CHAPTER I.

DEFINITION—LOCATION—AGE AND SEX AFFECTED—ETIOLOGY.

FISSURE.—The domain of surgery includes few diseases which produce such intense suffering to the patient as does the affection under consideration, and none in which proper treatment is followed by more prompt relief and more certain ultimate success.

Fissure, although so simple in extent and character and so readily curable, exercises a most potent influence in undermining the patient's health and strength, the constant pain and irritation to the nervous system being more than the majority of persons can endure.

DEFINITION.—We may define a fissure, or irritable ulcer of the rectum, as a superficial breach of the mucous membrane in the anal region, of a highly sensitive nature, giving rise to spasmodic contraction and paroxysmal pain of a peculiar character. According to Bodenhamer,[1] its shape may be linear, oblong, or circular.

LOCATION.—Its position is usually just within the verge of the anus, beginning at the muco-cutaneous junction or Hilton's line, and extending upward toward the rectum for a distance seldom exceeding half an inch. It may occupy any portion of the circumference of the anal region, but its usual site is at its posterior or coccygeal side.

MULTIPLE CHARACTER.—Although this lesion is usually solitary, we sometimes find it multiple, especially when it is of syphilitic origin.

AGE AND SEX AFFECTED.—Anal fissure is a disease of adult life, and is said to be more common among women than among men. Very young children, however, are not exempt, as many reported cases show. The late Dr. D. Hayes Agnew[2] mentions having seen it occur in infants not over two months old. Dr. A. Jacobi[3] is of the opinion that this affection is a more common one than is generally supposed, and believes that many of the fretful children who sleep badly and cry constantly, and often present symptoms simulating those of vesical calculus, suffer from fissure of the anus. He quotes Kjellberg, who at the Dispensary at Stockholm among 9098 children found 128 cases of fissure of the anus, of which number 60 were boys and 68 were girls; the majority were less than one year old, and in 73 cases the age was less than four months.

ETIOLOGY.—The explanation of the very intense pain by which this disease is characterized is to be found upon study of the structural arrangement of the termination of the bowel, with especial attention to the nerve-supply of the part. Therefore it will be in order to review at this point the more important anatomical features of the lower portion of the rectum.

The outlet of the intestine is closed by two sphincter muscles, the external being immediately beneath the skin surrounding the margin of the anus. It is elliptical in form, about half an inch in breadth on each side of the anus, and is attached posteriorly by a small tendon to the tip and back of the coccyx; anteriorly it becomes blended with the transverse and bulbo-cavernosus muscles at the central point of the perineum. The internal sphincter consists of the normal circular fibers of the rectum, considerably increased in number; its thickness is about two lines, and its vertical measurement from half an inch to an inch. It is situated immediately above and partly within the deeper portion of the external sphincter, being separated from it by a layer of fatty connective tissue.

These muscles—the two sphincters—are separated on the outer side by the attachment of the levator ani, some of the fibers of which are internally connected with the external sphincter; on the inner side the muscles are in contact, the line of union corresponding accurately with the junction of the skin and the mucous membrane. In most cases this junction of the sphincters is marked by a line of condensed connective tissue.[4] This line is known as "Hilton's white line."

Hilton has pointed out an important anatomical fact in connection with this line—to wit, that it is the point of exit of the nerves, principally branches of the pudic, which descend between the two sphincter muscles, becoming superficial in this situation, and are there distributed to the papillæ and mucous membrane of the anus (Fig. 1).

These nerves are very numerous, which accounts not only for the extreme sensitiveness of the part, but also, as stated by Andrews,[5] for its very abundant reflex communications with other organs. They play a very important part in the etiology of irritable ulcers. The exposure of one of their filaments, either in the floor or at the edge of the ulcer, is an essential condition of its existence.[6]

The upper portion of the rectum possesses very little sensibility, as the chief nerve-supply of the organ is at its termination and around the anus; hence it is that such grave diseases as cancer or ulceration may exist in the higher parts of the bowel and not manifest their presence by pain.

Andrews[7] directs attention to Hilton's diagram (Fig. 2), as showing that impressions from a fissure are carried to that part of the cord which supplies the pudic nerves and the ilio-lumbar, lumbar, and sciatics, which include the motor supply of the external sphincters as well as of the bladder and the lower extremities.

From these general considerations we can understand why reflex spasm of the sphincter is so constant and important a sign of this malady, and how other and more general reflexes are to be accounted for,—such as symptoms of bladder and urethral diseases, radiating pains, etc.

We also find in the nervous mechanism of the part an explanation of the predisposing causes, important symptoms, and pathology of this peculiar affection.

As to the immediate origin of this lesion, it may be said to arise from a variety of causes, such as atony of the rectum, or other conditions leading to constipated habits. In these cases the bowel becomes impacted with hardened feces, which when discharged overstretch the delicate mucous membrane, and thus, either by irritation or by direct abrasion, the ulcer is formed.[8]

In consequence of spasmodic or organic contraction of the external sphincter ani, fecal matter or some other foreign body lodges in the fossa between the two anal sphincters, and by its long-continued presence in this pent-up situation becomes highly irritating and gives rise to an obstinate fissure.[9]

Anal fissure sometimes results from the excoriations produced by vitiated and acrid discharges, such as occur in dysentery, chronic diarrhœa, cholera, leucorrhœa, etc. Hemorrhoids are frequently a predisposing cause and a complication of this affection.[10] They narrow the outlet of the bowel, and through the successive inflammatory attacks to which they are subject the neighboring tissue loses its elasticity, is rendered brittle, and is easily lacerated.

Polypi are not uncommon causes of this lesion.[11] The polypus is usually situated at the upper or internal end of the fissure, but it may be on the opposite side of the rectum, as in several cases coming under the author's observation.

Allingham[12] states that ulcer of the rectum may result from a congenital narrowness of the anal orifice, being then usually seen in children; or it may be caused by an hypertrophied condition of the sphincters, which has arisen from severe constipation or some rectal affection.

Anal fissure is sometimes produced by a superficial excoriation or ulceration of the outlet of the bowel, analogous to that so frequently observed upon the inside of the lips, the tongue, and other parts of the mouth. Bodenhamer[13] mentions having seen several severe cases of this disease produced by a kind of _aphthous ulceration_ in nursing mothers, and one in a child. They were attended with extreme burning pain and more or less anal spasm. He also states that in these cases the ulcerations of the anus were contemporaneous with similar ulcerations of the mouth; their coexistence and the exact similarity of their appearance left little doubt as to their identity.

Harrison Cripps[14] states that a source from which these ulcers sometimes take their origin is a little marginal abscess which has led to the destruction of the portion of the muco-cutaneous surface lying over it.

The anus is liable to a species of chapping resembling that of the lips in winter, which sometimes results in extremely painful fissures. Such a condition is supposed to be induced by the influence of a dry atmosphere or by some slight disturbance in the general health, rendering the parts friable and liable to crack from the slightest violence.

Fissure is sometimes of syphilitic origin. Finally, it may be due to mechanical injuries, such as uterine displacement, the severe straining efforts made in parturition, the careless use of the enema syringe, the awkward employment of instruments by the surgeon in the diagnosis and treatment of rectal diseases, etc.

Footnote 1:

"Anal Fissure," 1868, p. 45.

Footnote 2:

"Principles and Practice of Surgery," vol. i, p. 416.

Footnote 3:

"Intestinal Diseases of Children," p. 295.

Footnote 4:

Andrews, "Rectal and Anal Surgery," Chicago, 1889, p. 69.

Footnote 5:

_Op. cit._, p. 69.

Footnote 6:

Ball, "The Rectum and Anus," Philadelphia, 1887, pp. 128-129.

Footnote 7:

_Op. cit._, pp. 69-70.

Footnote 8:

Bodendamer (_op. cit._, p. 58) calls attention to a fact of some importance as bearing upon this point—to wit, that in some cases of constipation, while the diaphragm and other abdominal muscles act with considerable energy, the anal sphincters remain more or less contracted, and yield but slowly, so that the indurated feces contuse and abrade the surface of one or more points of the mucous membrane, which abrasions, if they do not heal, lay the foundation of the disease.

Footnote 9:

Instances of this condition as the cause of anal fissures are mentioned by T. B. Curling in his "Observations on the Diseases of the Rectum," second edition, London, 1855.

Footnote 10:

T. J. Ashton, "Diseases of the Rectum," second American from the fourth English edition, 1865, p. 46.

Footnote 11:

Allingham, "Diseases of the Rectum," fifth edition, London, 1888, p. 208.

Footnote 12:

_Op. cit._, p. 209.

Footnote 13:

_Op. cit._, p. 59.

Footnote 14:

"Diseases of the Rectum and Anus," second edition, London, 1890, p. 185.