THE TREATMENT OF SUPPURATING FISTULOUS

TRACTS.*

EMANUEL J. SENN, M.D.,

Instructor in Surgery, Rush Medical College, Chicago.

THIS subject is one of infinite importance and of such a comprehensive nature that I will not attempt to describe the treatment of the various different kinds of fistule, but will speak of the persistent variety following drainage or trauma, and which for no apparent cause continues to suppurate for an indefinite period of time, when there is gradual or sudden cessation of activity followed by complete definitive healing. Such fistulous tracts are a source of great annoyance both to surgeons and to patients; especially is this so if following in the wake of some brilliant operation, as it detracts from the surgeon's glory by precluding a complete cure; and prolonged continuous treatment is a cause of great inconvenience and worry to the patient.

In the treatment of fistulæ the cause is the essential element to be sought for and dealt with. The scope of this brief paper does not pretend to deal with the treatment of congenital fistulæ, such as branchial, omphalo-mesenteric, urachus, etc., which are a result of deviation from the normal embryonic development; nor of fistulæ such as intestinal, gastric, vesico-vaginal, in all of which there is great liability to a suppurative process; nor those following osteomyelitis, tuberculosis, stitch abscess, etc.

In the foregoing the etiological factor is evident, and the removal of it, provided such a course is possible, brings a favorable result. I wish to call attention to another phase of fistula which is most rebellious to treatment. I speak of the fistulous tract, per se, there being no focus in the bottom of the wound which might harbor microbic life, such as a sequestrum, non-absorbable stitch, unyielding suppurative cavity, etc.

The cause is situated in the walls of the fistula and is due either

*Read before the Mississippi Valley Medical Association, Louisville, Ky., October 5-7, 1897.

to pus microbes, their ptomaines, lack of intrinsic vegetative capacity of connective tissue cells and to the too often used strong chemical properties of antiseptics. That the presence of deeply seated microbes is the cause of protracted discharge is beyond doubt in the great majority of cases; but there are instances when there is every reason to believe there is perfect asepsis, drainage only having been resorted to for the removal of sanious discharges, but the drainage tract refuses to heal kindly after removal of the drain. It is well-known how the tissues of different individuals, under the same conditions, vary as regards the process of repair. We must not regard every discharging fistula when aseptic precautions have been taken as necessarily of a pyogenic character. The exudation in such cases is not pus, but lymph; as all post-natal embryonal cells physiologically secrete a fluid, macroscopically easily mistaken for pus. Let us consider the pathology of the walls of a chronic fistulous tract. The habitat of pyogenic microbes is not on the surface of the wall of a fistula but in the deeper connective tissues. After cell infiltration has taken place the vascular supply becomes diminished and nutrition is impaired with a consequent suppuration. It is by reason of the deeply seated microbes that fistula become so intractable. The sides of the fistula are lined with bluish-gray granulations, interspersed with areas of suppurative necrotic tissue. This region is anemic and the embryonal cells fall victims of the microbes and become pus corpuscles. Underneath the first layer or two of granulations the cells are more vascular, but they still furnish a favorable soil for bacterial life. If not surgically interfered with, the fungous granulations are thrown off gradually or the phagocytic action of the blood arrests further progress. This is a slow process and may be complicated by deeper burrowing of pus, forming an abscess. The surgical treatment of such a suppurative tract should, wherever practicable, consist in transforming it into an open wound by incision, followed by thorough curettage and secondary disinfection. Where this is not possible, less radical means must be resorted to. The active cause must be reached. If the fistula be direct, this is an easy matter, but if it is tortuous the microbic stronghold is difficult of attack. The conservative treatment resolves itself into the mechanical and chemical. By the former is meant the removal of microbes, pus and débris lining a fistulous tract, by thorough curettage, fol

lowed by aseptic dressings. The chemical or antiseptic irrigation treatment is not rational unless combined with the mechanical, and even then, probably, such solutions are of little avail. No less an authority than Schimmelbusch claimed that it was utterly impossible to disinfect a wound after infection. It is folly to use weapons which do not pierce the vital point. Even if antiseptic solutions could be used in their full strength, they would be unable to permeate the tissues and reach the cause. Again, it is a question whether antiseptics are destroyers of pus microbes in tissues; as wound products almost invariably contain albumen, which forms a chemical decomposition with antiseptic solutions, and the antizymotic power is mitigated or entirely lost. Antiseptic solutions have a deleterious effect on fixed tissue cells, diminishing their resistance; or, if sufficiently potent, cause their entire destruction. It is well known that certain chemical substances, such as turpentine and croton oil have pyogenic properties, producing the so-called chemical pus. May not chemicals in solution, such as our toxic antiseptics, produce products which have the appearance of pus, but which are still not clinical pus? Antiseptics which are of sufficient potency to destroy microbic life have the identical effect on surrounding granulation tissue. Strong antiseptic irrigation continued at intervals is directly antagonistic to the healing process. It is cell destruction instead of cell repair. I have seen case after case where irritating solutions such as bromine, iodine, bichloride of mercury, etc., had been flushed through fistulæ day by day without benefit until mechanical removal of abundant fungous granulations lining the tract by curettage had been resorted to, followed by dry dressing. After such a course had been practiced, there was immediate subsidence of symptoms, followed by definitive healing.

The rational treatment should not be based upon the attempt of direct destruction of microbes, which is well nigh impossible, but to render a fertile soil, which was favorable for their reproduction, barren. This is best accomplished through curettage, which must be done from the external opening to the bottom of the wound. When the fistula is tortuous, a uterine curette, the handle of which can be adapted to the curves of the walls, answers the purpose well.

This

operation must be done with considerable force irrespect

ive of hemorrhage, until considerable resistance is encountered, which shows that fixed cells have been met with. This insures the removal of some of the microbes themselves, which are, as a rule, deeply seated, although this is of secondary importance. But chief of all is the removal of unhealthy granulations and débris, the most fruitful soil of microbic cultivation. This operation is followed by non-toxic irrigation, such as solutions of boric acid, salicylic acid, Thiersch's solution, normal salt solution, acetate of aluminum, or sterilized water for the mechanical removal of detached débris and toxins.

Having removed as much of the culture medium as possible, the next procedure should have for its aim inhibition of remaining bacteria. This is best accomplished with dry dressing, provided the necrotic tissue has been removed entirely, otherwise dry dressing is an error, as it would only form protection to incubation of microbic life underneath.

Non-toxic antiseptic powders such as boric acid, salicylic acid, or what is still better, a combination of one part of iodoform to five parts of boric acid, should be thrown into the fistula. The combination of iodoform and boric acid is practically non-toxic. Iodoform, while probably not a direct antiseptic, forms certain combinations with microbes or their toxins, rendering them inert.

As these chronic fistula do not, as a rule, suppurate freely, tubular drainage is not called for. This form of drainage is not to be recommended except when the discharge is copious, as it does not aspirate pus but drains only by reason of gravity. Such action can only take place if the patient is in a favorable position. Iodoform gauze should be packed loosely to the bottom of the wound, as it keeps the walls of the sinus dry by reason of capillary action, and is also the source of active tissue stimulation.

After following the treatment outlined there may be a slight rise of temperature due to rapid absorption of toxins, but this rapidly subsides. The primary dressing should not be disturbed for four or five days, when it is removed, and if there is a discharge and the granulations appear flabby, the treatment is repeated. Nitrate of silver or other caustics should not be used, as the granulations are only superficially destroyed, leaving a necrotic area, which it ought to be the surgeon's object to obviate. If the granulations are persistently sluggish, it is well to occasionally pack the wound with gauze saturated with balsam of

Peru, as this agent stimulates the regenerative capacity of embryonal cells without impairing the vitality of surrounding tissues. In my hands most obstinate fistulæ have yielded under the treatment suggested, where previous antiseptic irrigation over extended periods of time proved of no avail.

THE GROWING NEED OF MEDICAL POLITICAL ORGANIZATION.*

JOHN PUNTON, M.D.,

Professor of Nervous and Mental Diseases, University Medical College; Woman's Medical College, Neurologist to All Saints, Germun, Scarritt, Kansas City, Fort Scott and Memphis and Missouri Pacific Railroad Hospitals.

THE marvellous progress of the science of medicine during the past decade is the wonder of the age.

In its voluminous annals no such triumphs are recorded and no such brilliant results achieved as those which belong to the present generation.

In a recent critical analysis of the actual work done by the three so-called learned professions, it was clearly demonstrated that scientific rational medicine easily took the lead in actual achievement, intellectual progress and evolutionary development, and that medicine far exceeded both law and theology in original investigation. (See Journal American Medical Association, February 13, 1897, p. 320.)

With such a record it would seem that the power and influence of the medical profession should be even greater today than ever before and its glorious tenets exalted to their highest degree.

But we are informed by no less a personage than Mr. Cleveland (ex-President of the United States), that our power and influence is rapidly waning and that our greed for scientific attainment is already threatening us with dire disaster.

"If," says he, "laws are needed to abolish abuses which your professional investigations have unearthed, your fraternity should not be strangers to the agencies which make the laws. If enact

*Read by title before the Mississippi Valley Medical Association, October 8, 1897, at Louisville, Ky.