In the first stage of the disease, the patient should be confined to bed, take gentle laxatives, apply leeches within the anus, have laxative and opiate enemata administered with the warm hip bath once or twice a-clay; and his diet should be purely farinaceous. And if by this treatment no amelioration is produced, and the diseased part can be reached by the knife, it should be extirpa ted, as lately done by Lisfrane. IF the pain can be subdued, the rectum bougie ought to be used, and may be anointed with an ointment of opium, hyos claim's, or hemlock; and where a short stricture exists, it ought to be divided in the four diagonal directions with the bistoury. Generally all kinds of external applications produce pain, even warm oil. If the patient can be removed to a warm climate, he ought instantly to go, and if not, the same soothing means must be continued until the disease either subsides or proves fatal. The com pound powder of ipecacuan in small doses is an excellent anodyne in this disease.
Abscesses very often occur near the anus, in consequence of the loose delicate cellular and adi pose tissues in this region, and when permitted to burst of their own accord, generally rupture with a small aperture, become fistulous, and occasion ally burrow towards the rectum, and even form a communication with it. They arise from consti pation and hemorrhoids; also from fish bones, Stc. which have been swallowed and arrested in the rectum; from bougies breaking, pieces of wood, and other foreign bodies slipping up the rectum. For the treatment of this, the reader is referred to acute abscess. When this becomes fistulous, the disease is termed a blind external fistula in ano, and should be freely laid open with the curved sharp-pointed bistoury, having a button of wax upon it, and afterwards treated as directed under acute abscess. All fistulous tubes are more or less callous. Sometimes this fistula burrows along the rectum for a considerable extent, having many digressions in its course in the natis, so that con siderable difficulty is occasionally experienced in arriving at its source; and when the surgeon has inserted the bistoury into what he conceives the root of the fistula, and pushed the instrument through the walls of the rectum, and cut outwards so as to make them one tube, he has probably by no means reached the termination of the fistula. In such cases, the daily insertion of sponge tent, making it larger at each introduction, will so ex pand the sinus or fistula, as to enable the operator to explore all its circuitous routes. If the matter
runs into the rectum, and there is no external aper ture, the affection is named a blind internal fistula, a variety which seldom or ever exists, but when it does, ought to be laid freely open.
When the fistulous tube opens both externally and into the rectum, which is the most common variety, it is styled complete fistula in ano, and is ascertained by inserting a probe into the fistula while the fore-finger of the left hand is in the rec tum. It is treated by inserting a probe-pointed bistoury'into the fistula onwards into the rectum, and cutting freely downwards and outwards, so as to convert the fistula and rectum into one tube. The after treatment ought to be the same as de scribed under acute abscess. The patient, after having motion in his bowels, should be careful to wash the surface clean with tepid water or a syringe. When fistula in ano occurs in a phthysi cal constitution, it is a question whether or not it should be cured, because it acts as a counter-irri tant, or on the principle of counter revulsion, ac cording to the doctrine of the ancients. Ligatures are used in France, but never in this country.
Prolapsus ani consists in an eversion of the rec turn, consequent either on relaxation or irritation, and occurs in children affected with ascarides or calculus in the urinary bladder, in adults from ges tation, hemorrhoids, constipation, dysentery, diar rlmea, and drastic purges ; and in old people more frequently than in those of the meridian of life. On some rare occasions, the prolapsed gut has become gangrenous and sloughed off. The prolapsus is to be returned by making the patient stand on his feet, with his head dependant or rest ing on a chair, and then taking a piece of fine soft linen, and pushing gently and gradually. When reduced, a recurrence is Lobe prevented by remain ing in bed for some time, or wearing a steel spring, delineated in Fig. 7 of plate DXV. by removing the cause if possible, and by injecting a strong decoc tion of oak bark. Sometimes it is necessary to fo ment the gut with warm water, or even to scarify or leech it before attempting reduction. Sponge has been inserted in the anus to prevent a recur rence, and pessaries have been worn; and the late Mr. Hey, Langenbeck, and Dupuytren, treat it by raising with the forceps or a ligature the skin around the anus, and removing this with curved scissors. A circular portion of the mucous tunic of the intestine has been also removed.