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.