200 
REPORTS OF CASES. 
Being about dusk that evening, the operation had to be 
postponed until the next day, but owing to other urgent 
cases coming to hand, I could not see her until the second day 
thereafter. 
At that time her temperature was 104 1-5°, pulse 74, and 
about six inches below the external orifice of the fistula a soft, 
fluctuating tumor had made its appearance, which upon pres¬ 
sure discharged the usual material. To operate, the patient 
was first cast on its right side, legs firmly tied, abdomen 
thoroughly cleansed with warm water, and the hair clipped 
as short as possible all around the orifice. 
The instruments used, besides a sponge and carbolized cat¬ 
gut, were a scalpel, probe bistoury, artery forceps, hypodermic 
syringe and curved needle. 
On probing the fistula, it was found to extend downwards 
between skin and abdominal wall to the bottom of the tumor 
above mentioned, where it pierced the abdominal wall. 
This being opened, and the sac thoroughly cleaned, a 
probe bistoury was introduced down into the stomach, mak¬ 
ing an incision directly upwards about six inches. A similar 
incision was made from the same point backwards, giving a 
right-angled incision base and perpendicular six inches in 
length. 
The included triangle thus produced being thrown back¬ 
wards exposed the stomach to full view. At first, the hem¬ 
orrhage was very profuse, but was soon controlled by cold 
water application. No blood could gravitate into the abdomi¬ 
nal cavity on account of the rumen being firmly pressed 
against the edges of the wound, which (the rumen) owing to 
the abnormal position of the patient, had turned so much on 
its axis as to hide the fistula several inches above the upper 
border of the incision. 
With hands and arms well oiled this was soon overcome 
by manipulating the organ and its contents. 
The hole in the wall of the stomach was oval in shape, and 
large enough to admit the first and second phalanges of my 
index finger, its borders attenuated and slightly granulating. 
With a sharp scalpel I removed a small triangle at the lateral 
