- Email: [email protected]
Ischiorectal abscess a consideration of the origin and the treatment
ISCHIORECTAL A CONSIDERATION
ABSCESS
OF THE ORIGIN AND THE TREATMENT S. JUDD BOCHNER, M.D.
Instructor
in Surgery, New York
Post-Graduate MedicaI SchooI, Columbia York Post-Graduate HospitaI
University;
Assistant Surgeon, New
NEW YORK
I
SCHIORECTAL abscess aImost invariabIy means that an anaI cryptitis has been overIooked; for go per cent of a11 para-anal inffammatory disease is of nonspecific origin and directIy traceabIe to an acute cryptitis. Acute cryptitis does not present a compIicated picture either for diagnosis or treatment, nevertheIess the amazing frequency with which its disabIing sequeIs enter the of&e and cIinic must bring about a reconsideration of the problem. Review of IOO consecutive cases of ischiorectal and pararecta1 abscess seen at the New York Post-Graduate HospitaI recta1 cIinic, showed that 44 patients had as their chief compIaint the discharge of pus from an aIready existing fistuIa or sinus varying in duration from two days to four years; 23 of these peopIe had had one or more previous operations for abscess without reIief. In questioning these peopIe, it appeared that three factors must pIay a part in this picture: (I) deIay on the part of the patient in consuIting his doctor, (2) deIay on the part of the doctor, and (3) incompIete therapy. SociaI taboos on the discussion of ana disease makes difflcuIt the dissemination of information that might bring the patient to the doctor suflicientIy earIy for the disease to be a simpIe probIem. NegIect at this “goIden period” of rectal surgery, however, is not aItogether the fauIt of the patient, for not infrequentIy he teIIs the story of having consuIted a doctor and of having been given a saIve or a Iotion for the teII-taIe para-ana itch, a cathartic for his constipation and admonition to return in two weeks. OnIy too often it is apparent that a proper recta1 examination had not been done.
AnaI crypts form pockets at the bottom of each of the coIumns of Morgagni. They take origin in the transitiona epitheIium of the intermediate zone and therefore are Iined by tubuIar gIands, more usuaIIy known as ana ducts. The mouths of the crypts are in part protected by the foIds and papiIIae of the coIumns. Acute cryptitis is a primary inffammatory disease of the gIands of the crypts. As the process continues the crypt becomes edematous and fiIIed with pus. The papiIIae are swoIIen, eIongated and even take on a poIypoid character. Exudate forms a mat about the swoIIen papiIIae effectiveIy seaIing the mouth of the crypt, and the mechanism is compIeted for the formation of a submucosa1 abscess. Pam-anal itching and burning appear earIy in the disease, for the puruIent discharge is decidedIy irritating. We often hear the mother say, “There is something wrong with BiIIy. He is aIways scratching himseIf.” Pain on defecation appears at a Iater stage of the disease, that is, when abscess has formed; the cryptitis has become seaIed off forming an intramura1 inflammatory mass. The recta1 examination wiI1 invariabIy expose a cryptitis or submucosa1 abscess. The patient shouId be either in the kneechest position, with knees we11 separated, or we11 over in the Ieft Sims position. The presence of hemorrhoids or fissure need not confuse the picture as they are incidenta rather than causative in their reIationship. The finger wiI1 eIicit a single point of tenderness and possibIy define the abscess as a mass the size of a pea. Direct examination by the use of an open specuIum and a good Iight wiI1 compIete the picture. This Iast procedure is essentia1 to a proper
280
American Journal of Surgery
Bochner-IschiorectaI
recta1 examination and shouId never be omitted. Treatment at this stage is reIativeIy simpIe and decidedIy satisfactory. DivuIsion of the ana sphincter to admit five or six fingers shouId be done sIowIy so as not to tear the tissues. The abscess is incised in the long axis of the gut, the incision extending from the mouth of the crypt toward the anal orifice. The mucosa1 ffaps of the abscess are resected to insure adequate drainage and to prevent any tendency to secondary pocketing. FoIIow-up visits to maintain a reIaxed sphincter and a freely draining wound until the entire cavity is fiIIed with granulations, wiI1 cure the disease. The subacute and chronic cryptitis forms the channe1 of origin of ischiorecta1 abscess and fistuIa. GranuIations and scarring effectiveIy sea1 the mouth of the crypt so that the process is forced to extend deeper into the ana ducts or gIands. The abscess, now more properIy a coIumn, reaches we11 into and beyond the muscIe coats of the anorecta1 cana1, and when rupture eventuaIIy occurs, it is into the highIy susceptible pararecta1 space. The secondary abscess so evoIved may be in the immediate pararectal tissue or at aImost any distance into the ischiorecta1 fossa. One of two things may happen at this stage: (I) rapid accumuIation of an abscess with rupture to the outside and the formation of a compIete recta1 fistuIa, (2) waIIing-off of the secondary abscess in the ischiorecta1 space with irreguIar drainage either into the rectum, or, and as eventuaIIy does occur, the formation of secondary channeIs and further foci of abscess. The second is obviousIy the more compIicated because the fistuIa so formed is compIex and may even be m&ipie in type. Continued reinfection within the virtuaIIy non-coIIapsibIe ischiorecta1 fossa sets up a vicious circIe. The infecting agent is retained in the isoIated gIand structures in and about the origin of the fistular tract. The persistence of these same gIands keeps open the origina tract to the ana crypt
Abscess
APRIL. 1937
and therefore to continued fresh source of infectious material. The irreguIar channeI becomes thickened by the repeated scarring and hyaIinization, so that the heaIing process at best is sIow and irreguIar. Pockets fiIIed with chronic puruIent debris form activating foci and are foIIowed by secondary acute abscess formation. The inadequacy of open drainage as a soIe form of treatment for this compIex picture is due to the non-coIIapsibIe character of the pathoIogy and to the fact that the entire process is contained in a relatively rigid fossa. Excision of a11 source material, that is, of the entire tract, associated with wide drainage of the cavity, though apparentIy very radica1, is the onIy compIete cure for the disease. TubercuIosis is the causative agent in approximateIy IO per cent of ischiorecta1 abscess. PuImonary tubercuIosis can aImost invariabIy be demonstrated by x-ray, and chest plates shouId be taken, if onIy for the protection of the surgeon, in a11 cases where there is a possibility of this disease. The patient with ana tubercuIosis gives a story of repeated operations for abscess without success. Examination shows the granuIations about the sinus to be puffy and rather watery in character. If such a patient has a chronic cough, Iook for tubercuIosis as the cause of ischiorecta1 abscess. The fact must be borne in mind, however, that a chronic cough by no means indicates that the ischiorecta1 abscess must be tubercuIous in origin. Surgery to be effective in this disease must eompIeteIy remove a11 the granulomatous tissue. Abscess of a piIonida1 cyst wiI1 occasionaIIy drain downward into an ischiorectal space. The recognition of the origin of this abscess and the Iine of the sinus is essentia1, for it wouId decidedIy compIicate an aIready compIicated picture to open this abscess into the bowe1. CompIete excision of the piIonida1 cyst and the tract is necessary to effect a cure. Recta1 diverticulitis is a rare cause of ischiorecta1 abscess. The mechanism in this instance is very similar to that of ana
NEW
SERIES
Var..
XXXVI,
No.
I
Bochner-IschiorectaI
cryptitis with abscess and rupture into the pararecta1 space. The depth and extent of the tract, however, modifies the treat-
FIG. I. AnaI crgptitis forms the channe1 of origin of isch&rectal abscess and fistuIa. Note the exudative character of the disease, irregular scarring, and scattered persistent gland structure at the bottom of the crypt.
ment, and the case must be treated as an intestina1 fistuIa passing through the ischiorecta1 space. Trauma as a cause of ischiorecta1 abscess is infrequent but nevertheIess does occur. When treated immediateIy as a penetrating wound with adequate drainage, a cure may be expected without much diffIcuIty. Malignancy in the ischiorecta1 space wiI1 form an abscess, but the abscess obviousIy is of secondary importance and need not concern us in this discussion. AnaI infection as a focus of genera1 toxic absorption comparabIe to disease of teeth, tonsils, appendix, or gal1 bIadder, has received IittIe consideration. Patients have Iost their teeth, appendix and gaI1 bladder in an attempt to reIieve rheumatism and have faiIed because of undiscovered Iow grade anaI cryptitis or even fistuIa. The routine medica examination shouId give the anorecta1 cana at Ieast as much attention as the teeth and tonsiIs. The treatment of ischiorecta1 abscess is not an offIce procedure. It must not be forgotten that 2~ oer cent of the cases of u
Abscess
American
Journal
of Surgery
281
ischiorecta1 abscess that enter the PostGraduate HospitaI recta1 clinic have had previous unsatisfactory operations
FIG. z. The walIs of the fistula are thickened by repeated scarring and hyaIinization. The chronic purulent inflammatory disease is progressive and forms foci for secondary abscess and sinus formation.
which had served but to compIicate the picture. Genera1 anesthesia is to be preferred; gas oxygen or ethyIene are adequate, and ether is rareIy necessary. A smaI1 low spinal anesthesia gives exceIIent resuIts, but the postoperative difficuIties, particuIarIy headache, compIicate the picture; however, where a genera1 anesthetic is counterindicated, parasacra1 bIock is preferabIe to the spina1. Incision of the abscess compIetes the fistuIa. The extent and direction of the fistuIous tract must be ascertained before further surgery is attempted, and this can best be done by the use of the ffexibIe siIver probe. If difficuIty is encountered, the ana crypt invoIved can usuaIIy be Iocated with ease, and the channe1 entered by a hooked probe from within the rectum. A compIete divuIsion of the ana sphincter is of course necessary to compIete the above procedure. The fistuIa is grasped upon the probe and excised in its entirety by actua1 dissection. The sphincter muscIes are preserved if possibie, but if necessary one or even both
282
American Journal of Surgery
Bochner-IschiorectaI
may be incised with IittIe or no damage. If the incision through the sphincter is made at right angIes to the muscIe fibers, union wiI1 be reestablished without suture and without appreciabIe functiona disturbance. The scar tissue forms an origin and insertion for the divided muscIe. AI1 tissue Aaps and coverings of the wound must be wideIy resected so as to produce the effect of saucerization, and so that proper coIIapse may take pIace without secondary pocketing of infected materia1. A Iight iodoform gauze packing compIetes the procedure. ShouId pocketing occur at a Iater date, a secondary operation to compIete the first must be performed. Postoperative hospital care is simpIe, for the patient is comfortabIe and rapidIy free of fever in spite of the radica1 surgery. After thirty-six hours an oi1 cathartic is given and in forty-eight hours the drains are removed. Regular Iow residue diet, mineral oi1 or agar-type cathartics and a daiIy sitz bath compIete the routine. After care of the recta1 patient is proIonged, but to obtain a good resuIt, it must be exacting. A we11 Iubricated bougie is passed every day for the first week and three times a week thereafter unti1 heaIing and epitheIiaIization is compIete. A smaI1 suppository of castor oi1 aud baIsam of Peru, equa1 parts, after each passage of the bougie, is very soothing to the patient. Periodic review is required for another six months to prevent a possibIe fibrous stenosis of the anus. The more compIicated fistuIas of secondary horseshoe type must be deaIt with as individua1 probIems. One must keep in mind the warning of MiIes, “it may be better to endure the discomfort of a discharging sinus rather than run the risk of permanent Ioss of contro1.” This is particuIarIy true when we reaIize that any form of treatment other than compIete radica1 excision wiII do nothing but add to the compIications. Bacteriophage therapy is reIativeIy untried in the treatment of pararecta1 inffam-
Abscess
APRIL,1927
matory diseases. CuItures at operation usuaIIy show a mixed infection with BaciIIus coIon acidi Iactici and green streptococcus as the predominant organisms. A potent mixed bacteriophage is avaiIabIe and might we11prove of considerabIe vaIue as an adjunct to surgery, more particuIarIy in the postoperative care of the more extensive wounds. SUMMARY
A review of IOO cases of ischiorecta1 and pararecta1 abscess showed that 44 aIready had fistuIar formation upon entering the cIinic and 23 had had one or more incompIete operations. The origin and pathoIogy of pararecta1 inflammatory disease is traced from the reIativeIy simpIe acute cryptitis to the compIex picture of ischiorecta1 abscess and fistuIa. Three factors appear to compIicate the picture; (I) deIay on the part of the patient; (2) deIay on the part of the doctor and (3) incompIete therapy. The principa1 sources of infection of the ischiorecta1 space other than that outIined, are tubercuIosis, piIonida1 cyst with abscess, perforated recta1 diverticuIitis, trauma and maIignancy. The entire excision of the fistuIar tract with wideIy open drainage is advocated as the desired form of treatment. Bacteriophage therapy as an adjunct to surgery is suggested. REFERENCES HIRSCHMAN, L. J. FocaI infection of anaI grigin. J.A.M.A.,g7:16og-1611,Ig31. LOCKHART-MUMMERY,J. P. F&da-in-ano. Lance& 230: 6574% 1936. MILES. W. E. AnorectaI fistmae. Post-Grad. Med. Jour., 12: 319-326, 1936. RANKIN, F. W., BARGEN, J. A., and Bum, L. A. Anal Infections. The CoIon, Rectum and Anus. PhiIadeIphia, W. B. Saunders Co., 1935 pp. 580608. TUCKER. C. C. and HELLWIG. C. A. AnaI ducts: comparative and developmental histology. Arch. Surg., of ana crypts. 31: 521-530, 1935. Histopathology Surg., Gynec., and Obst., 58: 145-149, 1934.
ABSCESS
OF THE ORIGIN AND THE TREATMENT S. JUDD BOCHNER, M.D.
Instructor
in Surgery, New York
Post-Graduate MedicaI SchooI, Columbia York Post-Graduate HospitaI
University;
Assistant Surgeon, New
NEW YORK
I
SCHIORECTAL abscess aImost invariabIy means that an anaI cryptitis has been overIooked; for go per cent of a11 para-anal inffammatory disease is of nonspecific origin and directIy traceabIe to an acute cryptitis. Acute cryptitis does not present a compIicated picture either for diagnosis or treatment, nevertheIess the amazing frequency with which its disabIing sequeIs enter the of&e and cIinic must bring about a reconsideration of the problem. Review of IOO consecutive cases of ischiorectal and pararecta1 abscess seen at the New York Post-Graduate HospitaI recta1 cIinic, showed that 44 patients had as their chief compIaint the discharge of pus from an aIready existing fistuIa or sinus varying in duration from two days to four years; 23 of these peopIe had had one or more previous operations for abscess without reIief. In questioning these peopIe, it appeared that three factors must pIay a part in this picture: (I) deIay on the part of the patient in consuIting his doctor, (2) deIay on the part of the doctor, and (3) incompIete therapy. SociaI taboos on the discussion of ana disease makes difflcuIt the dissemination of information that might bring the patient to the doctor suflicientIy earIy for the disease to be a simpIe probIem. NegIect at this “goIden period” of rectal surgery, however, is not aItogether the fauIt of the patient, for not infrequentIy he teIIs the story of having consuIted a doctor and of having been given a saIve or a Iotion for the teII-taIe para-ana itch, a cathartic for his constipation and admonition to return in two weeks. OnIy too often it is apparent that a proper recta1 examination had not been done.
AnaI crypts form pockets at the bottom of each of the coIumns of Morgagni. They take origin in the transitiona epitheIium of the intermediate zone and therefore are Iined by tubuIar gIands, more usuaIIy known as ana ducts. The mouths of the crypts are in part protected by the foIds and papiIIae of the coIumns. Acute cryptitis is a primary inffammatory disease of the gIands of the crypts. As the process continues the crypt becomes edematous and fiIIed with pus. The papiIIae are swoIIen, eIongated and even take on a poIypoid character. Exudate forms a mat about the swoIIen papiIIae effectiveIy seaIing the mouth of the crypt, and the mechanism is compIeted for the formation of a submucosa1 abscess. Pam-anal itching and burning appear earIy in the disease, for the puruIent discharge is decidedIy irritating. We often hear the mother say, “There is something wrong with BiIIy. He is aIways scratching himseIf.” Pain on defecation appears at a Iater stage of the disease, that is, when abscess has formed; the cryptitis has become seaIed off forming an intramura1 inflammatory mass. The recta1 examination wiI1 invariabIy expose a cryptitis or submucosa1 abscess. The patient shouId be either in the kneechest position, with knees we11 separated, or we11 over in the Ieft Sims position. The presence of hemorrhoids or fissure need not confuse the picture as they are incidenta rather than causative in their reIationship. The finger wiI1 eIicit a single point of tenderness and possibIy define the abscess as a mass the size of a pea. Direct examination by the use of an open specuIum and a good Iight wiI1 compIete the picture. This Iast procedure is essentia1 to a proper
280
American Journal of Surgery
Bochner-IschiorectaI
recta1 examination and shouId never be omitted. Treatment at this stage is reIativeIy simpIe and decidedIy satisfactory. DivuIsion of the ana sphincter to admit five or six fingers shouId be done sIowIy so as not to tear the tissues. The abscess is incised in the long axis of the gut, the incision extending from the mouth of the crypt toward the anal orifice. The mucosa1 ffaps of the abscess are resected to insure adequate drainage and to prevent any tendency to secondary pocketing. FoIIow-up visits to maintain a reIaxed sphincter and a freely draining wound until the entire cavity is fiIIed with granulations, wiI1 cure the disease. The subacute and chronic cryptitis forms the channe1 of origin of ischiorecta1 abscess and fistuIa. GranuIations and scarring effectiveIy sea1 the mouth of the crypt so that the process is forced to extend deeper into the ana ducts or gIands. The abscess, now more properIy a coIumn, reaches we11 into and beyond the muscIe coats of the anorecta1 cana1, and when rupture eventuaIIy occurs, it is into the highIy susceptible pararecta1 space. The secondary abscess so evoIved may be in the immediate pararectal tissue or at aImost any distance into the ischiorecta1 fossa. One of two things may happen at this stage: (I) rapid accumuIation of an abscess with rupture to the outside and the formation of a compIete recta1 fistuIa, (2) waIIing-off of the secondary abscess in the ischiorecta1 space with irreguIar drainage either into the rectum, or, and as eventuaIIy does occur, the formation of secondary channeIs and further foci of abscess. The second is obviousIy the more compIicated because the fistuIa so formed is compIex and may even be m&ipie in type. Continued reinfection within the virtuaIIy non-coIIapsibIe ischiorecta1 fossa sets up a vicious circIe. The infecting agent is retained in the isoIated gIand structures in and about the origin of the fistular tract. The persistence of these same gIands keeps open the origina tract to the ana crypt
Abscess
APRIL. 1937
and therefore to continued fresh source of infectious material. The irreguIar channeI becomes thickened by the repeated scarring and hyaIinization, so that the heaIing process at best is sIow and irreguIar. Pockets fiIIed with chronic puruIent debris form activating foci and are foIIowed by secondary acute abscess formation. The inadequacy of open drainage as a soIe form of treatment for this compIex picture is due to the non-coIIapsibIe character of the pathoIogy and to the fact that the entire process is contained in a relatively rigid fossa. Excision of a11 source material, that is, of the entire tract, associated with wide drainage of the cavity, though apparentIy very radica1, is the onIy compIete cure for the disease. TubercuIosis is the causative agent in approximateIy IO per cent of ischiorecta1 abscess. PuImonary tubercuIosis can aImost invariabIy be demonstrated by x-ray, and chest plates shouId be taken, if onIy for the protection of the surgeon, in a11 cases where there is a possibility of this disease. The patient with ana tubercuIosis gives a story of repeated operations for abscess without success. Examination shows the granuIations about the sinus to be puffy and rather watery in character. If such a patient has a chronic cough, Iook for tubercuIosis as the cause of ischiorecta1 abscess. The fact must be borne in mind, however, that a chronic cough by no means indicates that the ischiorecta1 abscess must be tubercuIous in origin. Surgery to be effective in this disease must eompIeteIy remove a11 the granulomatous tissue. Abscess of a piIonida1 cyst wiI1 occasionaIIy drain downward into an ischiorectal space. The recognition of the origin of this abscess and the Iine of the sinus is essentia1, for it wouId decidedIy compIicate an aIready compIicated picture to open this abscess into the bowe1. CompIete excision of the piIonida1 cyst and the tract is necessary to effect a cure. Recta1 diverticulitis is a rare cause of ischiorecta1 abscess. The mechanism in this instance is very similar to that of ana
NEW
SERIES
Var..
XXXVI,
No.
I
Bochner-IschiorectaI
cryptitis with abscess and rupture into the pararecta1 space. The depth and extent of the tract, however, modifies the treat-
FIG. I. AnaI crgptitis forms the channe1 of origin of isch&rectal abscess and fistuIa. Note the exudative character of the disease, irregular scarring, and scattered persistent gland structure at the bottom of the crypt.
ment, and the case must be treated as an intestina1 fistuIa passing through the ischiorecta1 space. Trauma as a cause of ischiorecta1 abscess is infrequent but nevertheIess does occur. When treated immediateIy as a penetrating wound with adequate drainage, a cure may be expected without much diffIcuIty. Malignancy in the ischiorecta1 space wiI1 form an abscess, but the abscess obviousIy is of secondary importance and need not concern us in this discussion. AnaI infection as a focus of genera1 toxic absorption comparabIe to disease of teeth, tonsils, appendix, or gal1 bIadder, has received IittIe consideration. Patients have Iost their teeth, appendix and gaI1 bladder in an attempt to reIieve rheumatism and have faiIed because of undiscovered Iow grade anaI cryptitis or even fistuIa. The routine medica examination shouId give the anorecta1 cana at Ieast as much attention as the teeth and tonsiIs. The treatment of ischiorecta1 abscess is not an offIce procedure. It must not be forgotten that 2~ oer cent of the cases of u
Abscess
American
Journal
of Surgery
281
ischiorecta1 abscess that enter the PostGraduate HospitaI recta1 clinic have had previous unsatisfactory operations
FIG. z. The walIs of the fistula are thickened by repeated scarring and hyaIinization. The chronic purulent inflammatory disease is progressive and forms foci for secondary abscess and sinus formation.
which had served but to compIicate the picture. Genera1 anesthesia is to be preferred; gas oxygen or ethyIene are adequate, and ether is rareIy necessary. A smaI1 low spinal anesthesia gives exceIIent resuIts, but the postoperative difficuIties, particuIarIy headache, compIicate the picture; however, where a genera1 anesthetic is counterindicated, parasacra1 bIock is preferabIe to the spina1. Incision of the abscess compIetes the fistuIa. The extent and direction of the fistuIous tract must be ascertained before further surgery is attempted, and this can best be done by the use of the ffexibIe siIver probe. If difficuIty is encountered, the ana crypt invoIved can usuaIIy be Iocated with ease, and the channe1 entered by a hooked probe from within the rectum. A compIete divuIsion of the ana sphincter is of course necessary to compIete the above procedure. The fistuIa is grasped upon the probe and excised in its entirety by actua1 dissection. The sphincter muscIes are preserved if possibie, but if necessary one or even both
282
American Journal of Surgery
Bochner-IschiorectaI
may be incised with IittIe or no damage. If the incision through the sphincter is made at right angIes to the muscIe fibers, union wiI1 be reestablished without suture and without appreciabIe functiona disturbance. The scar tissue forms an origin and insertion for the divided muscIe. AI1 tissue Aaps and coverings of the wound must be wideIy resected so as to produce the effect of saucerization, and so that proper coIIapse may take pIace without secondary pocketing of infected materia1. A Iight iodoform gauze packing compIetes the procedure. ShouId pocketing occur at a Iater date, a secondary operation to compIete the first must be performed. Postoperative hospital care is simpIe, for the patient is comfortabIe and rapidIy free of fever in spite of the radica1 surgery. After thirty-six hours an oi1 cathartic is given and in forty-eight hours the drains are removed. Regular Iow residue diet, mineral oi1 or agar-type cathartics and a daiIy sitz bath compIete the routine. After care of the recta1 patient is proIonged, but to obtain a good resuIt, it must be exacting. A we11 Iubricated bougie is passed every day for the first week and three times a week thereafter unti1 heaIing and epitheIiaIization is compIete. A smaI1 suppository of castor oi1 aud baIsam of Peru, equa1 parts, after each passage of the bougie, is very soothing to the patient. Periodic review is required for another six months to prevent a possibIe fibrous stenosis of the anus. The more compIicated fistuIas of secondary horseshoe type must be deaIt with as individua1 probIems. One must keep in mind the warning of MiIes, “it may be better to endure the discomfort of a discharging sinus rather than run the risk of permanent Ioss of contro1.” This is particuIarIy true when we reaIize that any form of treatment other than compIete radica1 excision wiII do nothing but add to the compIications. Bacteriophage therapy is reIativeIy untried in the treatment of pararecta1 inffam-
Abscess
APRIL,1927
matory diseases. CuItures at operation usuaIIy show a mixed infection with BaciIIus coIon acidi Iactici and green streptococcus as the predominant organisms. A potent mixed bacteriophage is avaiIabIe and might we11prove of considerabIe vaIue as an adjunct to surgery, more particuIarIy in the postoperative care of the more extensive wounds. SUMMARY
A review of IOO cases of ischiorecta1 and pararecta1 abscess showed that 44 aIready had fistuIar formation upon entering the cIinic and 23 had had one or more incompIete operations. The origin and pathoIogy of pararecta1 inflammatory disease is traced from the reIativeIy simpIe acute cryptitis to the compIex picture of ischiorecta1 abscess and fistuIa. Three factors appear to compIicate the picture; (I) deIay on the part of the patient; (2) deIay on the part of the doctor and (3) incompIete therapy. The principa1 sources of infection of the ischiorecta1 space other than that outIined, are tubercuIosis, piIonida1 cyst with abscess, perforated recta1 diverticuIitis, trauma and maIignancy. The entire excision of the fistuIar tract with wideIy open drainage is advocated as the desired form of treatment. Bacteriophage therapy as an adjunct to surgery is suggested. REFERENCES HIRSCHMAN, L. J. FocaI infection of anaI grigin. J.A.M.A.,g7:16og-1611,Ig31. LOCKHART-MUMMERY,J. P. F&da-in-ano. Lance& 230: 6574% 1936. MILES. W. E. AnorectaI fistmae. Post-Grad. Med. Jour., 12: 319-326, 1936. RANKIN, F. W., BARGEN, J. A., and Bum, L. A. Anal Infections. The CoIon, Rectum and Anus. PhiIadeIphia, W. B. Saunders Co., 1935 pp. 580608. TUCKER. C. C. and HELLWIG. C. A. AnaI ducts: comparative and developmental histology. Arch. Surg., of ana crypts. 31: 521-530, 1935. Histopathology Surg., Gynec., and Obst., 58: 145-149, 1934.