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ject, the surrounding tissue loses its elasticity, and is rendered friable and easily torn or broken. The exciting causes are constipation, induration of the faecal matter, and the violent action of the expulsive muscles requisite for its evacuation.
The examination necessary for ascertaining the nature and extent of the disease is almost always attended with much pain, and for this reason it will be often advisable to administer chloroform previously: as before stated, the fibres of the superficial sphincter are strongly and spasmodically contracted, and the fundament, instead of presenting a hollow cone, has rather the appearance of a flat surface with a minute perforation in the centre, marking the anal orifice. If by the forcible separation of the buttocks, the fissure cannot be brought into view, the speculum ani must be used; or by the careful introduction of the finger, it may be detected as an elevated ridge, palpable to the touch, in proportion to the existing induration. If the fissure be situated deeply in the columnar folds of the bowel, and the examination be made at an early period of the disease, the surgeon may not be able readily to detect it by his finger, but he will become acquainted with its locality by the patient complaining of pain at some one particular point. Should the fissure have taken on the ulcerative process, the limit to which it has extended may also be detected by the finger; but it will be necessary to make an examination with the speculum ani, that the exact condition, as well as the dimensions, may be ascertained previously to determining the plan of treatment.
My experience fully justifies me in stating that in the majority of recent cases it is not necessary to have recourse to an operation, although some of high authority in the profession assert that incision is the only effectual remedy, and that all sorts of applications, soothing and irritating, are unavailing.
If the fissure exists at the verge of the anus, and is of recent origin, the patient must be directed to have recourse to ablution with soap and water, night and morning: after evacuating the contents of the bowels, half a pint of cold or tepid water should be thrown up; and when this has been ejected, a small piece of lint, saturated with the following lotion, or one of similar properties, must be kept applied to the part.
fy Plumbi Acetatis, gr. x; Liquoris Opii Sedativi, rtlxx; Aquae Sambuei, Jiv. Misce.
When there is much spasm of the sphincter, the extract of belladonna, in the proportion of a drachm of the extract to an ounce of spermaceti ointment, or ointment of acetate of lead, is commonly successful in relieving this distressing symptom. Belladonna has been employed in combating pain and spasm in diseases of the rectum by many eminent surgeons for a number of years. Dr. Copland, in his valuable work, the ' Dictionary of Practical Medicine,' appends a note, stating that Dr. Graham, of Stirling, was the first to employ this medicine in diseases of the rectum and anus. On referring to the first volume of the 'Edinburgh Medical Commentaries' (a.d. 1774), p. 419, I find he applied it to the perineum, for a solid tumour situate in the recto-vaginal septum, and states he has observed great advantage to accrue in using it in diseases of the rectum and anus. Sir Benjamin Brodie formerly prescribed it in the form of a suppository; but from the serious symptoms sometimes produced by its influence on the brain, he is not now in the habit of employing it.
At the same time that local treatment is being practised, it will be necessary to attend to the state of the secretions and excretions, and to correct any error in the patient's habits and manner of living.
If, after a fair trial of the simple means that have been recommended, the fissure does not heal, but, on the contrary, the edges become indurated, and the surface pulpy and indolent, the free application of the nitrate of silver, at intervals of a few days, for two or three times, will generally induce a healthy reparative action in the part, though often at the cost of much pain to the patient. The use of belladonna ointment and enemata after stool must be continued.
But cases will occur in which both these plans fail, and it will be necessary to have recourse to a modification of the operation recommended by M. Boyer, namely, incision through the ulcer; but it need not be carried through the sphincter, as he advised, though since his time, and even at present, the greater number of surgeons divide the parts to the extent he recommended. That this improvement in the surgical treatment of fissure of the rectum should remain so little known is somewhat surprising, as both Sir B. Brodie, in his 'Lectures,' published in 1836, and Mr. Syme, in his work 'on the Bectum,' directed the attention of the profession to the fact of a very limited incision only being necessary to its cure.* The operation may be performed in two ways, either by cutting from within outwards, or without inwards. In either mode the patient must rest on his side, with his knees drawn up, and the buttocks projecting over the edge of a sofa or bed, or he may lean over a table or back of a chair. For the purpose of cutting from within outwards—the plan hitherto generally adopted—a straight probepointed knife, of the shape and size of the figure here given, will be most useful; it is made thicker at the back than an ordinary bistoury, by which a ridge or button on the end is ren- C dered unnecessary. The forefinger, previously oiled, being introduced into the rectum, the knife must be pressed flat upon it till the point reaches the upper margin of the fissure or ulcer, when its edge must be turned, and an incision made through the mucous membrane, without extending it through the other structures. The other mode of making the incision is that advocated by Mr. Syme, and is performed by transfixing the ulcer beneath its base with a small, sharp-pointed curved bistoury, and cutting inwards through its centre; the opposite side of the bowel must be protected by the introduction of the finger, as previously directed. Having on several occasions wounded myself, I find that in dividing the ulcer inwards from without, the better plan is to introduce the speculum, and to cut into the open side. In operating in this affection, as well as*in many others, the surgeon will experience great advantage if he is able to use the knife with either hand.
* Sir B. Brodie informed the author, that this modification of M. Boyer's operation was introduced by the late Mr. Copeland.