The symptoms of anal fissure often simulate closely those of uterine disease and bladder affections. Spasm of the sphincters in these cases may also simu late stricture, but a thorough examina tion will dispel all uncertainty.
Frequently, uterine disorders or hem orrhoids are associated with the fissure; in this event the case is treated for either one or the other of the first two com plaints, the presence of the other lesion being unsuspected and consequently neg lected. In all such instances a careful inspection of all the parts will at once prevent all errors. Small polypoid growths are often found at the upper portion of the fissure and unless removed will prevent successful treatment.
[Fissure of the rectum is one of the causes of dyspareunia, which may be di agnosticated as vaginismus. The cure of the fissure will be quickly followed by relief of the symptoms. C. B. KELSEY, Assoc. Ed., Annual, '92.] Etiology and Pathology.—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, and my experience would lead me to suspect that it often exists in many such cases without being discov ered. The intense suffering is due to the structural arrangement of the ter mination of the bowel, especially its nerve-supply. As is well known, the out let of the intestine is closed by two sphincter-muscles, the external being immediately beneath and parallel to the skin surrounding the margin of the anus. On the inner side, or rectal surface, the muscles are in contact, the line of union corresponding accurately with the junc tion of the skin and the mucous mem brane. In most cases this junction of the sphincters is marked by a line of con densed connective tissue, and is known as "Hilton's white line." Attention is drawn to this term because of an impor tant anatomical fact, which Hilton has pointed out in this connection: to wit, that it is the point of exit of the nerves, principally branches of the pudic, which descend between the two sphincter-mus cles, becoming superficial in this situa tion, and are there distributed to the papillre and mucous membrane of the anus. These nerves are very numerous,
and account for the extreme sensitiveness of the part and also for its very abundant reflex communications with other organs (Andrews, "Rectal and Anal Surgery," second edition, Chicago, p. 69). The ex posure of one of their filaments, either in the floor or at the edge of the ulcer, is an essential condition of the existence of irritable ulcer. 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 mani fest their presence by pain.
Irritable ulcer may arise from a variety of causes, such as atony of the muscular coat of the rectum, or oth-er conditions leading to constipation. In these cases the bowel becomes impacted with hard ened fakes, which when discharged overstretch the delicate mucous mem brane, and thus, either by irritation or by direct abrasion, the ulcer is formed.
William Bodenhamer ("Anal Fissure," '6S, New York) states that, in some cases of constipation, while the dia phragm and other abdominal muscles act with considerable energy, the anal sphincters remain more or less con tracted, and yield but slowly, so that the indurated faeces 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.
Irritable ulcers sometimes result from the excoriations produced by vitiated and acrid discharges, such as occur in dysentery, chronic diarrhoea, cholera, leucorrhcea, etc. Hemorrhoids are fre quently a predisposing cause and a com plication. 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 unich more easily lacerated.
Polypi are not uncommon causes; they are usually situated at the upper or internal end of the ulcer.