Staff Meeting Bulletin
Hospitals. of the ». »»
University of Minnesota
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Volume XV Friday, November 12, 1943 Number 7
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Volume rr
STAFF MEETING BULLETIN
HOSPITAIS OF THE • • •
UNIVERSITY OF M;IrOO:SOTA
Friday, November 12, 194;
INDEX
Number 7
PAGE
I. LAST WEEK ••••' ••• • • • • • • • • • • • • • 110
II. MEETINGS
. ~ .1. ANATOMY SEMINAR.
PATHOLOGY SEMINAR • •
• • •
• • •
• •
• •
• •
• •
• • •
, . .
• •
• •
110
110
;. BACTERIOLOGY SEMINAR • • • • • • .'. • • • • • 110
4. WAR-TIME GRADUATE MEDICAL MEETINGS • • • • • • 110
III. PERIRECTAL ABSCESS AND FISTULA • • • • of • • • • •
• '•• Wi11inm C. Bernstein and Walter A. Fansler 111 - 119
IV. GOSSIP
• • • :. o' • • • • ,. • • • • • • • • • • • •
120
Published for the General Staff Meeting each week
during the school year, October· to June, inclusive.
Financed by the Citizens Aid Society,
Alumni and Friends.
William A. O'~rien, M.D.
Date:
-
P1aoe:
Time:
Program:
November 5, 1943
Reoreation Room,
Powell Hall
12:15 to ~:15 p.m.
"CaroinoI1..a of Larynx"
W. R. Movius
L. R. Boies
110
3. BACTERIOLOGY SEMINAR
Thursday, November 16, 1943, 4:30 p.m.,
Room 129, Millard Hall.
"Etiology of Measles"
Sorothy Sawatzky Solvason
4. WAR-TIME GRADUATE MEDICAL
MEETINGS
12:00
6:00
,
Discussion: L. G. Rigler
K. W. stenstrom
L. R. Boies
Attendance: 108
Alice Carlson,
Record Librarian
II. ME:E:TINGS
1. ANATOMY SEMINAR
Saturday, November 13, 1943, 11:30 a.m.,
Room 226, Institute of Anatomy.
Leukemia in Man and Animals : Influence
of irradiation upon leukemia in experi-
mental animals.
Henry Kaplan
2. PATHOLOGY SEMINAR
MOnday~ November 15, 1943, 12:30 p.m.,
Room 104, Institute of Anatomy.
"Inf1uenzal l-Ieningitis"
H. D. Nester
The first session was held in Minneapolis
Tuesday, November 9,1943.
SUBJECT: Arthritis and Rheumatoid
Disease.
10:00 - 12:00 Ward walk, Wold-Chamber-
lain Naval AViation Base
Dispensary.
Dr. Charles H. Slocumb
Luncheon,Nava1 Medical
Dispensary Staff
2:00 - 4:00 Ward walk - Fort Snelling
Station Hospital,
Dr. Charles H.'Slocumb.
4:30 - 6:00 Lecture, Diagnosis and
Management of Arthritis
and Rheumatoid Diseaso.
Dr. Charles H. Slocumb.
Dinner, Officers' Club
(Arrrr:/ and Navy)
7:30 - 8:30 Difforentia1 diagnosis of
joint disease from radio-
logic standpoint.
Dr. Leo G. Rigler
8:30- 9:00 Discussion.
NEXT VlAR-TlME GRADUATE MEDICAL MEETING
in Minnoapolis will be held on
November 23, 1943.
Subject: Physical Medicine
Frank H. Krusen
Mi1and E. Knapp
Meotings held every 2 weeks in Minneapo-
lis. Also in Des Moinos and Clinton, Ia.
III. PERJRECTAL ABSCESS .AND FISTULA
III
along the bowel wall" either a subcutan-
eous or eublllUcous abscess is formed.
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INrRODUCTION
William C. Bernstein
Abscesses about the anorectal region
are relatively common and are of extreme
importance since improper care and treat-
nentmay lead to extensive necrosis of
tissue" multiple fistulae and sphincter
incontinence.
Absoesses occur at all ages but are
most frequent in adults from twenty to
fifty years of age.
The anorectal region is peculiarly
susceptible to infection and abscess
formation because of the anatomic rela..
tionships of the tissues involved. The
crypts of Morgagni are frequently tho
seat of inflammation secondary to irrita-
tion produced by foreign bodies or other
trauma. Infeotion easily spreads by
direct extension or through tho l~hatics
to the fatty tissue of the ischiorectal
fossae.
Any inflanmatory process in the lower
end of the bowel such as cryptitis,
papillitis, fissure, inflamed henorrhoid"
stricture, trauma or perirectal inflamma-
tion from injections may provoke the
formation of an abscess in this region.
'.rho Use of chemicals in the injection
treat:ment of rectal conditiona has boen a
frequent etiolog;tc factor in recent years.
E. coli1 staphylococci and streptococ-
oi are the organis]",m which are most fre-
quently foWld. in rectal abscesses. Oc-
casionally the gafJ bacillus or B. pyocyan-
eous is the offending organism. Contrary
to general opinion, the B. tuberculosis
io rarely found in rectal abscosses or
fistulae ;I.n parsons Who do not have other
tuberculous foci.
When infl~tion with infection occurs
in a crypt of Morgogni and the infection
extends into the ischiorectal fossa, an
abscess invariably results. The fatty and
areolar tissue offors little resistance
and the abscess develops rapidly. If the
infection burrows under tho skin or up
When an abscess fonne" the usual signs
of inflammation present themselves,
namely, pain, redness" heat" swelling
and later fluctuation. The tenu:>erature
and pulse are usually elevated and leu-
cocYtosis oocurs. Some abscesses, how-
ever, which are caused by organisms of
low virulence may develop with minimal
s~toms.
Adequate and early incision and drain-
age of anorectal abscesses is the rule
which must be followed in the treatIOOnt
of this condition if serious co~l1ca­
tions are to be avoided. Delaying oper-
ation and treating the condition with
sitz baths" hot packs, etc. causes fur-
ther necrosis and extension of the pro-
cess. Immediate incision is essential.
Buie states that it is not always
easy to determine the opportune moment
to inciso an abscess, but in general it
is best to allow the abscess to approach
as nearly as possible the point of rup-
ture. In special cases, he points out
that it my be necessary to open the
abscess immediately. By wafting the
wall of the abscess may become well
outlined and when it breaks through the
surface of the skin or 1s incised
through a thin partition, the wall of
.tho abscess becomes continuous with the
margin of the skin. The· advantage of
this method over the immediate incision
method is that little normal tissue is
inoised, thus preventing tho openinB of
new channels of infection. On the other
hand, Fansler feels that if tho absoess
is opened as soon as the diagnosis is
made, thore io less likelihood of tho
infection invading further recesses of
the ischiorectal fossae or extendinB
beneath the anococcygeal tendon to the
opposite fossa to form a bilateral
abscess. In other words, the destruction
of tissue and oxtension of the process
is held to a minimwn by early inoision
and the release of tho pun which is
under tension.
The abscess should be opened either
by a crucial incision over tho abscoss
or by the oo-called "scalping" operation.
,112
In this procedure a orucial incision
is mde and the flaps trinuned off with
scissors until the external wound is as
..",I. large as the abscess cavity. In this
way the abscess cavity received adequate
drainage and can be treated without the
necessity of packing.
Where the source of the infection can
be demonstrated in Em.Y one crypt, the
incision should be carried to the edge of
the sphincter opposite the crypt. If the
abscess is not too large the inoision
may be carried through the muscle fibres
to the crypt and the entire abscess and
fistula operation co~leted in one pro~
cedure.
In those oases where the primary open-
ing oan be demonstrated but whore it is
deemed inadvisable to cut through the
sphincter muscle at tho time, a heavy
silk thread (seton) is tied around. tho
sphincter musclo. At a later dato the
sphincter is sevored, thus completing tho
fistula operation with a minimum amount
of difficulty.
Absoesses occur at times in the retro-
rectal space.. Hcre an ample incision
should be made low on the posterior
reotal wall and should be kept open by
daily digital examinations.
An intramural abscoss is often the
result of infections or injuries to the
bowel wall without perforation. Here
the pUB collects between the mucous and
muscular coats of the bowel. This type
of abscess usually ruptures into tho
bowel spontaneously if not incised.
However, the abscess should be incised
at ita lowest point as soon as the
diagnosis is made.
Because of the wide variations in
the ol~aoter of the absoesses involv-
ing the anorectal region, it is diffi-
oult to lay down rules which are speci-
fic .in chax'acter, However, the follow-
ing general rulcs should be followcd:
1. Dctormin,e the source o.nd extent of
the losion before surgery is
atteI!ij?ted,
After tho abscess cavity is opened e,
widely and good drainage is established,
the oavity can be lightly packed with
vaseline gauze or gauzo soaked in 2% mer-
curoohromo solution, Hot applications or
hot sitz baths are started as soon as
possible after the anesthetio has worn off, 3.
and the wound. kept clean until nealing is
c~eto. After the original paoking has
been removed, further use of a paok io
usually unnecessary.
Consideration of the anatondcal
relationships of the reBiop is
importqnt if tho condition is to
be carod fo;r 1n tho best possible
:rpannel'~
Drainage, either ~s a proliminary
or curative procedure 1 should be
established at the earliest possible
D1Omont, . '
Where only the opening of the abooesa
has been performed, it is. best to inform
the patient that a fistula most l+kely
is present and further treatment will be
required, . .
In rare instances isohiorectal ab~
scesses which are not rolievod by drain-
age break through the levator musclea and
produce supralevator abscosses. Supra~
levator abscosses, on tho other nand,
when not incised throug~ the rectal wall
often break through the levators and
present themselves as isohioreotal
abscesses.
An anorectal fistula is a patholoe;ie
tract haVing its pr1mary opening within
an anal crypt or lower portion of the
rectum and ita secondary opening or
openings on the external skin about the
anus, Fistulae are practically alw838
the sequel of abscesses in this region,
For practical purposes it can be said
that anorectal fistulae begin as infeo~
tions in the crypts of Morgagni followed
by an ~baces8. With the external rup-
ture or inoision of the abscess a fis-
tula is formed. There are some oompli-
Diagrammatic Sketch Illustrating
The Various Types of Anorectal Abscesses
~_._._---------------_.-~--
"
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1-2 Cutaneous Abscosses
3 Infectious or Traumatic Abscoss
4 Ischiorectal Abscess
5 Marginal Absoess
6-7 Submucous or Intramural Absoess
8 Supra-levator Abscess
9 Pelvic Abscess
-,
113
cated types of fistulae which do not
follow this general course.
Fistulae oocur quite commonly and re-
present about one-fourth of all anorectal
disease. The disease occurs somewhat more
frequently in men. They are seen most
frequently in persons under middle age.
.
The types of fistulae which are de-
scribed are determined by their location
and by the type of abscess which preceded
them. We do not feel that fistulae should
be classifed as complete or 1ncoIlUllete
because incomplete fistulae are in reality
blind sinuses and by definition a fi~tula
must have a primary arid a secondary open-
ing. We prefer to classify fistulae by
describing the position of the primary
and secondary openings.
After an abscess about the anorectal
region has been opened and drainage
occurSI a fistula is present. In a short
time the discharl3e usually changes from
a purulent IllEl.terial to seropurulent fluid.
In most instances the dischargo soon
ceases and the external wound c10sos.
The fistula apparently is healed but
sooner or later the abscess re-forms and
the cycle is repeated.- Openings usually
result fromrecurront abscess formation.
In most instances the secondary open-
ings are not far from each other but the
sinuses ~ burrow considerable distances.
A draining external sinus in a patient
who gives a history of having had a pre-
vious abscess in tile anorectal rel3ion is
good presumptivel though not positivel
eVidence that a fistula exists. The
first effort should be to determine the
direction and course of the tract. Often-
times the sinus can be felt and traced
by diBital or bidigital examination, In
many cases both openings can be demon-
strated and in some cases a probe can be
passed from one opening to another. In
searchiD/3 for the prillIDJ:'y opening through
an anoscope one must be on the alert to
notice a minute drop of pus eXUding from
an orificel a sraa11 tuft of aranulation
tissue or a sDJall dimple-like scar on tho
surface of the crypt lining. A small
curved cr~~t hook often aids the examiner
in finding the primary openingsl and
where it is possible to use a bivalve spe..
114
oulum the crypt bases can often be
spread so that defects in their bases
are more easily seen.
Fistula tracts and openings high in
the rectal wall are more difficult to
find and. one must be keen in his search,
using the various nx>thods at his dis-
posal -- palpation, inspection, and prob~
ing. In many cases the extent of the
tract and the location of the openings
cannot be demonstrated until the pationt
is under an anesthetic and prepared for
oUI'gery.
The injection of dyes into fistulous
tracts to determine their primary open-
ings is often of value. Care ~hould be
token to inject the solution under the
most gentle prossure and perOXide or
other effervescing mteria1s sllould not
be used. Tho use of dyes to outline
the tract preliminary to surgery is
soldon nocessDry or advisable. The lin-
ing of the tract has a characteristic
appearance and we do not fool that stain-
ing of the tract gives additional help.
Injection of dyos ofton confuses the
operator when tho dye sproo.ds beyond the
limits of the fistula tract or fails to
ponetrate somo lateral branch of the
sinus •
Treatr:lent: Tho 4 card.inal points to
be r01l1ombered in ntteIT.\Pting to cure fis-
tulae about the anorectal rogion are the
follOWing:
1. Find the pr1r.Jnry opening.
2. Follow all tracts to their teroini
and open or excise them.
3. Remove all overhanging tissue I
leaving broad flat wounds which do
not require pnckine to keep open.
4. Carry out sufficient after-treatment.
If it is possible to pass a probe or
a directoo through the tract from one
opening to another, the procedure is
quito simple. Laying the tract open
and the excision of all overhanging edges
so that a shallow trough results will
cure tho fistula. Bleeding points are
controlled by pressure or by ligature.
In those cases where the seoondary
opening is a.pparent but a probe carmot
be passed through the tract, the follow-
ing procedure will be found useful. The
probe or director is inserted into the
tract as far as it will go. The tract
1s then laid open up to that point. It
will now be found that the probe can again
be inserted and the procedure repeated.
After several segments have been incised,
it may be possible to pass the probe
through to the primary opening and com-
plete the operation. If it is impossible
to find the primary opening or if it is
thoUGht inadvisable to cut through to the
opening in one operation, it is best to
inform the patient that a small part of
the fistula remaine which will have to be
taken care of with a secondary procedure.
Where mutliple openings are present,
tho cDnnecting sinuses should be laid
open and their edges trilml10d away. It
is well to remember that even thOUGh
many external openings are present, there
is rarely more than one primary opening
into the bowel.
Where the secondary openings are in
tho bowel wall, tho entire operation
must be done through an operating procto-
scope, but the principles of treatment
are the same, namely, all tracts must be
found and laid open. Com;plete excision
of the fistula tract is seldom necessary.
Cutting the Sphincter Muscle~
Since :most fistula tracts pass beneath
the external sphincter muscle, the ques-
tion of cutting through the fibres of the
sphincter arises. It has been definitely
established that cutt1n(3 through part or
all of the sphincter muscle is justifiable
when it 1s necessary to do so to cure a
fistula. There should be no hesitation
in doing this, providing the fibres are
severed at right angles and that proper
care is given to the would postoperatively
to prevent infection and improper healiIl6.
At ttmos it is necessary and justifiable
to sever the sphincter in more than. one
place. The actual control of the bowel
is baaed almost entirely upon tho internal
sphincteric musculature which is rather
115
infrequently involved in anorectal fis-
tulae. The external sphincter is a
voluntary muscle which aids in corqpletinc
the act of defecation and acts as a
voluntary emergency control in the case
of a liquid stool or pressure of gas
(a social aBset).
Packine: After tho fistula tract is
open in its entirely and the overhanging
edges re:moved, a gauze pack is usually
inserted in the wound .and left in place
for from 48 to 72 hours. After that time
the packie relIVed and the wound kept
clean by daily dressings and hot sitz
baths. The use of the pack following
operation is a controversial raatter. It
is our usual custom to insert a moderate
sized pack but not to repack the wound
after this pack is removed. Leaving
the pack in the wound too long is unde-
sirable. Healins of the sphincter is
retarded or even prevented by too long
a period of packing and a deep sulcus
may result adding to the postoperative
defortrlty.
Sa.1I!10n' s Rule: In the treatment of
anorectal fistulae a helpful rule which
may aid the operator in locating the
prinnry opening was established by
So.lnon at St. Mork's Hospital in London.
If a line be drawn from one ischial
tUberosity to the other, bisecting the
anus anteriorly and posteriorly, a
fistula which has its secondary or ex-
tornal opening anterior to this line
will have its primry openiIl(S in an an-
terior quadrant located by drawin.e a
straight line from the secondary opening
to the anorectal junction. Any second..
ary or external openings posterior
to the line will have the pri.mnry open-
ing in the ~dline posteriorly.
116
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Primnry
°l)Oning
(Intorna~
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Opening
(External)
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Schomatic Diagram to Represent the Rolationship of tho
Pr1nJa.ry to the Secondary Oponing in Anorocta.l Fistulae
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.1
DISCUSSION
INFLUENCE OF ANATOMICAL V.ABIATIONS
IN THE FORMATION OF PERIRECTAL AB--
SCESS AND FISTULA
Walter A. Fansler
The variations in type and. extent of
perirectal abscess and fistula is well
reoognized - at loast by proctologists.
Why these variations occur has not been
given much place in tho nedical literature•
It is recoGnized that occasionally the
origin of thes(3 los ions is in some distant
point, as female Gonitalia, prostato,
seminal vosiclos, posterior urethra, in-
focted sigmoid diverticulae, appendical
abscoss, Potts disease, high rectal
stricture, polvic infections, and. other
less frequont conditions. OccasioMlly
the roctal wall nay bo pierced by some
sharp object as a spicule of bone or a
sharp sliver of wood, which has boon
ingested or by some object inserted in
the rectum. The type and Virulence of
the infected organism my also play a
part in the type and extent of the
abscess. In one extreme a virulent or-
ganism '!!JAY develop a large painful ab...
scess involving the entire rectal fossa
in a few days, while on the other hand,
a.n attenuated strain may causo a slow
alt:Jost painless inflaJ:1I!latory mas to
117
In general contour the terminal por-
tion of the intestinal canal may open
o.."Cternally in one of 2 ways with all
intermediate variations. First as a
funnel-like aperture with the muscular
structure high in the funnel, or almost
as a protuberance extending level with
the contour of the buttocks. In some
instances upon straining the terminal
portion of the gut will actually protrude
to a point beyond the normal contour of
the sitting position of the individual.
It is obVious that an abscess develop-
ing in a crypt of Morgagni in an in-
dividual with the funnel-type outlet is
likely to have a more extensive lesion
than where the condition develops in a
recttun which terminates very nearly at
the surface of the body. Another factor
which influences the abscess formation
is the length of the anal canal where
the juncture of the anoderm and mucosa
occurs. The final factor is the location,
size and development of the sphincteric
:musculature. In some instances the
anal canal - that ia the portion of the
tube lined with anodorm, may be two
inches in length and in this case, the
terminal portion of the crypts of Mor-
gagni lio two inches within the body.
In others the anoderm.w1ll not extend
inward more than a small fraction of an
inch. In this caso tho rectal muoosa
(i.o. , the crypts- of Morgagni) oxtend
almost to the surrace of the body. It is
obvious that infection developing in
crypts of such different situation, will
produce entiroly different typos of
develop1 which may take 2 or 3 montl;1B to
reach the skin and ruptm.-e externally.
These factors are well recognized.
,
trpe Crypts of Morgagni are folds in
th~ mucosa in its terminal portion just
be£bi4e it joins the a.noderm. The point
of jUI'loture is usually a serrated line -
The anatomical variant is ono which the dentate line - though the size of
has not boon sufficiently oIl:!Phaeized" and the serrations are subject to wide varia-
ie probably tho ono of grGatest single im- tiona. The terminal portion of the
portanoe. While abscossos and fistulas crypts often extend some distance (as
'1.!JaY occas ionally develop from distant much as a cent izooter in extrmne cases)
foci of infection, by far the largost num- 'UIlderneath the anodertl. These blind
bar originato from an infection involVing pockets pre-dispose to infection and
the crypts or a orypt of Morgagni. fistula formation. Tho folds on each
Tuckorpointed out tho formation of yre- eid..e of the depression (orypt of Morgagni~
formed" duoto in the perirectal tissuo and are .called theColumne of Morgagni" and
connecting with tho crypts of Morgagni. they terminate by Joining the anoderm
Hill has dono further anatomical studies which forms the anal papillae.
on tileso struotureD and roconstructod
modos of actual dissection. Tucker be-
lieves that infeotion develops in theso
performed ducto opening into the crypts l
rather than in tho crypts thenselves.
While I am convinced these ducts do eXist,
at least in some individuals 1 I believe
that the original site ef infection 1s
in the crypt itself.
Before considering the anatomical
variationsl let us first consider tho
"standard" anatomy~ The rectum is n
tube consisting of two primary layors -
namely the muscular layor and tho lining
mucous membrane. This tube terminates
in the anal canal which is surrounded
by certain muscular elements 1 and often
somo perianal fat. I usc the term "cer..
tnin muscular eloments" because tho sur-
rounding muscular structure varies in
different individuals 1 and is an i~or­
tant factor in tho formation of abscess
and fistula. The lining of the anal
canal is squamous epithelium, which does
not contain sweat glands or hair folli-
cles. Contrary to som o.uthorsl thore
is 0. sharp line of demarcation between
the mucous membrane lining the recttun
and tho squa.nious opithel11.Ull lining the
anal canal. There is no such n thing as
n gradunl "Will of the wisp" chango from
oolumnar to squronous e~itheliwn - some-
times called "transitional opitholitun."
Since this lining is not nucous membrane
and ia not skin since thero are no hair
follicles and sweat Glands 1 the term
" d "ano erm seelnS an D.pproprinte ono and
will be used in futuro reference to this
particular structure.
,.
abscess. In one case the entire fossa
is likely to be involved. In the other
a more superficial abscess is likely to
result.
With tho variation of the location of
the crypts in regard to the anus, there
is also the variation as to their rela-
tionship to the sphincteric muscles.
Where tho anal canal is long and the
crypts are high, they are likely to be
situated at a point above where the
sphinctor encircles the anus. There-
fore any infection d~veloping in a crypt
above the sphincter, is liltoly to involve
the muscle in the procoss and necossi~
tatos its diVision, in curins the result-
ins fistula. On the other hand whore the
crypts ar0 located low in tho anal canal,
they are ,llOre likely to terminato below
the sphincter, and honce an abscess from
a orypt of this type doos not involve
the sphincter. This variation is doubt-
less the cause Why in somo casos it is
necessary to divido tho sphincter to curo
a fistula, while in other cases this
necessity doos not exist.
still another factor enters the pic~
ture, and that is the type and location
of tho sphincters. ~lese are usually de-
scribed as the internal and external
sphincters. The external sphincter is a
definite band of muscle tissue surrounding
the anal canal and enclosed in a sheath.
Anteriorly and posteriorly the muscle
thins out some of the fibers inserting
into the anococcygeal tendon and anterior-
ly into the conjoined tendon. A portion
of the fibers do complotely surround the
anal canal.
The internal sphincter is'less defin~
ito. Altho this is sometimes described
as a separate muscle, I think it better
described as tho internal sphincterio ring.
This ring is composed primarily of tho
terminal portion of tho levator ani mus~
clos and the terninal portions of tho lon-
gitUdinal and circular muscular layers of
the roctu;r1. This Iluscular bodJ' my be
represented as a thick constricting struc~
ture. 'Likewise the point of ternination,
of the lev[1.'tore :may be Cluite high ab~·e
the terlnination of the rectal muscles pro-
per. It r3aY be at a potnt below the roc-
tal muscles. In this case two distinct
118
bundles of internal sphincter fibers can
be isolated. In other instances the cir-
cular and longitUdlnal mus cular layers do
not tertdnate at tho s~e point caUdad,
so that 3 internal sphincter bundles may
bo differentiated. Thus it is possible
that an infoctious procoss may extend
into tho ischiorectal fossa between any
of theso internal sphincteric bundles,
thus necessitating tho division of one or
two of tho internal sphincterio bundles,
but not the third. In most cases, how-
ever, those muscular elements aro a
rather cor~act wholo. Tho relationship
between the internal and extornal sphinc-
ters, however, is subject to definite
variation. Those bands may bo closoly
approximated, or they may be qUite wide
apart. It is quito easy in tw.ny in-
stances by palpating the anal ca.nol. to
feol 0. distinct space between those mus-
oular bonds. This is why in :most in-
stonces that whero the muscle is in-
volved, it is only tho external sphincter.
While not invariably true, tho point
of penetration of tho infection, whether
high or low in the 1schio roctal fossa
(and often whether abovo or below the
sphinctor) is a factor in the extent of
involvonont of the 1schio fossa. Where
tho penetration is high a greator de-
struction of tissue is presont. This is
duo to tho fact that the site of origin
is higher in the fossa. and also to the
fact that it takes longer for the abscess
to reach tho surface externally, While
this is occurring the pus is under ten-
sion and the process extendo in other
directions, as well as toward the exter-
noJ. surface of the fossa. An abscess
which originatos in one fossa nay extend'
to the other, eithor posteriorly under-
noath the anococcygeal tendon, or anter-
iorly along the sheath of the transverse
porinei muscle. In the case of the
anococcygeal tendon, this may bo either
doeply or superficially placed. If super-
ficially placed the abscess is moro
likely to lie above it and hence spread
across behind it.
In conclusion, if perirectal abscesses
and fistulas nre to be cared for to the
best advantage, it is necessary to know
what cnn occur whon nn infection develops.
A knowledge of the anator:rl.co.l vnrio.tions
»which occur in this region and hdW they
my influence tho EJl'reo.c1 and ~tos:rcss
of thoBe infections is essential.
The nost ir4Portnnt fa.ctors ore:·
1. The length of the annl cDJlnl Q,Ild
the location of the crYI>to of
Morgagni in respect to the a.nnl
orifice •.
NOTES
A carefully elicited history should
be made a part of the record of every
patient who presents himself to the
physician with co~laints that arc refer-
able to the ano-rectal region and colon.
There are many times when a more concen-
trated and diligent search will be made
for pathologic findings when a well-taken
history suggests definite disease. So
diligent should the search be made that
when the findings on procto-sigmoido-
scopic examination fail to reveal dis-
ease, an x-ray study of the region ahouid
be ordered.
The symptoms which are most commonly
co~lained of by patients suffering
with disease of the colon and ano-rectal
region and which require complete inves-
tigation are the following:
1. Bleeding
2. Discharge
3. Diarrhea
4. Constipation
5. Changes in bowel habits
6. Pain
7. Protrusion
8. Swelling
9. Abnormal sensations (itching,
b"\U'Iling, craWling, sense of
fullness or weight in rectum)
119
~~ The va.riations in the forrntion,
location, nnd relationships between
the sphincteric nuscles.
3. The location of the crypts of
Morga.gni in relation to tho
sphincteric nusclea.
The necessity for proceeding with a
co~lete and thorough examination of all
rectal patients is no longer questioned.
Gone are the days when it is justifi-
able for a physician to omit this
exardnation beca.use it may be disagree-
able or embarrassing to the patient.
A well conducted proctologic exam1nation
ahould be no more obnoxious to a patient
than an examination of any other part
of the body.
It is well for all persons interested
in performing examinations of the ano-
rectal region to develop a systematie
approach to the problem. Only in so
doing will all details be carried out in
every case.
The following maneuvers can 1>e
systematically carried out in almost
every case.
1. Inspection of the external parts.
2. Palpation of the external parts.
3. Digital m1d bidigital examination.
4. Anoscopic examination.
5. Procto-sigmoidoscopic examinations.
There are a few cases where pain,
tenesmus or the physical condition of
the pationt may preclude the possibility
of a complete examination.
jt
IV. GOSSIP
We nominate for distinguish~d
service Wesley William Spink fo~ ppmins
to the assistance of Rosalind RuSeell on
her recent Visit to Minneapolis on con~
•nection with studies of Elizabeth Kenny
whoso life sho is to portr~y in n movie4
Marcus Rabwin, Minnesota graduate 1926
called last Friday after Statf Meeting
to ask me to locate Rosalind Russoll who
had missod her monthly check-up whilo
OIlrOute to Minneapolis. This is a
monthly practice for all screen players
as their lives are heavily insured during
production schedules. Miss Russell was
located without difficulty but prelimi-
nary preparations were difficult to make
as most places called thought they were
being kidded. Miss Russell ~rived in
due time, accoIJU)aniec1. by Mary Kermy and
again created a sensation in the hospi-
tal (almost as much as on her first visit).
Tho neoessary inspections wore mado and
Miss Russell was on her way. Needless
to say, our good friend Wesley has beon
the object of much attention since the
inoident••••Last Saturday morning Mary
MoCarthy, script writer for tho picture,
paid a Visit to the offico to discuss
some phases of the story. Miss McCarthy
is ono of those voluable Irish persons
who likes a good story and can also toll
one. Her description of tho proposed
picturo indicatos thoro will be many
dr~tic incidents from Miss Konn's
life contrary to impressions the story
will bo concerned only with the polio
inoident. For one vho has boen separated
from daily association with Hibernians
(en masse) the presence of Rosalind
Russoll, an Irish girl from Connecticut,
who is one of a fo.m1lyof nino, Mary
MoCarthy of San Francisoo, Sister Kermy
who be~ongs to tho Kilkenny Cat Clan all
at one time was quite an event•••••At
the dinner in honor of the Public Health
representatives from Mexico, Central and
South America last week Dr. Mario Prado~
Le.fort, Santiago responded for the group.
Dr. Vargas had actod as interpreter for
the day for those who found our English
too difficult. The good South American
representatives told us frankly that none
of them had heard of the University of
Mirmosota before coming hero, but that
they were impressed with its size and ob~
vious importance. Thoy felt that hero
120
" '\thero Vas a desire to serve others with
outkhowledge and not neccssarily just
.adhdemic achievement for its O'WIl sake.
'rhey urged more cultural representatives
from the United States and less Business.
They hoped as they had learned from us
that we might visit them and bring away
something of valuo (we must not forget
this). In oonversation during dinnor
they said they found our mealsrathor
si~le and tasty. Missed their meat ana
after ono hears them talk of how much
beef they havo, it is difficult to ima-
gine they really liked our food. We
asked politely if they ate anything be~
sides beef and thoy said yes, sometimes
pork but never mutton which they sent
to their English cousins. Tho guests
wero introduoed and I am glad someone
elso had the job, for this is the line-
up: Alberto Zwanck, G. H. Paula. Souza,
Hor!l1DJl Romoro, Mario Prado-Lefort"
Ortelio Martincz-Fortun, Miguel E.
Bustannnto J Carlos Enrique Paz Soldan,
and Federico J. Salvoraglio. After the
dinner tho visitors saW tho hOIOOCOning
show in Northrop o.hd were highly enter-
tained by tho antics of the North Amer-
ican students. It was a. most pleasant
day and everyone learned a great deal
about the different customs and praotioer
of the various countries •••Lt. Boone
Haddock, 22 year old Army Airforce offi-
cer was a recent caller at the Univer-
sity. He is an ex-patient of the U. S.
General Hospital 26 and came hore to
thank the University for its contr1bu~
tion to tho war effort. Ho was a vis ito:
at the home of Mr. and Mrs. Stowe Elliot
of St. Paul whose son had been his buddy
while in training in this country. Lt.
Elliot was killed in a crach before they
left. Lt. Haddock crashed in Sicily,
and was taken to #26 for treatment. The
nurse in charge of the operating room
was Lt. Elliot, sister of his friend who
had been killed. They had beon looking
for one another since they landed. He
coulc1n r t say too many good things a.bout
the hospital and especially tho work of
Major John R. Paine. At a luncheon in
his honor he told many stories about the
hospital and also had many things to tell
Mrs. Paine about what a wonderful sur-
geon her husband is ••••