FISSURE OF THE ANUS This is an affection which is, apparently, especially common in artificially fed children suffering from constipation. It consists of a small loss of substance brought about through a mechanical injury- of the mucous membrane of the anus. The ulcer is produced because of the perpetual stretching at every act of defecation, and the unavoid able infection arising in this region, partly through fecal masses and partly through the attempts to keep the part clean. The ulcer is situated, as a rule, behind the anal opening, in £1 line with the longitu dinal folds of the rectal mucous membrane, for the most part on the posterior wall near the coccyx. In order to make it clearly visible, one must have the pelvis of the patient elevated, and the legs widely separated and flexed on the trunk, and must hold the gluteal folds apart; and, with the fingers placed flatly on both sides of the anus, press these apart, in doing which the outer sphincter is stretched ancl the mucosa pressed forward. This, then, appears slightly reddened and swollen, partially- covered by a mucopurulent secretion, and, in the depth of the posterior rectal wall (seldom in other situations), is seen a more Or less deeply fissured ulcer, which bleeds on touching and has a yellowish or grayish, coated base. Exposing of the ulcer produces great pain. At the same time, every mechanical irritation, as the act of defecation, sets up a reflex spasm in the region of the sphincter, which already, in the attempt to open the anus, has most powerfully contracted.
The chronicity of this condition is brought about by a continua tion of the constipation, which causes the production of hard and dry fecal masses. Tbe removal of the.se masses front the rectum requires great exertion, and leads to a progressive deepening of the fissures, and eventually, also to the production of IICIT fissures, and to a gradual hypertrophy- of the external sphincter ani. The sphincter becomes thick ened in these eases into a tense ring as hard as cartilage, behind whieh the deep fissure or several of them are situated as though cut out with a chisel. The slightest touch produces an intensely painful paroxysm
which can be increased during tile act of emptying the bowel to a con vulsive se.zure. When the defecation leads to such sharp paroxysms fecal retention is soon produced, which, naturally, still further increases the trouble. The micturition is likewise affected in many; cases, either as retention or incontinence.
It is necessary for the diagnosis of the condition to make the fissure visible, in the manner above described. The presence of con stipation, pain before, and during, or even a short time after, defecation, the appearanee of blood, mostly in the form of streaks in the feces, suggests certainly a fissure although they can be produced by other causes. Moreover, there may be a loss of substance in the anal region, produced by eczema intertrigo. This, however, is situated, as a rule, on the outside of the rectum and not above the sphincter and does not cause such severe pa:n. In gonorrhual disorders, especially vulvo vaginitis, the process can be extended to the anus, and can lead to inflammation, with secondary ulceration of the reetal region. But this also is a process spreading front without, the association of which with the genital disorder is soon clear, and in any ease can be veri fied by an examination of the rectal secretion for gonococci. Syphi litic processes are frequently localized in this region and ulcerations of the anal =eons membrane belong to the early manifestations of hereditary syphilis. The other wide-spread syphilitic lesions are a proof of the specific nature of the lesion. Broad condylomata, a late symptom of hereditary syphilis, and localization of acquired syphilis, frequently surround the anal region. They, however, are situated at a point of transition between the skin and the mucous membrane, are much more superficial, and are easy to diagnose because of the variety in their appearance, their color, and, as a rule, the presence at the same time of other syphilitic manifestations.