A new operation for anal fistula. der general anaesthesia an incision is made antero-posteriorlv, about two inches long, near the centre of the open ing of the fistula, but the cut going a lit tle to one side. The skin and fascia are cut through, and the muscular fibres arc separated longitudinally by an Allis dry dissector or by the handle of the scalpel. The nerves and vessels are retracted, and the separation of the muscular fibres is continued alongside of the fistu bons tract until the gut is reached: the fistnlous opening. in the latter is then excised or sutured. the stitches only in eluding the serous coat. The entire fis tulous tract is then dissected out and the wound closed in the usual manner. The after-treatment consists in keeping the bowels at rest. The advantage of this operation is that it does away with section of the anal sphincter, which often leaves a patient in a worse con dition than the fistula. R. D. Fairer (later. Jour. of Surg.. April. 1901).
Pruritus Ani.
Symptoms. — This may be classed among the most annoying of the minor affections. Though not painful nor dangerous to life, it may produce marked ill health by interfering with rest. The ' severity of the disorder varies consider I ably, ranging from irritation to intoler able itching. Usually the pruritus oc curs at night after the patient retires, and lasts hours.
The itching may be so intense that it is almost impossible to avoid scratching, which, instead of giving relief, adds to the trouble. Nervous and excitable per sons are prone to attacks of pruritus dur ing the day as well as at night, espe . cially after exercise or on leaving the cold air and coming into a warm room. In marked cases a characteristic condi tion is the loss of the natural pigment of the part. The skin is not supple, but has a peculiar harsh and rough feel simi lar to that of parchment-paper. It is frequently fissured from scratching.
Etiology.—The causes are both local and constitutional. In many cases it is impossible to discover any causative fac tor, and it may then be considered, as stated by the Allinghams, as a pure neu rosis, occasioned or greatly aggravated by mental worry or overwork. Leueor rhceal discharge often excites pruritus by remaining in contact with the skin of the perineum and developing an eczema. In children, especially, it may result from the presence of Oxyuris vermicu laris in the rectum. Pediculi, or scabies, may also occasion it, or it may be ex cited by improper diet and highly-sea soned food.
IImmorrhoids, polypoid growths, fis sure, or fistula, from the irritation they set up and the abnormal secretion they produce, and chronic diarrhoea or dysen tery, may occasion pruritus. Erythema, herpes, and any variety of eczema, whether acute or chronic, may also give rise to it. It has also been traced to stricture and inflammation of the upper portion of the urethra. It frequently depends upon a varicose condition of the hwmorrhoidal veins, just as occurs in a similar condition • of the veins of the lower extremity. Uterine disorder, un cleanliness, and insufficient ablution of the anus, and, finally, the use of hard or printed toilet paper may excite it.
Gouty subjects and persons with a more or less marked lithic-acid diathesis are predisposed to attacks of pruritus ani. Hepatic disorders, which may or may not be associated with constipation, diabetes, and chronic constipation, fre quently act as causes, while excessive smoking and the free indulgence in al coholic liquids or of coffee may also in duce it. Excesses at the table, combined with a lack of proper exercise, not only predispose to pruritus, but also may be come its exciting cause. It has also been ascribed to disease of the spinal cord and brain.
Treatment—In the majority of in stances, especially if there be no ascer tainable local factor present, the affec tion must be treated by constitutional remedies as well as by local means. The Allinghams state that the difficulty ex perienced in its treatment has arisen in a great measure from its having been considered as merely a local affection, and only local means having been ap plied for its relief.
If the patient shows a lithmmic tend ency he must be treated accordingly. Out-of-door exercise should be advised; the diet should be carefully regulated; meats should be taken in small quanti ties. Rich gravies, sauces, and pastry are to be avoided, as well as all sweets; malt liquors and all wines except claret are objectionable.
Turkish baths are beneficial when taken once or twice a week. Massage is also of advantage. Medicinally the lithium salts are indicated, either in the form of the natural mineral waters or the effervescing lithium-citrate tablet. In cases in which the irritation is very se vere, the wine of colchicum, in doses of 5 to 20 minims, every four to six hours, answers best. Cripps recommends the following formula of Brodie's Magnesia, 6 grains.