fistula will close without any surgical interference. Seven years ago a patient applied to me with complete fistula of the right side; the external opening was about an inch and a quarter from the anus, and the internal one between two and three lines from the anal orifice. At the time he was under the treatment of Dr. Quain, at the hospital for Diseases of the Chest at Brompton, his lungs being seriously affected by tubercular deposit. On consulting with this gentleman, we agreed that it would not be advisable to do anything for the fistula, fearing to aggravate the pulmonary affection. He was directed to wash the anus with soap and water night and morning, and also after defecating, and not to allow the bowels to become constipated. The fistula healed about six months after I first saw him. He continued under the judicious medical treatment of Dr. Quain, and his health greatly improved: but in the early part of the autumn of 1855 he caught a severe cold, which increased the activity of the tubercular disease of the lungs, and terminated his life.

We must not delude ourselves or our patients with the idea that fistula can often be cured without an operation however, we now have the satisfaction of knowing that the formidable proceedings of former days are not requisite, and that an incision of limited extent is all that is necessary; the operation occupies

only a few seconds, and causes comparatively little pain. But there are some persons whose nervous susceptibilities are so exalted, and the dread of cutting instruments so great, that no reasoning or persuasion will induce them to consent to the best and easiest plan of treatment. Under these circumstances recourse may be had to the ligature. In past time it was frequently employed, but the tediousness of the process, when the ligature had to ulcerate through any thickness of parts, and the irritation that frequently attended its use, led to its being discarded. Mr. Pott* thus expresses his opinion. The terror which a cutting instrument necessarily carries with it, the fear of a flux of blood from some considerable vessels, together with a strange, nonsensical opinion that a gradual division of the parts was followed by a more sound cure than an immediate one by cutting, produced the coarse, unhandy method by ligature.

But as the whole operation is, on every principle of ease, expedition, safety, or certainty, unfit for practice, it would be an abuse of the reader's patience to dwell any longer upon it." Sir Astley Cooper says, Timid persons prefer this mode of treatment to the knife, although in the one case the irritation is long continued, and in the other, the pain is only of a few minutes' continuance.

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"That it succeeds in some instances I have known, for some of my patients, having submitted to this remedy, returned to me well.

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My objection to it is, that the irritation it produces is liable to occasion other abscesses whilst healing that for which it is employed."

Mr. Luke revived the use of the ligature, and invented several instruments for passing and tightening it in the first volume of the "Lancet" for 1845, are drawings and descriptions of these: he also recites nine cases treated by this method, but I believe he now regards incision preferable to it. I have on one occasion had recourse to the ligature, as the patient would not consent to any other operation, and a cure was effected. The ligature was kept tense by attaching an india-rubber ring, such as is now generally used to secure papers together, which being put on the stretch, was fastened to the buttock by a strip of plaster.

Since Mr. Pott propounded his principles of treatment of fistula by simple division, and proved the soundness of those principles in a very extended field of public and private practice, the objectionable operations formerly in vogue have in this country been almost entirely set aside. Yet some surgeons may still prefer the principles and practice of our forefathers. Mr. Syme* remarks, "As was to be ex*Op. cit., Third Edition, pp. 35, 36.

pected, however, many practitioners clung to the methods in which they had been educated; and even in the present day there are some who, whether from imbibing the bad example thus transmitted to them, or from an unhappy peculiarity of judgment, still prefer the old and unjustifiable process of excision. I have seen an eminent professor of surgery in Paris cut out the fistula, and understand that he continues to pursue this practice. Some years ago, a middleaged woman came under my care in the Surgical Hospital, on account of a recto-vaginal fistula, and stated that the complaint commenced with a fistula in ano, for which she had had an operation performed by the surgeon of a provincial hospital, who cut something out and laid it on the table, since which there had been a communication between the rectum

and vagina. More lately, a gentleman from the north of England applied to me on account of some unpleasant consequences resulting from an operation, or rather, series of operations, to which he had been subjected on account of fistula in ano. His principal complaint was inability to retain the contents of his rectum, which, notwithstanding the resistance of a carefully constructed bandage, were wont to be suddenly and involuntarily discharged, so as to cause great discomfort, and constant apprehension. Though prepared to find something far wrong, I was not less

surprised than shocked, upon inspecting the seat of the disease, to see no appearance of an anus, but instead of it, a deep excavation, at the bottom of which the mucous coat of the bowel presented itself to view, completely divested of the sphincter. From these and other facts of the same kind that might be mentioned, I fear it must be concluded that the plan of excision is still not entirely abandoned; but, feeling assured that those who persist in adhering to it, notwithstanding all that has been said and written on the subject, would not have their views altered by any argument in my power to use, I shall leave them to follow the progress of improvement at their own leisure."

When it was the custom to divide the rectum throughout the entire extent of the fistula, a simple knife was not by many deemed sufficient, and "ingenious, mechanical, and whimsical people have busied themselves in inventing instruments for this purpose : the syringotomy, the cultellus fulcatus, the probe razor, &c., have at all times been in use; scissors also of various kinds, both straight and crooked, have been employed in this operation; the first three may be made to serve the purpose very well; but to the last (the scissors), there is in this, as well as in almost every operation in which they are frequently used, a palpable objection, viz., that by pinching at the