the initial site of infection of the entire organism, but rather as indicating a priority of involvement in a given portion of the genito-urinary system in comparison with infection of neighboring parts. In discussing the general etiology of tuberculous infection of the genito-urinary tract, the word primary will be used simply in the sense of its local application, it being well understood that the infection must proceed in all cases from some antecedent, though often undiscoverable, focus.

The primary origin of tuberculous lesions in these regions and the subsequent sequence of infection have been the subject of much investigation. In the past decided differences of opinion have been entertained as a result of clinical and pathologic research. Following much experimental study in recent years, there is a greater unanimity of medical opinion as to the preponderating sites of infection and the more common direction of further dissemination. The parts most frequently involved are the kidney, Fallopian tubes, epididymis, and prostate. It is known that the tuberculous process may be primary in any of these organs. From a clinical or surgical standpoint it is fair to assume that the so-called primary origin of the disease occurs with almost equal frequency in the kidney, epididymis, and Fallopian tubes, with the prostate gland less commonly the seat of early infection. Research work now being conducted at the Phipps Institute in connection with renal tuberculosis forces the conclusion, however, that the kidney is by far the more frequent site of infection. The urine of 60 patients with pulmonary consumption was exhaustively examined for the recognition of tubercle bacilli. After eliminating all possibility of error resulting from the possible confusion of the bacilli with other microorganisms, it was found that the examination in 44 instances was attended by a positive result. This work was of importance in showing that tubercle bacilli were being excreted with the urine of phthisical patients to a much greater extent than had been generally supposed. The result was susceptible of a double interpretation-first, that the bacilli had been filtered from the blood through the glomeruli without

local lesion along the urinary tract, and, secondly, that genuine tuberculous lesions existed either in the kidney or along the downward course of the urinary system.

Heiberg and Morris report tuberculosis of the kidney to be found at autopsy in only 2 per cent. of the cases of pulmonary tuberculosis. Hamilton has shown that after the bacilli gain entrance to the circulation, they may be found in the glomeruli of the kidney, within the afferent arteries, in the interstitial tissue, and in the uriniferous tubules. Walsham, in his study of excretion tuberculosis, has demonstrated the presence of bacilli in the glomeruli without evidence of change in the surrounding tissues or in the vessels of the glomerulus. He has proved that the bacilli may become arrested at some point in the uriniferous tubes, often in the medulla of the kidney, and produce secondary foci of tuberculous infection. His views as to the epithelial spread of the infection in the kidney are indorsed by Benda, who calls attention to the presence of bacilli en masse in the midst of the epithelial constituents of the kidney in the common, straight, and convoluted tubules. He emphasizes the extension of tubercle deposit from the straight and common uriniferous tubes in explanation of the origin of renal tuberculosis in the medullary substance, but ascribes the infrequency of dissemination from the convoluted tubes in the cortex to the plugging incident to the tuberculous processes. Apropos of Walsham's study the further investigations at the Phipps Institute under the supervision of Walsh are of special interest. Sixty autopsies were performed upon tuberculous subjects, and the kidneys in each instance were cut into very small pieces and subjected to careful macroscopic and histologic examination. Definitely typical tubercles were found in 35 cases. In addition, the condition in other cases closely resembled a tuberculous invasion of the kidney, an assumption as to its probable character being justified by the presence of miliary tubercles in other organs. If the latter instances be included, a tubercle deposit was found in 63 per cent. of the cases. Out of 37 cases examined by Hein, tubercles were found in 21 instances, or about 57 per cent. In the light of such pathologic data it must be accepted that tuberculosis of the kidney exists in approximately one-half of the cases of pulmonary tuberculosis, and to a greater extent than in any other portion of the genito-urinary system. These results are in striking contrast to Senn's recent estimate that one out of every 18 consumptives exhibits a tuberculous process in some portion of the genito-urinary system. The pathologic institute at Prague has reported but 5.6 per cent. of renal tuberculosis recognized at autopsy upon adult consumptives, while Rilliet and Barthez report 15.7 per cent. among children.

It is probable that the frequency of primary involvement of the epididymis corresponds fairly closely to that of the Fallopian tubes. As a result of tuberculous infection of the epididymis an extension of the process may take place to the seminal vesicles, prostate, and sometimes to the bladder. From the Fallopian tubes the infection may be disseminated to the ovary, uterus, and peritoneum.

Primary tuberculosis of the bladder is exceedingly rare. Its secondary involvement may proceed from a downward infection originating in the kidney, or from an upward distribution emanating from the prostate or male genital organs. It is doubtful if upward extension of the tuberculous infection may take place from the bladder to the