CHAPTER III.

TREATMENT, PALLIATIVE AND OPERATIVE.

It is highly important to the success of any plan of treatment directed toward the cure of anal fissure, that attention be paid to the condition of the bowels. Regularity of habit should be established, and the evacuations rendered semi-fluid—as figured or hard stools generally aggravate the symptoms.

To accomplish these purposes, enemata or mild aperients should be employed, and the diet must be regulated, the use of bland and unirritating food being enjoined.

All drastic purges should be avoided, as they are more or less irritating to the extremity of the rectum.

In order to establish a daily evacuation of the bowels and to render the movement as painless as possible, I am in the habit of ordering an enema of warm water, or one of rich flaxseed tea, say from half a pint to a pint, to be administered every evening; preference being given to the night-time, as then the patient can assume the recumbent posture, which, combined with the rest, affords the most relief from subsequent pain.

If the first enema should prove ineffective, it should be repeated in half an hour. In order to relieve the pain and spasm of the sphincters attending the evacuation, it is well to use a suppository about half an hour before the enema is employed, consisting of:

℞ Ext. belladonnæ gr. 1/8 ad 1/2. Cocain. hydrochloratis gr. 1/4 ad 1/2. Ol. theobromæ gr. x. Misce, et fiat suppositoria j.

Or an ointment of extract of conium may be used, as recommended by Harrison Cripps:[25]

℞ Ext. conii ℨ ij. Olei ricini ℨ iij. Ung. lanolini ad ℥ ij.

A small quantity of this ointment should be smeared on the part five minutes before expecting a motion, and again after the motion has passed.

All ointments used in the treatment of rectal disease may be applied by means of a hard-rubber pipe (Fig. 7).

The various methods of treating anal fissure may be divided, for the sake of convenience, into the _palliative_ and the _operative_.

PALLIATIVE MEASURES.—Palliative treatment will meet with success in a considerable proportion of cases, especially when there is no great hypertrophy of the sphincter muscles. Allingham[26] states that the curability of this lesion does not depend upon the length of time during which it has existed, but rather upon the pathological changes it has wrought. He asserts that he has cured fissures of months' standing by means of local applications, where the ulcers were uncomplicated with polypi or hemorrhoids, and where there was not very marked spasm or thickening of the sphincters.

It is essential to the success of the treatment of fissure, especially by local applications, that rigid cleanliness of the parts be maintained; for this purpose the anus and the adjacent portions of the body should be carefully sponged night and morning and after each stool with hot or cold water, the temperature being regulated to suit the patient's comfort.

An excellent instrument for irrigating the rectum is the one devised by Dr. Edward Martin, of Philadelphia (Fig. 8). I have also employed Bodenhamer's instrument for this purpose (Fig. 9).

In applying the various local remedies it is necessary first to expose the ulcer to view, and to anæsthetize its surface with a four-per-cent. solution of hydrochlorate of cocaine, well brushed in with a camel's-hair pencil. The application of the cocaine may have to be repeated once or twice, at intervals of three or four minutes, in order to obtain the desired anæsthetic effect.

If any ointment has been used about the fissure, the anus should be subjected to a hot-water douche before using the cocaine, as cocaine will not exert its anæsthetic influence on a greasy surface.[27] For this purpose Martin's irrigator (Fig. 8) answers admirably. The parts should subsequently be dried thoroughly with cotton or a sponge. A convenient sponge or cotton mop holder is shown in Fig. 10.

Among the different remedies that have been used for the local treatment of fissure of the anus may be mentioned the following: Nitrate of silver; acid nitrate of mercury; fuming nitric acid; carbolic acid; sulphate of copper; the actual cautery, etc.

Of these topical applications, the _nitrate of silver_ is the best. Its effects are various: it lessens or entirely calms the nervous irritation which is so important a factor in producing spasmodic contraction of the sphincters; it shields the raw and exposed mucous surface, by forming an insoluble albuminate of silver; it destroys the hard and callous edges of the ulcer, and tends to remove the diseased and morbid action of the parts.

The form in which I usually employ this salt is in solution (from ten to thirty grains to the ounce). To attain the best results, the solution should be used once in twenty-four or forty-eight hours, according to circumstances. It may be applied by means of cotton attached to a silver applicator or cotton-holder (Fig. 11), or to a piece of wood. The application is made by separating the margins of the anal orifice with the thumb and index finger of the left hand, and introducing into the anus the probe charged with the solution.

According to Bodenhamer,[28] if the ulcer is more than one-third of an inch above the margin of the anus it will be necessary to use the speculum.

The solution is to be applied to the fissure only; a few drops are all that will be required. If thorough local anæsthesia has been induced by the use of cocaine, the application of the silver salt produces little if any suffering; for by the time the anæsthetic has lost its effect the acute pain caused by the nitrate of silver will have passed away.

After each application the part should be well smeared with an ointment of iodoform (thirty grains to the ounce). The odor of the iodoform may be disguised by the addition of a few drops of otto of roses. Iodol may be used instead of iodoform, and in the same way.

After the ulcer has been touched once or twice with the silver solution, the effect will be, in those cases which are benefited by this treatment, a considerable mitigation of the severe pain which has troubled the patient when at the closet and afterwards; and the sore will present a healthy granulating appearance, and slowly contract in size.

In children and in young persons, unless the fissure be complicated with some other affection, this lesion is almost always curable by adopting the foregoing mode of treatment.

Some authorities speak highly of the use of the _acid nitrate of mercury_, _fuming nitric acid_, _carbolic acid_, _the actual cautery_, etc., but in my experience their employment is attended with more suffering than follows the employment of the nitrate of silver or the simple operative treatment which will presently be described. Furthermore, the application of these remedies is not so certain to effect a cure as either of the two procedures just mentioned, so that I rarely resort to their use.

The daily introduction of a _full-sized bougie_, made of wax or tallow, will sometimes act beneficially in cases of fissure, by distending the sphincter and producing such an amount of irritation as will set up a healing process in the ulcer. An application of cocaine or of belladonna ointment should be made to the part prior to the employment of the bougie.

Allingham[29] strongly advocates the local use of the following ointment:

℞ Hydrarg. subchlor gr. iv. Pulv. opii gr. ij. Ext. belladonnæ gr. ij. Ung. sambuci ℨ j. M. Sig.: To be applied frequently.

This authority states that he has cured many cases with this ointment alone.

Another excellent ointment recommended by Mr. Allingham[30] is the following:

℞ Plumbi acetatis } __ Zinci oxidi } aa gr. x. Pulv. calaminæ gr. xx. Adipis benzoatis ℥ ss. M.

An ointment of red oxide of mercury, thirty grains to the ounce, has also cured many cases.

The "Brinkerhoff System," as applied to fissures of the anus, is thus described by Dr. Edmund Andrews:[31]

"Once or twice a month, as the itinerant doctor comes around on his circuit, he inserts his little speculum, cleans out the ulcer, and applies to it a solution of nitrate of silver, forty grains to the ounce. Between the applications the patient uses a morning and evening treatment himself. Each morning he is to evacuate the bowels, then inject the rectum with lukewarm water, and finally insert into it a little ointment, consisting of three grains of carbolic acid and eight grains of sulphur to the ounce of vaseline or lard.

"For evening treatment he uses 'Brinkerhoff's Ulcer Remedy,' having the following composition:

℞ Extract of hamamelis dist f ℨ v. Solution of persulph. of iron f ℨ j. Cryst. carbolic acid gr. ij. Glycerine f ℨ ij.

M. Sig.: Add half a teaspoonful of this to the same quantity of starch, and about an ounce and a half of water. Inject into the rectum every evening."

OPERATIVE TREATMENT.—In the more severe cases local treatment will fail to effect a cure, and operative interference will be necessary. There are three methods of repute to be considered in this connection: (1) _forcible dilatation_; (2) _incision_; (3) _a combination of these two procedures_, dilatation and incision.

FORCIBLE DILATATION.—This is the operation recommended by Récamier, Van Buren, and others. It consists in introducing the two thumbs into the bowel, back to back, and then forcibly separating them from each other until the sides of the bowel can be stretched as far out as the tuberosities 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. As pointed out by Allingham,[32] it is well to repeat the stretching in other directions until the entire circumference of the anus has been gone over. In this manner, by careful and thorough kneading and pulling of the muscles, the sphincters will be made to give way, and will be rendered soft and pliable. This procedure should always be done with the patient thoroughly under the influence of an anæsthetic, and should occupy at least five or six minutes.

This operation is perfectly safe, but, as it is no less severe than the operation by incision, and as in some cases it fails to effect a cure, I can see no advantage in adopting it instead of the more satisfactory and always successful plan of treatment by combined dilatation and incision. It may be found preferable in some cases on account of the prejudice of patients against the use of the knife.

INCISION.—A fissure can be cured by this method, by making an incision through the base of the ulcer and a little longer than the fissure itself, so as to make sure of severing all the exposed nerve-filaments. The cut should divide the muscular fibers along the floor of the ulcer.

In a fair proportion of cases this operation will meet with success, but it is not so certain and radical as the operation next to be described.

It has the advantage over the other operations, however, of being nearly or entirely painless under local anæsthesia produced by cocaine, and therefore, when general anæsthesia is contra-indicated, or is refused by the patient, this method is worthy of a trial.

DILATATION AND INCISION.—This operation, if skillfully and carefully performed, I believe to be a radical and unfailing cure for the disease. The bowels should be cleared out by a dose of castor-oil and an injection; after which, under ether-anæsthesia, the sphincters should be dilated in the manner previously described. This being accomplished, and the ulcer properly exposed, a straight blunt-pointed bistoury (Fig. 12) should be drawn deeply across the surface, making a cut about an inch in length and a third of an inch in depth. Instead of the blunt bistoury, a sharp-pointed scalpel may be used (Fig. 13). It should be entered at the margin of the anus, passed under the ulcer, and made to protrude above the ulcer, the overlying structure being then divided from without inward.

The subsequent treatment consists in keeping the patient in the recumbent position, and in the use of a little opium to confine the bowels. After three or four days a laxative may be given, from which time daily alvine movements should be secured. In seven or eight days the patient can begin to move about; but for at least two weeks he should avoid standing long on the feet. No dressing is required further than bathing the parts with a little warm water and carbolic acid soap, to remove any offensive discharges. For the same purpose, peroxide of hydrogen may be employed.

THE SUBCUTANEOUS DIVISION OF THE SPHINCTERS, as recommended by some authors for the cure of fissure, is not a satisfactory method, and is mentioned here solely to condemn it. It is not only uncertain in its results, but is also painful, and in more than one instance has been followed by abscesses.

Footnote 25:

_Op. cit._, p. 189.

Footnote 26:

_Op. cit._, p. 215.

Footnote 27:

W. P. Agnew, M.D., "Diagnosis and Treatment of Rectal Diseases," second edition, 1891, p. 97.

Footnote 28:

_Op. cit._, p. 111.

Footnote 29:

_Op. cit._, p. 214.

Footnote 30:

_Op. cit._, p. 215.

Footnote 31:

_Op. cit._, pp. 75-76.

Footnote 32:

_Op. cit._, p. 221.