“In speaking of large abscesses which sometimes form high up by the side of the rectum and above the sphincter muscle, BRODIE makes the following excellent observations:-"When the existence of such an abscess is ascertained, you ought without delay to puncture it; otherwise not only will the patient have to undergo a great deal of unnecessary pain, but the abscess will extend itself in the pelvis until it attains an enormous size. You must ascertain the situation of the abscess, by observing to what part the pain is referred, and by examining the rectum with the finger. Then introduce a lancet through the external skin by the side of the anus, in the direction of the abscess, until the matter flows. Frequently the abscess is at such a depth that the lancet does not reach it until nearly the whole of the blade has penetrated the soft parts; and sometimes an ordinary lancet is scarcely of sufficient length to accomplish what is wanted. You are then to introduce a probe-pointed bistoury through the opening thus made, and divide the rectum at the lower part of the abscess, carrying the incision downwards, so as to include the sphincter ani muscle, as you would in an ordinary case of fistula. These incisions make a free opening into the abscess, which is immediately emptied of its contents. The wound is then to be dressed in the ordinary way, and nothing more is wanted. It is quite unnecessary, in these cases, to lay the whole abscess open into the rectum; the free division of it at the lower part is sufficient; and if the incision were to extend further, it might give rise to a dangerous hæmorrhage from large blood-vessels beyond the reach of the finger. I have met with abscesses, such as I have now described, containing from half a pint to a pint of matter. I have had no opportunities of dissection so as to ascertain their exact locality; but from examinations made with the finger, after they have been opened, I am led to suspect that their usual situation is between the levator ani muscle and the pelvis, and that the division of the lower part of this muscle, as well as that of the whole of the sphincter ani, is necessary to the cure.

"These large pelvic abscesses occur in some instances as the original and only malady. In other cases, as I explained in my last lecture, they are the result of an abscess lower down, or a common fistula. I have met with several cases such as I am about to describe. I have been consulted concerning a fistula near the lower part of the rectum, which I have layed open in the usual manner. But, after some time, I have found that the parts showed no disposition to heal, or that they healed imperfectly, and that there was a discharge of pus much greater than could be accounted for from the apparent extent of the sore surface. I have thus been led to make a further examination; and at the upper part of the sinus which had been previously laid open, I have discovered a small orifice, through which a long probe might be passed to a great depth. I have laid open the lower part of this upper abscess into the rectum, and could then introduce my finger so as to feel the broad inner surface of the pelvis on one side, and what seemed to be the levator ani, on the other. After this second operation, the purulent discharge has immediately become much reduced in quantity, and in the course of a short time the patient's cure has been completed.” (p. 186.)]

930. The usual modes of operating on rectal fistulas are incision and ligature, as the early mode of treatment with the hot iron or caustic is now put aside, and cutting out the fistula must be confined to those cases in which it is connected with scirrhous or carcinomatous degeneration.

931. For the operation on the rectal fistula by cutting a quantity of instruments have been invented, as the syringotome, the curved bistoury, the special apparatus of DRUMMOND, RETTLER and BRAMBILLA, the fistula-knife of POTT, SAVIGNI, REMM, DZONDI, and others. But the most simple and certain proceeding is, when, for cutting the wall of the fistula only a common straight bistoury, a grooved probe without a blind point, and a wooden gorget are used. After having emptied the rectum with a clyster and removed the hair in the neighbourhood of the fistula, the patient is to be laid in his bed, or on a couch upon the side of the fistula, with the thigh of the affected side stretched out straight, and the other bent towards the pelvis. The grooved probe is to be introduced through the canal of the fistula and its internal opening into the rectum, where it is found by the finger which has been therein introduced. The oiled gorget is then to be passed into the rectum, its hollow directed towards the side of the fistula, and the probe pressed against it. The probe

and gorget being felt to touch distinctly, are to be held with either hand, and both moved together. The probe is given to an assistant, who at the same time separates the buttocks, and the gorget being pressed against it, a straight bistoury is to be introduced along its groove, till it reaches the gorget, and in drawing out the bistoury all the parts between the probe and the gorget are divided, which is shown by the probe and gorget being drawn out through the wound without disturbing their contact after the incision is completed. If the canal extend higher than the internal fistulous opening, a pair of blunt scissors should, according to the advice of some, be introduced into the wound, upon the forefinger, and the remaining partition divided. This, however, is according to foreign and home experience not indispensable (par. 928.) If the internal fistulous opening be very deep, a fine flexible, silver, hollow sound may be introduced by the fistula into the rectum, its end brought down out of the gut with the forefinger, and the parts lying upon it divided with a bistoury pushed along the groove.

Further observations on the seat of the internal opening in rectal fistula must decide, whether this be not always connected as above said, (par. 928,) and whether the division of the wall of the fistula from the inner opening be sufficient for the cure although the fistulous canal extend higher.

[My common practice in operating on rectal fistula, has been for years, to use a soft silver director which will bend. Having introduced the forefinger of one hand into the rectum, I pass the director through the fistulous passage, and if, as is generally the case, there be a hole in the gut, into the rectum; but if there be not an opening, or if it cannot be readily found, I bore the end of the director against the wall of the gut, upon the finger introduced, and thus speedily penetrate into the cavity of the rectum. Having thrust the end of the director well through, I bend it round with the top of my finger, till I have brought it through the anus externally, and then thrust it a little further. till its point rests upon the opposite buttock. Having both ends of the director, and both apertures of the fistula well in sight, I divide the sphincter and its tegument, by running a pointed curved bistoury along the groove of the director. I think this mode of proceeding is best, because it shows to what extent the parts are divided; and also that thereby the upper part of the wall of the fistula tears, and is therefore less likely to unite by adhesion, then when clean cut, as quick union is not desirable. BRODIE also recommends the practice of bringing the end of the director through the anus, and dividing upon it.

If I do not bring the probe out, I prefer the old practice of cutting on the finger, which must be first introduced into the gut, then the fistula should be examined with a probe, and its direction and extent being ascertained, the probe is withdrawn, and a button-ended curved bistoury passed in its room, through the opening in the gut, if there be one, but if not, the bowel is to be rubbed between it and the finger till it make one; the end of the finger is then carried over the end of the knife, which being thus defended, the hand that holds the handle of the knife grasps the other, and the finger and knife are together drawn down, cutting through the sphincter as they are brought out. There are, however, two inconveniences as regards this operation, the Surgeon may cut his finger severely, or break the knife in the fistula, which I have seen when the patient has been unsteady.-J. F. S.]

932. In an internal blind fistula, the director should be carried to its bottom, pressed against the gorget, introduced into the rectum, and the partition divided with the straight bistoury, as in the former case.

933. After the completion of the operation and after the wound has been properly cleaned, the forefinger of the left hand should be introduced into the rectum, to the upper end of the wound, and then by means of a probe or pair of forceps well oiled, a tent of lint should be passed up and put lengthways between the edges of the wound, so as to prevent them touching; a wad of charpie is then to be put on, to be fixed with sticking plaster, then a compress, and the whole held together with a T

bandage. After the patient is put to bed in a convenient position upon his side, an opiate should be given, and the bandage is to be removed every time the bowels are relieved, (which should be every twenty-four hours,) after that the rectum has been cleared with lukewarm water; with the remark that in the following dressings the tent is no longer to be oiled, is to be thinner and thrust in less deeply as the wound is lessened by granulation. The scarring is promoted by the careful application of lunar caustic. The opinion of POUTEAU and others, that after the operation of cutting a rectal fistula any dressing is unnecessary and injurious, which of late has found advocates in von WALTHER, JAEGER, and others, I cannot accede to, inasmuch as experience has only shown that without dressing, the edges of the divided partition readily in part unite, and the fistulous passage does not close. That kind of dressing in which the wound is completely filled with several tents, and one thick tent is introduced into the rectum, as BOYER, SANSON, TEXTOR, I myself, and others have recommended, I consider as unsuitable, and have given it up for the above-mentioned more simple treatment. A. COOPER (a) put after the operation a dry tent in the wound, and on the following morning applied a soothing poultice; in two or three days the tent comes out, and a probe should be frequently introduced into the wound for the purpose of preventing the adhesion. Poultices are to be continued, and when granulations spring up the tent must be again introduced, and by this treatment much pain and severe inflammation and suppuration are prevented.

934. The accidents which may occur during and after the operation by cutting are severe bleeding, too much or too little inflammation, copious suppuration, colic, diarrhea, retention of urine, and costiveness.

A severe bleeding, if the bleeding vessel cannot be tied, or if the bleeding cannot be stopped by the application of styptics, requires plugging, in which a firm wad of lint bound crossways with two strong threads must be introduced into the rectum, up to the bleeding vessel, and between them, as they hang down from the gut, sufficient lint is to be introduced to fill the rectum, and then the threads are to be tied upon it. In females the vagina must also be plugged (1).

Severe inflammation requires besides loosening or removing the bandages, cold applications, leeches, soothing applications, clysters, oily mixtures, and the like; copious suppuration needs a corresponding strengthening treatment; spasmodic colic, oily mixtures with opium, soothing clysters and warm applications; for retention of urine, the use of the catheter, warm applications to the region of the bladder, soothing remedies and clysters, which are also equally indicated in costiveness (2).

[(1) Instances, though rare, have occurred of death from bleeding after the division of a rectal fistula, and I recollect seeing such a case very soon after I became a student, in which the patient died within twenty-four hours of the operation. COPELAND objects very properly to the practice here advised of stuffing the rectum for the purpose of stopping the bleeding. "I have," says he, " so frequently seen the hæmorrhage kept up as long as this method of plugging the intestine was persevered in, and cease spontaneously when every kind of application was omitted, and the parts left for a short time exposed to the open air, together with a cool room, and avoiding all drink that hurries on the circulation, that I cannot help thinking that the irritation of the compresses keeps up the bleeding, and that the most eligible mode of treating it, when it is impossible to secure the vessel with a ligature, is to take off every kind of dressing, and to suffer the part, as much as possible, to be exposed to the external air. *** I am persuaded, from repeated experience, that by being too busy with compresses, and styptics, and astringents, and such like applications, we most frequently only hide the bleeding and rather prolong its continuance, than otherwise. *** After many unsuccessful attempts to secure a bleeding vessel under such circumstances, I once accomplished it by introducing a blunt gorget into the rectum; and by keeping the gut thus dilated, I was enabled to see the orifice of the bleeding artery and to secure it." (pp. 90-91.)

(a) Lectures on Surgery, vol. ii. p. 333.

(2) BRODIE observes, that "in a very few cases erysipelas appears to extend up the mucous membrane of the rectum into the other parts of the intestine; and this is a most formidable disease indeed. The symptoms are very peculiar, and as far as I know, are not described by writers. The pulse becomes very rapid and at the same time weak; then it is irregular and intermitting; the abdomen is tympanitic in consequence of the intestines being distended with air; hiccough takes place; there is a great prostration of strength, and the patient often dies in the course of three or four days, sometimes sooner. *** This internal erysipelas, however, is not necessarily fatal. I have known more than one case in which it manifestly occurred, but without the usual prostration of strength, and the patient recovered. When I have met with a case of this kind, I could never entertain a doubt as to the medical treatment which should be employed. It is sufficiently indicated by the symptoms; and for the most part, the great failure of the vital powers demands the free exhibition of cordials and stimulants." (p. 185-86.)] 935. The ligature of a rectal fistula (Ligatura Fistulæ Ani) consists in tying together the whole wall, separating the rectum from the fistula, with a thread which, by gradual tightening, cuts it through; in this case as the fistulous wall is divided, the part cut through, heals from above downwards. The proceeding in tying the rectal fistula varies according to its seat and condition. The best materials for the ligature are several hempen or silken threads put together, or a silken loop-shaped thread, and the silver or leaden thread recommended by many persons.

[LUKE, of the London Hospital (a), during the course of the present year has advised the treatment of fistula in ano, by tying it with a thread, and says:-"The advantages of this method over that by the knife, are; first, the shorter period which usually elapses before the final cure; second, the less pain which is felt during the treatment; third, the absence of the dread which the knife generally inspires, and the consequent inducement which it offers to the patient to submit to effective curative treatment; and lastly, the avoidance of all hæmorrhage.

The treatment is to be conducted in the following manner:-an eyed-probe, armed with dentist's silk, is introduced through the fistula into the rectum, from whence the silk is withdrawn through the anus, by means of a catch-spring, introduced into the rectum upon the finger of the operator. The parts to be divided are then inclosed between the two extremities of the ligature, to which a small fistula-tourniquet is subsequently attached, by passing them through holes provided for the purpose. The requisite amount of tension is maintained by a screw. Care must be taken that the ligature be not so tight, as to cause more than slight uneasiness. After the lapse of two or three days, ulceration of the inclosed part commences and the tourniquet becomes loosened, indicating the necessity of the ligature being made tighter." (p. 221.)

Dr. NELKEN (b) has proposed for this operation "an instrument composed, first, of a rod about eleven and a half inches in length, the upper third of which is divided into four equal parts, united to each other by hinges so arranged that they can be closed only in one direction, the last being furnished with a knot and a hole to pass the ligature, and second, of a tube, through which the former is passed when threaded. The finger being placed in the rectum, the apparatus thus prepared, is passed upwards into the fistula until the extremity reaches the finger, the tube is then withdrawn to an extent equal to one of the four divisions of the rod; the whole is next pushed forwards, the finger in the rectum causing the rod to bend downwards as it penetrates into the intestine; the same manœuvre is repeated until the ligature appears at the anus, when the Surgeon seizes it, and terminates the operation." (p. 403.)

Although LUKE mentions nine cases in which he had in this way successfully tied anal fistula, I must confess I should not feel disposed to adopt it unless the patient would not submit to the knife, which I am quite sure produces a cure quite as quickly and with less inconvenience; for after the inflammation excited by the fresh cut subsides, there is scarcely any pain during the two or three weeks, usually necessary for healing the wound.-J. F. S.]

936. In complete rectal fistula, of which the internal opening is not very high, a flexible leaden probe should be introduced through the canal of the fistula into the rectum, which is then with the forefinger of the left hand already in the gut to be drawn out at the anus and a thread passed

(a) Lancet, vol. i. 1845, New Series.

(b) Medical Times, vol. xi. 1845.

into its eye. In the same way, in complete fistula, silkworm gut may be introduced into the rectum, and by it the thread carried in.

937. For tying complete or inwardly blind fistulas which extend very high up, DESAULT, REISINGER, as well as WEIDMANN, SCHREGER, and DEMME have proposed particular apparatus, of which that of REISINGER is preferable. It consists of a blunt silver tube and a probe, provided with a trocar point, which fits the tube, of a watch-spring, which in front has a button and behind an eye, and of a pair of forceps with a movable gorget. 938. In a complete rectal fistula, REISINGER'S apparatus is to be used in the following manner :-The patient being put in the same position as for cutting, the silver tube with its ensheathed probe is to be passed through the fistula into the rectum for about three lines' length, which is ascertained by the finger already there. The forceps having been oiled are then introduced into the rectum without the gorget, opened, and passed somewhat deeper in, that the tube may project between the arms of the forceps and be held fast by them. An assistant then removes the probe from the tube and passes in the watch-spring, which is provided with the ligature, through the tube into the rectum. As the watch-spring projects from the tube, it must be seized with the forceps, which, being closed, are drawn back, so that the watch-spring is drawn out of the anus, after it the ligature, and then the tube is to be removed.

In a fistula of the rectal sheath the tube must be brought through the sheath and the fistulous opening into the rectum, and then treated in exactly the same way. According to MOTT (a) a seton should be first introduced into this kind of fistula, and left there for some days; a thread is then to be drawn through the fistulous opening, and by means of an eyed needle the ends found in the sheath are to be drawn through the perinæum and the two ends tied together, as in rectal fistula.

939. In an inwardly blind fistula, the tube with its probe is to be carried by the fistulous canal to its very bottom, the blunt probe removed, and the trocar-pointed one introduced, without projecting it from the tube. The forceps, opened, are then passed with the gorget into the rectum about an inch above the tube, and both instruments inclined towards each other so that the tube becomes situated between the arms of the forceps. The assistant now thrusts the trocar-point out of the tube, by which the rectum is perforated and the trocar-point between the forceps' arms pressed against the gorget, so that the latter may recede from the forceps. The tube being then kept pressed against the gorget, an assistant draws out the trocar, and by means of the forefinger of the hand holding the forceps, the gorget is withdrawn, and removed from the forceps, which are then closed and the tube held by them. The watch-spring is then introduced through the tube, and proceeded with as already described.

940. The two ends of the thread introduced, are passed into the two openings of a small silver tube, and tied with a simple knot and loop, so tight that the patient may feel a degree of pressure but no pain. For the first day he must keep quiet, but afterwards may go about his usual business. Every three or four days the knot should be tightened as already directed; and care must be taken for the daily passage of soft motions. If much pain arise, the ligature must be tied more loosely, but in other respects the treatment is to be, as after the operation of cutting. The same mode of treatment is to be continued till the partition of the fistula is divided. In order to prevent the destruction of the ligature, at the

(a) Gazette Médicale de Paris, 1841. No. 18.