FISSURE OF THE ANUS (Symptomatology, see Fisch], vol. iii.) This consists of a loss of substance of the mucous membrane at the border line of the anus, usually posteriorly. The constant play of the sphincter and its continuous forcible contraction interfere \Vail the formation of epithelium over the ulcer.
In those cases in which internal treatment fails (diet, local appli cation of amrsthetizing suppositories, cauterization with silver nitrate 5 to 10 per cent., tincture of ratany, cupri sulphas,.potass. permanganate) we will only succeed in getting a final cure by excluding temporarily the action of the sphincter muscle. The sovereign remedy is the blood less dilatation in very light ether narcosis. The operator introduces both thumbs or first fingers and dilates the anus so far that the sphincter tears, and during the consequent paresis of this muscle the ulcer heals. After the procedure we apply hot fomentations, keep the patient in bed for two or three days, and procure soft stools by the proper diet.
The bloody operation consists in incising the fissure, but this is hardly ever done in children.
Periproctitic may easily form in the loose peri rectal tissues through infection from the intestine (foreign bodies, splinters of bone) or from long persisting deep fissures.
The anatomical conditions of the pelvic floor, its successive closures by the sphincter exte•nus, the sphincter interims, and the levator ani muscles, and the interposed may give very varying symptoms of suppuration in this region, from the slight diffuse perianal swelling and infiltration which protrudes into the rectum and will soon lead to a fistula, to the grave ascending gas-forming infections, caused by the bacterium]) soli mixed with other malignant germs, which may end fatally by reaching the peritoneum. They can undermine the tense tissues
closing the floor of the pelvis.
In all cases the treatment can only he operative and must take place at once to prevent spreading. The superficial abscesses are opened radially, best right into the anal opening, analogous to the operations for fistuhe, because we can thus best exterminate the abscess cavity. We also try to reach the deeper abscesses through the skin, as opening these through the rectum is rarely sufficient. The line of incision varies with the location of the infiltration. Should the suppuration go over the mid dle line, we will best make it accessible by a transverse incision parallel to the sphincter and between the anus and coccyx; then we dissect up wards until the pus cavities drain to the outside.
The after-treatment should see to the drainage and a posture which will assure an easy flow of pus, keeping in mind the possibility of inter ference with urination, because this may be affected either mechanically (compression by the abscess), or through infection (propagation to the muscular coat of the bladder), or through nervous reflex influence.