circumstances of artificial anus, to which first SCARPA and subsequently DUPUYTREN have paid especial attention, and of which they have given very excellent account. PHYSICK'S operation is, however, well worthy of being better known, and it is therefore here given from Dr. B. H. COATES's report (a):—

"The two ends of the intestines," says COATES," were found, by careful examination, to adhere to each other for some distance, and the form thus presented has been compared in this case to that of a double-barelled gun. The next method proposed by Dr. PHYSICK, was to cut a lateral opening through the sides of the intestines when they were adherent. But not knowing the extent of the adhesion inwards, he thought it necessary to adopt some preliminary measures for ensuring its existence to such a depth as might admit of the contemplated lateral opening, without penetrating the cavity of the peritoneum. By introducing his finger into the intestine through one orifice, and his thumb through the other, he was enabled to satisfy himself that nothing intervened between them but the sides of the bowels. He was thus enabled, without risk, to pass a needle, covered with a ligature, from one portion of the intestine into the other, through the sides which were in contact, about an inch within the orifices, which ligature was then secured with a slip knot. This operation was performed on the 28th January, 1809. The ligature was nearly drawn sufficiently tight to ensure the contact of those parts of the peritoneal tunic, which were within the noose. When drawn tighter, it produced so much pain in the upper part of the abdomen, of a kind resembling colic, that it became necessary immediately to loosen it. The ligature in this situation, gradually made its way by ulceration through the parts which it embraced, and thus loosened itself. It was at several periods again drawn to its original tightness. After about three weeks had elapsed, concluding that the required union between the two folds of peritoneum was sufficiently insured, Dr. PHYSICK divided with a bistoury all the parts which now remained included within the noose of the ligature. No unfavourable symptom occurred in consequence. On the 28th February, the patient complained of an uneasy sensation in the lower part of the abdomen, and on the 1st of March he extracted with his own fingers some portions of hardened fæces from his rectum. On the 2nd March two or three evacuations were produced in this manner. On the 3rd an enema, consisting of a solution of common salt, was directed to be given twice every day. The first of these occasioned a natural stool, about two hours after its administration. The same effect was produced on the 4th, 5th, and 6th, and the discharges from the orifices in the groin now became inconsiderable. Adhesive plasters, aided by compresses, were employed, not only to prevent the discharge of faces from the artificial opening, but with the additional object of procuring the adhesion of the sides. This last effort was unsuccessful. On the 24th June, an attempt was made to unite them by the twisted suture. Pins were left in for three days, and adhesion was in fact effected; but owing to the induration of the adjacent parts, the wound again opened. On the 27th July, a truss of the common construction, furnished with a very large pad, and surmounted by a large compress, was applied to the wound. By these means the discharge of faces from the groin was completely prevented, and the patient had regular evacuations per anum, except when from improper diet or cold, he became affected with diarrhea. At such times, a small portion of the mere fluid matter escaped by the sides of the compress. Not satisfied with this state of things, Dr. PHYSICK made several attempts to improve the patient's condition. On the 2nd August, a mould of the parts was taken in plaster of Paris, and being covered with buckskin, was employed as a pad for the truss. This expedient answered extremely well, as long as the patient continued in the same posture in which the mould was made; but as soon as the form of the parts was altered by a change of position, faces escaped from the orifice. A bandage was then applied to the body, furnished with a thick compress, and having that part of it which crossed the patient's back formed of elastic extensible wire-springs, such as are used in braces. This also, however, proved ineffectual. The truss, with a compress and a large pad stuffed in the common way, was then reapplied, and found to answer completely the purpose of preventing the discharge of faces, the hope of an entire closure of the orifice being abandoned. On the 10th of November he was discharged from the hospital in good health and spirits, and applied himself, with very good success, to acquire the profession of an engraver." (p. 271-72.)]

921. When the intestinal scissors have divided the partition, which happens usually in from seven to ten days, and the separated part of the bowel is found between its arms, soothing clysters must be con(a) Account of a Case in which a new and peculiar operation for Artificial Anus was performed in 1809 by PHILIP SYNG PHYSICK, M.D., then

Professor of Surgery in the University of Pear sylvania. Drawn up for publication in Neth American Med. and Surg. Journal, vol. ii. p. 263.

tinued, and closing of the fistula only attempted, when the relief of the bowels has been effected for some time in the natural way, even without injections. The closing of the fistula (often the most difficult part of the whole treatment) may be effected by quiet, by a moderate compressing apparatus with variously-formed pads and elastic belly-band, by touching with lunar caustic, by pressing the edges of the fistula together with a peculiar compresser (a) invented by DUPUYTREN, by sticking plaster, by suture, or by the removal of the whole circle of mucous membrane preventing adhesion at the mouth of the fistula, and even by detaching part of the external coverings above the opening, and laying it before it. In general a small fistulous opening remains for years, then only occasionally do a few drops of intestinal dirt escape, and afterwards it closes of itself. In those cases where artificial anus cannot be cured, various proposals have been made to catch the excrement. The most simple, and in most cases most suitable, is a belly-band, which, instead of a pad, is furnished with an ivory plate having an opening in its middle, and connected by means of a cylinder of elastic rosin, with a silver vessel, out of which the escape of the stools is prevented by a valve (b).

DIEFFENBACH (c) at last cured an artificial anus arising from a lance wound, which had withstood every plan of treatment, in the following manner :-He destroyed with the hot iron not only the edge of the intestine adhering to the opening, but also a considerable portion of the intestine within the belly, and in every cauterization the peritoneum participated. This burning was free from pain. He first burned the edges of the intestine; some days after, he introduced a curved hot iron, of the thickness of a feather-stem, through the hole, into the cavity of the intestine and carried it round. The opening gradually became smaller; granulations sprung from within, and by repeated burnings with smaller hooks, which he introduced to the extent of an inch about the inner edge of the opening, it diminished to the size of a small fistula. This also closed by the repeated introduction of a heated fine silver probe. The patient was perfectly restored after nine months.

922. If an unnatural anus communicate with the cæcum, and arises from ulceration, neither funnel-shaped lengthening of the peritoneum, nor projecting partition are produced, as after gangrene of a coil of intestine; and it is therefore more difficult to cure. Suture is useless. The skin has been detached about the opening, and brought together with some stitches, but equally without avail. Autoplasty has been attempted, but the laps have sloughed. The skin about the opening may be pared off, without the inner parts being touched, so that the escape of fæculent matter may be prevented, and that the dragging of the threads may be better borne; otherwise, for the purpose of rendering the tearing and dragging less, semicircular cuts may be made in the skin, of which the concavities should be directed towards the unnatural anal opening, upon which, when the operation is finished, slight pressure may be made by graduated compresses. VELPEAU (d) also proposes the introduction of a tube of gum elastic, provided with several holes, through which waxed threads are to be carried, from within outwards, through the previously pared edges of the opening. When the aperture has scarred, the threads are to be cut through, and then the tube being set free, passes by stool; a mode of treatment similar to that proposed by REYBARD for the union of wounds of intestines (par. 525.) Perhaps DIEFFENBACH's above-mentioned burnings may be applicable to such cases of artificial anus.

(d) Memoire sur l'Anus contre nature dépourvu d'éperon, et sur une nouvelle manière de le traiter. Paris, 1836.

(a) BRESCHET, above cited, pl. iii. fig. 2. (b) COLLIER, in FOTHERGILL'S Medical and Physical Journal, 1820, June. (c) CASPER'S Wochenschrift, für die ges. Heilk., 1834, p. 265.

D.-OF RECTAL FISTULA.

(Fistula Ani, Lat.; Mastdarmfistel, Germ.; Fistule à l' Anus, Fr.)

POTT, Treatise on Fistula in Ano; in his Works by EARLE, vol.

DESAULT, Œuvres Chirurgicales, vol. iii. p. 380.

DETZMANN, Dissert. de fistula ani. Jenæ, 1812. 4to.; with plates.

REISINGER, F., Darstellung eines Verfahrens, die Mastdarmfistel zu unterbinden. Augsburg, 1816.

8vo.

KOгHE, Darstellung und Wurdijung der Kurmethoden der Afterfisteln; in RUST's Magazin, vol. i. pt. ii. p. 259.

SCHREGER Ueber die Unterbindung der Mastdarmfisteln; in his chirurgische Versuchen. Nürnberg, 1818. vol. ii. pt. i.

COPELAND, THOMAS, Observations on the principal Diseases of the Rectum and Anus. London, 1814.

8vo.

BELL, CHARLES, A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate, and Rectum. Third Edition; with Notes by Shaw. London, 1822. 8vo.

BRODIE, Sir BENJAMIN, Lectures on Diseases of the Rectum; in Medical Gazette, vol. xviii. 1836.

923. Under the term Rectal Fistula is comprehended every fistulous suppurating passage in the neighbourhood of the rectum, in which either merely the tissue surrounding the outer walls of that gut is destroyed. or the fistulous passage communicates with the cavity of the rect m Rectal fistulas are therefore distinguished into the perfect, (F. ani complete,) and imperfect, (F. ani incompleta,) according as they have an external and internal opening communicating with the cavity of the rectum ; or they have an internal or external opening alone, imperfect internal (external blind) and imperfect external (internal blind) rectal fistulas. They also present numerous other differences; the fistulous canal may extend far up into the cavity, may be accompanied with many external openings, may extend far beneath the external skin, and be accompanied with callosities and hardening, with foreign bodies, with disease of the neighbouring parts, the bladder, urethra, vagina, and so on, or even with caries of the bones of the pelvis.

924. The causes of rectal fistulas, are injuries of the internal coat of the rectum by foreign bodies which pass with the stools, producing inflammation and suppuration, suppurating bunches of hæmorrhoids, by which the internal membrane of the rectum is destroyed. These fistulas generally form slowly; the patient has for a long time itching at the anus, and a knobby swelling forms about it, which often merely empties itself by a small opening, or the fistula has little disposition to break externally, but rather spreads upwards, and may be connected above by a second opening with the rectum (a); or an abscess may form about the anus from hardening, from injury, from burrowing of pus from another part, which deprives the exterior wall of the rectum more or less completely of its cellular tissue. These abscesses are often critical, and the patient is thereby freed from other complaints, from affections of the chest and so on; often they are merely consequent on gorging of the hæmorrhoidal vessels, from diseases of the breast and liver.

925. The condition of the fistula is in part shown by the nature of its origin, the fæcal or merely purulent discharge, and the passage of intestinal gas from it, especially after examination with the probe.

926. According to the observations of SABATIER, LARREY (b), and (a) SCHREGER, Annalen des chirurgischen Clini- (b) Mémoires de Chirurgie Militaire, vol. ii. cum's auf der Universität zu Erlangen, 1817, p. 92. p. 415.

RIBES (a), the internal opening of rectal fistula is most commonly found immediately above the part where the internal membrane of the rectum joins the external skin, rarely about, but never higher than five or six lines; at least such was the case in seventy-five corpses in which RIBES examined rectal fistulas.

[ASTLEY COOPER mentions a case of fistula which had a very remarkable course:-" A man died of a discharge from a sinus in the groin, having also a fistula in ano; and upon tracing the sinus in the groin, it passed under POUPART'S ligament, and taking the course of the vas deferens, descended into the fistula in ano." (p. 326.)]

927. These observations, which agree with my own experience, must assist the Surgeon in the examination of rectal fistulas. A thickish probe should be introduced horizontally and nearly parallel with the perinæum, at least in women, because in them the opening of the rectum is less drawn in, than in the male, in whom the probe must be directed rather more upwards. The probe should be introduced into the canal of the fistula, and without leaving it, carried, towards the lower end of the rectum, where sometimes the opening is found, and the probe may be felt penetrating into the gut by the forefinger therein introduced. In many cases when the patient protrudes the rectum, and the edges are drawn aside with the fingers, the internal opening of the fistula may be seen. If the examination be not thus proceeded with, the internal opening must be sought at the bottom of the fistula; the wall of the rectum may be easily penetrated. If several external fistulous orifices be present, they all must be examined in order to determine whether they be connected with each other. The examination must be repeatedly made whilst the patient is on his side, with the trunk bent forwards, upon his back with the thighs drawn up, and whilst standing. Catgut bougies and injections may also be employed for the close examination of the state of the fistula. In the examination of incomplete internal fistula, those parts at which the patient has always specially felt pain, or which are indicated by softness, hardness, or laxness, must be carefully examined, partly with the finger and partly with the probe, which should not be hook-like and curved, but straight, as the canal of the fistula often stretches upwards (b) ( par. 924.) The part, which about the anus is harder and painful to the touch, shows the bottom of the external blind fistula. The colour of the skin is here usually changed, and on pressure pus flows into the rectum. These symptoms, however, are often wanting, and the patient merely feels pain.

928. The cure of the rectal fistula which has an internal opening, is only to be effected by division of the sphincter muscle, and the partition between the fistulous passage and the gut. If the canal of the fistula extend far up, a relapse is more certainly prevented by beginning the division from the external opening. Many observations support this, and there is the proof that the most important part of the operation for rectal fistula consists in the division of the sphincter muscle, whereby the collection of fæcal matter in the rectum is prevented, and the union of the walls of the fistula possible. An imperfect external rectal fistula does not always require this division of the partition, because if in such case due care be taken for the proper escape of the pus, the stripping of the rectum is not so considerable as to render doubtful the connexion of the walls of the fistula with the neighbouring parts. The operation for rectal fistula must be in Révue Médicale, Historique et Philosophique. Paris, 1820, livr. i. p. 174.

(a) Recherches sur la situation de l'Orifice interne de la Fistule à l'Anus et sur les parties dans l'épaisseur desquelles ces ulcères ont leur siége;

(b) SCHEEGER, above cited, p. 98.

considered to be contra-indicated, when it seems to be a vicariously secreting organ, by which other ailments are lessened or removed, (here the annoyance of the patient may be relieved by enlarging the external opening of the fistula, and by cleanliness, and the cure must be proceeded in at least not without careful preparation, according to the circumstances of the patient,) and if it be connected with other diseases of the pelvic bones, of the bladder, of the prostate gland, of the vagina and so on, or with phthisis, or incurable disease of the liver, which cannot be removed by the operation for fistula. Those rectal fistulas are to be considered incurable which are very old, have many openings, are connected with ruptures and callosities, where too much must be done to destroy them, and where the internal opening is out of reach. If the fistula have existed a long while, the operation must not be undertaken without the introduction of issues; and also if the fistula and the neighbouring parts be much swollen and inflamed, the operation must be withheld till these symptoms are put aside.

[The following observations of BRODIE should always be borne in mind when considering the propriety of operating for fistula :-"In those cases in which a fistula in ano occurs in connexion with some organic disease of the lungs, or liver, I advise you never to undertake the cure of the fistula. No good can arise from an operation under these circumstances; but if you perform it, one of two things will happen: either the sinus, although laid open, will never heal, or, otherwise, it will heal as usual, and the visceral disease will make more rapid progress afterwards, and the patient will die sooner than he would have done if he had never fallen into your hands." (p. 186.) And ASTLEY COOPER also observes:-" The Surgeon often brings discredit upon himself by operating in these cases, in the last stage of phthisis, when no operation ought to be performed, and when it is impossible that the disease can be cured: therefore that death which is the result of pulmonary disease, is falsely attributed to the fistula in ano.” (p. 328.)]

929. The abscesses which form in the neighbourhood of the rectum are either phlegmonous, defined and accompanied with throbbing pain, or they arise gradually in form of little not very painful knobs, or they occur after the protrusion of the rectum, with simultaneous collection of fæcal matter and pus, are of great extent, and commonly produce, especially with persons of bad constitutions, wasting suppuration and gangrenous destruction. In the former case leeches and soothing applications are to be employed, and the abscess should be opened early with the lancet, to prevent the destruction of the cellular tissue in the neighbourhood of the gut; and if the canal do not communicate with the gut, it may be hoped that simply by the covering bandage and the use of soothing applications, or in old fistulas of this kind, by injections exciting inflammation, the cure may be effected. In hard and little painful swellings, soothing poultices and dissolving plasters may be used; they should be opened when soft and the further treatment be such as in the former case. But if in internal blind fistula the outer wall of the rectum be exposed to some extent, the division of the partition between the fistulous passage and the gut is requisite. When a large abscess has formed about the anus, if it have arisen from tearing of the wall of the rectum, a sufficiently large opening (but not a transverse cut, which would at the same time divide the wall of the gut) must be made, attention paid to the free escape of the pus, to the necessary means for supporting the powers, and afterwards when the fistulous passage has become more contracted, the division of the partition between the fistula and rectum must be proceeded with. (SABATIER) (a).

(a) Médecine Opératoire. Nouv. Edit., 1822, vol. ii. p. 309.