PALLIATIVE TREATMENT will be re quired where there is a positive refusal on the part of the patient to submit to an operation, and in persons whose gen eral health is broken down and in whom the reparative powers are inadequate. Chronic alcoholism, albuminuria, dia betes, malignant disease, etc., are condi tions in which operative measures may be attended with risk and in which it may be advisable to resort to palliative measures. Phthisis is not an absolute contra-indication to operative measures. The rule usually followed is to operate in those cases of tubercular subjects in which the disease is quiescent, but to avoid such interference if the lung mis chief is active.
Incomplete external fistulae and even complete fistula; of somewhat recent origin and not extensively indurated may be cured by non-operative measures; but such treatment requires constant atten tion on the part of the practitioner as well as a willingness on the part of the patient to give sufficient time to the treatment. Even under such circum stances the process of repair is slow, and in many cases the result will not be per fectly satisfactory. It is true that fistulae sometimes recover spontaneously or are cured by simple means, such as the mere passage of a probe used in examining the fistulous track; but instances of this kind are rare. In certain selected cases of fistula a cure may be effected by stimu lating the sinus and allowing free drain age. This is done so as to avoid the use of the knife, when possible. To obtain satisfactory results the following indica tions should be borne in mind: That the external orifice should be perfectly free; that the sinus should be kept clean, so as to prevent putrefactive changes; that an effort be made to excite a healthy action in the fistulous channel; and, finally, that the parts be kept as quiet as possible. To meet the first indication, it is neces sary to dilate the outer opening of the fistula with sponge or sea-tangle tents, or with Lee's antiseptic slippery-elm tents. The latter are made of selected slippery-elm bark and are compressed under high pressure. Owing to their non-irritating and demulcent properties, they are to be preferred. The second in dication (that the sinus be kept clean, so as to prevent putrefactive changes) is best carried out by the use of bichloride of-mercury solutions 1 to 4000 or car bolic-acid solutions 1 to 80. Such solu
tions are injected into the sinus by means of a long, flexible silver cannula attached to an hypodermic syringe. The third in dication (to excite a healthy action in the sinus) can be met in one of a number of ways. Anesthesia of the channel with an injection into the sinus of a 2-per cent. solution of cocaine, using the same syringe and cannula that are used for cleansing the fistula, is desirable. If the wall of the sinus is somewhat indurated, it is better to insert a small, flexible curette and scrape the wall of the fistula along its entire length; or Mathews's fistulatome may be used. The sinus is now prepared for some one of the various stimulating substances which have been recommended for this purpose. Among these may be mentioned tincture of io dine, 1 part to 4 of water; nitrate of silver, 20 to 60 grains to the ounce; sul phate of copper, a saturated solution, or carbolic acid mixed with equal parts of glycerin and water. These substances may be applied by means of cotton at tached to a silver probe or to an appli cator, or they may be injected into the sinus by means of a syringe and silver cannula.
If the fistula be a complete one and the substance used be applied as an injec tion, the finger should be passed into the rectum and made to cover the internal orifice of the sinus, so as to prevent the escape of any of the fluid into the bowel.
Regarding the fourth point (keeping the parts at rest.), the patient, while under treatment, should be confined to the horizontal position either in bed or on a sofa; congestion of the parts is thereby lessened. A firm pad placed over the anus and supported by a T bandage is useful in limiting the mo tions of the parts, due to the alternate contraction and relaxation of the leva tor-ani muscle. The chance of success in the palliative treatment of this dis ease will be greatly increased if due at tention be paid to the general health of the patient; when circumstances render it possible, a change of air should be ad vised.