A careful examination of the rectum should be made with a well oiled finger, protected by a condom, in order to find whether or not other cause,,, such as rectal polypi, foreign bodies, and the like account for the pain and the blood on defecation.
The treatment of these fissures is medical or operative. The indications for the medical treatment are causal and local; that is, it attempts to remove the causes of the fissure, and therefore the ob stacles preventing its healing. The constipation should be relieved through proper nourishment, and a careful cleansing of the region of the anus should be insisted upon. This is best clone, perhaps, with cotton tampons well anointed with vaseline, so as to diminish every mechanical injury from without. In addition, local manipulation should be considered, in order to modify tbe pain at every act of defe cation, and by properly greasing the end of the intestine to effect the smooth passage of the stool. This is most satisfactorily accomplished through the use of suppositories containing some anodyne, which are introduced before emptying the bowel [for example, anmsthesin .25 Gm. (4 gr.), butyr cocoa q.s. to make two suppositories; or, co caine muriat .03 Gm. (.45 gr.) to make 3 suppositories, extract of belladonna, in equal doses, in children of six months; double quan tity later]. In the meantime, medication which produces superficial slough and so promotes eicatrization should be applied to the small ulcer.
Felizet-Branca recommend for this purpose a daily enema with extract of ratanhim (11 per cent. in water), or, 5 per cent. ratanhice oint ment. I prefer to touch the part with silver nitrate, followed by the application of salt solution to lessen the pain of the treatment. By others, copper sulphate (5-10 per cent. solution), chloral (2-3 per cent. solution) are reconmended, either as injection or irrigation. Treatment with orthoforrn, after previously carefully cleansing the fissure and pencilling it with a 5 per cent. solution of orthoform in col lodion, has been recommended; still, because of the poisonous properties of this rentedy, care should be exereised.
If all these methods are unavailing, and the fissure becomes con stantly broken open and extends further into the tissues, if the sphincter becomes greatly hypertrophied, and the child, because of the pain and loss of sleep, suffers in nutrition and becomes anamic and thin, then one is obliged to resort to surgieal interferenee. Of the various methods recommended, namely, incision, excision and dilatation, the last is the least dangerous and inost effieacious. It is earried out in deep nar cosis and results, as a rule, after a few days in a complete cure. For a niore detailed description of the method, and the after-treatment, the reader is referred to the text books on the Surgery of Children.