CASE XIX. FISTULA IN PATIENT OF CONSUMPTIVE HISTORY.
A young married lady, wife of a country clergyman, dark, petite, of consumptive type, first consulted me in October 1896, for troubles incident to pregnancy. This was her history: For a long time she had suffered from post-nasal catarrh. Six years before I saw her she had piles and fissure, which were both operated on several times. Now post-nasal catarrh, piles, and fissure do not occur unless there is some constitutional dyscrasia behind them, and the business of the physician is to find out what that dyscrasia is, and remedy it if possible. On enquiring about the family, I ascertained that one uncle and one aunt had fistula. The uncle was operated on, and subsequently died of phthisis. The aunt refused to be operated on, and after several years the fistula healed, and she became quite well. When I saw the patient first, there was no rectal trouble, but she was constipated, her natural habit being one of relaxation. In April, 1897, the child, a healthy boy, was born. The following August an abscess formed near the anus, and this subsequently opened externally, a fistula resulting; or rather two fistulae, one opening being near the anus and one near the coccyx. At this time she was under the care of the country doctor who attended her in her confinement, and he strongly advised operation. She was nursing her child all the time. The operation was declined, and Mrs C. again came under my care. Silicea 3 was prescribed in iii-gr. doses, and a Calendula lotion. The patient’s general condition improved very much, and in April 1898 the coccygeal opening had closed, but the other remained open. Bacill. 100, Maland. 30, and Acidum fluoricum were now given in succession.
The patient had a busy and somewhat arduous life, and the demands on her energies were greater than the supply, so that with her delicate constitution the strength was rather reduced.
Mar. 15, 1899. Soon gets run down in body and spirits. A little blood comes from one opening. Often much irritation just before the monthly period. Ulcers inside bottom lip close to the gums. These generally appear at the period. She used to have them constantly, but has been free from them for a long time previously to the last few months.
Rx Teuc. Scorod. O, ten drops three times a day.
May 1. Feeling better. Discomfort when the bowels act. Full feeling on the wound side afterwards.
Rx Teuc. Mar. ver. O, ten drops ter die.
June 21. Better. No inconvenience from the wound.
In November of this year there was rather an anxious period, as chest symptoms developed.
Dec. 20, 1899. Hard cough, with pain on left side of chest on coughing. Three times little spots of blood appeared, and once thick blood in the expectoration.
Rx Phosphorus 3 every two hours.
Dec. 24. Ever since the cold, has had full feeling in the left chest as if there was something to be coughed up. Often taste of blood in the mouth. Got up a little old-looking blood this morning. I saw the patient on this occasion, and found the chest resonant. A little increased vocal resonance at right apex. No distinct dulness. A little pain in left apex. Cough was worse when lying on right side.
Continue. In a few days there was great improvement in all symptoms, and by the end of the mouth all fear of chest complications was at an end. A second pregnancy now followed, the child being born Dec. 1900.
The patient required a good deal of treatment subsequently to this, among the remedies given were Therid. 30, Elaps 12, Bellis 3x, Stephylococcin 200. The result of it all is that the fistula gives no trouble, and the husband writes:- “Mrs C.’s health generally seems to have wonderfully improved, thanks to scientific medicine.”
CASE XX. RECTAL AND SCROTAL FISTULA AND ASTHMA.
This case, that of a city gentleman, Mr T., aged 48, illustrates in a no less marked degree the relation between fistula in a no and lung disease. In this case the fistula is associated with asthma, and when from any cause the discharge from the fistula is arrested the asthma is much worse.
Mr T.’s mother died of consumption when he was an infant. Twenty years before I saw him he had rheumatism, which began as writer’s cramp in the right thumb. By the use of soda baths the pain was driven from the thumb to knees and ankles, and finally to right great toe. Eight years before he had stricture of the urethra, which was operated upon, and the result of the operation was that a fistula formed, discharging in the centre of the scrotum, beneath. In addition, there is a rectal fistula discharging near the anus. Appetite not good. Bowels act regularly. Liver and spleen both enlarged. The lungs were somewhat emphysematous. The asthma was always worse on Sundays, and was sometimes better in cold weather. Breathing was worse when lying down, and in the morning. His face had the dusky look of persons whose blood is not well oxygenated. The appetite was not good. Had pains round the abdomen after meals. He had been vaccinated in infancy only.
Rx Tuberc. k. 30, three doses to go over the month. Urt. ur. O, gtt. v. in a wineglass of hot water every two hours when required for an asthmatic attack.
Oct. 30, 1902. Very much better. Eats more than he used to do. After the first powder had asthma all day, but with the exception of a little “stuffiness” in the morning he was well till a few days back. Bowels act much better; stools black. Fistula discharges, but gives no trouble.
On these remedies he continued to make steady progress for some months. The asthma which was his chief trouble, as it crippled him for the time being and rendered him unable to come to his business from his residence in the suburbs, kept in abeyance. In March, during the stormy period, his breathing was very bad. There was a good deal of wheezing in the chest, which was worse when he lay on the left side.
Rx Thuja 30, three doses in the month. Urt. ur. O when required, as before.
Sept. 28, 1903. Good progress was made up to this date, the asthma seldom troubling him, and the fistula being quite manageable. The report on this date was: Not very well. For two days in the week asthma has been bad, making it impossible to lie down at night, the only comfortable position being standing, holding on to the bed-post. The drops (Urtica) cause him to sweat all over, especially about the genitals. Fistula not discharging much. Bowels not confined.
Rx Tuberculinum k. 30, once in ten days; Lobel. acet. O, gtt. iii, in wineglass of water every two hours when required for asthma.
Nov. 10, 1903. Twice had to take the drops, but the attacks were not so severe. He was able to lie down. The Lobel. did not relieve as promptly as the Urtica, but the effect was more lasting.
Repeat.
Dec. 17, 1903. Scrotal fistula appears to be healing. Not so much itching as formerly.
Repeat.
Jan. 27, 1904. Anal fistula appears to be healed.
Repeat.
April 15, 1904. Had an attack of vomiting four days ago, and the next day severe pains under right breast, right arm, and below right scapula. Breathing caused pain, and he couldn’t lie down any way. A local doctor who was called in said this was “severe congestion, but no pneumonia and no pleurisy.” The discharge form the scrotal opening had ceased. The scrotum seemed filling with matter. The skin was inflamed and irritated, becoming sore when rubbed, and matter was exuded through it. He had found that when the first opening had closed, matter found its way along the urethra.
Rx Nat. Sulph. 30, every four hours. Calendula lotion to be applied.
April 19, 1904. Better. Repeat night and morning. July 11, 1904. No asthma. Right leg swelled last week. (I found it slightly oedematous).
Things went on well after this under Nat. Sul. 30, Bac. test. 30, and Thuja 30.
May 10, 1905. Patient wrote to me:- “The fistula seems to have closed up in part. Nothing comes through this way, but there is much swelling in the fork. Unable to walk.”
Rx Silicea 30, every four hours. Calendula lotion. May 17, 1905. Very much better. Opening occurred in the night. Breathing much better.
Repeat night and morning.
Since this time the patient has had no real trouble. The anal fistula ceased discharging, and the scrotal one, which still acts as the constitutional outlet, is easily managed, and the patient’s general health is vastly better than it used to be.
CASE XXI. SCROTAL FISTULAE FROM TUBERCULOUS TESTICLES.
Before leaving this subject I should like to relate briefly a case of fistulae of a different kind.
Mr. D., a Greek gentleman, 35, came to me on June 13, 1904, with fistulous openings on each side of the scrotum, communicating with swollen and tender testes. The history of the case was that he had recently been under an eminent surgeon, who had opened the abscesses and had recommended the removal of the testicles as they were, undoubtedly, tuberculous. This measures the patient objected to, and hence his visit to me.
He was a very delicate patient. His father had died of dropsy and his mother was melancholic. One sister had died of anaemia. As a child the patient had had depression, and there was a curious history of depression in the family. His mother had three sisters, and two of them suffered from melancholia. The patient had had influenza fifteen years before. Had malaria in Sidonia, the attacks coming on every eight days. Since a child he had had eczema at the back of the knees, on elbows, and on perinaeum. The swelling of the left testicle had come on suddenly, as a sequel to influenza. The patient had never had any venereal disease, though he had suffered from nocturnal emissions. The surgeon who operated on him gave as one inducement to the patient to submit to castration that “in any case he would never pass semen again.”
