Anal fissure is technically a small ulcer, the result of a crack or elongated break in the mucous membrane at the anal orifice. The ulceration is of a character distinct in itself, not so destructive or so extensive as the ulcer found higher up in the rectum. The prefix, anal, distinguishes this ulcer from the rectal ulcer. Fissure in anew exists almost entirely within the folds of the mucous membrane covering the external sphincter, and is a most painful and distressing affliction in comparison with the rectal ulcer, which is situated above both sphincters and attended with little or no pain. An anal fissure is a small, more or less superficial ulcer, just within the margin of the anus and involves or extends from the bottom of one of the rugger formed by the contraction of the external sphincter muscle. The ulcer is usually triangular in form and extends upward into the longitudinal axis of the anal canal for the distance of one-half inch. The apex is generally found, on inspection, at the lower margin of the internal sphincter, and the ulcer varies in depth in different cases. In some the ulceration involves only the mucous membrane, while in others the sub mucous tissue, or, in those of long standing, the muscle fibers of the external sphincter can be seen and form the floor of the fissure. When the external sphincter contracts, the lateral borders overlap the floor of the fissure and must be drawn apart to view its full extent. Sometimes, there is found a small fold of skin at the lower border of the fissure, or to one side of it, which is called the sentinel pile. The position of the ulcer may be at any point in the circumference of the anal canal, but as a rule is found in the median line or to the right or left of it, posterior

The chief characteristic of a fissure is its extreme sensitiveness, the slightest touch causing intense pain with spasm of the sphincters and elevators an muscle. The skin and mucous membrane is most sensitive.

The pain will vary in character from the extreme superficial pain at the much cutaneous junction to an almost constant ache referred to the tip of the coccyx associated with the deep ulcer. Fissure in anew is found at all ages from infancy to old age.

Causes. Catarrh proctorial is probably the commonest of all causes of fissure in anew, especially when associated with constipation. Besides this, anal fissure may be caused by congenital narrowing of the anal orifice, eczema, polyp, diarrhea, syphilis, or by any cause which interferes with the normal elasticity of the mucous membrane or the sub mucous tissue of the anal canal. An anal fissure is primarily due to a tearing of the mucous membrane.

Fissure may also result from over distention of the vagina and tearing of the anal tissue in parturition.

Fig. 47. Ordinary position of lateral fissure.

Symptoms. The most important symptom is pain, sometimes associated with dyslexia and frequent urination, the latter more often associated with the anterior fissure. There may be blood or pus in the fecal mass. The pain is probably due to the exposure of the nerve ends as in any fresh cut surface, which, if left uncured, excites a chronic local neuritis. The presence of blood and pus in the fecal mass, with the subjective symptoms of pain occurring after the stool for a period varying from one-half to two hours, is almost a positive sign of a split or fissure in the mucous membrane of the anal orifice.

Treatment. Treatment of the anal ulcer or fissure may be either palliative or operative and cases should be treated selectively. The treatment of a recent tear is very simple, while the deep chronic fissure, with hypertrophy of the sphincters, is very difficult. It is wise to try palliative treatment in all cases for two to three weeks and at the end of that time, if a marked improvement has not occurred, operative treatment should be instituted. It is well in these cases to thoroughly explain to the sufferer in advance the proposed method of treatment, emphasizing that palliative treatment cannot be considered certain although worthy of a fair trial.

Operative treatment is indicated when the fissure is complicated by other rectal diseases; when the ulcer is deep and exposes the muscle fibers of the external sphincter; or when the edges are thick and the sphincters hypertrophied.

Palliative treatment consists of the application of local remedies, the relief of constipation, the catarrh condition and local cleanliness, but depends largely upon the duration of the fissure. Many have been quickly relieved by mild as stringent applications such as Hammerings, while in others the solid stick of nitrate of silver, or pure ichthyology, has failed to procure the desired results. Ordinarily, the longer the fissure has existed, the more we have to stimulate, with due consideration for the patient, as the anal margin is probably the most sensitive part of the body. Balsam of Peru, nighrate of silver and pure ichthyology are in my judgment the best remedies for the palliative treatment of the chronic inaugurated ulcer. Pure ichthyology has given me more uniform satisfaction, as compared with the others, when applied every second day, after an insulation of orthonormal or the topical application of a cocaine solution to relieve pain. Along with this treatment, local cleanliness, the normal control of the bowels and rest in bed should be insisted upon, if possible. In treating the constipation, one must always bear in mind that a catarrh condition usually exists and therefore the resinous bearing cathartics, which irritate the rectum and anal canal should be avoided.

Cauterization is recommended by some surgeons in almost all cases of fissure in anew which have not yielded to cleansing and stimulating treatment. Cauterization is usually done under a general anesthetic, but often local anesthesia is considered sufficient, although the latter is usually confined to the use of the chemical cauterizes - silver, nitric acid, carbolic acid, liquor potassium, or copper sulphate. The use of the Jacqueline cattery point is almost exclusively applied under general anesthesia; only one cauterization is as a rule sufficient, but in persistent cases it may be necessary to repeat the procedure two or more times. It is well, when a general anesthetic is used, to dilate the anal ring at the time the cauterization is made. However, cauterization with the severe chemical cauterizes and the actual cattery has not proved a success in my experience, and, while healing has occurred, a certain degree of pain has often been complained of by the patient for a long period afterward. This pain was attributed by me to a certain amount of deep-seated nerve injury, or to a scar of undue hardness.