FISTULA. 
f 
525 
and extend to insertion of the sterno-maxillaris. These are 
described by anatomists under the name of prescapular 
glands. 
Etiology. —The next question is that of cause, and, like 
Darwin’s first drop of protoplasm, some points are not easily 
explained. In discussing this subject under the four topics, 
origin—bacterial, sources from whence these microbes are re¬ 
ceived, mode of entrance, and factors which determine the 
location of the pre-fistular abscess, I wish to make, incidentally, 
the following points: That suppuration rarely or never 
occurs without the presence of pyogenic microbes or their 
products; that the initial abscess is usually the result of a 
local auto-infection ; that fistulas may be indirectly trans¬ 
missible, due to anv one or to a combination of several 
pyogenic microbes, and therefore not specific; that one at¬ 
tack gives no immunity, but predisposes to others ; that exter¬ 
nal injuries may serve to fix their location but are not to be re¬ 
garded as primary causes. 
Origin — Bacterial .—In the early days of antisepsis, when 
healing without pus was first demonstrated possible, we re¬ 
ceived the old dictum — u No micro-organism—no pus.” Since 
those days, this question has been argued back and forth by 
Ogston, Fehleisen, Zuckerman, Nathan, Watson Cheyne and 
De Bary, who uphold it, and Grawitz, Councilman, Uskoff, 
Rosenbach, Orthman and Janowski, who oppose it. Dr. Senn, 
in his surgical bacteriolog}q concludes that pus microbes are 
the essential causes of suppuration; while Fraenkel, in his 
text-book on bacteriology, concludes that the weight of 
evidence is on the other side. Some admit that suppuration 
may occasionally be produced by deep injections of germ-free 
irritants like silver nitrate, ammonia, turpentine or cadaverine; 
but I think the great majority of competent observers hold 
that the great and common cause is the presence and activ¬ 
ity of pyogenic micro-organisms in susceptible tissues, and 
that certain of these organisms may be regarded as specific 
exciters of suppurative tissue changes. 
Ogston, as early as 1881, patiently examined the contents 
of sixty-nine abscesses for micro-organisms and found 
