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.