Intestinal fistulas are openings interconnecting different portions of the gut. Usually, they are single but the double type is rare. On that account, triple fistulas deserve documentation, especially one that goes back to 1848. Incidentally, another 1848 case concerned growth of a black eye cancer that found its way into the substance of a white kidney tumor.

A recent work on the fistula mentioned it as an intrinsic “abnormal communication between two portions of the intestine.” [1] As things stand, a double fistula must be uncommon let alone a triple case, especially one that went back to 1848. This is in tune with the results usually printed in the Transactions of the Pathological Society of London, which began publications from that period. [2] This included a rare case of triple fistulas which deserves abridgment.

On 4^th March, 1848, Adams [3] reported a case of colloid cancer of the rectum and colon. Indeed, the triple nature of the fistulas deserves historical abridgement thus.

The preparation was removed from the body of a man aged thirty-five, who had suffered for a considerable time with symptoms of stricture of the rectum. The portion of the rectum lying in the concavity of the sacrum was the principal seat of the disease: to this part a portion of the transverse colon was dragged down, and firmly adherent for about four inches of its length; the sigmoid flexure was remarkably twisted, and at its lower part involved in the mass of colloid which formed a globular tumour of the size of a man’s fist. The tumour had a long irregular central cavity, into which there were three intestinal openings. The transverse colon entered it from above by a perforation of the size of a half-crown; the sigmoid flexure entered it from the right side by a constricted opening, probably the natural canal, though altered in position by the twisting of the gut, and the rectum led out of it at the lower part, also by a contracted aperture: the internal surface of this central cavity was not sloughy, but tolerably smooth, though irregular from the nodulated projections of the colloid.

In those days, surgical pathology was naturally in its infancy. [4] However, colloid cancer, as the name implies, was patently striking even on mere inspection. It was such an inspection that also facilitated a contemporary report of eye black cancer being seen within the whitish tumor of the kidney. [5] Indeed, I have published it as an early case of cancer to cancer metastasis. [6]

It is of interest that small bowel fistula may be of inflammatory origin. Moreover, when the associated sepsis is severe, it “should be managed in specialized intestinal failure units.” [7] Of course, the management of malignancy is a different story altogether.