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show by-and-by, in connection with surgical practice. It is admitted by every one, that in the greater number of cases of fistulæ in ano, there is an inner opening to the gut as well as the outer opening; and I am satisfied the inner opening always exists, because I scarcely ever fail to find it, now that I look for it in the proper place, and seek it carefully. I have, in a dead body, examined the parts where fistula had existed several times, and in every instance I have found an inner opening to it. This affords a very reasonable explanation of the formation of these abscesses it is almost impossible to understand, on any other ground, why suppuration should take place in the vicinity of the rectum more than in any other part of the body, and why the cellular membrane there should suppurate more than cellular membrane elsewhere. Moreover, the pus contained in an abscess near the rectum scarcely ever presents the appearance of laudable pus, it is always dirty coloured and offensive to the smell; sometimes highly offensive, and occasionally you find feculent matter in it quite distinct. There is no reason why an abscess, simply formed in the cellular membrane, should smell of sulphuretted hydrogen; but there is a good reason why it should do so if it be connected with the

rectum.

"This being the case, it is easy to understand why

these abscesses do not heal. The least quantity of mucus, even from the gut, or of feculent matter issuing into the cavity of the abscess, is sufficient to cause irritation, and to prevent it healing; and I have, more than once, in the living person, been able to trace the progress of the formation of one of these abscesses. For example, I was sent for to see a lady who complained of some irritation about the rectum, and on examining it, I found an ulcer on the posterior part. I ordered her to take Ward's paste, confect. piperis nigri, or cubeb pepper-I forget which. A month afterwards she again sent for me, and I found there was an abscess. I opened it, and from the outer opening a probe passed into the gut through the ulcer, which had been the original cause of the disease. The original opening of an abscess is generally very small indeed, but occasionally it is large, and when the ulceration has proceeded to some extent, large enough to admit the end of the little finger. The inner orifice is, I believe, always situated immediately above the sphincter muscle, just the part where the fæces are liable to be stopped, and where an ulcer is most likely to extend through both tunics." Mr. Syme* remarks: "I do not hesitate to affirm, that when a fistula in ano is formed, the mucous membrane always remains entire in the first

* Diseases of the Rectum,' Third Edition, p. 25.

instance, and is never perforated until after suppuration has taken place." M. Ribes* presumed that inflammation and ulceration of piles was the common origin of fistulæ in ano; he says: "In one hundred cases of fistula of this part, ninety-nine are formed by this procedure, and have their origin from this cause." From cases that have been under my own observation, I differ in opinion from the authors just quoted, as to the internal opening being always formed either in the one way or the other, and am convinced that perforation of the intestine takes place both from within and without; but, however interesting the question may be, pathologically considered, it does not affect the plan of treatment to be adopted. Practically, the more important subject is the situation of the internal opening, it being essentially necessary to the success of the operation that the whole of the parts intervening between the two openings should be divided; and unless the internal opening is searched for in the right direction it will most probably escape detection; and from this cause many complete fistulæ have been considered to be incomplete, or blind external fistulæ. But the greater evil arising from the inaccurate knowledge of its usual locality was, that surgeons were induced to divide

Quarterly Journal of Foreign Medicine and Surgery,' vol. ii., 1819, p. 20.

the intestine much higher than necessary; and frequently, from the internal opening not being included in the incision, the disease returned, or the wound would not heal. To M. Ribes attaches the merit of investigating the question, and showing that the interal opening is never at a greater distance than an inch and a quarter from the anus. Sabatier first called his attention to the fact. Ribes examined the bodies of seventy-five people who had fistula at the period of their death in the majority, the internal opening was just above the point of junction of the mucous membrane of the intestine and integument of the anus; and not in a single instance did he find it situated at a greater distance from the anal margin than five or six lines. Since the publication of the results of his observations, they have been verified by several eminent surgeons; yet the practical deductions therefrom are not always at the present day properly considered or acted upon by all practising the surgical

art.

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The symptoms of fistula in ano are not always very acute occasionally there is great pain, but more frequently a feeling of uneasiness only about the anus is complained of, with more or less tenesmus at stool, and difficulty in the evacuation, particularly if the bowels are costive, or the function of the digestive organs deranged in complete fistula in ano, and in the blind

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internal form of the complaint, the evacuations are smeared with pus and mucus, perhaps also slightly with blood. One, and sometimes the chief, source of annoyance to a patient with fistula is, the discharge, in a greater or less quantity, of purulent or mucopurulent 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

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