ORIGINAL COMMUNICATIONS Short articles of practical help to the profession are ally be returned if request and postage for or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than anything else. -RUSKIN. RECORD Rectal Diseases in Office Practice. R ECTAL abscess is a painful and, at times, serious condition. Not alone is there danger of septic absorption and tissue destruction, but, when untreated, the abscess usually burrows its way along the path of least resistance, externally, internally, or both, to form a fistula. Approximately 20 to 30 per cent. of patients requiring treatment for rectal affections suffer from abscess or its sequel, fistula. Abscess may occur at any age, but it is most common during the active years of life (from 25 to 45 years). It is more common in men than in women. Rectal abscesses may be large or small, and single or multiple. They are located beneath the skin, beneath the mucous membrane of the rectum, or in the deeper perirectal tissues. An erroneous impression exists among many physicians that most rectal abscesses and fistulæ are tuberculous in origin. Actually only a small percentage of abscesses are due to this cause. Any of the pyogenic bacteria may be found in a rectal abscess. B. coli is frequently present. Classification and Description. Rectal abscesses may be classified according to their location, as follows: (1) SUBTEGUMENTARY ABSCESS. This type of abscess is superficial an usually small. It is situated beneath the perianal skin near the mucocutaneous border. Etiology: Traumatism is the most co mon cause of subtegumentary abscess This may occur as a bruise, as a prurit condition (involving scratching), or a local irritation of any kind. Suppurating external hemorrhoids may become st tegumentary abscesses. Symptoms and Diagnosis: Abscess e neath the perianal skin usually starts as a sensation of discomfort which soon comes sharply painful. The pain is usually severe, considering the small of the abscess, and it is greatly increas by defecation. Diagnosis is readily made by inspecti and palpation. The abscess is extremely tender. There is little systemic disture ance. If a fistula results, it is known a marginal fistula. Treatment: The treatment is that of superficial abscess anywhere in the body Heat may be employed temporarily to re duce tension and so relieve pain, but t incision should be made as soon as [ sible. Temporizing may result in ginal fistula or even, perhaps, in extens of the pus into the ischiorectal space. The base of the abscess is injected wi 2 per cent. novocaine solution and a s ciently large crucial or a T-shaped incis is made. Pus is evacuated, the ca is lightly packed, and dressings are? plied. Daily applications of pure ph to the inner walls of the abscess car followed by alcohol (to neutralize th phenol), stimulate granulation from base of the cavity. Illustration showing the locations and the approximate areas of swelling in the various types of rectal abscess. A, subtegumentary abscess. B, submucous abscess. C, ischiorectal abscess. D, pelvirectal abscess. Symptoms may be absent or there may be only a vague sense of rectal discomfort. Due to its situation above the pectinate line, where sensory nerve fibers are few, there is perhaps little or no pain. The abscess may not be discovered until it Treatment: Submucous abscess should be incised as soon as possible, to permit free drainage of pus. Satisfactory exposure may be made through the operative type of anascope-speculum. A linear incision is made through the mucous membrane in the long axis of the bowel. The incision must be carried to the most dependent portion of the abscess cavity. No anesthesia is required. Pus is evacuated and the cavity is lightly packed and treated as described above (under subtegumentary abscess). This is the only type of abscess where incision of the mucous membrane is permissible. Even though an ischiorectal or pelvirectal abscess points internally, it should be evacuated by external incision. (3) ISCHIORECTAL ABSCESS. This is the most frequent and therefore the most important type of rectal abscess. It develops in the ischiorectal space (or both ischiorectal spaces) below the levator ani muscle and medial to the ischium. If it does not break internally into the rectum or externally to the skin to form a fistula, it may follow the lower border of the levator ani muscle and find its way into the ischiorectal fossa of the opposite side to form a horseshoe abscess. Etiology: Ischiorectal abscess usually arises from some lesion in the anal canal or lower rectum. Any injury or disease destroying the continuity of rectal mucous membrane may permit the entrance of the ever-present bacteria, with consequent suppuration and abscess formation. The loose areolar tissue, with its poor blood supply, offers little resistance to bacterial invasion. Among the specific causes of ischiorectal abscess may be mentioned: traumatism by hardened feces or foreign bodies, fissure, cryptitis, proctitis, ulcerating or suppurating hemorrhoids, neoplasms, the unhealed results of operative procedures, and certain debilitating systemic diseases. External trauma may predispose to the condition by lowering tissue resistance. Symptoms and Diagnosis: The onset of an ischiorectal abscess is often attended by fever and the symptoms of septic absorption even before the advent of pain. When pain becomes evident, it rapidly increases in severity, until it is intense. The region is swollen, indurated, red, tense, and tender. Pain sometimes subsides temporarily when the pus breaks into a new area. It then reappears with greater intensity as pus accumulates. When the pus is evacuated, either spontaneously or surgically, symptoms rapidly subside. In some cases grave symptoms of septic absorption are manifest. When of sufficient size, swelling is seen lateral to the external sphincter muscle, sometimes extending nearly to the tuberosity of the ischium. Occasionally sufficient pus may accumulate to destrov most of the areolar tissue and nearly fill the ischiorectal fossa. If the abscess bursts into the rectum to form a fistula, the opening is most frequently found in the mid-line posteriorly, between the sphincters. Diagnosis is made by bimanual palpation (one finger within the rectum). Prognosis: An ischiorectal abscess if untreated, or if improperly treated, will probably become a fistula, an entirely unnecessary sequel. (a Poulticing and hopeful waiting course too frequently adopted) make a fistula inevitable. All palliative measures are contraindicated. They accomplish nothing and cause the loss of valuable time. Every hour lost adds to the danger of further tissue destruction, toxemia, and fistula formation. Treatment: Early and free incision, if possible even before pus forms, is the only proper treatment of ischiorectal abscess. It is imperative that the opening be made large enough to insure proper drainage. A small stab incision may per mit some discharge of pus, but the open ing will probably close too soon, and little good will be accomplished. Operation may be performed under general or local anesthesia. The former (nitrous oxide-oxygen is very satisfac tory) is preferable. It is quicker and permits better digital exploration and the breaking down of pockets in the abscess cavity. If local anesthesia is used, the injection should be made along the proposed lines of incision, sufficiently deep. Considerable pain may be experienced if the injection is not deep enough. Technic Lines are marked over the ab scess with indelible pencil, to indicate the exact length and width of the intended incision. With the patient under anesthesia, general or local, a crucial or a T-shaped incision is made. If possible the longer cut should be made from the anus outward. This prevents muscle injury and permits better healing. It also makes treatment easier in case a fistula develops. The incisions should be made the entire length and width of the abscess cavity. The gloved finger is then inserted into the cavity and any pockets present are broken up, making one large cavity. The cavity is packed loosely with iodoform gauze and wet dressings are applied. Dressings should be changed whenever soiled. The iodoform gauze packing should be changed daily until the cavity becomes too small to retain it. If the tissue bridges over and pockets form within the abscess cavity during the process of healing, these must be broken down with the finger, or another abscess or a fistula may develop. Even if the abscess points internally, it is necessary to make the incision externally, to prevent it from rupturing into the rectum. In this way formation of a fistula may be averted. If the abscess has already ruptured into the rectum, external incision is necessary in order to facilitate drainage and treatment, and to prevent further damage to the mucous membrane. In this case a complete fistula is formed, which must be treated accordingly. (4) PELVIRECTAL ABSCESS AND (5) RETRORECTAL ABSCESS. The above conditions are similar except in location, so that they may be considered together. These are the most serious types of rectal abscess, but fortunately they are uncommon. Both lie above the levator ani muscle (supralevator abscess), between the upper border of this muscle and the rectal wall. The former lies in the so-called pelvirectal space and the latter in the retrorectal space (between the rectum and sacrum). Supralevator abscess may be deep, and considerable tissue may be damaged before it is recognized. It usually occurs secondary to, or as an extension from, suppuration in other organs, particularly the genito-urinary organs, the bones of the pelvis, or from an appendicular, psoas, or perinephric abscess. It may, less often, be caused by those injuries or diseases which cause ischiorectal abscess. Symptoms may be of a serious nature. Severity and character of the symptoms depend upon the causative factors, which, in turn often mask the abscess. may be symptoms of pressure, of tissue destruction, and of grave toxemia. Per There foration through the rectum, bladder, or peritoneum may occur. Diagnosis is often difficult. Prognosis is grave and depends to a great extent upon the underlying cause and the early recognition and evacuation of pus. Tuberculous or cold abscess may be either supra-or infralevator. There may be little or no pain, even if the abscess is quite large. Treatment: As with all forms of rectal abscess, the treatment is early incision and drainage. Causes of the condition should be ascertained and corrected if possible. Incision should be through the perineum (pelvirectal abscess) abscess) or between the rectum and coccyx (retrorectal abscess) with upward dissection. these are major operative procedures, technic will not be considered here. 3701 N. Broad Street. As Progress and Changes in the Healing Art Since 30 Years Ago. W By FRANK BATES, M. D., Coalgate, Okla. E note many changes in our work of then and now. Our work then consisted mostly of calls to the bedside of the sick. Office practice did not appeal to us of much importance. Preventive medicine was not so popular as now. Many of us were riding horseback. The family doctor in the country was the whole cheese, often doing surgery in the homes; sometimes it would be a log cabin, Hospitals for country folks were not so often thought of thirty years ago in the then Indian Territory. Some of us doctors would do appendectomy in the home, using the kitchen table for operating table. Operate for empyema, amputate an arm or a leg. If there was a fractured arm or leg we were called in haste to the bedside, run a horse down to get a doctor in a hurry. How differently now! It has been a long time since I have been called to the bedside in case of fracture. Now the patient is brought to the office in a car, x-ray is used when necessary, the fracture adjusted and immobilized and sent home, to return at intervals, till time for the appliances to be removed and the case dismissed. 1Read at Atoka, Coal Co., Medical Society, October 8. 1929. Nowadays doctors consider their office practice of very much importance, and the better our office is equipped, the more we do in the office and the better our income, and right here is where physiotherapy comes in. There is room for a great deal of improvement with us country doctors in our equipment and methods of practice. We need to modernize more than we have. We are losing a lot of the cream of our practice to the city doctors, and many cases go to the hospitals that we should treat at home, thereby losing money and prestige for the country doctors. I will mention some of the equipment of which we have failed to avail ourselves. A few of us have some of them, but we are all more or less behind the well equipped doctors of today. Blood pressure instruments most of us have. A microscope is important to have in any doctor's office. I mean country doctors, because we haven't a laboratory near to depend on. Any of us can learn to use a microscope, and I want to say that no doctor can treat and dismiss a case of gonorrhea and tell his patient he is well till he has tested his prostatic strippings or centrifuged urine with the microscope and found a negative test of 3 specimens 10 days apart. That was the procedure requested by the department of public health during the late war. Of course, in syphilis we always look for a negative before dismissing a case. Why not in gonorrhea? In our office equipment also I will mention electric massage, to displace the chiro and osteopath, and the electric cautery, which any of us can learn to handle in minor work especially, such as removing warts, moles, external growths, and hemorrhoids, most of which go to hospitals for treatment nowadays, and could be done in any doctor's office. We neglect suggestive therapeutics, the big club of the christian sciencers. The above mechanical equipment any of us can handle with just a little study and practice. There are other electrical appliances which call for special training in the physical and chemical effects on the tis sues of the human body and the therapeutic application of same. There are some dozen or so of different currents the effect of which are as different as that of quinine and calomel. Anything that has power for good, rightly used, has just as great power for harm if wrongly used. Take, for instance, radium, x-ray and the ultraviolet ray. Electricity is a fine servant, but if you let it get loose or from under control, it is a bad master, as bad as a kicking mule. A doctor must know the fundamental principles of electricity to get the proper therapeutic effects just as one must know the physiological effects of drugs to properly administer the same. At this day and time these things are not beyond our reach or our understanding. If we can not handle them all, each one added to our armamentarium in our office is money well spent. or I will mention, too, the diathermy cur rent. As its name implies, it is heat. There are several kinds of heat: radiant heat as from a stove, conductive heat as from a hot water bottle, conversive or convective heat as from the electrode of a high-frequency current diathermia. Take two electrodes of the same dimen sion; apply, we will say, to the knee, and the heat, converges to a point within the knee midway between the electrodes. Use in synovitis. Then take a large flat electrode and apply to the back; on the other wire you attach an electric needle and apply the needle to a growth, or say, for instance, the tonsil. It will produce coagulation or destruction of the tissue at your will. It is used to treat enlarged tonsils instead of tonsillectomy now by some of the best throat specialists. Also it is used to remove warts, moles, skin cancer, facial blemishes, and hemorrhoids. It can be done with local anesthesia. leaves a clean antiseptic wound, and is bloodless. I quote here from THE MEDICAL WORLD, by Eli Browning, of Burlington, Iowa: Patient, age 28, after having suffered for three days with acute tonsillitis, could hardly talk for pain, his tonsils were greatly swollen Had been unable to eat for 24 hours. Under local anesthesia I treated each tonsil with diathermia needle, not enough to cause coagu lation, but enough to shrink them. He went home, had a good night's rest, ate a hearty breakfast next morning; has not had any re currence of sore throat since. Three years have elapsed. This experience could be multiplied many times. This doctor also mentions another case that had a tonsillectomy performed. The throat became infected, almost took the life of the patient, and she could not talk |