closed with sticking plaster For the purpose of rendering the opening callous, after perforating the cheek, the introduction of a sufficiently thick thread, first smeared with digestive salve, and subsequently with drying remedies, and to be moved daily till suppuration have ceased, has been recommended; in that case, the closing of the external fistulous opening first takes place, which, if small, may be effected by frequent touching with lunar caustic; or, if larger and very callous, by paring with the knife, and drawing together with sticking plaster. The aperture is also sometimes attempted to be kept open, by the introduction of a golden or leaden tube, over which the external wound heals.

DUPHOENIX penetrates the cheek with the bistoury, and puts a canula into the inner half of the wound, for the purpose of preventing its union, and at the same time to conduct the spittle into the mouth, till the external wound, the edges of which are brought together with sutures, has healed.

ATTI (a) introduces, into the opening made with the trocar, a leaden canula, the end of which in the mouth he splits into three, and bends back on the membrane lining the cheek; the outer end must not reach the skin, and is kept in its place by a thread carried round the ear. After a sufficient time the thread should be divided, the canula removed from the mouth by the nail of the forefinger, and the internal opening remains per

manent.

3. The membrane of the cheek is to be penetrated twice, obliquely at the bottom of the fistula, with a trocar, and through these openings a leaden thread is introduced, the middle of which should lie in the bottom of the wound, and the ends projecting within the mouth, are to be brought together and cut off near the inside of the cheek. The external wound is to be closed by the twisted suture. The spittle flows along the leaden thread into the mouth, the external wound closes, and the thread drops into the mouth. This treatment is preferable to the others, as no repeated bandaging of the wound is necessary. I have proved this plan in several cases where other modes of treatment have been employed without benefit (b).

CROSERIO (c) proposes, instead of perforating the cheek from without to within, according to the plan of DEGUISE and BECLARD, to thrust the trocar from within outwards, also to make the second perforation with a trocar from without inwards, the canula of which has no shoulder, and therefore after the introduction of the leaden thread may be withdrawn through the mouth.

4. In simple fistula, the membrane of the cheek should be pierced with the bistoury, and the external edges of the fistula brought together. But complicated fistulas must be cut out, and the outer edges of the wound brought together (d).

BONAFONT (e) exposes the Stenonian duct to the extent of a centimètre, isolates the corresponding ends of the fistula for some millimètres, perforates the cheek with a trocar, draws the end of the Stenonian duct, with a thread into the canula, which is left behind, and fastens the thread in a cleft of the canula. The union of the external wound is effected by suture.

[The fistulous orifice into the parotid duct, resulting either from abscess of the gland or any other cause, is not so easy of union as CHELIUS would wish to infer, but on the contrary often very tiresome to treat. DESAULT punctured the cheek with a trocar and canula, through the fistulous opening, and introduced a seton into the mouth. The seton was removed daily, and gradually increased in size till a permanent passage into

the mouth was formed, and then the seton having been removed, the external wound which had been left open, was touched with caustic and healed. BECLARD in two cases successfully employed a leaden style, one end of which he passed into the mouth and the other into the interrupted duct, and completed the operation by bringing together the edges of the external fistulous orifice, which had been previously pared, with a twisted suture. A much more simple and equally effectual plan is to pass, through the fistula in the cheek, into the mouth a needle and thread, the latter of which is to have a knot made on its end, only of sufficient size to be received when drawn from the mouth into the bottom of the fistulous aperture. The end in the mouth is to be tied on a little bit of stick close to the inside of the cheek. In the course of two or three days the knot ulcerates into the mouth and a new way is formed, by which the secretion of the gland passes, and if the case turn out well, the fistulous orifice soon contracts and heals, care being taken by a compress to prevent the saliva finding its way out externally. Sometimes, however, it is very difficult to induce the external wound to unite, and the production of a new surface, either by paring the edges or touching with caustic, and keeping them in apposition is necessary.-J. F. S.]

909. It is always necessary that the patient, when the external fistulous orifice is to be closed, should keep the lower jaw as quiet as possible till the cure is completed; and only take fluid food through a tube. A carious tooth is often the cause of failure of the operation for salivary fistula, and must therefore be removed before the operation is repeated.

910. The swelling up of the Stenonian duct into a fluctuating tumour, which must be distinguished from an encysted tumour, may, if the duct only be stopped up, be perhaps removed by the introduction of a fine probe. If this be not possible, the swelling should be opened with a lancet from the mouth.

If a stony concretion have formed in the salivary duct, it must be cut upon within the cheek, and taken out. The continued flow of the spittle prevents the closing of this opening.

["The ducts both of the parotid and submaxillary glands," says SYME(α), “ are liable to become the seat of calcareous concretions, which are named salivary calculi. Their composition is phosphate of lime, agglutinated by a small quantity of animal matter. They have usually a yellowish-white colour, oval figure, and finely tuberculated surface. They vary in size from that of a millet-seed to that of an almond with the shell. In the parotid duct, they are very rarely met with, but in the submaxillary duct, not unfrequently. [I doubt their frequency even in the submaxillary duct; ASTLEY COOPER in his Lectures used to mention having removed one from the mouth of the elder CLINE, and LAWRENCE in his Lectures (b) speaks of having taken out one "which was about the size of a small bean." (p. 765.) In the Museum of the Royal College of Surgeons of England there are only six specimens, either from the duct or substance of the submaxillary gland; but one from the parotid gland; and some small concretions from the tonsils. Besides these I do not know of any other instances, and have never seen one.-J. F. S.] "They occasion pain, swelling, and hardness," continues SYME, "and sometimes impede the flow of the saliva or give rise to the formation of an abscess. In the parotid duct the symptoms thus produced are apt to be confounded with those of rheumatism, tooth-ache, gumboil, or suppuration of the maxillary antrum; while under the tongue, they may be occasionally mistaken for those of encysted tumours. In all cases of doubt, it is right to search the duct with a probe, and to feel for the calculus, by pressing on the place where it is suspected to be. So soon as a free incision is made, the concretion escapes, together with the fluid accumulated about it. The original situation of these concretions is immediately within the orifice of the ducts; but they have also been found imbedded in the substance of the submaxillary gland, where they excited an increased and unhealthy secretion, with general swelling and hardness of the gland. In such cases the calculus, if distinctly recognised, may be extracted by cutting down upon it, from the mouth." (p. 427.)

Among the specimens at the College (c) there is one large submaxillary calculus an inch and a half long and three quarters of an inch broad, taken from a very old man, who

(a) Lancet, vol ii. 1830.

(b) Principles of Surgery.

(e) A descriptive and illustrated Catalogue of

the Calculi, &c., &c., contained in the Museum of the Royal College of Surgeons in London. 1845. 4to.

"was conceived to be dying, being nearly choked by the tumour, when in consequence of an effort, the calculus was thrown out and he recovered." In another the stone is stated to have occasioned a quinsy." One specimen was removed after it had been twelve years breeding," and another "formed in twelve days.” (p. 191.)—J. F. S.]

B.-OF BILIARY FISTULA.

(Fistula biliosa, Lat.; Gallenfistel, Germ.; Fistule biliaire, Fr.) 911. Biliary Fistula originates in a division of the gall-bladder, or ducts, after they have become adherent to the peritoneum. The bile is poured from the fistulous opening, and although its loss be often very considerable, it is rarely that important symptoms are produced. Not unfrequently the fistulous opening closes of itself, in general after the escape of a gall-stone; often it breaks again, and the patient then usually finds himself better. The fistula is mostly situated in the region of the liver; frequently, however, at a tolerable distance from it.

I have observed the case of a woman in which, after severe symptoms, a fistulous opening formed near the navel, and out of it a considerable quantity of gall-stones, of the size of peas, escaped from time to time.

912. The cause of biliary fistula is usually a collection of bile in the gall-bladder, (Hydrops vesiculæ fellis,) by which is formed beneath the short ribs a swelling, at first defined, regular, and fluctuating, which slowly increases, and is accompanied with pain, that had existed previous to the swelling, and at first not severe. It often is diminished by pressure, or spontaneously, when the gall-bladder is much distended, in which case part of the bile is forced into the intestine, and is followed by bilious stools, with colicky pain. These symptoms distinguish the filling of the gall bladder from abscess of the liver. If the swelling of the gall-bladder be considerable, it adheres, by means of the inflammation set up in it, with the peritoneum, and forms an opening by ulceration, through which the bile escapes. Gall-stones are usually the cause of this collection of bile. The gall-bladder or the bile-ducts may also be ulcerated by abscess; in which case, after it has opened, pus is discharged, mixed with bile.

[Biliary fistulas, from whatever cause, are very rare. I have never seen a single example of this disease; but I much doubt the possibility of distinguishing its precise origin. It certainly is possible that if, when the bile-duct is stopped, the gall-bladder be over distended, it may adhere to the wall of the belly, and that ulceration may ensue, by which its contents are discharged externally, and the aperture may continue fistulous. But there is in the museum of St. Thomas's Hospital an enlarged gall-bladder, from stoppage of the common biliary duct, capable of holding at least three, if not four pints of fluid, which did not ulcerate, but was mistaken for an abscess of the liver, and tapped once or twice, and also another, in which the duct being stopped, the gall bladder had become adherent to the duodenum, ulceration between them had taken place, and the bile thus finding an immediate passage into the bowel, the gall-bladder ceased to serve as a receptacle, and shrivelled to the size of an almond. And it is in this way probably that the gall-bladder more frequently empties itself than externally. The aperture by which abscess in the liver discharges itself, may become fistulous, and have the bile flowing from it, at first mixed with pus, but afterwards almost, if not quite pure. My friend Dr. Roots informs me he has seen one case in which, after an abscess of the liver, bile was discharged; and my dresser, GUEST, tells me, that he saw in the Manchester Infirmary a man who, two months after falling on his loins, had an abscess burst in the right hypochondriac region, from which pus and bile at first escaped, subsequently only bile; and that he had seen this person alive, and in tolerable condition as to health, eighteen months after the accident, although his motions being very white, it is probable that little bile could have assisted in the process of digestion. -J. F. S.]

913. The cure of biliary fistula requires first, the removal of its usual causes, viz., gall-stones (the existence of which is shown by the careful introduction of a probe.) After which the fistula soon closes of itself. For the removal of the gall-stones, the enlargement of the fistulous orifice is necessary, which is best done with catgut, or with a tent, so as not to destroy the adhesion of the gall-bladder to the peritoneum, under which circumstances effusion of bile into the cavity of the belly would occur. The fistula must be so much enlarged, that a pair of forceps may be introduced with the left forefinger, the stone grasped therewith and withdrawn ; in doing this, care must be taken, in moving the forceps about, that no part of the gall-bladder itself be caught hold of. The opening of the fistula should not be closed, so long as gall-stones are believed to be still there; otherwise the fistula will break out afresh. When all the stones are removed, the fistula usually soon closes with a simple covering bandage; and the scarring may be promoted by careful touching with lunar caustic, and suitable pressure. At the same time such remedies must be employed as will diminish the disposition of the bile to concrete, and will assist nutrition.

C.-OF FECULAR FISTULA.

(Fistula Stercorea, Lat.; Kothfistel, Germ.; Fistule Stercoraire, Anus contre nature, Fr.) SABATIER, Mémoires sur les Anus contre nature; in Mémoires de l'Académie de Chirurg., vol. v. p. 592.

DESAULT, Œuvres Chirurgicales, vol. iii. p. 352.

SCHMALKALDEN, Præs. KREYSIG, Dissert. Nova Methodus intestina uniendi. Vieb.,

1798.

TRAVERS, BENJAMIN, An Inquiry into the process of Nature in repairing Injuries of the Intestines, &c. London, 1812. 8vo.

SCARPA, Sull' Ernie, Memorie Anatomico chirurgiche. Milan, 1809. fol. Translated by Wishart as A Treatise on Hernia, with Notes. Edinburgh, 1814. 8vo.

REISINGER, F., Anzeige einer vom Prof. DUPUYTREN zu Paris erfandenen und mit gluchlichsten Erfolge ausgeführten Operationsweise zur Heilung des Anus artificialis, nebst Bemerkungen. Augsburg, 1817. 8vo. With a copper-plate.

Nachtrag in Salzb. medic. chirurg. Zeitung, 1818, No. 18, p. 286.

BROSSE, Beobachtung eines mit der Darmscheere von Hrn. Prof. DUPUYTREN in Hôtel-Dieu zu Paris augestellten Heilungs versuches eines künstlichen Afters; in RUST's Magazin, vol. vi. p. 239.

BRESCHET, Anatomisch-chirurgische Betractungen und Beobachtungen über die Entstehung, Beschaffenheit und Behandlung des widernatürlichen Afters; in VON GRAËFE und von Walther's Journal, vol. ii. pt. ii. p. 271, and pt. iii. p. 479. LIORDAT, Dissert. sur le Traitement de l'Anus contre nature. Paris, 1819. DUPUYTREN, Mémoire sur une Méthode Nouvelle pour traiter les Anus accidentales, lu à l'Académie Royale des Sciences, en Janvier, 1824; in Mém. de l'Acad. Roy. de Méd., vol. i. Paris. 4to. Also, De l'Anus contre nature, des dispositions anatomiques des effets, du siége du prognostic, du diagnostic et du traitement; in Leçons Orales de Clinique Chirurgicale, vol. ii. p. 193.

REYBARD, J. F., Mémoires sur le Traitement des Plaies des Intestins et des plaies pénétrantes de Poitrine. Paris, 1827.

London, 1830. 8vo.
London, 1838.

Hennen, John, Principles of Military Surgery. Third Edition. LAWRENCE, WILLIAM, A Treatise on Ruptures. Fifth Edition. TEALE, T. P., Article Intestinal Fistula; in Cyclopædia of Practical Surgery, vol. ii. p. 191. London, 1841.

914. Fæcular Fistula is an old opening communicating with the cavity of the intestine, which, according to its size, discharges either only

a part of the fæcal matter, whilst the rest passes by the natural passage, or by which all the excrement passes, and then the disease is called an unnatural or artificial anus (Anus præternaturalis, artificialis.) The external opening is mostly round, contracted, and surrounded with radiated creases of skin; its edges are red and irritable; frequently there are several external openings leading to one canal: for the most part, the skin is firmly attached to the muscles, it is rarely degenerated, raised from the muscles, and forming a canal; the ends of the bowel are frequently connected directly with the peritoneum; frequently they are retracted, and the peritoneum forms a funnel-like elongation.

915. The effect of the fæcular fistula, and in a more advanced degree of the artificial anus, upon the whole organism, is very decided. By the escape of the chyle, which passes only through a part of the intestinal canal, is the nourishment lessened, though the appetite be great, and the patient quickly wastes, especially at first. The nearer the artificial anus is to the stomach, the more severe are these symptoms. If it be further down, at the lower end of the ileum or in the colon, more decided stools are passed, and the nourishment is not so much affected. By the continuance of the out-flow, the parts excoriate and become very painful. The mucous membrane of the intestine exposed to the air becomes redder, and less villous, but does not cease to secrete a large quantity of mucus. In artificial anus merely mucous fluid of a white colour, and varying consistence, which is secreted from the large intestines, passes through the rectum. The lower part of the intestinal canal gradually contracts together, but retains its permeability. BEGIN (a) has, however, observed an almost complete closing and wasting of the lower portion of the intestine.

[ASTLEY COOPER (b) mentions the case of a man "with a strangulated umbilical hernia, which sloughed, and occasioned an artificial anus. As he was recovering from the effects of the strangulation and sloughing, and was allowed to take food in any considerable quantity, it was observed that part of what solids he ate passed out at the artificial anus within half an hour after he had swallowed them, and that fluids passed out in ten minutes after they had been taken into the stomach. Although he took sufficient food to support a healthy person, he wasted rapidly, and died in three weeks. On examining his body after death, and tracing the jejunum, the lower part of that intestine was found entering the hernial sac, and in it the opening was situated.” (p. 52.)]

916. Not unfrequently a prolapse of the intestine is produced suddenly in artificial anus, as a consequence of straining, or gradually by ensheathing, which often attains considerable size (nine inches and more.) It occurs mostly only at one end of the intestine, has usually a more or less conical form, is contracted at the base, and its point has an opening through which the stools escape. The protruded part has a red colour, is well moistened with mucus, and usually is not very sensitive; frequently a peristaltic motion is observed, as in the intestines, and at first it is so contractile that the slightest touch causes retraction; it increases with straining, and diminishes or entirely recedes in the horizontal posture, or with sufficient pressure. The constant irritation to which it is exposed, thickens and renders it like the external tegument; it even becomes blackish. The protrusion may form adhesions with the opening from which it projects, and may even become strangulated. If the protrusion be of the lower end of the intestine, there escapes from it only a white, mucuslike fluid; but the stools pass out from the side of its base. If both upper

(a) DUPUYTREN, Leçons Orales, p. 211.

(b) Lectures on Surgery, vol. iii. TYRREL's Edit.