734 S U R G 
the patient generally becomes easy, and free from fever. The 
matter, though plentiful, is good. 
On other occasions, the fistula in ano begins as an erysi¬ 
pelatous inflammation, without any of the circumscribed 
hardness which characterizes the preceding tumour. The 
affection, on the contrary, spreads more extensively; the 
disease is more superficial; the quantity of matter small, and 
the cellular membrane sloughy to a considerable extent. 
Sometimes, the complaint begins somewhat like a car¬ 
buncle. The skin is of a dusky red, or purple kind of colour, 
and, although harder than in the natural state, yet it is not 
nearly so tense as in phlegmonous, or erysipelatous inflam¬ 
mation. 
At first, the pulse is full and hard; but, if no relief be ob¬ 
tained, it soon becomes unequal, low, and faultering; and 
the strength and spirits are greatly dejected. The matter 
formed under the skin is small in quantity, and bad in qua¬ 
lity, and the cellular membrane is in a sloughy state. This 
species of the disease affects persons, whose habit is bad. 
Sometimes the fistula in ano first appears as an iuduration 
of the skin near the anus; but without pain or alteration of 
colour; which hardness gradually softens or suppurates. 
The matter may either point in the buttock, at a distance 
from the anus; or near this latter part; or in the perineum. 
The matter may escape from one opening, or from several. 
Sometimes, there is not only an external aperture, but another 
internal one communicating with the cavity of the intestine. 
In other instances, there is only one external, or internal 
opening. 
The matter may be formed at a considerable distance from 
the rectum, which is not even laid bare by it; in other cases 
it is laid bare, but not perforated; sometimes it is both de¬ 
nuded and pierced. 
These inflammations can scarcely be prevented from sup¬ 
purating. Hence, the indications are, to moderate the 
symptoms, to promote the formation of matter, and, when 
this has collected, to let it out, and treat the sore in such a 
manner, as shall be most likely to produce a speedy cure. 
A soft poultice is the best application for promoting sup¬ 
puration. When the inflammation is phlegmonous, the 
thinner the skin is suffered to become, before the abscess is 
opened, the better. If the patient be of a full, sanguine 
habit, venesection, and mild purgatives, are proper. 
When the attack is of an erysipelatous kind, and there is 
a sloughy state of the cellular membrane; the sooner it is 
opened the better. 
When the fistula in ano commences with that kind of in¬ 
flammation which a carbuncle exhibits, no evacuations are 
necessary. The part should be opened early by a very free 
incision. 
In opening all abscesses about the anus, the incision should 
be so large as to divide the whole of the skin covering the 
matter. Thus the abscess will be discharged at once; 
future lodgment of matter will be prevented; and con¬ 
venient room will be made for the application of proper 
dressings. 
All fistulas in ano do not necessarily interest the rectum; 
sometimes the matter is so distant from the intestine, that 
the surgeon has no more to do with this part, than if it 
did not exist, and the abscess is to be treated upon general 
principles. 
The operation consists in dividing the rectum, from the 
top of the hollow, in which the matter is lodged, as far as 
the anus. Thus the sinus is converted into an open wound. 
A narrow, curved, probe-pointed knife, is the proper instru¬ 
ment, and if it can be guided by the director, introduced 
through the track of the fistula, quite as far as the intestine, 
so much the better. The surgeon’s fore-finger in the rectum 
will here feel the point of the knife. Then the director, if 
used, is to be withdrawn, and the operation is to be com¬ 
pleted, by bringing the knife out, with its point applied to 
the finger, which was in the intestine. In this manner, all 
that is between the edge of the knife and the anus, must ob¬ 
viously be divided. 
E R Y. 
Immediately after the operation, a soft dossil of fine lint 
should be introduced, from the rectum, between the lips of 
the incision. This first dressing should remain, till loosened 
by suppuration. All the future dressings should be light. 
Of the Chest. 
The outer surface of the chest is the frequent seat of can-, 
cer: in this place, therefore, we may properly describe the 
operation for the extirpation of that disease. 
The operation is usually performed as the patient is in a 
sitting posture, well supported by pillows and assistants. 
The pectoral muscle is to be made tense by keeping the 
arm back, by means of a stick, placed transversely behind 
the back, in front of the arms, above the bend of the elbow. 
If none of the integuments are to be removed, a straight 
incision is to be made through them; the tumour is to be 
regularly dissected all round from the circumjacent parts; 
and lastly, its base is to be detached from its connections, 
from above downward, until the whole is separated. 
If the outer incision has been made transversely, the lower 
half of the swelling should be separated from its surrounding 
connections, before the dissection of the upper portion is 
begun, by which means, the surgeon will not be incommoded 
by the blood, from the vessels above, falling into the lower 
part of the wound, before the detachment of the adjacent 
portion of the tumour is effected. As soon as the lower half 
of the swelling is separated from its connections, the surgeon, 
is to undertake the dissection of the upper half. 
Such are the modes of removing all simple tumours, which 
are not of a malignant nature, nor of immense size. ' 
When the tumour is of a malignant nature, and adherent 
to the skin and pectoral muscle beneath, the operator is to 
remove, at least, an inch or two of the fat on every side of 
the disease. The portion of the skin, intended to be taken 
away, must be included in two semicircular incisions; which 
meet thus () at their extremities; and when the base of the 
tumour is to be detached, the surface of the pectoral muscle, 
wherever it is adherent to the tumour, is also to be removed. 
The advantage of making the incision in the preceding, 
manner obviously consists in enabling the surgeon to bring 
the edges of the wound together after the operation, so as to 
form a straight line, and be capable of uniting by the first 
intention. 
The mere magnitude of a tumour frequently renders it 
highly judicious to take away a portion of the skin in the 
above method: if none were removed, the dissection of the 
tumour would be exceedingly tedious; and, after the opera¬ 
tion, the loose undistended skin would lie in folds, and form, 
as it were, a large pouch for the lodgment of the matter. 
In the extirpation of a diseased breast, the direction of the 
external incision must partly be determined by the shape of 
the tumour; but according to Dessault, there are advantages 
in cutting as much as possible transversely, when circum¬ 
stances will allow. It is alleged, that, as the integuments 
are more yielding upwards or downwards, than they are in a 
cross direction, especially near the sternum, the transverse 
wound may be more expeditiously united; and that, as the 
great pectoral muscle only acts perpendicularly, with respect 
to the edges of the incision, it cannot tend to separate them. 
Dessault thought these advantages of higher importance, than 
that of the easy escape of the matter at the depending angle 
of the wound ; the reason generally assigned for preferring a 
perpendicular cut. 
As in the abdomen, so in the chest, an important prac¬ 
tical distinction arises as to whether wounds penetrate or do 
not penetrate the cavity; for wounds of the thorax are 
dangerous when they pass through its parietes, but very im¬ 
portant when they are only partially divided. 
It is frequently difficult to pronounce, however, whether 
a wound extends into the cavity of the thorax or not. Many 
punctured wounds are very long and narrow, so as not easily 
to admit a probe to their termination. 
Sometimes, however, the passage of air into and out of 
the chest, through the wound, leaves no doubt that the in- 
