position; he gave to Monsieur Felix fifty thousand crowns; Monsieur Daquin one hundred thousand livres; Monsieur Fagon twenty-four thousand livres; Monsieur Bessiere forty thousand livres, and to each of his apothecaries, in number four, twelve thousand livres; and to one Cage, Monsieur Felix's apprentice, four hundred pistoles."

The sum total of these fees equalled £14,700.

If the health of the individual is good, and all circumstances are favorable, a fistula may sometimes be made to heal without an operation. Sir Astley Cooper* mentions, in his lectures, two cases which were cured by injections. I have succeeded in several instances in healing them without operation, though the cure has been somewhat tedious. When a patient objects to the necessary operative proceedings, we may try other means; constant pressure must be made upon the track of a sinus, which should be injected with a solution of sulphate of zinc, or copper, or nitrate of silver. When the cavity of the fistula has been hard and callous, I have cauterised it throughout its course with nitrate of silver. The following is the manner of doing it; having ascertained the precise direction and sinuosities of the fistula, a probe is to be bent into the form that will most readily pass; it should then be coated by dipping it into the caustic melted in a watch-glass over a spirit-lamp; thus armed, it must be rapidly passed into the fistula, Op. cit., vol. ii, p. 334.

*

and allowed to remain a few seconds, and then withdrawn; a simple poultice or water-dressing should be applied for the first twenty-four hours, and after that pressure must be made along its course. During the treatment the bowels must be kept open, and soap and water used to the anus night and morning. By these means we shall sometimes succeed in healing the fistula; but it is a plan not to be relied on. An isolated case will occur now and then, in which a fistula will close without any surgical interference. Four 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 Discases 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 prin

*Op. cit., vol. iii, pp. 125, 126.

ciple 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.

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

'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 expected, 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 middle-aged 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 His principal complaint was inability to retain the

ano.

Op. cit., Third Edition, pp. 35, 36.