The Radical Cure of Fistula in Ano Without the Knife.

A PROMPT and successful result, in several cases of anal fistula by injection of iodine, has induced me to call renewed attention to this subject.

While disclaiming, of course, any originality for this plan of treatment, the manner in which I have employed it is perhaps somewhat new. At all events, it has thus far been entirely and permanently successful in my hands; and the suggestions of M. Henry, assistant to M. Bonnafont, as long ago as 1858, on this subject, seem to me to have met with undeserved neglect.

The iodine should be employed in the form of a saturated ethereal tincture. Its advantages over the officinal or alcoholic tincture are obvious. It is not only stronger, and thereby excites inflammatory adhesion in the walls of the tube, but the ether evaporates almost momentarily, and a pure coating of iodine is left along the fistulous track, which doubtless encourages absorption.

The instrument I have used is an ordinary hypodermic syringe, with small silver canula, which may be readily bent to correspond with the direction of the sinus, and the mode of operation is as follows:-After exploring the fistula with a very small probe (the ordinary probe of the pocket-case is far too large), after determining its course and extent, the patient is to be placed in a good light and a glass rectal speculum introduced, with its fenestrum opposite the internal orifice of the fistula. The canula is now bent to the required curvature and introduced, when the syringe, filled with tepid water, is screwed on, and the surface thoroughly cleansed of all extraneous matter. This step is not only essential, but serves to allay timidity, or dread of the subsequent operation. Next, by pressure, the fistula in its whole extent should be dried out, and the iodine will thus come in direct contact with its walls. Introduce now into the speculum a quantity of absorbent cotton. This will absorb any of the iodine which might otherwise be injected through and injure the mucous membrane, and by its characteristic stain will serve to show the completeness both of the fistula and of the operation. The canula may now be re-inserted and the injection made. It should be done slowly, and at the same time the canula gradually withdrawn. Every part of the surface will thereby be reached.

The operation, which is not very painful, should be premised with a cathartic and folI owed with a full anodyne, as ordinarily with the time-honored knife method. The patient need not be confined to his bed, or room, even or an hour.

Thus far I have performed this operation. four times, and, as remarked above, with immediate and complete success. The patients were, all but one, below thirty years old. One was tuberculosis, but no appreciable injury told is in phthisis a conservative drain. In my accrued from thus checking what we were once first case, a clerk, æt. 23, there was a dense and almost cartilaginous state of the fistulous wall, and the injection had to be repeated; but in the others one "sitting" alone was called for.-L. C. Pike, M. D., Norway, Maine, in Mass. Med. Jour.

Prevention of Pitting in Small-Pox.

THE Occurrence of pitting in small-pox has been entirely prevented by Dr. Lewintaner, of Constantinople, by antiseptic treatment as follows: The entire head and face, except the eyes and the neck, are covered with plaster consisting of three parts of carbolic acid, and fifty parts each of olive oil and starch. The body is covered over with a mixture of three parts of salicylic acid, thirty parts starch, and seventy parts olive oil. The internal treatment consisted in giving quinine acid solution.-Wien. Klin. Woch.-Clinique.

Is There a Prostate ?

voices urin., denies the existence of a special Dr. J. A. Fort in Revue chirurg. des mal de organ known as the prostate. What is commonly termed the prostate is, in his opinion, simply a collection of urethral follicles, differing in no wise in function from the glands in the vicinity. The disease described generally as a prostatitis is a posterior urethritis which has invaded the urethral glands. Patients special variety of chronic posterior urethritis suffering from prostatic trouble suffer from a attended with inflammation of the nẹck of the bladder.-Internai. Jour. of Surgery.

Croton Oil Locally For Tonsillitis.

Dr. Charles Cobbs, of New Athens, Harrison Co., Ohio, writes us that he has found one-half drop of croton oil, applied daily to the affected tonsil with a probe, will permanently cure suppurative tonsillitis. He has proven it in his own case, among others.

DR. D. W. CATHELL, Baltimore, Md., the talented author of that most valuable work "The Physician Himself," writes :-"Dear Doctor:-Allow me to congratulate you upon your valuable work, 'The Physican as a Business Man.' If you had done no other good in the world, the production of a work so directly and clearly to the point that so many physicians need instruction upon, will constitute you a benefactor, and will remain a monument to you for years and years to come."

Original Communications.

Short articles on the treatment of diseases and experience with new remedies are solicited from the profession for this department; also difficult cases for diagnosis and treatment.

Articles accepted must be contributed to this journal only. The editors are not responsible for views expressed by contributors.

Depy must be received on or before the twelfin of the month for publication in the next month. Unused Manuscript cannot be returned.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest posible words, or Ais reader is sure to skip them; and in the plurnest possible words, or his reader will certain isunderstand them. Generally, also, a downright fact y be told in a plain way; and we want downright facts at present more than anything else.-RUSKIN.

READ. REFLECT. COMPARE. RECORD.

Notes and Comments.

EDITOR MEDICAL WORLD:-It would be well

if each of us who have seen the results of the Keely treatment were to describe the cases, as Dr. Johnson has done (page 16). In this way the true effects of the treatment would become known, and it would not be difficult to refer the symptoms to the remedies that can produce them. Thus, by a diagnosis by exclusion, the truth might be discovered.

I want to prefix one remark to Dr. Schafer's directions for making coffee: Select the berry yourself; choosing that known to the trade as pea-berry Santos. Many of the berries are small and rounded, not flat. They are taken from the tips of the branches, where but one bean is in each berry. This is the finest coffee, and it is generally sold as Mocha, though it comes from Brazil.

Dr. Walling might have added to his argument in favor of alkaloidal medication (page 19) another of equal importance; namely, that the use of these drugs compels the physician to be careful as to his diagnosis, and to study the physiological action of his remedies. It is the substitution of the rifle for the shotgun. The rifle carries farther and shoots straighter; but it requires careful aiming.

I cannot recall a case where the retention of smegma under the prepuce gave rise to reflex symptoms; but in a number of cases it has caused balanitis of more or less severity, while in others I am sure it has led to masturbation. It is not right allow a boy to go about with a tight prepuce after he has reached the age of six years; especially as it is so easy to relieve the difficulty by stretching with a pair of expanding forceps. I have done this many times, and never circumcise.

Dr. Thompson's suggestion (page 25) as to the insolubility of coated pills is of importance. Many times the pill runs the gastro

intestinal gauntlet safely, and could be recovered, none the worse for the trip. The same may be said of the popular compressed tablet. Those of terebene are absolutely insolable, and many of the recoveries under the use of these tablets may set down as instances of the miad cure. I generally direct all pills and tablets to be chewed up; and very few persons really object to the taste, if they are really ill, and are satisfied that it is for their benefit.

Referring to Dr. Hobbs' treatment for a leg ulcer (page 25) by leeching, it will be seen that this treatment is aimed at a condition of local plethora, while his podophyllin and iodide are remedies for general plethora. And yet Dr. May cured a similar ulcer by injecting bovinine under the skin near the ulcer. Do not these two cases aptly show how our treatment must be guided by the general condition of the patient, and not by the "name" of his melady? The two principles that underlie our theraphy are depression and stimulation; as they have been for all past time and will be for ages to come. The old doctor whose system consisted of "brandy up to the bleeding point, and bleed down to the brandy point," had better success in practice than the one, who, disregarding these principles, confined himself to specifics.

Umbilical hemorrhage has in my experience been due to syphilis, or to very vigorous crying. By the latter, the straining forces open the vessels formerly connected with the cord and as yet but weakly closed. The indication is the same as in any other hemorrhage, to tie the vessel itself with as little tissue as possible, and to prevent crying and to prevent crying Once I transfixed the umbilical tissues with hare-lips pins and put a rubber cord over them. Very severe and prolonged crying is apt to be due to constipation.

I have several times spoken of a remedy for pruritus; but the dreadful suffering of a really bad case leads me to reply to Dr. Hoyer (page 33), although your older readers may accuse me of repetition. Pruritus is often associated with uric acid diathesis, and careful dieting for this condition is the first essential. Little meat, thorough digestion of starches, and the avoidance of overeating, are the main points. A dose of good malt extract, with a tablet of papoid, at the beginning of each meal, is the best digestant. This prescription is of much. value :

so many good ideas) that compound tincture of benzoin would relieve pruritus ani. I tried it on an old case, and the instant the benzoin touched the surface the itching was annihilated. But the local effect of the drug was so severe that the patient found it best to take his meals off the mantelpiece for several days. So I weakened the benzoin down, using an ointment of 20 to 60 grains to the ounce of lanoline and found the addition of twenty to sixty grains of ammoniated mercury, was an improvement. Thus equipped, I sallied forth to combat pruritus; and in every conflict since, I have come out the conqueror. Were I in the business, I'd advertise a reward of dollars for any case of pruritus which my wonderful ointment fails to cure, and make a million. Being only a poor grubber of a practising physician, very few persons in or out of the profession will ever hear of it, or learn of its remarkable qualities.

Diabetes is a rare disease here, or else some one else gets them. In the few cases I've seen lately, I have given jambul ; and every one has has gone away cured, in his own estimation at least, and has not reappeared. This is one of the really good remedies for which we are indebted to Parke, Davis & Co.

Dr. Thacker has given us a singular case (page 34). The history points to abscess or hydatids of the liver, or abscess near it. Collections of pus near the colon are said to take the odor of fecal matter. The oozing of such illsmelling pus from the umbilicus looks as if the vein leading to the liver in fetal life had reopened and the abscess were discharging by it. It looks like a good case for abdominal section. If pus oozes out at the navel, a probe might be introduced; perhaps one of the little whalebones we use to worm through a urethral stric. ture, and thus the source of the discharge may be reached. A microscopic examination of the discharge would also serve to show its origin. But whether an abscess or a fecal fistula, a section is clearly indicated.

For Dr. Smith's case (page 34) I would wash out the bowels and mop the rectal ulcer with nitric acid; then give sulphur until the eczema reappeared, and arsenic until it is well. That retrocedent eczema is the cause of some obstinate affection of the internal organs I have little doubt; especially when the eczema, as in this case, disappears from the skin spontaneously and the internal disorder shows itself at the same time

I tried to secure accounts of the present epidemic for my "Influenza number,' from every state and territory in the Union; but the majority of those to whom I wrote were down with the disease themselves. This proves my own observation, that the present epidemic

prevails mostly among the upper classes, the wealthy and the men of brain.

WILLIAM F. WAUGH, M. D. 1725 Arch St., Philadelphia.

[We are very happy to announce that Dr. Waugh has reconsidered his proposed removal to Chicago, and has given it up. The opposition of the Doctor's patients and friends in general was too much for him to resist; so he will remain among us.-ED]

Effects of Iodine on Enlarged Prostate.

EDITOR MEDICAL WORLD:-The prostate is a complex gland, formed during the third month of fetal life, and gradually increasing until after puberty, when it attains its full integrity. It then remains"in statu quo" until a man reaches fifty or fifty-five years of age, when it frequently becomes more or less of a nuisance. It is largely composed of involuntary circular muscular fibres; but there is also much true glandular structure imbedded in its substance. Both these components are prone to overgrowth, the fibrous and muscular tissues becoming hypertrophied, just as occurs in fibroid tumors of the uterus. If the fibroid tissues are more enlarged than the muscular, examination per rectum will reveal a hard, swollen, nodular prostate, which will prove very rebellious to treatment; if the muscular tissue predominates, the gland will be swollen, but soft, and more amenable to absorption. When the lower part of the prostate is hypertrophied, its lateral lobes bulge into the rectum, flatten the fecal mass, and impede its expulsion. The patient often mistakes this for constipation. When the upper part is enlarged, the lobes impinge on the prostatic urethra, narrowing its channel, and obstructing the flow; or else, if the upper central part, lying between the ejaculatory ducts, is affected, it partially blocks the entrance to the bladder, thus further hindering micturition. This condition is also misleading, and may pass for stricture; whereas no stricture, properly so called, can ever exist in this situation. In general enlargement of the whole gland, these troubles annoy the patient, "fore and aft."

The influence of iodine in glandular swellings is almost proverbial. It has been credited with the power of diminishing the size of healthy glands, as the mammæ and testes; but this is very doubtful, except such diminution of volume as naturally attends decreased secretion, which iodine often produces. But in disease, it seems to assist in the breaking down and absorption of precocious tissues. Strumous glands, enlarged tonsils, parotid and bronchial glands, bubo, bronchocele, epididymitis, in fact most glandular hypertrophies, improve

under iodine, and there are analogous reasons for expecting that it would be remedial in the earlier stages of enlarged prostate. The writer has seen cases of impeded micturition, distinctly referable to the prostate, improve under its influence, and rectal examination has convinced him of diminution in the swelling. Surgical interference has not, up to now, accomplished much, excepting, of course, the necessary but temporary relief afforded by the catheter; and we are justified in seeking and searching all methods, old or new, that are likely to prove of even the smallest service. Iodides, while helping other glandular swellings, have no tangible effect in this. Quinine, salicylates, and ergot have been tried, but found wanting.

But iodine has some claims

for further trial. The liquor iodi comp. is a convenient form for its administration. Ten minims in a wineglassful of water may be given three times a day (unless it produce iodism), and an iodine paint (one drachm to an ounce of almond oil), applied to the perineum, is a useful adjunct. Tincture of iodine may be used in the same dose, but it is apt to derange the stomach. Many articles of food contain an abundance of iodine, such as beans, watercress, oysters, and potatoes; these form a good supplementary diet, as also, when obtainable, those mineral waters that favor iodine, such as Kreutznach and Woodhall Spas. They have an undoubted influence in promoting the absorption of uterine fibroids, which closely resemble prostatic hypertrophy, thus further suggesting the use of iodine in the latter disease.

often does during the second or third week, I would recommend

RExtract of hyoscyamus..

Dover's powder.............

.grains ii .grains iv

M. Sig. At a dose; to be repeated every 3 to 6 hours, as may be necessary.

This is also sufficiently anodyne to secure rest and sleep. The condition of the stomach must be carefully watched. We generally find that organ more or less disturbed, and while vomiting is not common, yet there is some irritation, with tenderness on pressure, and the patient will complain of a sense of fullness after eating-a sort of dyspepsia-or sometimes there may be a gastric catarrh. At all events, unless you can succeed in correcting the trouble, your patient will soon begin to lose flesh and strength, because he can not digest his food. It is not only useless but harmful to fill the alimentary canal with food that can not be digested. If there is much gastric catarrh I give

B Bismuth sub. nit..
Ipicac powdered..
M. Divide into 10 powders.

.dram j grain x Sig.-One every 3

hours, Or an infusion of peach leaves. The object is to relieve the gastric irritation as soon as The possible by any means in our power. oral, pharyngeal and laryngeal catarrh nearly always present, is very annoying to the patient, and can be much relieved by

M. Sig.-Use as a spray several times a day. You will find this not only pleasant but effectual. Besides, if you relieve the oral catarrh you will remove one of the causes of repugnance to food, so often manifested by fever patients. The bronchial catarrh is apt to persist throughout and does not yield readily to treatment; fortunately it does not often cause much trouble.

The suppression of urine may be so great as to require attention. I generally find the following sufficient to give relief:

R Fluid extract of Gelsemium......drops v Infusion buchu..... .ounces i

M. Sig. At one dose; to be repeated in 2 hours if

necessary.

I rarely have to give more than three to six doses to satisfy the patient. I think the suppression is more apparent than real, as the urine passed probably contains the normal quantity of the solid constituents, and the water has passed off through the skin, as the sweating is often profuse long before the fever has left. The fever rarely runs high enough the first week to require reduction. If the patient insist on "something to stop the fever"

I

give a placebo of gum water with a little muriatic acid added. If, however, the fever or, more properly, the temperature, is persistently above 103 degrees, I give a sponge bath, or if convenient I give a cold or graduated bath. In order that a sponge bath can be of much use as an antipyretic, it must be properly given. First, the clothing of the patient must be so arranged that the bath can be given without exhausting the patient. I think one garment (as an ordinary night gown) is sufficient clothing for a fever patient. direct the nurse to bathe one part at a time, and keep the remainder of the body covered; to proceed slowly, allowing the water to evaporate from each part, and thus proceed until the whole body has been bathed. I am well aware that some claim that the sponge bath will not reduce the temperature, but it will if properly used, and it possesses the advantage of being easy of administration, and does not fatigue either patient or nurse. The newer antipyretics have a place in the treatment, also, but with care. I often give a single dose of antipyrine at night if the fever is high. It is not convenient or desirable to wake a patient from sleep to give a bath, and for that reason I give the antipyrine in a sufficient dose to bring the fever down a degree or two, and this will be sufficient for the night. But the too common practice of giving the remedy in large doses often repeated, so as to hold the temperature down near normal, is not to be commended. I am sure that I have seen harm done by the practice. Aconite, veratrum, and gelsemuim are not the ideal sedatives in continued fevers. I have discarded them for that purpose.

Low muttering delirium can be relieved by one drop doses of tincture of belladonna, repeated every two or three hours. Active delirium is best controlled by something like "bromidia," in appropriate doses after reducing the temperature. Often the delirium disappears as soon as the temperature falls, without the use of the nerve sedatives. I do not use quinine except as a tonic, and, of course, in small doses-usually two to four grains. I have in former years tried quinine in fifteen or twenty grain doses, until the patient was deaf as a post, but it has no curative effect.

If the tongue and visible mucous membranes are very red, I give very dilute muriatic acid "ad-libitum" as a drink, or lemonade or dilute vinegar.

If the dark dirty color of the tongue and mucous membranes obtain indicating "sepsis," I prefer to all other internal antiseptics

B Fluid extract baptisia tinctoria.. drams iis
Water......q.s.......
....ounces iv
M. Sig.-Teaspoonful every 2 or 3 hours.

If we bear in mind the fact that the disease is self-limited, and that drugs are only useful or necessary to relieve or correct certain conditions, and, as far as we know have no curative effect on the disease itself, and that they may even do harm, it is not necessary to warn the intelligent physician against giving any active medicine without a clear indication for its use. A placebo is often the very best prescription.

The diet: You have all read time and again the old law, about how the diet must be. But

the application is not so easy. You can prepare your arrow root or sago or starch, and your soups and broths, but you can not make the patient eat them. It is essential that the patient receive nourishment, but what to prepare or how to prepare it is often a problem not easy of solution. In the first place, the patient usually has no appetite. The oral catarrh has perverted or suspended the sense of taste so that food is disappointing or disgusting. While it is not always perhaps best to allow the patient to choose his own alimentation, yet where there is no positive indication that harm will result, I tell the patient to eat whatever he pleases, well kuowing that so long as the appetite is poor he will only eat a "bite" or two of anything, and after the appetite returi s he will eat whatever you give him.

In short, as we have a case of acute dyspepsia in all its essential points, the diet must be suited to the peculiar condition present. Underdone lean roast beef, raw oysters, soft boiled eggs, milk, either sweet or sour, baked apples, or even raw ripe fruit, celery, lettuce, spinach, tomatoes, or other vegetables poor in starch, may be allowed. The usual slops, as water in which toasted bread has lain, or the so called gruels made of meal and water, of the strength of meal one part, water 20,000, or even the so-called beef tea, are about equivalent to absolute diet, which means absolutely no diet.

The patient in the worst cases may be so reduced as to require stimulants, and the question arises, shall we use alcoholic or the diffiusible stimulants? My choice is lager beer, as it contains sufficient alcohol, and the bitter of the beer is equal as an appetizer to nux or hydrastis, and it is usually well tolerated by the stomach-a great advantage-while brandy or whiskey is often irritating-perhaps from impurities. The diffusible stimulants, of which aromatic spirits of ammonia is a type, if given in sufficient quantity, are often rejected by the stomach, besides, even if they are equal to the alcoholics as stimulants, they lack the element of food said to belong to alcohol.

Disinfectants : The best disinfectant is pure air, but as it is cheap it is often neglected.