tubercular sinus forms. Fistula is often associated with phthisis pulmonalis, and is not unusually linked with piles, cancer, or stricture.

There are three varieties of fistula-the blind external (Fig. 167, A), the blind internal (Fig. 167, B), and the complete (Fig. 167, c). The external opening is usually near the anus, but may be far away, and there may be only one pathway or there may be several sinuses. In a healthy individual the external orifice is small and a mass of granulations sprout from it. In tuberculous fistula the external orifice is large and irregular, with thin and undermined edges, shows no

FIG. 167.-Fistula in Ano: A, blind external; B, blind internal; c, complete (Esmarch and Kowalzig).

granulations, extrudes small quantities of sanious pus, and the skin about it is purple and congested (Bowlby). In a fistula following an anal abscess the internal opening is just above the anus, between the two sphincters. In fistula following an ischio-rectal abscess the internal opening is above the internal sphincter. In an old fistula the track becomes fibrous and cannot collapse. The symptoms of fistula are passage of feces and wind through the opening and of a discharge which stains the clothing. A probe can be carried from the external opening into the bowel. After a time incontinence of feces is apt to come on, repeated attacks of inflammation thickening the rectum and destroying its sensi

bility. From time to time the opening will block, and new abscesses may then form. In examining a fistula, use Brodie's probe, as its flat handle enables one to locate the direction a bent probe has taken.

Treatment. In treating a fistula prepare the parts antiseptically, as antiseptic work, though it will not prevent pus, will limit suppuration. Pass a grooved director through the sinus, bring its point out externally, and lift up the tissues between the sinus and the surface. Incise the tissues (Fig. 168). Push the finger to the depth of the wound, to determine that the sinus does not ascend above the internal opening. Slit up the sinuses and scrape them. Curette the sinus, and if it is very fibrous clip it away with scissors and forceps. Cut away diseased skin; irrigate with corrosive-sublimate solution (1:1000); pack with iodoform gauze; and dress with gauze and a T-bandage. In forty-eight hours remove the dressings, irrigate with peroxide of hydrogen and then with corrosive sublimate (1:5000), dust in iodoform, insert lightly to the depths of the wound a piece of iodoform gauze, and reapply the dressings. Dress the wound thus every day until healing is almost complete. It is unnecessary to confine the bowels beyond forty-eight hours, at which period, if they have not moved, an enema is given. If the dressing be stained with feces, re-dress at once. Get the patient out of bed as soon as possible. Should an operation be undertaken if phthisis exists? Many of the old masters said no. Matthews sums up the modern view: In incipient phthisis, operate; in rapidly progressive fistula, operate whether cough exists or not; if much cough exists, do not operate unless the fistula is rapidly progressive; in the last stages of phthisis, do not operate.

Pruritus of the anus is a symptom, and not a disease. It may be due to piles, fissure, seat-worms, eczema, nerve-disturbance, kidney-disease, jaundice, constipation, opium-habit, torpid liver, dyspepsia, alcohol, tea, vesical calculus, smoking, urethral stricture, uterine disease, ovarian trouble, and mental disorder. The itching, which is fearful, is worse at night. Treatment-Remove the cause. Further, before going to bed wash the parts with very hot water, dry them, and apply at frequent intervals a mixture containing 3j of camphophenique and 3j of water (Matthews). Matthews commends the following mixture: Chloral, 3j; gum-camphor, 3ss; glycerin and water, each 3j.' In this disease a "scarfskin" forms, which must be made to peel off by iodine, pure carbolic acid, corrosive sublimate (grs. iv to 3j of cosmoline), calomel (3ij to 3j of cosmoline), or campho-phenique.

Fissure of the anus is a crack at the anal orifice producing spasm of the sphincter. The pain is due to twigs of nerves upon the floor of the crack. Fissure is caused by constipation or traumatism. The symptom is violent burning pain, sometimes beginning during defecation, but usually at the end of the act, and lasting for some time. Constipation exists, and often pruritus. Examination discloses a fissure, usually at the posterior margin, running up the bowel onequarter to one-half an inch. Piles often exist with fissure.

Treatment. In palliative treatment prevent constipation, wash out the rectum with cold water, and apply an ointment made by evaporating 3ij of the juice of conium to zij and adding it to 3j of lanolin and grs. xij of persulphate of iron. In operative treatment stretch the sphincter, incise the floor of the fissure, and scrape it with a curette.

1 Diseases of the Rectum.

XXVIII. ANESTHESIA AND ANESTHETICS. Anesthesia is a condition of insensibility or loss of feeling artificially produced. An anesthetic is an agent which produces insensibility or loss of feeling. Anæsthetics are divided into (1) General anesthetics, as amylene, chloroform, ethylene chloride, ether, bromide of ethyl, nitrous oxide, and bichloride of methylene; (2) Local anesthetics, as alcohol, bisulphide of carbon, chloride of ethyl, carbolic acid, ether spray, cocaine, ice and salt, and rhigolene spray.

General anesthesia may be required to prevent the pain of labor and of surgical procedures; to produce muscular relaxation in herniæ, dislocations, and fractures; and to aid in diagnosticating abdominal tumors, joint diseases, and malingering.

Heart disease is not a positive contraindication to surgical anææsthesia. It is quite true that anæsthetics are dangerous in people with fatty hearts, but shock is equally dangerous, and the surgeon stands between the Scylla of anesthesia and the Charybdis of shock. Whenever possible, prepare a patient for anæsthesia. Always examine the urine if the nature of the case allows time. If albumin exists, operation is not contraindicated; but the peril of anæsthesia is greater, and certain dangers are to be watched for and guarded against. If much albumin is present, postpone operation except in emergency cases. Give a purgative the night before. In the morning, allow no breakfast if the operation is early, but if the patient is very weak order a little brandy and beef-tea. If the operation is to be about noon, give a breakfast of some beaf-tea and toast or a little consommé; never give any food within three hours of the operation, but brandy is admissible if it is required. If the stomach is not empty at the time of operation, vomiting is inevitable and portions of food may enter the windpipe; if the stomach

contains no food, vomiting is less likely to happen, and even if the vomited matter enters the windpipe it will do little harm, as it consists chiefly of liquid mucus. Vomiting is dangerous also because of the great cardiac weakness which precedes and follows it. Before giving the anaesthetic see that artificial teeth are removed and that the patient does not have a piece of candy or a chew of tobacco in the mouth. Always have a third party present as a witness, because in the anaesthetic sleep vivid dreams often occur, and erotic dreams in women may lead to damaging accusations against the surgeon. Place the patient recumbent, and see that the clothing is loose, particularly that there is no constriction about the neck and abdomen. Do not have the head high unless this position is demanded by the exigencies of the operation. The anesthetizer must have a mouth-gag, a pair of tongue-forceps, a hypodermic needle in working order, and solutions of strychnia, atropia, digitalis, and brandy. It is always well to have an electric battery at hand. Accidents, it is true, are rare, but they may happen at any time, and hence the surgeon should always be prepared for them. Any danger which arises must be met with promptness and decision, or action will be of no avail. Many surgeons give a hypodermatic injection of morphia. a short time before operation, to steady the heart, prevent vomiting, and aid the bringing about of insensibility with very little of the anesthetic.

The two favorite anæsthetics are ether and chloroform. Chloroform is more dangerous than ether in general cases, though it is more agreeable, less irritant to the lungs and kidneys, and quicker in its action. Recovery from chloroform is quicker and quieter than that from ether, but chloroform vomiting lasts longer than ether vomiting. Chloroform may induce sudden and even fatal syncope. Dr. Hare's experiments on animals show that chloroform may kill