*

ilium, or pubis, cannot be benefited by incisions so long as the osseous parts remain diseased; if any portion of the bone be necrosed, it must be extracted, or be thrown off by nature, before a recovery can be looked for. Mr. Syme mentions two cases connected with disease of bone: the one a man who had been repeatedly operated on for fistula in ano, without obtaining relief: a careful examination discovered an exfoliation from the tuberosity of the ischium lying in a capsule formed by the origins of the flexor muscles of the leg. The second case that of a young woman, who suffered from fistula in ano; a probe being felt to grate against a hard substance, it was extracted, and found to be a thin scale of bone, probably detached from the arch of the pubis.

In the Lancet't there is an account of a man, aged forty-seven, who was in St. Thomas's Hospital, having fistula in ano, for the cure of which the usual operation was performed, but without benefit, and the patient continued to experience excruciating pain; subsequent examination discovered the rectum to be considerably ulcerated, and partaking somewhat of the characters of cancer: this condition was ultimately discovered to depend on caries of the sacrum. Lately there was a man at the Marylebone In

* On Diseases of the Rectum,' Third Edition, pp. 54, 55.

† Vol. ii., 1855, p. 461.

Oct., 1856.

firmary with fistula in ano, connected with necrosis of the tuberosity of the ischium: the dead bone was removed by operation.

Abscess from disease of the hip-joint, in its advanced stage, usually opens posteriorly, and below the articulation, but sometimes matter will burrow and effect an opening near the anus; it is scarcely necessary to say, in such a case, the operation with the hope of curing the fistula would be entirely useless.

The subjoined cases are examples of some of the more ordinary forms of fistula in ano.

Fistula in ano, the effect of a kick.

A young gentleman, æt. seventeen, at one of the public schools, received a kick from a companion, which was followed by the formation of an abscess; it was allowed to burst, and, beyond keeping some lint to the part, to prevent his linen being stained, nothing had been done: during the vacation, he came under my care. I found an external opening between one and two inches from the anus; a probe passed into this could be felt by the finger in ano, in contact with the walls of the intestine, which were very much thinned; no internal communication could be discovered. Constitutional treatment was had recourse to for a few days, and after the bowels had been thoroughly unloaded, an incision was made through the sinus and bowel from the point at which it was denuded. It was deemed advisable to keep him in

bed for a week; the bowels were kept easy by laxatives, and an enema of eight ounces of thin gruel injected every morning; the wound was lightly dressed, and in about three weeks had quite healed.

Fistula in ano; two external openings; operation; cure. Mrs. æt. twenty-seven when I was consulted she had been married six years, and had had no family. Two years previously to her marriage she experienced heat, itching, and fulness in the rectum: these symptoms increased, and after a time she occasionally lost a small quantity of blood at stool. A few months after marriage an abscess formed near the anus, preceded by heat and severe throbbing pain: she used poultices and it broke, the skin giving way in two places. Previously to the abscess bursting, she had observed by her linen that there was a slight purulent discharge from the anus. After the matter had obtained vent she had less pain, but continued to have great uneasiness, and was annoyed by a constant discharge of pus.

On making an examination, two small fistulous openings presented, one being about an inch from the anus, and the other an inch and a quarter from the first, its direction being outward and backward; a fistulous track, extending between the two openings, could be felt like a cord beneath the finger: at an angle with this sinus, another could be felt extending towards the bowel; a probe readily passed from the one external opening to the other, but, from the acute angle formed by the two sinuses, it could not be made to enter the bowel. At a quarter of an inch above the anal orifice, a

U

small hard tubercle could be felt; and pressure produced some pain at this point. She had always been of a costive habit, and had not been accustomed to take much exercise. Her pulse was not quick but rather sharp, her tongue was furred and notched, and she was much troubled with flatulence; the renal secretion was disordered, there being an excess of uric acid. Medicines were prescribed to unload the bowels and improve her general health. After persevering in these for ten days the operation was performed. She had taken a dose of castor oil early in the morning, and an enema had been administered an hour before I arrived at her house, by which means her bowels had been thoroughly relieved. I first divided the sinus between the two external openings, and was then able to pass a probe through the fistula into the bowel without the slightest difficulty, the end being brought in contact with the finger of the left hand, introduced into the rectum; a small curved bistoury was made to follow the probe, and the intervening tissues divided; only a few drops of blood were lost. A piece of lint was gently inserted between the lips of the wounds; and she took half a drachm of wine of opium in camphor mixture.

On the third day, the bowels not having been moved, she took a dose of castor oil: the dressings came away when it acted. After this the wound was lightly dressed each day, and in little more than a week she was quite well.

Fistula in ano following an abscess caused by wet and cold.

F. M——, æt. thirty-five, a coachman in a nobleman's family, of moderate stature, and robust constitution. After driving the greater part of a cold wet day, he felt towards

the evening a burning heat in the integument near the anus, and during the night severe throbbing pain commenced: this continued three days, when he had a slight shivering fit, after which the acuteness of the pain subsided, and resolved itself into a dull aching sensation; on the fifth day from the commencement of the attack, he applied to me. There was then very little constitutional disturbance; the tongue was somewhat furred, and his skin dry. On making an examination, the skin between the anus and the tuberosity of the ischium was observed to have a dusky red appearance, and fluctuation was perceptible to the touch. I made a free opening with a bistoury, and evacuated about an ounce ard a half of unhealthy pus; he was desired to keep a poultice to the part, and to see me in a few days.

In a week after the abscess was opened I made a careful examination with a probe, and could not detect any communication with the bowel, there appearing to be a thickness of tissues of at least half an inch between the walls of the abscess and the bowel. He appeared to be progressing favourably; and he was directed to keep the bowels regular, to live moderately, and to see me again in a short time.

He did not see me for several weeks, as he considered the abscess would heal in time; he had had pricking pain in the part occasionally, but not at all severe. I made an exploration with a probe, and now discovered the coats of the bowel denuded immediately above the margin of the anus. On the following day, with the assistance of Mr. Thompson, I divided the structures between the external opening and the denuded bowel. The wound was lightly dressed, and he was ordered to remain in bed. When I called on the follow