PLUMBING

A DISTINGUISHED but facetious physician once remarked that the primitive, rudimentary and unromanticscience ofplumbingboastedof a " superscience" or "higher plumbing" which formed a cult widely and universally followed and designated the science ofsurgery. The weaponsemployed in both sciencesmay vie with each other in complexity and are innumerable,but whilst the plumber is well content to pursuehis avocationwith the tools. used by generationsof his forbears, no youthful surgeon is happy until he hasdevisedsome Dewand cunning variation of some implement of his art, whereby he may both win renownandpossiblymore successfully ply that art. , Metaphorically speaking, however, a huge abyss liesbetweentheindicationsfor theuse ofthesevarious implementsin the two cases. For whereas the plumber's spannervaries directly in hugenesswith the sizeanddelicacyof the nut he isunscrewing,the instrument of the surgeon varies in the inverse direction,so that we seehim approachingthatrobust organ, the brain, with a powerful electrically-driven drill and the fury of his efforts to uncover that unhappystructurewould lead one to believethat he regardsthis, as he doesmostotherorgans,asvestigial. Both sciences may be said to find their highest developmentin the cunning manipulation of pipes and tubes,which are cleared,stopped,patched,and short-circuited at will, and only a surgeon would really appreciatethe savageglee that fills the breast of thetriumphantplumberwho has,aftersomelabour and more emotion, pierced the obstruction in a refractory drain. As a devoteeto " higherplumbing" onelearnsthat the majority of " leaks" in the humanframe follow upon diseaseor operationson the pelvic organs. From an anatomical standpoint they may be grouped into "sinuses"and "fistul:e". A sinus usually arises through an intraperitoneal abscesspenetratingthe abdominalwall anddischarging externally. If anythingsuch as aforeign body or a portion of deadtissuepreventshealing,a tubular ulcer or sinus results. If thedischargefrom a sinus slowlyincreases in quantity, the pus shouldbe examinedfor tubercle bacilli and the clubbed hyphre of Streptothrix actinom,yces. A fistula is an abnormalcommunicationbetween the skin andbowel or otherhollow viscus. In other words, it may be defined as a tubular ulcer, one extremityof which opensinto a canallined by mucous membrane, whilst the other penetratesthe skin. It may be congenital or acquired through injury, operation, gangrene, suppuration, tuberculous or malignant disease. The differentiation betweena sinus and a fistula may ッ ヲ セ ョ be difficult, and require careful clinical as well asradiologicalexamination. The passageof urine, f:eces orflatus through the track, however, establishesthe diagnosisof fistula.