Practical observations of the ætiology, pathology, diagnosis, and treatment of anal fissure

Front matter

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PRACTICAL OBSERVATIONS

Section I

History. — Progress, the all-absorbing and controlling idea of the age. The science of medicine no exception to this all-prevailing principle : its upward and onward tendency evident. The ignorance heretofore on the subject of the diseases of the anus and the rectum. The failure to make a proper exploration of the rectum one of the causes of this ignorance. Since the introduction of anaesthetics, the surgery of the rectum, especially its manipulative branch, has made rapid progress. These, and the now common use of the speculum ani and the rectal endoscope, are daily revealing the dark and hidden mysteries of this darksome passage. Fissure of the anus received but little attention previous to the time of MM. Boyer, Beclard, Dupuytren, Blandin, and a few others. About fifty years ago, M. Boyer called especial attention to the subject of this disease, from having treated a large number suffering from it in its most aggravated form. He was of opinion that the disease called fissure of the anus, by the ancients as well as by the moderns, was not identical with that which had come under his own observation ; and that previous to his time this disease was never observed with attention, neither was it accurately described nor correctly treated by any one. From this sweeping declaration the author dissents in toto. A comparison between the fissura ani of the ancients and that described by M. Boyer. The former believed it to be simply what its name imports, a superficial breach of surface of the mucous membrane, of a peculiar form ; the latter believed anal fissure to be always accompanied by a painful spasmodic contraction of the sphincter ani muscle, and that this painful contraction indeed constituted the real disease, whether attended by any breach of surface or not ; the former, that it was an idiopathic disease of the mucous membrane ; the latter, that it was an idiopathic disease of the sphincter ani muscle itself. The ancients, when speaking of fissura ani, do not mention anal spasm. What Paulus /Egineta, Albucasis and iEtius say on the subject of fissura ani. The chief indication in the treatment of this disease by the ancients was to convert the original fissure or ulcer into a recent wound by scarification and by topical medication. It is worthy of remark, that a fresh wound made in the mucous membrane, or in the irritable fissure of the same, is not attended with the same severe suffering, after the act of defecation, that arises from the original fissure or idiopathic disease ; that such a wound produces at first nothing but a common soreness, but at the same time tends to relieve the pain and cure the disease. The ancients then, to cure this disease, converted the primitive or original lesion into a recent or fresh one, and thus ultimately healed it. What have

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the moderns now any better than this ? Even if the fissure is attended by anal spasm, all that is necessary, as a general rule, to effect a radical cure is to heal the fissure, and the anal spasm will cease of itself. From what M. Boyer says, he doubtless believed that he himself was the first to make the discovery that anal spasm always accompanied anal fissure, and that it was its characteristic or pathognomonic sign ; indeed, all his admirers attribute to him the origination of this idea. In this, however, both he and they are mistaken, for nearly three hundred years before he or they promulgated this idea, the celebrated French surgeon, Ambrose Pare, accurately described the disease called fissure of the anus, as consisting of cleft and very long little ulcers, situated in the orifice and the canal of the anus, and attended by very sharp and burning pain, and by great contraction and narrowing of the anus. The description and the treatment of fissure of the anus given by M. Pare. The consideration of the theory of those of the moderns who teach that anal spasm is in reality the idiopathic disease, of which the breach of surface or fissure, if any, is but an accidental accompaniment or consequence. The views on this subject of each of the following eminent surgeons who held this doctrine, — MM. Boyer, Dupuytren, and Sir Benjamin Brodie. The declarations of these gentlemen, however, on this subject have never been verified by any satisfactory ante- ox post-mortem examination, and rest merely upon assertion. The views of MM. Blandin, Sanson, Quain, and Bushe in opposition to this theory. The views of M. Velpeau in conciliation of these conflicting theories. . Pages 3-21

Section II

Spasmodic Contraction of the Anus. — Nervous irritation in muscular parts often occasions partial and sometimes obstinate contractions. "When this occurs in the anal canal it constitutes what is generally called spasmodic contraction of the anus. There are three kinds of muscular contraction — the spasmodic, the permanent or organic, and the mixed, which partakes of the characters of both. The first can always be dilated to the full size of the canal in which it exists, and of which nothing can be learned by dissection after death, because the spasm depends upon a living and active principle which ceases with life. The second and third can not only be detected in life, but can be demonstrated post-mortem. How a spasmodic contraction may become permanent or fixed. Anal spasm as an entity a disease in itself. The independent existence of anal spasm is a theory held by some of the most able surgical writers on the diseases of the rectum and anus ; but as the principles of it rest purely upon the evidence of facts, fairly and fully ascertained and set forth, they fail, in the opinion of the author, to establish it. The author shows that the numerous cases which these writers have presented to illustrate this theory are, in reality, cases of anal fissure, or of some other disease of the mucous membrane of the inferior extremity of the rectum ; or of disease in the genito-urinary organs, and not cases of primary or independent disease of the sphincter ani muscle itself. The following are the authors quoted in this work who have treated anal spasm as an entity, a disease in itself, and who have made it a subject of special consideration : — M. Boyer, Mr. Copeland, Mr. Baillie, Mr. Gaitskell, Mr. Blackett, Mr. White, Mr. Howship, Mr. Calvert, Mr. Mayo, M. Chelius, Mr. Salmon, Dr. Bushe, Mr. Curling, and Mr. Malyn. The views and the cases of each of these authors given, with comments upon the same 21-40

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Chapter II. Fissure Of The Anus

Section I.

Name. — The disagreement among authors as to the precise application of the term fissure of the amis. It is incorrectly applied by some to anal spasm, a mere symptom of anal fissure, and by others equally incorrect to every superficial lesion of whatever character, situated in the inferior extremity of the rectum, and about the margin of the anal orflce. The term fissure of the anus in its limited sense, or in its strict application. The term as used in its more extended sense. The difference in the form of these superficial lesions of the inferior extremity of the rectum and about the anal orifice. Their characteristic form is doubtless imparted to them by the irregularities of the mucous lining of the rectum, disposed as it is into numerous rugae. This term not a good one to designate this painful affection, inasmuch as the mere form of the lesion, whether linear, circular, or oblong, is not the characteristic sign, neither does it determine the true nature of the disease. Its use, however, has been so long sanctioned by authority that the author does not feel at liberty to venture upon the substitution of a newly created one. The term thus retained by the author as a nosological distinction, he strictly confines to superficial breaches of surface in the anal region of a highly sensitive, irritable, or painful character, whether linear, oblong, or circular ; or whether' attended by anal spasm or not. Mr. Curling very appi"opriately denominates fissure of the anus, " irritable ulcer of the rectum" He, together with Mr. Quain and Mr. Smith, of London, repudiates the term, fissure of the anus Pages 43-46

Section II.

Physiology. — A brief description of anal fissure given as preliminary to the subject of physiology. It is an idiopathic disease of the mucous membrane of the inferior portion of the rectum ; or of the muco-cutaneous coat about the anal orifice, and not a disease of the muscular coat, or muscular fibres of the intestine, nor of the sphincters of the anus. The excessively irritable and excitable fissure of the mucous membrane communicates its irritability and excitability to the muscular coat and to the sphinctores ani muscles, and causes one or both of them to contract violently. The sphincter ani muscles are sympathetically impressed or influenced by the morbid condition of the fissure — hence the spasm. In some morbid conditions of the anus, or anal region, whether induced by fissure or by some other cause, extreme sensibility of the nerves of the part and spasmodic contraction of the anus coexist as parts of the same disease. Sensibility of the terminal outlets of the body. The sensibility of all mucous membranes is greatest at the extremities, or the outlets of the canals which they line. The outlets of the body are supplied or endowed with a peculiar nervous influence which is obviously connected with their proper function. The direct cause of the extreme and agonizing pain in anal fissure is the result, to a great extent, of the violent involuntary spasmodic contraction of the sphincters of the anus upon the already highly sensitive and painful ulcer. This view of the subject is in accordance with the pathology of the disease, as well as with the physiological condition of both sphincters of the anus, whose involuntary contraction, both tonic

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and spasmodic, is entirely owing to a peculiar nervous endowment. The tonic and the. muscular contraction of the anal sphincters. The explanation of each. The influence of the will upon the anal sphincters. These two muscles stand in physiological function between the involuntary and voluntary system of nerves. The supposition that a special nervous influence is necessary to govern the relaxation and the contraction of the anus has be*en entertained by several eminent physiologists. The views of the ingenious and talented Italian, Professor Bellingeri, on this subject. The fibres of the anal sphincters may be stimulated to action directly by the will, or indirectly by reflex irritation, the one action being voluntary and the other involuntary. The philosophy of reflex action in its relations to nervous phenomena is at the present time attracting great attention. To know that all morbid manifestations may be due to reflex influence is of the highest importance. The nervous endowment of the rectum. Hypertrophy of the external sphincter of the anus. . Pages 47-53

Chapter III. Etiology

Constipation of the Bowels as a Cause of Anal Fissure. — The ancients attributed fissure of the anus principally to constipation of the bowels, and to the desiccated condition of the stercoraceous matters incident to such a constipated state. It is obvious how constipation with all its train of evils, retention and induration of the faeces, and the violent action of the expulsive muscles requisite for their evacuation, may be a cause of anal fissure. Anal fissure is sometimes the result of inflammation, and the attendant turgescence of the mucous membrane of the anal canal. It also sometimes results from the excoriations produced by the vitiated and irritating discharges in dysentery, diarrhoea, cholera, and other visceral diseases. Obstinate ulcers or fissures are sometimes produced in the fossa between the two anal sphincters, by the continued lodgment in this situation of faecal matter or other foreign bodies. Severe straining efforts a cause of anal fissure. A somewhat frequent cause is a deficiency in the secretion of the natural lubricants — the mucous and other secretions of the inferior extremity of the rectum and about the anal orifice. Anal fissure from mechanical injuries, such as the lacerations which are produced by over distention, by the passage of hard fasces, as well as those which sometimes follow surgical operations, and the careless and awkward use of the pipe of the enema syringe, the speculum ani, the rectal sound or bougie. It is sometimes the result of external violence communicated by falls, blows, etc., upon the anus, the nates, or the coccyx. Anal contraction as a cause of anal fissure. Anal fissure from the frequent use of enemata. Anal fissure from cutaneous affections. The venereal origin of anal fissure. Can anal fissure be produced artificially ? Are the causes of anal fissure obscure ? Who are the most obnoxious to anal fissure ? 57—67

Chapter IV. Classification And Description Of Anal Fissure

Section I.

The Seat, the Anatomical and the Pathological Characters of Anal Fissure. — The importance of distinguishing and describing fissures of the anus in

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accordance with their location. Some authors think such distinction of no therapeutical value. The great difference in the appearance of the fissure or ulcer, arising from its location. MM. Blandin and Dupuytren acknowledge the importance of such distinction. M. Blandin divides anal fissures into three divisions. The author distinguishes them into four classes, according to their locality, describing the peculiar character they assume in each of such position. A description of the seat, the anatomical and the pathological character of each class. . . . Pages 71-78

Section II.

The Symptoms and the Signs of Anal Fissure. — The most striking feature in the nature of anal fissure is the great disproportion which exists between the extent of the solution of continuity, and the intense suffering it occasions. The characteristic or essential symptoms of anal fissure. The interval of time and its length between the act of defecation and the accession of the pain, as a pathognomonic sign of anal fissure. What Mr. Colles and Mr. Quain say on the subject of this phenomenon. The explanation given of it by Prof. Van Buren and Mr. Malyn. Symptoms and signs of anal fissure in infants. They differ essentially from those manifested in the adult. The difference pointed out 79~9°

Section III

Physical Exploration, Diagnosis, and Prognosis. — The measures necessary to be observed previous to making a thorough inspection of the rectum. The position of the patient and the manner of making the exploration. The external appearance of the anus in anal fissure. It is almost always strikingly retracted. The condyloma or pendulous projection, composed of the integument at the margin of the anus, and located at the base or inferior extremity of the fissure. It exists in most all cases, and is an unerring guide to the fissure itself. The digital examination of the anal canal and the preparatory measures necessary for it. The specular examination of the inferior extremity of the rectum and the preparatory steps necessary to it. Description of three anal speculae used by the author. The examination by means of the probe. The diagnosis. The prognosis. The complications of anal fissure. . 90-103

Section I

Precautionary and Palliative Measures. — It is highly important to the success of any treatment of fissure of the anus that constipation of the bowels, if it exists, should be corrected, by securing their daily evacuation, and thereby preventing faecal accumulation. It is also a primary object to prevent the formation of acrimonious matter in the bowels, and to take especial care to preserve an easy and regular transmission of their contents, which for this purpose should as much as possible be kept in a semi-fluid state, as figured or hard stools generally aggravate the symptoms.

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These several ends must be effected by enjoining the most bland and unirritating diet ; and by the use of emollient enemata, or mild aperients. The measures recommended by the author to accomplish the certain evacuation of the bowels daily, and the easy - transmission of their contents. The following as palliatives to be used sometimes in certain cases and under certain circumstances — leeching, fomentation, horizontal posture, cold applications, and local anaesthesia. The palliative measure of M. Gossement Pages 107-109

Section II

The Treatment as Pursued by the Author. — It consists of topical medication combined with dilatation and sometimes scarification or incision of the mucous membrane. The chief indication is to modify the surface of the ulcer and transform it into a simple or a common sore. Distention of the spasmed anal sphincters ; its object, and the method of accomplishing it. The author's method of treating anal fissure in infants. 110-119

Section III

The Different Methods of Treatment. — These may be included under the following heads : — 1. Topical Applications ; — 2. Cauterization ; — 3. Dilatation ; — 4. Incision of the Mucous Membrane ; — 5. Excision of the Fissure ; — 6. Complete Division of the Sphincters of the Anus. The treatment by topical applications. It is said by some to be merely palliative, and by others to be impracticable, or positively injurious. The author proves by the highest authority, that it has not only been found practicable, but that it has been attended with the most complete success in numerous instances. The numerous and various topical applications given, together with the names of those who employed them, and the success or failure attending their application. 2. The treatment by cauterization. The indication contemplated by the use of the cautery, either in its potential or in its actual form. The potential cautery employed in the treatment of fissura ani from the earliest times. The different kind of caustics, with their mode of application. M. Jules Guerin recommends the actual cautery. Objections to this remedy. 3. The treatment by dilatation. The object and the method of employing it in anal spasm when caused by fissure of the anus. Dilatation by the use of the bougie. It was employed and recommended by Mr. Copeland, Mr. Gaitskell, and Mr. Howship as early as 1815. The principle of muscular distention and dilatation as recommended and so successfully employed by M. Recamier. Dilatation by the use of different kinds of tents. Forcible and instantaneous dilatation of the sphincters of the anus by means of the fist, was first executed and recommended by M. Maisonneuve. This operation met with no favor. A modification of this operation was subsequently made, by substituting the thumbs for the fist. The manner of performing it as practised by M. Nelaton, who is its advocate. This method of dilatation of the anal sphincter in fissure of the anus and some other diseases of these parts is adopted and recommended by Professor Van Buren. The objections. A modification of it recommended by the author, in which the index fingers are used instead of the thumbs. 4. The treatment by incision of the mucous membrane. Mr. Copeland the first who recommended it as a substitute for M. Boyer's operation. What Sir Benjamin Brodie and Mr. Quain say on this subject. Mr. Curling and Mr. Smith are of opinion, that besides the division of the mucous membrane and submucous cellular tissue, it is necessary to the success

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of the operation that some of the muscular fibres should be divided. The author differs from this opinion. The modus operandi of this operation. The author's method of performing it by a new instrument. 5. The treatment by excision of the fissure. This operation, the author believes, was first proposed and executed by M. Velpeau. In it the integrity of the muscular coat is preserved, neither the muscle nor the muscular fibres of it being interfered with. The modus operandi. 6. The treatment by complete division of the anal sphincters. The merit of first executing and recommending this operation in case of anal fissure, is universally attributed to M. Boyer. The objections to this operation. It is founded upon a mere hypothesis. The anal spasm for which the operation is advised is only a symptom, an effect, or a result of the fissure, which is in reality the real disease. The operation is wrong in principle and mischievous in practice, and cannot be approved of, upon rational grounds. All treatment is irrational that is not immediately directed to the morbid condition of the mucous membrane of the part, or that does not immediately tend to heal the fissure itself, which is the real disease. The operation was considered to be infallible by M. Boyer ; it is, however, proved by MM. Recamier, Beclard, Velpeau, and others, not to be so. The accidents and the dangers of the operation. The manner of performing it as advised by M. Boyer. A modification of M. Boyer's operation by M. Blandin. It consists of the submucous and subcutaneous section of the sphincter ani muscle. It is ingenious, simple, far less formidable and repulsive, equally successful, and attended with much less risk. A description of the instrument, and the manner of performing the operation. The proceeding of M. Boyer as modified by the late and lamented Dr. Hayward, of Boston. It consists of the division of the sphincter ani from without inwards, instead of from within outwards, as in the operation for complete fistula in ano. The manner of performing the operation. Pages 1 19-147

Section I

Illustrative Cases. — Case I. Anal fissure of nine months' standing, caused by obstinate constipation of the bowels, and the continued use of drastic purgatives. Case II. Anal fissure complicated with haemorrhoids. Case III. Anal fissure complicated with a small blind internal fistula — the patient having been treated several months for internal irritable piles. Case IV. Anal fissure of an aggravated character, in which the sphincters of the anus had been divided with the knife. Case V. Anal fissure in a little boy three years old, caused by obstinate constipation of the bowels, the result of inactivity of the liver induced by intermittent fever. Case VI. Anal fissure complicated with fistula in ano, spermatorrhoea, and ascarides of the rectum. Case VII. Anal fissure complicated with a blind internal fistula. Case VIII. Highly irritable ulcer, situated in the fossa between the external and internal sphincter of the anus. Case IX. Irritable ulcer of the rectum simulating uterine disease, and a large accumulation of hard and impacted faeces in the left colon simulating a tumor in that region. Case X. Anal fissure in an infant ten months old. Dentition,

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persistent diarrhoea, and procidentia ani. Case XI. Anal fissure, previously diagnosed and treated by different physicians, severally as neuralgia of the inferior extremity of the rectum, internal piles, and constipation. Case XII. Anal fissure attended by great flatulency, and accompanied alternately by constipation and diarrhoea. The true nature of the case having been overlooked, it was treated severally as dyspepsia, anal neuralgia, and internal piles. Case XIII. Anal fissure complicated with haemorrhoids. In this case the fissure, having been entirely overlooked by the previous medical attendants, was diagnosed and treated by them as irritable piles. Case XIV. Anal fissure complicated with haemorrhoids and with spermatorrhoea. Case XV. Anal fissure the result of the application of nitric acid to the mucous membrane of the anal canal. Case XVI. Anal fissure from a rupture of the mucous membrane of the anal canal, the result of a fall upon the nates. Case XVII. Several fissures complicated with numerous condylomata and with permanent contraction of the anus. Case XVIII. Anal fissure complicated with an intolerable pruritus of the anus. Case XIX. Anal fissure in an infant suffering from aphthae. Case XX. Anal fissure complicated with haemorrhoids and an affection of the prostate gland. Case XXI. Anal fissure complicated with haemorrhoids, the fissure ocated between two of them. Case XXII. Anal fissure caused by chronic irritation of the mucous membrane and muco-cutaneous coat of the anus. Error in diagnosis and failure to afford relief by previous treatment. Case XXIII. Anal fissure in a nursing mother who was suffering severely from aphthae. Case XXIV. Anal fissure complicated with haemorrhoids and with an anal fistula. Case XXV. Fissures and aphthous abrasions and ulcerations of the anus in connection with nurses' sore mouth. Case XXVI. Anal fissure following the ligation and sloughing of a haemorrhoidal tmnor. Case XXVII. Anal fissure in a patient with albuminous urine, whose general health was much impaired. Case XXVIII. Anal fissure the result of obstinate constipation of the bowels, and the passage of scybalous faeces. Case XXIX. Irritable ulcer, situated in the fossa between the external and internal sphincter of the anus Pages 151-192

Chapter First. Introduction

PRACTICAL OBSERVATIONS

ON THE

ETIOLOGY, PATHOLOGY, DIAGNOSIS, AND TREATMENT

OF

ANAL FISSURE.

Chapter I. Introduction

Section I. — History.

Progress, either in remodelling the ancient order of things, or in creating a new one, is the one and controlling idea of the present age, and no theories that stand in the way can long exist. Systems and doctrines, gray with the growth of ages, are in a few days overthrown and swept away like cobwebs, although crystallized by time, and fortified by the genius and labors of a hundred generations. The science of medicine is no exception to this all-prevailing principle, as it too is now rapidly moving onwards and upwards. There is no better evidence of the rapid march of medical science at the present time than is found in the increased accuracy of diagnosis, aided by a careful study of the physical signs of disease.

The ignorance on the subject of the diseases of the rectum which had so long prevailed, and which to a certain extent still more or less exists, may very justly be attributed to the failure on the part of practitioners generally to make a proper exploration of this organ. The rectum heretofore

ANAL FISSURE.

has been a terra incognita in the domain of surgery, into which the practitioner did not care to pry : it has been considered a <fc sort of land of the Cimmerians, where quacks alone could breathe, and where humbug darkened the air." But this ignorance and this darkness are now being rapidly dispelled, and this organ is now becoming as subservient to the laws of physical exploration as any other. The surgery of the rectum, particularly as it regards its manipulative branch, has made rapid strides since the introduction of anaesthetics. These, and the now common use of the speculum ani and rectal endoscope, are daily revealing the dark and hidden mysteries of this darksome passage.

Anal fissure received but little notice from surgical writers previous to the time of MM. Boyer, Dupuytren, Blandin, Velpeau, Becklard, and a few others. This neglect or ignorance of the subject, on the part of the ancients, as well as on the part of the moderns, was, however, not confined alone to the disease in question, but extended to most all of the diseases of the rectum and anus. It is therefore highly creditable to the pathologists of recent times, that they are extending their researches to every form of suffering incident to these parts, and are laboring assiduously in this field which had been so long entirely neglected by their predecessors, and when found was nothing but a tabula rasa^ but which, as before remarked, is now being cultivated, enriched and developed by their conjoint and active labors.

About half a century ago the celebrated French surgeon Baron Boyer directed special attention to the subject of this disease, in consequence of having treated a large number of adults of both sexes who had suffered from it, in its advanced stage or in its most severe form ; indeed all the cases that came under the immediate observation of this distinguished surgeon at that time seemed to have been of a most aggravated character. From the circumstance, doubtless, of the great severity of these cases, and especially of their having been accompanied by spasmodic contraction of the sphincter or sphincters of the anus, he came to the conclusion that the disease which he had seen and treated as fissure of the anus could not be identical with that so denominated by the ancients as well as the moderns, inasmuch as he had consulted their works in vain to find a description of it, to accord with the disease as it presented itself to him. He says it is true that Albucasis makes mention of a disease which he calls fissure of the anus, and which he does not describe, but which he recommends to be treated by paring or scarifying the fissure with the nails or with a sharp instrument, and that by this means and the aid of God the disease would be cured. But, says Boyer, the affection of which Albucasis speaks cannot be similar to that which came under my own observation. Boyer also says that M. Sabatier makes mention of anal fissure as being a disease consisting of narrow and long excoriations about the margin of the anus, and as being an affection both painful and difficult to cure, and that it was astonishing no author had yet spoken of it, or had given a description of it. To which Boyer further remarks, that Sabatier was no doubt ignorant of the fact, as he himself had been but a short time previous, that M. Lemonnier, in a work on fistula of the anus 3 published as long ago as 1689, describes fissure of the anus as follows: — "Les ragades ou fissures sont de petits ulceres douloureux, piquans et sans grosseur, qui suivent la longueur des rides du fondement, et qui ressemblent assez a ces engelures ou crevasses, que le froid produit aux levres etaux mains pendant l'hiver; elles sont quelquefois causees par l'endurcissement des matieres fecales, qui, s'etant amassees dans le rectum en gros volume, et qui rendues apres par un exces de chaleur, par leur dessechement et leur sejour, excorient ou fendent le sphincter et l'anus en passant." — (Tratte de la Fistule de L'Jnus, p. 160. Paris , 1689.) "Now it is evident," says