FISTULA. 
531 
such cases. Why do not domestic animals other than soli- 
peds commonly develop fistulas ? Is it a question of tissue 
resistance, anatomical peculiarity, or a difference in histologi¬ 
cal elements? The chemist might give us a non-toxic, diffusi¬ 
ble antiseptic, that will pass through the circulation and be 
excreted unchanged and capable all the while of destroying 
pathogenic microbes. There is a mysterious part played by 
certain portions of the lymphatic system that we could wish 
made plain. We do not even feel certain that we know why 
fistulas occur more frequently in the superior cervical than 
in the gluteal or dorsal regions. 
Treatment. —Many annoying features appear in the 
treatment of these cases which may be well understood and 
yet difficult to handle, for example, the well known tendency 
to recur after indefinite periods of apparent soundness—just 
such cases as a physician must deal with in- a latent and local 
tuberculosis—which may ,under certain conditions—become 
suddenly general and active. Or, like the case reported by 
Gussenbauer, in which an apparently strong, healthy young 
man developed a case of lymphangitis and lymph-adenitis of 
left arm, followed by a circumscribed gangrene of skin and 
flexor tendons. Lymphatic glands did not suppurate but en¬ 
larged. After eight months of good health a large, acute ab¬ 
scess in left axilla, which convinced Gussenbauer that pyo¬ 
genic organisms had remained in those glands latent for eight 
mon’hs. Nepveau reports two similar cases in which the 
latent periods were much longer. 
Internal treatment, consisting of alteratives and tonics, 
may sometimes be used with advantage. Twenty-nine prac¬ 
titioners out of the forty-nine with whom I have corresponded 
on this subject advise more common use of such treatment. 
Generous food and tonics are always in order if patient is un¬ 
thrifty. 
The conditions which experience has taught me are neces¬ 
sary to successful treatment of fistulas are briefly : 
(a) Free escape of pus to carry out microbes and ptomaines. 
(b) Destruction of the pyogenic membrane lining old si¬ 
nuses and cavities. 
