OPERATION BY ELASTIC LIGATURE.—The advocates for the use of the elastic ligature maintain that with it there is no hemorrhage. This is a matter of considerable importance when the fistula penetrates deeply, and also in those rare cases of hemorrhagic diathesis where severe bleeding is apt to follow a trivial incision. For the introduction of the elastic ligature we are indebted chiefly to Dittel, of Vienna. This ligature causes strangulation of the parts by the firm pressure it constantly exerts upon the included structures; it cuts its way out in a week's time or less. It is stated by those who have an extended experience with this plan of treatment, that, contrary to what might be expected, the pain attending the ulceration of the band through the tissues is slight, especially after the first twelve hours. Consequently, this method would prove an excellent way of treating fistula if it were always to be relied upon to effect a cure. Unfortunately, this is not the case, for it often happens that after the ligature has cut its way through, and the superficial parts have healed, the fistula remains uncured. The reason for this is to be found in the fact that the ligature has dealt with the main track, only, of a fistula in which exist one or more secondary channels and diverticula. I therefore resort to this method of treatment only in that class of patients who have an insuperable dread of any cutting operation; when the fistula is uncomplicated with sinuses; in cases of deep fistula where there is danger of wounding large vessels; in cases in which the patients are debilitated by means of some chronic disease; and, finally, in patients of known hemorrhagic tendency. It is a valuable adjunct to the use of the knife in dealing with cases in which a sinus runs for some distance along the bowel. The method of employing this ligature is as follows. A solid cord of india-rubber, about one-tenth of an inch in diameter, may be threaded to a probe having at one end a rounded opening, or eye, through which the ligature is passed. The probe enters the fistula from the external to the internal opening, and passes out through the anus. To facilitate the passage of the cord, the rubber should be put on the stretch. After the ligature is passed, a soft metallic ring is slipped over the two ends of the cord; the cord is then tightly stretched and the ring slipped up as high as possible and clamped. [Illustration: FIG. 46.—Allingham's Ligature-Carrier.] If the internal opening be any distance up the bowel, Allingham's instrument (Fig. 46) facilitates the passage of the ligature. In using it, remember that it is intended to draw the cord from the bowel out of the external orifice, and not _vice versa_. This instrument has been modified and improved by Helmuth, of New York. (Fig. 47.) [Illustration: Fig. 47—Helmuth's Ligature-Carrier.]