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FISSURE OF THE ANUS AND THE LOWER PART OF THE
This disease, of frequent occurrence, and giving rise to more uneasiness and suffering, in proportion to the pathological condition of the structures involved, than perhaps any other disease to which the human frame is liable, has met with very little consideration from the majority of surgical writers, and is even unnoticed in most systematic works on surgery: although the distinguished surgeon, M. Boyer, in the tenth volume of his 'Traite des Maladies Chirurgicales,' published in 1825, well described this malady, in this country it has not received that attention which the subject demands; and there is strong reason to believe the diagnosis and treatment are not so familiarly known as might be desired—a fact to be regretted the more, as little difficulty presents itself in either.
Fissure of the anus usually occurs during the middle period of life. Dr. Bushe * has not observed * Op. cit., p. 100.
this affection before the age of eighteen, or later than sixty-nine years of age. Professor Miller* says, "they" (fissures) "have been observed in children at the breast;" but this must be of rare occurrence, the predisposing and exciting causes seldom existing till after puberty. One of the latest writers on diseases of the rectum objects to the term fissure, and speaks of the affection as "irritable ulcer of the rectum:" although, in many instances, when the surgeon is first consulted, it may present the form of an oblong ulcer, yet I have no hesitation in saying the primary condition was essentially a fissure or crack of the mucous membrane.
In the majority of cases, the lesion is confined to the mucous membrane only, but occasionally extends to the submucous cellular tissue, or even to the muscular fibres of the sphincter: the inferior extremity of the fissure is usually immediately within the margin of the external sphincter, or implicates the skin at the margin to a slight extent, but is not unfrequently situated higher up. A fissure may exist on either side, or perhaps on both sides of the bowel: it most frequently occurs posteriorly, and more rarely anteriorly. If an examination is made early in the disease, the fissure has the same appear
* 'Practice of Surgery,' by James Miller, F.R.S.E., Edinburgh, 1852, p. 380.
ance as the crack that occurs in the lip during the decline of catarrh; but it soon degenerates into an ulcer, in the same manner as wounds of other parts that do not heal readily, and will be most commonly observed to be about an eighth of an inch in width, and from a quarter to an inch in length. At first the edges are sharp, and the surface florid, but after the disease has existed for some time, the former become indurated and raised, and the surface pulpy and ash coloured; the surrounding membrane may be inflamed, and its surface rendered friable, or the ulcerative process may extend, and an ulcer be formed, varying in size from a fourpenny piece to that of a shilling.
The symptoms in the early stage of this disease are not generally severe, and are only experienced while at stool, when, at some point or other, there will be smarting of greater or less severity, or perhaps only a slight stinging or pricking sensation may be felt; if the disease is allowed to progress, the smarting during the act of defecation will be greatly increased, or the pain may be burning or lancinating, followed by excruciating aching and throbbing, with violent spasmodic contraction of the sphincter muscle, continuing from half an hour to several hours.
The stools, when solid, will be streaked with purulent discharge, and slightly with blood, and when more soft will be figured and of small* size, leading the inexperienced to imagine stricture of the rectum to be the cause of the sufferings endured; charlatans also have availed themselves of the latter symptoms to delude their victims into the belief of the existence of a more serious malady. The disease being fully established, the pain will be induced by sneezing, coughing, forced respiration, and by micturition; and so violent does the agony become, that individuals thus afflicted even avoid taking sufficiency of nourishment, in order to lessen the quantity of faeces: they also in their dread postpone the calls of nature, but only with the effect of aggravating their torments. Sitting is painful, and in order to protect the anus from pressure, the patient rests on one hip or on a corner of a chair, or he may be compelled to remain recumbent. Partaking of highly-seasoned dishes and fermented liquors will always involve the penalty of increase of pain: in females, the pain will also be increased during the menstrual period. From nervous irritation, pains are often felt in other parts, simulating sciatica, or rheumatism; the urinary organs are also liable to be sympathetically deranged, and thus the attention may be diverted from the real seat of disease.
It is stated women are more subject to this affection than men. I have observed it frequently in both sexes; and am unable to say that the one is more obnoxious to it than the other: want of proper exercise certainly predisposes to it. Women are sedentary both from habit and the usages of society: in them also, constipation, one of the exciting causes, is frequent, partly arising from their habitually neglecting to obey the calls of nature, which for a time they do with less inconvenience, in consequence of the greater capacity of the pelvic cavity than in the male, but thereby laying the foundation of protracted or permanent ailment: men are sedentary from the various occupations in the affairs of life; and among the working classes, many are compelled by the nature of their business to maintain the sitting posture for a number of hours consecutively, and in these all diseases of the rectum and anus are extremely prevalent.
The predisposing causes are constriction of the anal orifice, either from spasmodic action of the sphincter, occurring from intestinal irritation produced by the ingesta, or a vitiated and acrid condition of the secretions, or from the cicatrization of wounds after surgical operations, accidental or specific ulcers, or injuries to the part. Haemorrhoids are frequently the predisposing cause, and a complication of this affection: they narrow the outlet, and by the repeated attacks of inflammation to which they are sub