37 Soc. Trans., vol. ii.
38 Darley, On the Liver, 1883, p. 536.
Examinations and explorations of the abdominal viscera by the hand introduced into the rectum, having for their object the detection of tumors or morbid growths, are procedures which have fallen into merited disrepute, and are mentioned here in condemnation. However, some years since, Morton, in consultation with (J. Forsythe) Meigs, satisfactorily demonstrated the absence of a suspected renal calculus by this method.
The distension of the rectum with water, either free or contained in a rubber bag, in order to facilitate operations upon the pelvic viscera, has been lately brought into notice by Garson at a meeting of the British Medical Association. The most significant point brought out at the meeting was that the water-distended rectum displaced the distended urinary bladder upward and forward until it occupied a position quite outside of the pelvic cavity, carrying along with it the peritoneum both in front and behind. By this method of distension it was found possible so to raise the peritoneum in front of the bladder as to leave a clear working space of four centimeters between the upper border of the symphysis pubis and the edge of the peritoneum: this may prove useful in suprapubic lithotomy, as well as in operations upon the uterus and its appendages during laparotomy.
RÉSUMÉ OF THE THERAPEUTICAL AND SURGICAL TREATMENT.
FISSURE OF THE ANUS, in its true sense, is not to be confounded with ulcerations either slight and superficial in extent, or with more grave ulcerations involving not only the anus, but the mucous membrane of the rectum also. The true fissure is a mere linear crack or abrasion or superficial ulceration. The pain accompanying this condition is out of proportion to the length and depth of the fissure, varying from slight uneasiness to as severe suffering as that caused by a deep and extensive ulceration.
The treatment to be adopted in such cases is first to regulate the bowels and to insist upon a scrupulous cleansing of the part after each evacuation. Much sitting is to be avoided and a sedentary mode of life is to be discouraged. Sometimes a few light topical applications of the solid nitrate of silver will bring about a cure, or a lotion of the same of the strength of from two to ten grains to the ounce of water should be applied with a camel's-hair brush every other morning. The ointment of the oxide of zinc, combined with any of the local anæsthetics, will be found useful. As a dernier ressort in obstinate cases an incision should be made through the fissure, together with a thorough dilatation of the anal sphincter.
ULCER OF THE RECTUM, OR THE GRAVER FORM OF FISSURE OF THE ANUS.—In the milder forms of this very common and painful affection the treatment consists in thorough cleanliness of the part; the ulcerated surface may be cauterized with nitrate of silver, and subsequently the application of the red precipitate ointment or the lotio nigra. Should a vaginal discharge exist, treatment should be instituted with a view to its arrest, as the irritating fluid coming in contact with the ulcer would prevent its healing. The treatment of that variety of ulceration where the disease is situated partly without the anus and partly within the rectum, besides the use of the means enumerated above, embraces the daily introduction of a full-sized bougie made of wax or of yellow soap. Henry Hartshorne says: "Experience leads me to have especial confidence in collodion, to which one-fiftieth of glycerin has been added to lessen its constricting effect." Glycerite of tannin and tinct. benzoin. comp. have been useful. J. C. Peters39 recommends the use of iodoform suppositories. Tarnier40 dusts the part with the same drug in fine powder. Créquy41 has had success with a dressing of charpie saturated in a solution of hydrate of chloral. For the more extensive and obstinate forms of ulceration the three methods of treatment mainly relied on are—by cauterization, by dilatation, and by incision. The caustics usually relied upon are the fuming nitric acid and the acid nitrate of mercury, one application of either of these often exciting healthy granulation. This application is to be followed by the use of an ointment consisting of thirty grains of calomel and three grains of morphia to one ounce of lard. If there is much spasm of the sphincters, extract of belladonna may be added.42 During this treatment the bowels should be kept rather loose by the use of compound licorice powder, and if much pain is experienced an opium suppository should be used. Dilatation, first practised by Récamier, consists of the introduction of the thumbs of the operator into the rectum, placing them back to back, and then forcibly separating them from each other until the sides of the bowel can be stretched out as far as the tuberosities of the ischia. On account of the fact that both cauterization and dilatation are not infrequently followed by relapse, the method of operation which includes both incision and dilatation can usually be relied upon. The bowels should be thoroughly emptied by a laxative, and an enema should be given three hours before the operation.
39 Philada. Med. Times, Nov. 8, 1879.
40 Bull. gén. de Thérap., Sept. 30, 1875.