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instance, and is never perforated until after suppuration has taken place." M. Eibes* presumed that inflammation and ulceration of piles was the common origin of fistulae 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 fistulae have been considered to be incomplete, or blind external fistulae. But the greater evil arising from the inaccurate knowledge of its usual locality was, that surgeons were induced to divide 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. Bibes 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. Eibes 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.
* 'Quarterly Journal of Foreign Medicine and Surgery,' vol. ii., 1819, p. 20.
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 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 mUtter, 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 Cooper* 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 horse-shoe fistula will be formed; that is, a communication will exist around the posterior
"Lectures of Sir Astley Cooper, Bart., on the 'Principles and Practice of Surgery,' with Notes by Tyrrell,' vol. ii., p. 326.