Dr. George Gourley and Miss Zula Garrett were married recently at the bride's home in this city, and will make their home at Bradley. Dr. and Mrs. Frank S. Lott and daughters are members of a house party at the country home of Mr. and Mrs. G. M. Smith near Mt. Vernon. Dr. C. S. Means attended the annual convention of eye, ear and throat men held at Oakland, Mich., August 30th and 31st and September 1st. Dr. and Mrs. C. C. Weist spent a week at the Glass hotel at Buckeye Lake. Dr. A. M. Steinfeld has just returned from a year's study with the leading orthopedists of Europe. He has opened an office at 206 East State street and will limit his practice to orthopedic surgery. Dr. Harry Southard of St. Francis Hospital, with his parents, Dr. and Mrs. Southard of Marysville, is visiting Yellowstone Park and other interesting western points. They will spend several days with Dr. Southard of Seattle, Wash. According to the last report of the Protestant Hospital, 1,371 patients were cared for, 347 medical, 989 surgical and 35 maternity. There were 861 private patients and 510 charity. Two hundred and seven children were cared for-123 of whom were charity. Dr. Thomas K. Wissinger returned Thursday morning from a month spent in hunting and fishing in the lake regions of Minnesota. While there he was taken ill, however, and is just now recovering, so that he will not be able to resume his professional duties for some little while yet. URIC ACID. The Chemistry, Physiology and Pathology of Uric Acid and the Physiologically Important Purin Bodies, with a discussion of the Metabolism in Gout, by Francis H. McCrudden. Paul B. Hoeber Medical Books, 69 E. 59th St., New York City, N. Y. Canvas, $3.00; paper, $2.50 net. To persons who are interested in the chemistry, physiology and pathology of uric acid this book will be found exceedingly interesting. It is an exhaustive and scientific study of this important product in the human body in its relation to gout and rheumatism. Professor of Proctology, Ohio M edical University; Rectal Surgeon to Anal fistula is an unnatural channel into or through the perianal structures. It is the most frequent pathologic condition of these parts, occurring, according to Allingham's figures, more than twelve hundred times in four thousand cases on record at St. Mark's Hospital, London. It has also the unsavory reputation of being the most intractable of the nonmalignant diseases of the anus and rectum. Careful statistics from the most conservative sources put the percentage of cures at less than fifty. Chronicity is essential to the fistulous state. An abscess with a recent sinus is not a fistula. There must be present the channel lined with a well defined connective tissue coat, due to cell infiltration in response to nature's efforts to heal, before a fistula can be said to be present. Fistulae are grouped under two general classifications, viz: Complete and Incomplete. These terms of course need no explanation. They are further classified according to the *Read before the Columbus Academy of Medicine, September 17, 1906. structures into or through which they burrow, and also according to their tendency to involve or connect with neighboring organs. Any one of these many types may be either simple or specific. Many conditions have been evoked under the head of Etiology, but one only needs mention in so short a paper as this, and that of course is "infection." Infection tells the story, although the circumstances governing its entrance into the tissues may widely vary. No age is exempt from fistula, although those in mature years are more liable. In my own practice I saw an infant three months of age with a well defined subtegumentary fistula. Cases are also noted among those of extreme age. It occurs more frequently in males. The relation of fistula to tubercular disease is a matter of great practical importance. Figures from different sources vary as to the frequency of their connection, this difference being due to the fact that some hospitals pass all fistulous cases at once to the surgical side and few cases therefore get into the department of internal medicine, where the cases of tuberculosis are found. It is necessary to consider this subject from two view points, viz: "Tuberculosis in the fistulous," "Fistula in the tuberculous." The percentage of tuberculosis in those afflicted with fistula varies from fourteen per cent, as noted by Allingham, to fifty per cent in Tuttle's clinic at the New York Polyclinic. The percentage of fistula in the tuberculous varies from one to five per cent. The high percentage of general tuberculosis in the fistulous is a strong argument in favor of the occurrence of primary tuberculosis in this part. It is of great importance that this fact be borne constantly in mind, for the treatment of tubercular fistula varies radically from that applicable to the type brought on by the ordinary pus producing bacteriae. Koch lays down the dictum that it is impossible for the tubercle bacillus to pass through the intestinal canal; however, observations by the best clinicians and careful microscopic examination of the discharges have demonstrated absolutely the fact that such infections by the tubercle do occur in these parts primarily, and remain localized, walled off by a dense band of fibrous tissue until some untoward incident breaks down this protecting barrier, the tubercle escapes, attacks other organs and the system is overwhelmed by the onslaught. Symptoms. Following a history of local infection of greater or less severity the patient notices increasing difficulty in keeping the parts clean; also involuntary discharge of gas and feces. Pain is rarely a prominent symptom. Examination reveals usually an external opening surrounded by an elevated mass of cicatricial tissue, from which is discharged a more or less fetid purulent fluid. In addition to this, the palpating finger can usually make out the channel of fibrous infiltration running up the bowel. In blind external fistula the discharge is small in quantity and the fistula tends to close and reopen, each fresh discharge of debris being preceded by some symptoms of local infection. Blind internal fistulae are very difficult to detect. There is usually an obscure history of abscess or ulceration. This recurs at intervals and is, contrary to the usual rule, accompanied by much pain. This history should prompt a careful digital examination of the parts when the characteristic induration of the fistulous tract may be made out. It has been said in regard to blind fistula, that, “blind fistula means blind surgeon." However pleasant this tautological epigram may sound, the fact remains that there are fistulae in which the external opening remains patent after the internal opening has closed, or in which no internal opening has ever existed. It is easily understood of course why blind internal fistulae do not heal, but the reason for this failure on part of the external type is not so evident. The failure of this type to heal may be due to one of several reasons, the chief, however, being lack of sufficient drainage. The presence of a small necrotic mass may also be sufficient to interfere with the proper cicatrization of the sinus, and there may be a connection of the original cavity with the rectum by means of the lymphatic channels. All blind fistulae, therefore, constitute practically chronic abscesses. Diagnosis. This has usually been made before the patient sees a physician, particularly in the complete variety. The symptoms are characteristic and are not liable to be mistaken for anything else. Palpation is of the greatest value, as by it the direction of the channel from the external opening can be made out. The probe is an over-worked and over-estimated instrument in determining the direction of complete fistula or the blind external variety. Its value is great in determining the depth and course of pockets and sinuses, especially when the fistulous tract courses deeply under the aponeurotic structure and palpation is rendered thereby less available. Injection of colored fluids, e. g., sterilized milk or methylene blue solution, sometimes locates the internal opening when other procedures fail. The location of the internal opening is of the greatest importance, for on its discovery depends more than on any one other factor the success or failure of the subsequent treatment. Allingham advises when using the probe that the finger should not be in the bowel, as its presence there causes a contraction of the sphincters and a consequent distortion of the channel of the fistula, which makes its examination extremely difficult and unsatisfactory. A point concerning the location of the internal opening which is of great practical value is as follows: In the anterior anal quadrants the internal opening is as a rule found immediately above the external, while in the posterior quadrants the inner opening is situated in or near the posterior commissure. This rule usually holds good and is worth keeping in mind. In the vast majority of cases the internal opening is between the two anal sphincters; it may, however, be found several inches higher up. As before stated the trained finger is the most reliable aid in diagnosis. Palpation demonstrates an indurated mass leading from the external opening to nodular elevation or cicatrix higher up. The anatomical structures involved should be determined especially with prognosis in mind. A submucous fistula naturally could hardly be classed with those severe types which burrow deeply through the muscles and their aponeuroses. The history of these two varieties differs much; in the submucous fistulae constitutional symptoms are slight or absent, |