When this plan of treatment fails, sort to operative measures is indicated. Ichthyol is of great value in the ment of fissure of the anus. At the first application the fissure is anesthetized with cocaine and pure ichthyol is ap plied with a cotton-carrier or a glass rod. For the succeeding applications, which at first are made daily, then on alternate days, cocaine is generally un necessary. A cure is usually achieved in from six to twelve days. Proper atten tion must be given to the bowels. Co nitzer (Munch. med. Woch., Jan. 17, '99).
-There are three methods worthy of consideration in this connection: (1) forcible dilata tion; (2) incision; (3) a combination, of these two procedures, to wit: forcible dilatation and incision.
Forcible Dilatation.—This is the op eration recommended by Recamier, Van Buren, and others. It consists in intro ducing the two thumbs into the bowel back to back, and then forcibly separat ing them until the sides of the bowel are stretched as far out as the tuberosi ties of the ischia. It is essential to place the ball of one thumb over the fissure, and that of the other directly opposite to it, in order to prevent the fissure from being torn through and the mucous membrane being stripped off. This pro cedure should always be done with the patient thoroughly under the influence of an anesthetic, and it should occupy about five minutes.
The operation is a perfectly safe one, but as it is no less severe than the op eration by incision and as in some cases it fails to effect a cure, there is no ad vantage in adopting it instead.
Fissure of the rectum should call for surgical, and not palliative, treatment. It is simple of cure by gentle divulsion of the sphincter-muscle. If the physician is averse to giving an anesthetic for this purpose, he can practice moderate stretching several times with a small divulsor, and a rapid cure will be ef fected in the greatest number of cases. J. M. Mathews (North Carolina Med. Jour., Apr. 20, 'OS).
Incision. — The incision should be made through the base of the ulcer and a little longer than the fissure itself, so as to sever all the exposed nerve-fila ments. The cut should divide the mus cular fibres along the floor of the ulcer. In a fair proportion of cases this opera tion will meet with success, but it is not so certain to result successfully as the operation next to be described. It has
the advantage over the other operations, however, of being nearly or entirely pain less under local cocaine anesthesia. When, therefore, general anwsthesia is contra-indicated or is refused by the patient, this method is worthy of a trial.
Dilatation and Incision.—This opera tion is a radical and unfailing cure. The bowels should be emptied by a dose of castor-oil and an injection, after which, under general anesthesia, the sphincters should be dilated in the manner pre viously described. A straight blunt pointed bistoury should then be drawn lightly across the surface, making a cut extending about an eighth of an inch above and below the limits of the ulcer and about a sixteenth of an inch in depth. Usually it is a good plan to curette the entire floor of the ulcer, in addition.
The after-treatment consists in keep ing the patient in the recumbent position for twenty-four hours, keeping the parts cleansed, and applying iodoform. In a week or so the parts will be perfectly well.
Fistula in Ano.
Definition. — An unnatural channel leading from a cutaneous or mucous sur face to another free surface or terminat ing blindly in the substance of an organ or part.
Varieties.—For all practical purposes we may divide fistulm into the following four forms: (1) the complete, in which there are two openings, one in the rectum and one on the skin more or less remote from the anus; (2) the incomplete inter nal, in which there is a communication with the cavity of the rectum by means of an opening in the mucous membrane, but none with the external surface of the body; (3) the incomplete external, in which there is an external opening through the skin, but no communica tion with the bowel; and (4) the com plicated, or so-called complex, variety, in which there are many sinuses and numer ous external openings. Some of these tracks run outward; some extend up the bowel beneath the mucous membrane; while others travel around the bowel and open in the other buttock, giving rise to the variety known as the horseshoe fis tula. The second and third varieties named are frequently spoken of as blind fistuhe.