Hippocrates, the father of medicine, Celsus, Galen, and other writers in the early times, described fistula as a disease; and, naturally enough, through the influence of heredity, contagion, imitation, and auto-suggestion, every author on the subject to the present day has chimed in most complaisantly with his “Ditto! ditto! ditto!” “Me too! me too! me too!” I am sure that the rank and file of my medical brethren will agree with me that modern authors are hardly justified in this servility to the ideas of the fathers of medicine in this recreance to their duties toward suffering humanity. Is it that they do not know better, or that they are naturally servile and thus too lazy to do their own thinking?

Let me in connection with this point call your attention to a practice that many of us have been suspicious of for a long time, a suspicion that has been confirmed for me by one who speaks from positive knowledge; otherwise I should not refer to it here. The practice I am about to describe will make it plain why we have so many “Ditto and Me-too” authors on proctology and other medical subjects.

An eminent surgeon who mentally is as large as the human race, and has room for all that is good in medicine and surgery, narrated the following incident of his career to a learned doctor from Georgia and myself recently. Snatching occasionally a few moments from a busy practice, he has prepared sufficient material to make a book, and desired some competent person to edit it before publication. So he consulted an ethical co-worker concerning such a person. In a few days a gentleman called at the doctor’s house to inquire about the contemplated publication. The caller asked the title and size of the book, and when told volunteered the startling information that he could have the work ready in a few weeks’ time, but that in the meantime he would like to hear the doctor lecture once or twice that he might catch a few peculiar expressions to use in the work, so that the doctor’s friends, when reading the book, would say, “That sounds just like the doctor; that is his style of talking.” The would-be scribe never asked for the author’s manuscript, so accustomed was he to rely upon the medical literature to be found in the libraries of the city for all the information needed. It is hardly necessary to add that the professional bookmaker was summarily dismissed. The doctor’s manuscript is still unpublished.

There is a third reason for so many “Ditto and Me-too” authors. Publishers of medical books naturally desire to extend their business, and in order to do this they must issue new works of medicine in the same way that lay publishing houses compete for new works of fiction. Now, doctors usually obtain professorships in some institution by paying five thousand dollars or more for them, and in due time a publisher of medical books will tempt the professor to become an author. They place before him their great facilities for getting up a book, arguing that consequently but little or no labor on the professor’s part is required. They point out to him the fame and honor the publication will bring him, and at the same time estimate how much money they will make out of it. In due time a “Ditto and Me-too” medical brief, rÉsumÉ, or treatise, is published covering the whole history of the subject, from Biblical mention of it to the present day. All of us have observed what a great amount of stuffing or padding it takes to make a book that is to sell for five or seven dollars. It occurs to me that it might be wise to get up a conference of enlightened physicians to take some practical steps or to devise some laws that will prevent such impositions on the too confiding medical brethren by unscrupulous publishers that rob them of their hard-earned income through delusive advertising. Still, before any action is taken that would result in effectively closing the door to this practice, it may be as well that the eyes of more of us should be opened that we may not continue to be duped and stung again and again by “Ditto and Me-too” scrapbooks with hundreds of pictures. When seeking for new and better information to help suffering humanity, let us be served for a little while longer with “rehashed rot.”

Pardon this digression. We will now consider, at first hand, the subject of fistula.

As a rule, pus in a fistula is a secondary symptom of chronic proctitis, except those fistulÆ that occur from traumatic injury to the region of the rectum, anus, and buttocks. Early in my practice I entertained the idea that the formation of pus occurred at the point of dissolution of the tissue, and that, as the volume of pus increased it made its way in the direction of least resistance through it, if the abscess had not been opened by an incision. The idea was well founded when it was applied to the traumatic origin of an abscess and fistula, but not when their origin was traced to chronic proctitis.

It may seem incredible to all who read this that a mucus channel or a fistula can be formed for ten, twenty, forty, or more years before the formation of pus takes place in it; and that the pus exerts no part in producing the diameter or length of the fistula, which may have a capacity of six, eight, or more ounces of fluid. As soon as the chronic inflammatory process has penetrated one or more layers of the mucous membrane, mucus channel or fistula-formation must take place. If the sphincter muscles be rather weak or lax I would not expect sacculation of the rectal mucosa to occur to any extent. In these cases, however, the muco-cutaneous channels are usually found quite large and numerous. Of course the extent of the ano-rectal symptoms in each case depend upon how severe the chronic inflammatory process has been, and is, at the lower portion of the enteric canal. Often you will find that the seat of the most active chronic inflammation is in the middle and upper portion of the rectum, involving also the sigmoid colon. In these cases the ano-rectal symptoms are not numerous, if there be any at all, on the mucous membrane, but under it you may expect mucus channels that serve as outlets for the inflammatory product.

In every case of chronic proctitis and sigmoiditis submucous and sub­tegu­men­tary fistulÆ can be found, and my experience in tracing them warrants me in stating that peri­proc­titis and peri­sig­moid­itis is present also; the latter pathological condition being due to the invasion of submucous and sub­tegu­men­tary channels or fistulÆ around the outside of the structure of the anus and rectum, extending far up into the neighboring tissues of the pelvic space that support the rectum and sigmoid flexure.

The formation of pus in a submucous or sub­tegu­men­tary channel that has existed for many years does not make it a disease; it is only another incidental phase added to an already existing symptom of chronic proctitis.

Mucus fistulÆ should be diagnosed and treated early in their formation, or at least before the tissues involved became so deteriorated as to form pus in quantity sufficient to occasion the usual period of suffering, fever, loss of rest and sleep before the pus is freed from its enclosure. The formation of pus in a mucous fistula is only incidental and marks a stage in the distinctive changes that have been going on for many, many years in the tissues involved in the inflammatory exudation.

The numerous small and large submucous and sub­tegu­men­tary fistulÆ found in every case of chronic proctitis and sigmoiditis was the most grave and far-reaching of the numerous symptoms, but for three decades I have fully realized the baneful effects from mucus irritation, and the self-poisoning by the absorption of large quantities of serum and fibrinous septic material from the surface of the mucous membrane involved, as well as that from numerous long, cavernous mucus fistulÆ: a fearful double source of auto-intoxication, for which it is useless to prescribe diet, tonics, and travel for building up the system and restoring the health.

Besides the numerous general symptoms, arising from self-poisoning by fecal and mucus absorption, we have more or less marked local symptoms in many cases; and if these be not present, the diagnosis can be made out from the general debility of the system and the character of the chronic proctitis and sigmoiditis.

The local symptoms of mucus fistulÆ, peri­proc­titis, and peri­sig­moid­itis are, each of them, universally diagnosed as a disease: Such symptoms as pruritus ani, scroti, vulvÆ, lumbago, sciatica, myalgia, rheumatism, prostatitis, coxitis, disease of the coccyx, chafing about the anus and along the thigh and scrotum, difficulty in getting up after sitting for a while, pain in the back of the neck, lame back, legs feel tired, and sometimes pain is very annoying, abnormal color of the skin, painful or sore spots at times, confinement in bed for many weeks from severe continuous pain in and about the rectum, etc.

Up to the present time proctologists have paid little or no attention to proctitis and sigmoiditis, which is a grave disease, with a far more serious symptom, that of mucus fistulÆ of great length and diameter, extending in all directions in the pelvic cavity and tissues of the buttocks, the large area of tissue found so full of holes, might be likened to a sponge occupying the same space. They are very numerous in every case of chronic proctitis and sigmoiditis.

This will explain why an incidental symptom like pus in a fistula is commonly called a disease by the “Ditto and Me-too” authors, and why it is so frequently met with in practice. At some hospitals one-half of the cases treated suffer from fistula in which pus has formed. Why the per cent. is not much greater I am unable to explain, except to give credit to the defensive and restorative power of the human body. If the peri­proc­titis and peri­sig­moid­itis, brought on by the mucus fistulÆ, is not treated at the same time as the cause, the treatment will be of no consequence in effecting a cure of the chronic inflammation of the lower bowels. Every mucus fistula should be located and healed at the time that the disease itself is treated; then the work will be well done. Every mucus fistula should be diagnosed and treated before the breaking down of the tissues reaches the pus-forming stage, and thus obviate all suffering, annoyance, and possible death. Attention to this course will ensure your treatment of the disease, and its symptoms, to be taken in time.

The only hindrance to the successful office treatment of a fistula in which pus has incidentally formed is the fear that you can not cure it, or that you will fail, or that at a hospital it could be cured quicker, better, and cheaper. These ideas are born of heredity, timidity, fear-habit, power of auto-suggestion, and too much caution on your part. They are all falsehoods and should not be heeded for a moment. During thirty years of practice in my specialty I have sent seven of my fistula patients to a hospital for treatment, and four of that number I afterwards very much regretted sending, as I could have accomplished the cure in a safer and better way by the usual office method of cure. In fact every fistula, pus or no pus,—I do not care how bad it may be,—can be cured by office treatment and at the same time aided by the home attentions of the patient. There may be periods of a year or more when your energies are overtaxed with numerous patients, and you feel like dividing the labor with some fellow-practitioner, and this in a measure accounts for those I induced to go, or was willing to have go, to the hospital.

Unless overwork is the excuse, you need never send a fistula patient to a hospital for treatment. I have everything to say in praise of the ambulant treatment of ano-rectal fistula and the mucus channels, since my practice thus far has been devoid of any unfavorable results,—a fact which should have much weight in favor of the ambulant office treatment of all of the many symptoms of chronic proctitis, sigmoiditis, and colitis.

Mucus fistula is very easily healed in all cases, and those cases in which pus has incidentally formed are likewise not difficult to cure. All you need to do is to instill intelligence in a stupid patient, if you haven’t an intelligent one, and induce him to utilize or improvise a few home conveniences for cleansing the fistula night and morning between office visits. During the treatment of the fistula patients will be able to attend to their imperative duties.

To properly explore a fistula and its branches, if any, as to whether pyogenesis (pus) has taken place or not, it is essential to have the external opening through the skin of sufficient depth and size to permit of the application of remedies over all its surface. For a mucus fistula antiseptic remedies can be applied after a thorough irrigation by hot water at a temperature of one hundred and twenty degrees, or more, for half an hour or less time, as the case may demand. Where pyogenesis (pus) has occurred in a mucus fistula there may be more or less necrotic tissue formed, which will require the use of an escharotic remedy as well as very hot water irrigation, followed by an antiseptic remedy, if not already incorporated in the hot water used.

As a rule I see a fistula case once or twice a week, as the case may require. There is no packing of the fistula after the morning and evening home treatment—I have never found it essential. A T-bandage is worn, with absorbent cotton, over the opening of the fistula, preventing soiling of the clothes while attending to daily duties.

Never mind what the “Ditto and Me-too” proctologists have copied or rehashed about the curing of a fistula, which they persist in calling a disease. Just be resourceful, safe, and sane in all you do, and every fistula will get well long before you have cured the chronic proctitis and sigmoiditis, of which the fistula, as a rule, is a symptom.