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 at any time becomes stained with feces, re-dress at once. Get the patient out of bed as soon as possible. Cut the sphincter at a right angle to its fibers, and do not cut it more than once at one operation. If there are two fistulæ, cut one through, and when one heals cut the other. In some straight sinuses the tract can be extirpated and the parts sutured, primary union occasionally resulting. If fecal incontinence results from an operation for fistula, remove the scar tissue and endeavor to suture the separated muscular fibers. 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, nervedisturbance, kidney disease, jaundice, constipation, inebriety, opium-habit, torpid liver, dyspepsia, alcohol, tea-drinking, vesical calculus, smoking, urethral stricture, uterine disease, diabetes, ovarian trouble, and mental disorder. The itching is worse at night, and is often of fearful intensity. Treatment.-Remove the cause. Prevent constipation. Further, several times a day, wash the parts with very hot water, dry them, and apply a mixture containing 3j of campho-phenique 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 iodin, pure carbolic acid, corrosive sublimate (grs. iv to 3j of cosmolin), calomel (3ij to 3j of cosmolin), or campho-phenique. In obstinate cases paint the parts, night and morning, with a mixture of 60 grs. of alum, 30 grs. of calomel, and 300 grs. of glycerin, or smear with an ointment composed of part of oleate of cocain, 3 parts of lanolin, 2 parts of vaselin, and 2 parts of olive oil (Morain). In very severe cases touch with a solution of silver nitrate (1:10) or employ the Paquelin cautery.

of a

Fissure of the anus is an irritable ulcer at the anal orifice producing spasm of the sphincter. Pain exists because of twigs of nerves upon the floor of the crack. Fissure is

1 Diseases of the Rectum.

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 hours. Constipation exists, and often pruritus. Examination discloses a fissure, usually at the posterior margin, running up the bowel one-quarter to one-half an inch. Piles often exist with fissure.

Treatment. The palliative treatment is to prevent constipation, to 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 gr. xij of persulphate of iron. Pure ichthyol may do good. In operative treatment stretch the sphincter. In order to stretch the sphincter the patient is to be anesthetized, the surgeon's thumbs are inserted into the rectum, and the parts are stretched until the thumbs touch the ischia. After stretching the sphincter incise the floor of the fissure, scrape it with a curet, and touch with nitrate of silver stick.

XXIX. 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. Anesthetics are divided into—(1) General anesthetics, as amylene, chloroform, ethylene chlorid, ether, bromid of ethyl, nitrous oxid, and bichlorid of methylene; (2) Local anesthetics, as alcohol, bisulphid of carbon, chlorid of ethyl, carbolic acid, ether spray, cocain, ice and salt, and rhigolene spray.

General anesthesia may be induced to abolish the usual 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, fractures, and malingering.

Heart disease is not a positive contraindication to surgical anesthesia. It is quite true that anesthetics 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 anesthesia. Always examine the urine if the nature of the case allows time. If albumin exists, operation is not contraindicated; but the peril of anesthesia is greater, and certain dangers are to be watched for and guarded against. If much albumin is present, postpone operation except in emergency cases. If much sugar exists, the danger

is considerable, as diabetic coma occasionally develops. Give a purgative the night before giving the anesthetic. In the morning allow no breakfast if the operation is to be performed at an early hour; 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 beef-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 almost inevitable and portions of food may enter the windpipe; if the stomach contains no food, vomiting is far less likely to happen, and even if it occurs and vomited matter should enter the windpipe it will do little harm, as it consists chiefly of liquid mucus. In cases of intestinal obstruction in which there has been stercoraceous vomiting, there is much danger that vomiting will occur during anesthetization. Vomiting of this sort is profuse, sudden, and dangerous. It may flood the bronchial tubes and cause death by suffocation. In such a case wash out the stomach before giving the ether. Vomiting is dangerous also because of the great cardiac weakness which precedes and follows it. Before giving the anesthetic 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 an anesthetic 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 hypodermatic needle in working order, and solutions of strychnin, atropin, digitalis, and brandy. It is always well to have an electric battery and a can of oxygen 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 morphin 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 anesthetics 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. Hare's experiments on animals indicate that chloroform may kill by respiratory failure occurring secondarily to failure of the vasomotor center; but certain it is that clinically the danger of chloroform is paralysis of the heart, and this condition may come on so rapidly that death may occur almost before an attempt can be made to save life. Berkley Hill has proved that most chloroform-deaths that take place after considerable of the anesthetic has been taken, arise from paralytic distention of the heart. Sudden death, when inhalations of chloroform have just commenced, may be due to the nasal reflex. If ether kills, it does so through the respiration, and not the heart, and there is usually time to undertake means of resuscitation, which means are apt to be successful. Chloroform is to be preferred to ether in the following cases: for children under ten years of age, in whom ether causes great outflow of bronchial mucus, which may asphyxiate; for people over sixty, free from advanced cardiac disease, at which age most persons have some bronchitis, and ether chokes them up with mucus. Ether also irritates the kidneys, which at the latter age are apt to be weak or diseased. Chloroform is preferred for labor cases, when moderate anesthesia only is required; and for operations on the mouth and nose. In cleft palate chloroform should always be used to limit cough and to minimize salivary flow. In ligation of a large artery which is overlaid by a vein, ether exercises the unfortunate influence of greatly enlarging the vein. Hence in such a case chloroform makes the operation easier. In goiter operations ether should not be used, as it enlarges enormously the veins. Chloroform is preferred for patients with difficult respiration from any cause; for patients with kidney disease and for patients with diabetes. Some surgeons do not use ether in abdominal operations because they believe it may cause persistent oozing of blood, but this view is not in accord with the author's experience. Ether is safer in patients with heart disease, and is the best and safest anesthetic for general use. Both ether and chloroform may induce changes in the blood. In many cases they produce a diminution of hemoglobin. In some cases they produce alteration in the shape of the corpuscles. This is especially true in anemic blood. Ether produces leukocytosis. These blood-changes indicate that prolonged anesthesia may mili

tate against recovery from a severe operation. In anesthesia the temperature drops from one to three degrees, hence the patient should be carefully covered during the operation. The question as to the effect of ether on the kidneys is much disputed. Most surgeons believe that it tends to cause albuminuria or increase existing albuminuria; others deny this.

Administration of Chloroform.-In administering chloroform have at hand a mouth-gag, tongue-forceps, a clean towel, a hypodermatic syringe, solutions of strychnin, atropin, and brandy, an electric battery, and a can of oxygen. Use only pure chloroform (Squibb's). The patient must be recumbent. No special inhaler is required, but the drug may be given upon a thin towel, a napkin, or a piece of lint. The inhaler of Esmarch is very useful. In operations about the face Souchon's instrument is serviceable. Souchon's apparatus is so arranged that chloroform may be given through a tube which is introduced through the nose, the instrument being well out of the way of the operator. Some surgeons cocainize the nares before giving chloroform, so as to prevent the dangerous nasal reflex (Rosenberg). The chloroform-vapor must be well mixed with air. The chloroform is sprinkled on the fabric with a drop-bottle. Put the napkin well above the mouth, add five drops of chloroform, and tell the patient to take deep and regular breaths. Add a few more drops of chloroform, and when the patient grows so accustomed to it as not to choke, turn the wet part of the fabric toward the face and place it near the mouth; do not touch the mouth with the wet lint, because it will blister. It is a good plan to smear the lips with cosmolin to prevent blistering. If the drug is given gradually, struggling is not usually violent or prolonged. Never pour on a large amount at one time. During the stage of excitement do not suspend the administration of chloroform unless respiration becomes difficult, in which case suspend it until the patient takes one or two respirations. Chloroform-vapor is not inflammable, hence it is safer than ether when a hot iron is to be used about the face and when there is a lighted lamp or a stove in a small room; but the presence of flame decomposes chloroform into irritant products of chlorin, which sometimes cause the patient and the surgeon to cough. A combination of chloroform and oxygen is used by some administrators. The patient who is anesthetized with the mixed vapor retains a good color, but it requires a considerable time to render him unconscious.