source of annoyance to a patient with fistula is, the discharge, in a greater or less quantity, of purulent or muco-purulent matter, soiling the linen, making it wet and uncomfortable, and producing excoriation of the nates. In complete fistula, the escape of flatus and mucus from the intestine is a further source of annoyance, and should the fistulous channel be very free, feculent matter will also be expelled. Besides these symptoms, the minds of many people are affected with an impression of physical imperfection and weakness in their organization, rendering them miserable and unhappy. As in other diseases affecting the rectum, various sympathetic pains are experienced: they are referred to the back, the loins, and the bottom of the abdomen; pain extends down the leg and to the foot, which is not unlikely to be attributed to sciatica, unless the history of the case is carefully inquired into.

The external and internal openings differ in character according to the duration of the disease, and the cause that has given rise to it. In some cases, especially in phthisical patients, the opening will be prominent, and the edges hard and round. In others the aperture will be indicated by a crop of pale and flabby granulations, prone to bleed from slight violence done to them. If the abscess which originated the fistula was of a gangrenous character, the opening will most likely be irregular, and the surrounding skin livid and undermined, and its vitality reduced by the destruction. of the subjacent cellular tissue with the bloodvessels that ramified therein. In many instances both the internal and external openings will be very small, and liable to escape notice in a superficial examination: when such is the case, their position will most readily be detected by making pressure on the surrounding parts, and causing the matter to exude, or the fistulous track may be felt as a cord under the integument.

Generally there exists but one internal opening, and that is within five or six lines of the margin of the anus, as before stated, but now and then a second will be found: though some writers maintain such is never the case, yet others of undoubted ability and veracity have stated they have met with instances where a second, and in one instance a third, was present; and specimens in the Museum of the Royal College of Surgeons, and other pathological collections, establish the fact. We meet not infrequently with several external openings, which arise from the abscess having been allowed to pursue its own course and burst; if it has been

of the gangrenous form, it is more than probable there will be more than one external opening, or the several openings may depend on the formation of distinct abscesses at separate times, which may or may not communicate with each other.

The track of a fistula is not always direct, but in many cases is tortuous: sometimes it will be found coursing just beneath the integument to the margin of the anus, then passing upwards immediately under the mucous membrane, and opening into the rectum, or it may pass through the fibres of the sphincter muscle; in which case the passage of the probe may be impeded by its fibres, should the exploration produce spasmodic action. Sir Astley Cooper1 mentions having examined the body of a man who died of a discharge from a sinus in the groin, and who also had a fistula in ano: he traced the sinus to the groin, under Poupart's ligament; it then took the course of the vas deferens, and descended into the fistula

in ano.

The cavity of an abscess may extend considerably above the internal opening of a complete fistula, even for three or four inches. After gangrenous abscess, the bowel is sometimes extensively detached from its connections with the adjacent tissues, and what is termed a horseshoe fistula will be formed; that is, a communication will exist around the posterior part of the rectum. A pathological preparation in the Museum of St. Thomas's Hospital shows this condition of the parts, and there are others in several of our

museums.

When a patient complains of symptoms of fistula, a careful examination must be made: if the patient be a male, he should be desired to lean over the back of a chair, or rest with his elbows on a table; but if he be nervous, or the patient a female, it is better to place him or her on a couch or bed, with the buttocks projecting, and the knees drawn up towards the chin. The nates being separated, the external opening of the fistula must be sought for; if it be not evident to the eye, pressure must be made with the finger by the side of the anus, especially where any hardness can be felt, when most likely matter will be made to ooze out, and thereby indicate its situation. According to the side on which the fistula exists, the forefinger of the one hand, being previously

1 Lectures of Sir Astley Cooper, Bart., on the "Principles and Practice of Surgery, with Notes by Tyrrell," vol. ii, p. 326.

oiled, must be introduced into the rectum, a probe slightly curved is then to be inserted into the external opening, and carried gently on; in the female it must be directed almost transversely, as in them the anal concavity is less than in men. Varying the position of the point of the probe, according to the resistance it meets with, we shall soon be able to discover the internal orifice, or feel the end of the probe through the intestine, where it is denuded, and where the internal opening would be, were the fistula complete. It is necessary to bear in mind the usual situation of

the internal opening, or the point of the probe may be too much elevated, and carried above it, and the surgeon commit the error of supposing he is unable to detect it in consequence of the height at which it is situated, or that the fistula is of the blind external form.

In making the exploration, no force should be applied to the probe, or it may be thrust through the walls of the sinus into the loose cellular tissue surrounding the gut, and a very erroneous impression of the course of the fistula obtained. It must be recollected that a probe is an instrument not to be directed with an absolute control, but one from which we are to gather information: it is to guide and instruct us. The probes I am in the habit of using are fashioned like the annexed woodcut, with a flat handle, which, however, is not designed that the instrument may be grasped with greater firmness, but for the purpose of affording a clear idea of the relative direction of the point when hidden from view in the cavity of the sinus. The internal opening may often be detected by those whose sense of touch is acute, either as a slight tubercle, if the sinus be callous, or by feeling a slight depression at the point where it exists."

It is no wonder that our ancestors entertained the greatest dread of fistula in ano, and considered it one of the most formidable of diseases, when we think of the barbarous proceedings which were had recourse to in its treatment. With the term fistulous was always connected an idea of callosity or diseased condensation and alteration of the structure of parts, which could only be removed either by cutting instruments or caustic, and severe were

the tortures the unhappy sufferers were subjected to. Some surgeons, fearing hemorrhage by excising the fistula, made use of the most active escharotics, whereby they laid the cavities of the rectum and fistula into one, while at the same time they supposed the callosity to be wasted and consumed.

Dionis' tells of one Le Moyne, at Paris, who acquired great reputation for the cure of fistula: "His method consisted in the use of caustics, that is to say, with a corrosive unguent, with which he covered a small tent, which he thrust into the ulcer; by which he daily, little by little, consumed the circumference, taking care to enlarge the tent daily; so that by the widening of the fistula, he discovered its bottom. If he found there any callosity, he corroded it with his ointment, which also served to destroy the coney burrows; and at last with patience he cured many. This man died old and rich, by reason he made his patients pay very well for their cure, in which he was in the right; for the public value things no otherwise than in proportion to the sum which they cost. Those who were affrighted at the thoughts of the scissors, threw themselves into his hands, and though the number of rascally pretenders is very great, they never yet want practice."

Others who had less dread on the subject made use of various formidable instruments for cutting out the fistula. A Dr. Turner, who practised somewhat more than half a century since, used an iron scoop, which he describes as made "like a cheesemonger's taster, to be thrust up the rectum, and assist in the division of it.” Mr. Pott remarks, "What ideas this gentleman had of the disease, or of human sensation, I cannot imagine."

In all ages up to the present, there have not been wanting impudent pretenders, with some never-failing nostrum for the cure of fistulæ, or some mysterious manner peculiarly their own, with which to delude the unwary sufferer. Louis XIV. had fistula in ano, and being unwilling to submit to the operation, various methods were proposed to him for curing the disease without incision, but being unwilling to have them tried on his own person, he caused a number of his subjects, suffering from fistula, to be treated

1 "A Course of Chirurgical Operations and Demonstrations in the Royal Garden at Paris," published A.D. 1733, p. 224.

by the different plans which were suggested. Dionis1 thus relates the history :

"In the year 1686, there arose near the king's anus a small tumor, inclining towards the perineum; it was neither inflamed; it grew slowly, and, after ripening, broke of itself, by reason that the king would not suffer Monsieur Felix, his principal chirurgeon, to open it, as he proposed. This small abscess was attended with the ordinary consequences of those not sufficiently opened to admit the application of remedies to the bottom of the cavity; there was only a small orifice through which the matter run; it continued to suppurate, and at last became fistulous.

"The sole way left of curing it was manual operation; but the great cannot always be brought to yield to it. A thousand persons proposed remedies which they pretended to be infallible, and some of them, which were conceded to be the best, were tried, but none of them succeeded.

"His majesty was told that the waters of Barège were excellent in these cases, and it was also reported that he would go to those waters; but before taking the journey, he thought fit to try them on several patients: four persons were found who were afflicted with the same distemper, and sent to Barège at the king's expense, under the direction of Monsieur Gervais, chirurgeon in ordinary to his majesty: he made the necessary injections of this water into their fistulas for a considerable time, and used the proper means for their cure, and at last brought them all back, as far advanced towards that end as when they first went thither.

“A woman reported at Court that going to the waters of Bourbon, in order to be cured of a particular distemper, she was by the use of them cured of a fistula, which she had before she went thither. One of the king's chirurgeons was sent to Bourbon with four other patients, who returned in the same condition they went.

"A Jacobine friar applying to Monsieur Louvoy, told him that he had a water with which he cured all fistulas; another boasted of a never-failing ointment; and yet others proposed different remedies, alleging the cures which they pretended to have done. The minister, determining to neglect no means in order to the procuring a restoration of a health so important as that of the king,

1 Op. cit. p. 228.