CELSIU

Rectal Short-Stops.

BY S. G. GANT, M. D,

KANSAS CITY, MO.

Professor of Gastro-Intestinal and Rectal Surgery, University Medical College.

TREATMENT OF ANAL FISTULA BY THE LIGATURE METHOD.

ELSUS was the first to advocate the treatment of anal fistula by ligation. Dr. William Allingham, of London, and Prof. Dittel, of Vienna, several years ago attempted to popularize it, but met with limited success. This was a natural consequence, because it is not suited for the treatment of fistulæ as a rule, but does good work in selected cases.

The operation consists in passing a ligature through the sinus and out at the anus. After it is tied tightly, it constricts all intervening tissues, and is allowed to cut its way out. The ligature can be introduced, threaded on an ordinary probe, which has an eye, by means of which can be drawn from within the rectum to the outside. The material used may be ordinary silk or elastic, the latter being preferable, because it makes uniform pressure. A piece of solid India rubber, from one-twelfth to one-eighth of an inch in thickness, is the most desirable, the ends of which can be secured by slipping a piece of lead with a slit in it over them, the lead being secured by the aid of strong forceps. The following are some of the advantages claimed for the ligature operation:

I.

2.

3.

It does away with the knife.

Can be done without an anesthetic.

It is comparatively painless.

4: It permits the patient to walk about in the fresh air.

5. There is no bleeding.

I will now enumerate some of the objections that have been raised against this operation:

It requires a longer time to effect a cure than does incision.

2. Only the main sinus can be included; hence the operation will be a failure when there are other sinuses leading off from the main one.

3. The ligatures have been known to cut only part of the way out, thus requiring the knife to divide the remaining tissues.

4. It is not suitable for operations on fistulas in general. As I take it, the field for ligature operation should be confined to persons who refuse to be operated upon by the knife, and those who are anemic or have phthisis. This operation is especially adapted to the treatment of phthisical patients, from the fact that they can take their usual amount of out-door exercise while the ligature is sloughing off, with comparative little annoyance, and, further, from the fact that they have not lost any blood.

RECTAL POLYPI.

Polyoid tumors of the rectum are occasionally met with by those who do much rectal work. There are two kinds, Adenoid or soft and fibrous

or hard. They are sometimes mistaken for malignant growths, but more frequently for internal hemorrhoids. If we are at all careful we can differentiate from these diseases. A polypus is peculiar, in that it is narrowest at its attachment to the rectal wall, and largest at its free end, in fact it hangs like a bell-clapper, and the finger can be passed around it with ease. It causes the discharge of large quantities of mucous, and protrudes during defecation. Cancerous tumors seldom protrude, and can be felt as hard thickened masses well above the sphincter, while piles are soft, vascular tumors. These, as a rule, will protrude, but can be differentiated from a polypus by their broad attachment and the absence of a pedicle. Again, polypi are usually single, while hemorrhoids are multiple. They can be radically cured in five minutes by the clamp, excision and cauterization, or by ligation.

ABSENCE OF COCCYX AND SACRUM BELOW THE PROMONTORY.

Recently a gentleman was referred to me for treatment. After a careful examination I found that his immediate suffering was caused by inflamed hemorrhoids. In addition to this there was a total absence of the coccyx and of the sacrum as well, below the promontory. Ordinarily, the sacral region is oval, here it was concave, giving the parts a very peculiar appearance. The defect was congenital, and had never given him any inconvenience. I removed the piles by the clamp and cautery method, and he resumed his work on the eighth day.

RECTAL DONTS.

I. Dont venture a diagnosis until after a careful examination.

2. Dont turn a speculum while in the rectum and you will avoid much pain.

3. Dont force the finger or speculum into the bowel, wait until the sphincter becomes accustomed to it by gradual pressure, and it will slip in. Dont go into details when explaining the technique of an operation

to a patient.

5. Dont fail to operate at the earliest opportunity; your patient may change his mind.

6.

Dont omit to prepare your patient for operation, and opium will not be required to tie up the bowel.

7. Dont use suppositories for post-operative pains; relieve it promptly by hypodermic injection.

8. Dont fail to move the bowel on the third or fourth day, or impaction and severe pain will follow.

12.

Dont give solid food for first few days.

Dont mistake hemorrhoids, polypi and prolapsus, the one for the

Dont use mechanical dilators, the fingers are better and less dan

Dont sever the sphincter obliquely, but at a right angle. Dont agree to cure pruritus ani or a cicatricial tissue stricture within a specified time, and embarrassment will be prevented.

13.

14.

Dont divide the sphincter but once in multiple fistula, make the branch sinuses communicate externally with each other and with the rectum by the main tract.

15. Dont pack the wound following an operation for fistula too tightly or granulation will be arrested.

16. Dont forget to inform your patient that incontinence is a possibility under the most favorable circumstances.

Dont operate for fistula on patients suffering with acute phthisis,

or acute Bright's disease.

Dont keep patients suffering from tubercular fistula in the house, but give them the benefit of sunshine.

19.

Dont fail to divide all branch sinuses, otherwise a second operation will be required.

20. Ligate or twist all bleeding vessels.

LONDON LETTER.

[SPECIAL CORRESPONDENCE]

A SCHOOL OF TROPICAL MEDICINE

Is being founded in London, although it has met with some opposition. The school is to be in connection with the Albert Docks Hospital, which is in the center of the shipping, and where a large number of foreign sailors suffering from diseases peculiar to the tropics are admitted. The school has the support of and is to receive a subsidy from the Colonial office. Residential rooms are being built, and it is intended that all surgeons in our colonial service shall undergo a course of training here. A small school of tropical medicine has likewise been instituted at Liverpool.

Another educational institution has also been started in London, the

MEDICAL GRADUATES' COLLEGE AND POLYCLINIC,

for which commodious premises have been secured, and include lecturerooms, museum and library, and a clinical laboratory. The object of the Medical Graduates' College and Polyclinic is to increase the facilities offered to medical men for acquiring technical skill and advancing their scientific and clinical knowledge. It will seek to accomplish this object not. only by affording instruction under its own roof, but by entering into close association with existing hospitals, medical schools and institutions in the metropolis and throughout the United Kingdom.

Death has been busy in the profession of late. DR. KAUTHACK, who was elected Professor of Pathology at Cambridge only in 1897, died in December, of malignant disease, at the early age of 35. Professor Kauthack had already won for himself a reputation as a pathologist and bacteriologist, and his loss is a great one. He is succeeded by Dr. Sims Woodhead. In the early part of January, DR. COATS, Professor of Pathology at Glasgow, died, aged 52, also of malignant disease. Lastly, I have to chronicle the death of

SIR WILLIAM JENNER, BART.,

who, however, was no relation to Edward Jenner, of vaccination fame. Sir William Jenner, who died on December 11th, was born in Chatham in 1815, and received his medical education at University College, London, and became qualified in 1837, obtaining the degree of M. D., London, in 1844. Shortly after this he turned his attention to the study of typhus and allied fevers, with which his name has ever since been identified. From 1847 to 1849 he made a detailed study of the cases of continued fever admitted into the London Fever Hospital, and in the latter year published his essay "On the identity or non-identity of typhoid or typhus fevers," in which he finally established the non-identity of these two diseases. He subsequently became physician and professor of clinical medicine at University College, and physician to the Children's Hospital and London Fever Hospital, and physician in ordinary to the Queen. He was an admirable clinical teacher, impressing the main facts in some graphical phrase which remained in the memory: "When you see a woman with a big belly, always, even if she be a Queen, think of pregnancy." "In typhoid fever, when delirium begins headache stops-headache and delirium always mean meningitis." Speaking of the D trap he said: "I call it the double D trap, because it deals out death and disseminates disease." His other best known writings are his essays on Rickets, Tuberculosis and Abdominal Tumors.

Richard T. Hewlett.

THE ASSOCIATION OF ALUMNI OF THE LONG ISLAND COLLEGE HOSPITAL have in print a History of Alumni up to date. It promises to be an excellent suggestion on the part of Dr. J. H. Raymond, the historian of the society, and all of the alumni will rejoice in having recollections of dear old Alma Mater made bright in this souvenir.

THOUGH the war with Spain is ended and the popular mind has dropped back into a more or less quiescent state, the present days are no less days of history making than were those of '98. The reader who hopes to keep in touch with the progressive world will find the American Monthly Review of Reviews an invaluable aid. In it are condensed and epitomized the events of the month. The newest and the best in the world of literature is also presented and a feature of especial interest during the past months has been a few pages devoted to the best foreign and American cartoons. As a whole the American Monthly is unique and no magazine can take its place.