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Fistula in Ano and Rectum. Probably, nearly as many suffer from fistula as from hemorrhoids; some prominent rectal specialists claim that it is of more frequent occurrence. The celebrated Mr. Allingham, of England, is of this opinion. Mr. Allingham is rectal specialist of St. Marks Hospital, London, where presumably more cases of fistula resort for treatment than to any other hospital in the world. He has acquired a great reputation for the treatment of fistula through this means, and probably even in his private practice on this account, more fistula cases fall under his notice than there do of hemorrhoids.

The celebrated Mr. Chas. B. Ball, of Sir Patrick Dunn's Hospital, Dublin, Ireland, who has written a very valuable work on rectal diseases, recently, estimates that a greater number suffer from hemorrhoids than from fistula.

Drs. Van Buren and Kelsey, of our own country, are of the opinion that more suffer from hemorrhoids.

Dr. Matthews, of Louisville, Ky., is of the same opinion.

My private note book, of cases treated, shows nearly two cases of hemorrhoids to one of fistula. I have kept an accurate account for the last fourteen years, in which I have been making special treatment of rectal diseases, and this

No. 11.

leads me to believe that hemorrhoids are of more frequent occurrence than fistula. My observation further proves to me that more men are sufferers from fistula than women. I think we may assert that, with very few exceptions, fistula results from an abscess, and this abscess is induced from some mechanical injury.

I am of the opinion that we would never have an abscess of the anus or rectum unless there was some direct injury. This may be so slight that our attention has not been called to it, but, nevertheless, I believe it exists. Following an abscess, in this locality, unless it has received surgical attention, we have, as a rule, fistula. A fistula is a false opening or pipe. An anal fistula is one where both openings are external to the sphincter muscles, or a few fibers of the external sphincter muscle may be embraced in it.

A rectal fistula, on the other hand, is one where the internal opening is in the rectum, embracing the entire sphincter muscles or the greater portion of them. An abscess in most any other locality will heal without leaving an opening or sinus. But in this place the necessary evacuations of the rectum keep up a constant irritation, and does not allow healing to take place. Then, again, if the fistula is internal or complete, gas, mu

cus and fecal matter will get into it and prevent healing. Fistulæ are 64 complete" " and "incomplete." A complete fistula is one where the opening extends from the surface externally to the anus or rectum internally. When the opening is in the skin and does not penetrate the mucous membrane internally it is called external incomplete. When the opening is in the mucous membrane and does not pass through the skin externally it is called. internal incomplete. The external opening of a fistula generally is within an inch of the anus, and if complete we will find the internal opening just within the anus (anal fistula), or between the internal and external sphincter muscles (rectal fistula). This may vary in such a way that the sinus will not run in the direction of the anus at all, but in a contrary direction, away from it. Or the internal opening may be even above the internal sphincter muscle, or the external opening may be several inches from the rectum.

Fistulæ, as a rule, do not very long remain incomplete. Usually, inside of three months, they become complete, by ulceration or some other means. Fistulæ are sometimes designated as blind external or blind internal; this is simply the incomplete variety. A complete fistula may be straight or curved. We have a variety that passes half way or nearly around the rectum, the internal opening being on the opposite side from the external opening. These have received the name of horse-shoe fistula.

There is not much difficulty in finding the external opening of a fistula. There is usually a slight elevation where it exists. Sometimes we do not have this, but by pressing upon the parts where a fistula is suspected we can usually cause a drop of pus to exude from the external opening. An educated finger will generally be able to find the internal opening. As a matter of fact a fistula may be traced by the finger. It feels very much like a small pipe stem under the skin, perhaps not quite as hard, but nearly so.

In examining a fistula, I first find the external opening, into this I pass a silver probe and by gentle pressure, if the fistula be straight, it will pass through

with but little trouble. If I do not succeed with a straight probe, I bend it and try again. Of course, if there is much curve you will not be able to get a probe through it. I then try a whalebone filliform bougie. If I do not succeed with this, I take a violin string next to the bass. I seldom ever fail with this, but if I do and want to satisfy myself that the fistula is complete, I inject tinct. of iodine, milk or ink, then introduce a speculum and thus ascertain if any has passed into the rectum. This injection should be made before introduction of the speculum as the pressure produced by the instrument will close the sinus so that nothing will pass through it. The probe should be passed for the same reason before introducing the finger. When we find mucous membrane between our finger and the probe, which is quite a common occurrence, a little boring process will cause the probe to pass through it. In this class of cases there usually is an internal opening which we have failed to find, but this does not particularly matter so far as the treatment is concerned, as the opening we make with the probe is most always above the opening which exists.

An abscess, preceding a fistula, is often severely painful, but after the fistula forms there is not much pain, but there is great annoyance from the passage of flatus, mucus, pus and soft stools through it, keeping the clothes soiled, and almost always there is a very offensive odor. Occasionally a fistula will become closed on the outside, thus retaining secretions that will set up considerable inflammatory action until the old opening is renewed or a new opening formed. Sometimes we have a number of external openings, a honey-combed condition. Internally we seldom have more than one or two openings.

Fistulæ may produce a great amount of nervous prostration, a breaking-down of the physical system, more than the slight discharge would seem to justify. Then again a patient may have a fistula for years with quite a purulent discharge, and still not become very much reduced.

Is a fistula ever beneficial? This is a question I am often asked. I must answer I believe not. An idea has been

prevalent that a fistula was an outlet prepared by nature to relieve humors and poisons of the system. That this discharge protected internal organs from becoming diseased; that it was particularly beneficial in preserving the lungs from the disease; if a fistula was cured the disease would go to the lungs and we would have consumption.

I am glad to observe that with the better class of surgeons this idea has exploded. I believe if we have an unnatural drain upon the system from a fistula, or any other disease, that it is advisable to stop it if we can. As I said, when speaking of piles, I know of no disease that is beneficial to the human system. Therefore, it is my opinion that fistulæ should be cured. It stops the exhaustive drain, the nervous trepidation and excitement, relieves the mind, and the patient will live longer, and certainly in more comfort.

Consumption and fistula are quite apt to occur in the same individual. We hear it often remarked that Mr. A. had a fistula cured and he immediately went into a decline with consumption. Grant it, but still he lived longer, in my opinion, than he would have done if he had not had his fistula cured. I do not claim that curing a fistula will, by any manner of means, cure consumption. It will simply, I believe, extend life.

There are only two diseases where I would hesitate to treat a fistula, if they were present, or, in fact, any other surgical operation, to-wit: diabetes and albuminuria. Surgical operations do badly in these diseases.

The treatment of fistula consists, firstly, in local applications that will close the pipe; secondly, division of all the parts between the fistula and the anus or rectum. But very few complete fistulæ can be cured by the first method. We may try passing carbolic acid, comp. tinct. of benzoin, tinct. of iodine, or in fact any irritant, through the fistulous track, but we will be much more liable to fail in curing by this means than we will be to cure.

An instrument like a urethrotome, with hidden blades, may be passed through the fistula and the blades opened and withdrawn. This, once in a while, will cure-not very often, however.

A few years ago I treated a gentleman for hemorrhoids who also had a fistula. I intended to treat his fistula when through with the piles. When I was ready to treat the fistula I found it closed throughout its entire extent. The inflammation produced by the treatment of the piles evidently caused the cure of the fistula.

Spontaneous cure of fistula is of very rare occurrence. I have recently seen it claimed that stretching the sphincter muscles will cure fistula. I have tried this and failed. I did not use a drainage tube, however, which is recommended after the divulsion.

Local applications so often failing to cure, our recourse then is the cutting of the intervening tissue between the fistula and rectum. This has been done in a good many ways, two only that I consider good treatment: first, the rubber ligature, and second, the knife. I have found the rubber ligature a very efficient and satisfactory method of treatment. It does better, however, in a straight fistula than in one that is curved, on account of the difficulty in passing it through one that is curved. To pass it through a straight fistula I find nothing better than a common silver probe. I thread my probe with the ligature, pass it through the fistula, introduce my finger, catch the end of the probe, and bring it out of the anus. I then pass both ends of the ligature through a perforated shot, draw it pretty tight and compress the shot with a tooth forceps. We can not tie rubber.

Mr. Allingham has invented an instrument for the purpose of passing the ligature, but I do not like it as well as the probe. It takes from four to sixteen days for the ligature to cut through. Healing, to a certain extent, takes place as the ligature cuts. In a curved fistula where I use the ligature, I pass my probe as far as it will go, cut down upon it and bring it out. Then using this as an external opening, passing probe again until it enters the bowel, bringing it out as in a complete fistula. This gives me two ligatures in the same fistula. This all can be done with but little pain, if we use the cocaine pretty freely.

I never have failed to cure with the ligature, provided I have been able to

get it through all of the fistulous track. It produces considerable pain and inflammation, but this acts favorably in the healing process. Some, however, suffer very little, and, contrary to my advice, many continue their work without any great inconvenience while the ligature is doing its work. Many patients shudder at the idea of a knife, and positively refuse to submit to its use in the treatment of fistula. They will undergo the treatment by the ligature, hence my advice would be in these cases to use the ligature. With the ligature there is no danger of primary hemorrhage, as sometimes occurs with the knife.

The knife may be used in several ways. A probe-pointed bistoury may be passed through the fistula, the point caught with the finger and brought out of the anus. This will divide the intervening tissue. A round pine stick, or a tallow candle, may be introduced into the rectum and a sharp-pointed knife may be passed through the fistula until it catches in the stick or candle, when they may be withdrawn; of course, this brings the knife with them.

The best method, however, is to use a fistula director. This is passed through the fistula, the finger is introduced, catching it and bringing it out at the anus, then any knife may be used in cutting through all the substance between the director and the rectum. If any arteries are severed, which is a rare occurrence, they should be ligated. The wound is then packed with absorbent cotton filled with iodol, or iodoform. A pád of cotton is then placed over it and fastened with a bandage.

A grain of opium had better be given to hold the bowels in check for two or three days. About the third day the cotton may be removed, which may be done by soaking it with warm water, or having patient sit in a warm bath for a little while. At this time the bowels had better be moved with castor oil. An injection of a pint of warm water may also be used in the rectum. After the action the parts may be washed with carbolic water and the cut again filled with the cotton and iodoform. If the healing process becomes sluggish, which occasionally occurs, we may stimulate by ap

plying compound tincture of benzoin, tincture of iodine, or a ten-grain-to-theounce solution of nitras argentum. Kennedy's Extract of Pinus Canadensis, or Listerine are both good applications for this purpose.

The healing takes from two to six weeks. If there is but little vitality it will take even longer than this. Patients with fistulæ, as a rule, require iron and tonics, and a good nourishing diet. Cod-liver oil may generally be used with benefit.

Cutting with a wire, silk, linen, electricity, the ecraseur, cat gut, Paquelin's cautery, etc., have all been used. The objection to linen or silk is the necessity of having to tighten them every day or two. Cutting with galvanism, I should think, would answer very well. I have never tried it.

I am often asked if fistula can be prevented. I answer, if we can see the case when the abscess first begins, and lay it open thoroughly, we can often prevent fistula. GEO. J. MONROE, M. D.

Louisville, Ky.

The Treatment of Masturbation. Dr. De Armond's excellent article, in the MEDICAL BRIEF for October, is well worth reading, and shows him to be an accurate observer, as well as a good physician, but, I'd like to ask the doctor if he considers all cases of debility arising from masturbation incurable? I do not believe they are, nor do I think that marriage should be forbidden to men who masturbate, since I find that such men as Flint, Van Buren and Watson advocate marriage in cases of this character. Perhaps there may be a few old and broken down men who can not be persuaded to abandon the secret vice, but these are rare exceptions to the general rule. I believe that many patients can be benefited by marriage, if not cured, and that many more can be absolutely cured by galvanism, by tonics, by exercise, and the judicious administration of the bromides. I do not think that the doctor can controvert this statement, nor do I think it fair or just, charitable or kind, to turn away patients without making an effort to cure them. In reply to the doctor's remarks upon marriage, I

would say that I deem it wrong for parents to prompt their children to marry for money alone, and yet many make that the only consideration; as a consequence divorce and adultery are more common today than ever before. I believe that a marriage based upon love, sincere mutual love, is an heaven-designed condition, and if I could have my own way I would tax all bachelors heavily, so that bachelorhood would be unknown, and I would apply the money, derived from such taxation, to the support of the widows and orphans. I think that the Georgia statute taxing all jackasses and bachelors a wise law.

New York City. L. G. DOANE, M. D.

Etiology of Epilepsy.

In no disease does the cause bear a more direct relation to the treatment than in epilepsy. If we understand the cause of this affection, we can, in a great majority of cases, relieve our patients with a proper course of treatment directed towards the removal of the cause. It is necessary for us to understand the etiology of diseases as well as the symptomatology, diagnosis, prognosis, and treatment, and especially is it of utmost importance for us to understand the causes of epilepsy before we can institute a rational plan of treatment. The causes may be either predisposing or exciting, and when they are found to exist in the nerve centers it is termed centric or idiopathic irritation, and when they are found to exist in some other part of the body, it is termed eccentric sympathetic or peripheral irritation.

PREDISPOSING CAUSES.-Some authors contend that inheritance plays an important part in the production of this trouble. While this sometimes seems to be the case, yet there are equally as many cases where heredity seems to act as no predisposing cause whatever. It seems as if more persons have epilepsy at or just before the age of puberty than any other time, which is thought to be due to the change the system undergoes at that period, rendering the nervous system of a more excitable condition. A strumous diathesis, a peculiar conformation of the head, and hydrocephalus are considered as predisposing

causes by some authors, and a predisposition to epilepsy may be created by the continual operation of the exciting

causes.

EXCITING CAUSES.-These causes are very numerous; in fact, we can say anything which has a tendency to create a disturbance of the cerebral functions may act as an exciting cause of this trouble. Exposure to the direct rays of the sun, blows upon the head, pressure upon the brain by pieces of bone or tumor, violent bodily exertion, foreign bodies in the ear or nose, retrocession of cutaneous eruptions, irritation of the stomach and bowels caused from the presence of worms, and irritation of the medulla oblongata are among the most frequent exciting causes of epilepsy.

Furthermore, we have other prominent factors in the etiology of this trouble, such as excessive indulgence in the stronger passions, as immoderate sexual intercourse and that disgraceful, debasing, degrading and polluting habit of masturbation; irritation caused from an ingrowing toe-nail has produced epileptic fits where there was a predisposition to them, and the sympathetic irritation existing between the brain and certain inflammatory affections may excite this trouble. Genito-urinary reflex irritation from adherent or contracted prepuce is more often the cause of epileptic spasms than is generally supposed. As evidence of this we have cases from the age of five to fifteen, reported by Trousseau, Reverdin, Carpenter and Sayre, that had this congenital malformation, and who were subject to epilepsy, and the operation of circumcision promptly relieved them when the treatment by various remedies had failed, so this should lead us to investigate the condition of the genital organs when we are treating a case of epilepsy. And again, we have cases reported by Field, Trousseau, Ramskill, Schwartzkopf, Albrecht, Liebert, Baly, Sinkler, Rush, Tomes, Sieveking and Ashburne, that were suffering from epilepsy and the source of the trouble was traced to dental irritation.

In these cases reported by the abovenamed authors, the epileptic fits prevailed in spite of all medical treatment, but finally they were completely re