Prognosis.—With proper treatment irritable ulcer can be promptly cured and practically without risk.
Treatment.—The first step is to estab lish regularity in the intestinal func tions. Enemas or mild aperients should be employed and the diet regulated, the use of bland and unirritating food being enjoined. All drastic purges should be avoided. To obtain a daily evacuation of the bowels and to render the move ment as painless as possible, a 10-grain suppository of iodoform is to be followed, in one-half hour, by an enema of rich flaxseed-tea. from half a pint to a pint. This should be administered every evening before retiring, the pa tient being then able to assume the re cumbent posture, which. combined with the rest, affords the most relief from subsequent pain. Immediately after an evacuation of the bowels is obtained, an other 10-grain iodoform suppository is to be inserted into the rectum. The sup pository relieves the pain, and is far preferable to opiates, which tend to con stipate. If the enema should prove in effectual, another should be employed in half an hour.
— Palliative treatment will meet with success in a considerable proportion of cases, espe cially when there is no great hyper trophy of the sphincter-muscles. The Allinghams state that the curability of this lesion does not depend upon the length of time during which it has ex isted, but rather upon the pathological changes it has wrought. They have cured fissures of months' standing by means of local applications, where the ulcers were uncomplicated with polypi or limniorrhoids, and where there was not very marked spasm or thickening of the sphincters.
Rigid cleanliness is essential. The anus and the adjacent portions should be carefully sponged night and morning and after each stool with hot or cold water, the temperature being regulated to suit the patient's comfort.
Before applying remedies the ulcer should be exposed and anaesthetized with a 4-per-cent. solution of the hydrochlo . rate of cocaine, using a camel's-hair pencil, and repeated once or twice, at intervals of three or four minutes.
Among the remedies used the follow ing may be mentioned: Nitrate of silver; acid nitrate of mercury; fuming nitric acid: carbolic acid; sulphate of copper; the actnal cautery. Of these, the nitrate of silver is the best. It lessens or ob viates the nervous irritation underlying spasmodic contractions of the sphinc ters; it shields the raw and exposed mu cous surface, by forming an insoluble albuminate of silver; and destroys the hard and callous edges of the ulcer.
To attain the best results, a solution of 10 to 30 grains to the ounce of dis tilled water should be used once in two or three days, according to circum stances. It may be applied by means of cotton attached to a silver applicator or to a piece of wood, separating the mar gins of the anal orifice with the thumb and index finger of the left hand. The solution is to be applied to the ulcer only; a few drops are all that will be required. If thorough local anesthesia has been obtained the drug produces little, if any, suffering. After each application the part should be dusted with iodoform.
Fissure of the anus without operation: The patient remains in bed on fluid diet for one week, taking 10 drops of tincture of opium three times a day. Absolute constipation being thus obtained, the fissure is sprinkled with iodoform or calo mel, but without the use of any antisep tic liquids. After eight days a large dose of castor-oil is given. Often the first defecation is quite painless, and the fis sure is cured. Rarely has this treatment to be repeated. I. Boas (Revue d'Obstet. et de Gyn., Jan., 1900).
Fissure in ano is a pathological condi tion of the anal innervation comparable to nervous dysphonia, cough, etc. Mass age to relax the spastic condition should be resorted to and the patients be taught to introduce the finger into the rectum and practice rotary and other movements. Later on the rectal tube may be used, the bowels being carefully regulated. Improvement usually follows within four or five days, and cure is frequent. O. Rosenbach (Berliner klin. Woch., Mar. 12, 1900).