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 PRACTICAL OBSERVATIONS 
 
 ETIOLOGY, PATHOLOGY, DIAGNOSIS, 
 AND TREATMENT 
 
 ANAL FISSURE. 
 
 BY 
 
 WILLIAM BODENHAMER, A.M., M.D., 
 
 PROFESSOR OF THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM, ANUS, AND 
 
 GENITO-URINARY ORGANS. 
 
 " Truth is not the child of authority, but of time ; and were we to allow ourselves to suppose, that 
 nothing more, or new, could be taught, it is pretty clear that nothing more, or new, would be learnt." 
 —Lord Bacon. 
 
 " Nunquam aliud natura, aliud sapientia dicit." — Juvenal. 
 
 ILLUSTRATED BY NUMEROUS CASES AND DRAWINGS. 
 
 NEW YORK r 
 
 WILLIAM WOOD & CO., 61 WALKER STREET. 
 
 1868. 
 O 
 
w* 
 
 
 Entered according to Act of Congress, in the year 1868, by 
 
 WILLIAM WOOD & CO., 
 
 In the Clerk's Office of the District Court of the United States for the Southern District ol 
 
 New York. 
 
 The New York Printing Company, 
 
 81, 83, and 85 Centre St., 
 
 New York. 
 
PREFACE, 
 
 The exquisitely painful affection termed fissure of the anus, notwith- 
 standing the labors of some of the most eminent surgical authors, is yet by 
 no means well understood by the profession. The diagnosis, as well as the 
 treatment of it, is far from being established upon a solid basis. There is 
 as yet no agreement even, among surgical writers, as to the precise applica- 
 tion of the term fissure of the anus, and there still exists a great diversity 
 of opinion as to the best method of cure. The author is therefore of opin- 
 ion that there is much still to be learned in relation to this disease, and that 
 it requires more careful research for its further elucidation. A more 
 thorough and critical investigation of the subject would now seem to be the 
 more especially necessary, since some of the authorities in treating it, have 
 completely mixed up and confounded disease, cause and effect, thereby 
 occasioning much obscurity and confusion, which prove a formidable obstacle 
 to a correct understanding of the true nature, cause, and treatment of this 
 distressing malady. The erroneous and conflicting opinions of these authors, 
 however, might be passed by without note or comment, as harmless, did 
 they not lead to a treatment not only wrong in principle, but most mis- 
 chievous in practice. The author's object, therefore, in this work will be 
 principally confined to the consideration of the disease to which the term 
 fissura ani really, truly, and legitimately belongs ; and by so doing endea- 
 vor to remove some of the obscurities, the difficulties, and the confusion 
 which surround it. 
 
 Besides these several considerations, which led the author more immedi- 
 ately to call the attention of the profession to the subject of this affection, there 
 are others equally weighty. There is no complete and systematic treatise 
 on the subject, and the disease is of exceedingly practical importance, in 
 consequence of the great suffering to which it gives rise, and its frequent 
 occurrence in our own country, and from the fact of its being not unfre- 
 quently overlooked, or confounded with some other disease. It is also 
 highly interesting from the circumstance that it admits, if well understood 
 and judiciously treated, of speedy and complete relief without resorting to 
 
IV PREFACE. 
 
 the grave operation of M. Boyer, or any other serious or formidable 
 measure. Whilst on the other hand, when not well understood, it is 
 liable through misdirected measures to be seriously aggravated. Great good 
 may be done by one well acquainted with the disease, while much harm by 
 one who treats it ignorantly. 
 
 Anal fissure is by no means uncommon in this country, although some 
 eminent authors are of opinion that the disease, as described by M. Boyer, 
 is extremely rare, being scarcely ever observed by American practitioners. 
 The able and highly accomplished medical writer, Dr. Reynell Coates, of 
 Philadelphia, who is the author of the most able production on anal fissure 
 in this country, remarked in 1841, that — "We have never met with it, 
 either in public or in private practice, and several eminent surgeons in 
 Philadelphia declare that it has not occurred under their observation." 
 (American Cyclopaedia of Practical Medicine and Surgery. Vol. II. p. 
 118. Philadelphia, 1841.) That this disease is not rare or uncommon in 
 this country, the author himself has had ample opportunities of verifying, 
 during a practice of thirty years in the cities of New Orleans, La., Louis 
 ville, Ky., and New York ; having within this period treated, he is sure, 
 more than a thousand cases. This, it seems to him, must be the experience 
 of every surgeon of extensive practice, especially of those in our large cities. 
 
 So far as the author's treatment of this disease is concerned, he has nothing 
 new to offer in this work. He has no novel method to recommend, which, 
 by some species of coup de main practice, would hold out to both the sur- 
 geon and the patient an instantaneous or miraculous cure, by which to 
 excite the enthusiasm of the former and the hopes of the latter. He has 
 only recommended a steady and a skilful perseverance in carrying out the 
 practice of well known, long tried, and safe measures to a successful issue ; — 
 hence he is aware that his treatment will be unattractive to those purely 
 surgical enthusiasts who delight more in obtaining their ends by a prompt 
 recourse to the knife, or to manual force, than by the milder, safer, and 
 surer measures offered in the judicious practice of a long tried, less ostenta- 
 tious, though much more solid and conservative method of cure. 
 
 In this work, besides the method especially adopted and recommended 
 by the author, he has, as far as his knowledge extends, fully given all other 
 methods, from the earliest times, with all the improvements, down to the 
 present ; and, for the benefit of the student as well as the practitioner, this 
 has been done in as succinct, as practical, and as accessible a form as possible, 
 or as the nature of the case would admit. 
 
 It may be alleged by the learned and the experienced that, in treating 
 such an apparently simple subject as anal fissure, the author has been too 
 prolix, too diffuse ; but let it be remembered that he has not written entirely 
 
PREFACE. V 
 
 nor even principally for these. " Doctis indoctisque scribimus" It is the 
 great aim of the author to make that which is true, rather than that which 
 is new, more generally known through all the ranks of the profession. 
 
 Should this work, as the author humbly trusts it may, aid in clearing the 
 diagnosis of anal fissure and spasmodic contraction of the sphinctores ani ; 
 or in removing some of the obscurities, perplexities, and doubts to a clear 
 understanding of the true character and treatment of fissure of the anus, 
 he will feel amply rewarded for his labor. But, whether this expectation is 
 realized or not, he has at least endeavored, to the best of his ability, to 
 accomplish all that an individual under such circumstances could hope to 
 effect, by candidly and fully submitting to the profession everything on this 
 subject which a considerable experience, both in reading and in practice, has 
 instructed him. 
 
 In conclusion, the author would observe that he has illustrated this work 
 by a number of diversified cases, some of which he treated many years ago, 
 and by numerous drawings. The instruments represented by some of these 
 were manufactured at the old established house of Messrs. George Tiemann 
 & Co., No. 6j Chatham Street, New York. The intelligence and the in- 
 genuity of the members of this firm, as surgeons' artists, the author has had, 
 for a number of years, the most ample opportunities of witnessing. 
 
 New York, October,. 1868. 
 
TABLE OF CONTENTS. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 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 identi- 
 cal 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 con- 
 traction of the sphincter ani muscle, and that this painful contraction indeed consti- 
 tuted 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 
 
Vlii TABLE OF CONTENTS. 
 
 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, how- 
 ever, both he and they are mistaken, for nearly three hundred years before he or 
 they promulgated this idea, the celebrated French surgeon, Ambrose Pare, accu- 
 rately 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 con- 
 sideration 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 perma- 
 nent 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 com- 
 ments upon the same 21-40 
 
TABLE OF CONTENTS. IX 
 
 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 what- 
 ever 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 char- 
 acteristic 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 char- 
 acter, 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 sub- 
 ject of physiology. It is an idiopathic disease of the mucous membrane of the infe- 
 rior 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 sensi- 
 bility 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 
 
X TABLE OF CONTENTS. 
 
 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 physio- 
 logical function between the involuntary and voluntary system of nerves. The sup- 
 position 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 involun- 
 tary. 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 evacua- 
 tion, may be a cause of anal fissure. Anal fissure is sometimes the result of inflam- 
 mation, and the attendant turgescence of the mucous membrane of the anal canal. 
 It also sometimes results from the excoriations produced by the vitiated and irrita- 
 ting discharges in dysentery, diarrhoea, cholera, and other visceral diseases. Obstinate 
 ulcers or fissures are sometimes produced in the fossa between the two anal sphinc- 
 ters, 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 secre- 
 tions 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 disten- 
 tion, 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 vio- 
 lence 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 
 
TABLE OF CONTENTS. XI 
 
 accordance with their location. Some authors think such distinction of no therapeu- 
 tical 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 pecu- 
 liar 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 character- 
 istic 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 phenom- 
 enon. 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 posi- 
 tion of the patient and the manner of making the exploration. The external appear- 
 ance 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 exami- 
 nation 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 com- 
 plications of anal fissure. . 90-103 
 
 CHAPTER V. 
 
 THE TREATMENT. 
 
 Section I. 
 
 Precautionary and Palliative Measures. — It is highly important to the suc- 
 cess 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 trans- 
 mission 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. 
 
Xll TABLE OF CONTENTS. 
 
 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 medi- 
 cation 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 Divi- 
 sion 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 dif- 
 ferent 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 
 
TABLE OF CONTENTS. Xlll 
 
 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 instru- 
 ment, 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 divi- 
 sion 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 opera- 
 tion. Pages 1 19-147 
 
 CHAPTER VI. 
 
 CONCLUSION. 
 
 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 com- 
 plicated with a small blind internal fistula — the patient having been treated several 
 months for internal irritable piles. Case IV. Anal fissure of an aggravated char- 
 acter, 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 rec- 
 tum. Case VII. Anal fissure complicated with a blind internal fistula. Case VIII. 
 Highly irritable ulcer, situated in the fossa between the external and internal sphinc- 
 ter 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, 
 
XIV TABLE OF CONTENTS. 
 
 persistent diarrhoea, and procidentia ani. Case XI. Anal fissure, previously diag- 
 nosed 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 diar- 
 rhoea. The true nature of the case having been overlooked, it was treated severally 
 as dyspepsia, anal neuralgia, and internal piles. Case XIII. Anal fissure compli- 
 cated 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 spermator- 
 rhoea. Case XV. Anal fissure the result of the application of nitric acid to the mu- 
 cous 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 pros- 
 tate 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 gen- 
 eral health was much impaired. Case XXVIII. Anal fissure the result of obstinate 
 constipation of the bowels, and the passage of scybalous faeces. Case XXIX. Ir- 
 ritable ulcer, situated in the fossa between the external and internal sphincter of the 
 anus Pages 151-192 
 
 Section II. 
 
 Bibliography. 192-199 
 
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 diag- 
 nosis, aided by a careful study of the physical signs of 
 disease. 
 
 The ignorance on the subject of the diseases of the rec- 
 tum 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 con- 
 sidered 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 igno- 
 rance 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 suf- 
 fering 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 num- 
 ber 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, doubt- 
 less, of the great severity of these cases, and especially of 
 
ANAL FISSURE. 5 
 
 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, in- 
 asmuch 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 raga- 
 des ou fissures sont de petits ulceres douloureux, piquans et 
 sans grosseur, qui suivent la longueur des rides du fonde- 
 ment, 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 
 
ANAL FISSURE. 
 
 Boyer, " from what M. Lemonnier says, that he understood 
 the disease called fissure of the anus. But this malady 
 which he describes, is it the same which I myself have 
 observed? I do not believe it." M. Boyer did not consider 
 that the fissura ani spoken of by Albucasis and other 
 ancients, nor that mentioned by Sabatier and so well 
 described by Lemonnier, could have been similar to that 
 which he himself had observed and treated; because no 
 particular mention is made by these authors of the agoniz- 
 ing pain and the anal spasm which sometimes accompany 
 this disease ; and because the measures they had recom- 
 mended and adopted were, as they themselves declare, 
 completely successful in curing it; whereas all the patients 
 that had come under the immediate care of himself for 
 the treatment of anal fissure, had suffered the most exqui- 
 site pain, attended by violent spasmodic contraction of the 
 sphincter ani, and had previously employed every variety 
 of application that could be suggested capable of procuring 
 relief without affording the least permanent benefit. In 
 another place Boyer again refers to the same subject in the 
 following language : — " Tel est le resultat de mes observa- 
 tions sur une maladie jusqu'a present meconnue, et contre 
 laquelle on a employe des remedes tres-souvent inutiles, 
 quelquefois nuisibles, et toujours insuffisants." — (fTraite 
 des Maladies Chirurgicales, 'Tome Z 7 /., p. 614. Cinqideme Edit. 
 Paris, 1849.) 
 
 From these several premises this celebrated surgeon comes 
 to the conclusion that the disease which he denominates 
 fissure of the anus, if it was not a recent disease, or un- 
 known, was, at least previous to his own time, never 
 observed with attention, neither was it accurately described, 
 nor correctly treated by any one. Now from this sweeping 
 conclusion of M. Boyer, who furnishes no adequate detail 
 of the facts upon which his opinions rest, I most respect- 
 fully beg leave to dissent in toto, simply because I believe 
 
ANAL FISSURE. 7 
 
 his premises are not founded in truth. He has done both 
 the ancients and the moderns more or less injustice, as I 
 shall fully demonstrate before I dismiss the subject. From 
 the high position of this author, the extensive circulation 
 of his views upon this subject, and the consequent influence 
 his opinions must have upon the medical profession, not 
 only in his own but in other countries, it becomes a ques- 
 tion of no little moment, how far those views are founded 
 upon a rigid induction of facts; for without these, theories 
 in medicine are at least worthless, if not pernicious in their 
 results. The adroit and skilful manner in which M. Boyer 
 handles the subject of this disease, and the highly chaste 
 and classic language in which he clothes his opinions, are 
 so fascinating that his doctrine finds a ready reception in 
 the unwary mind. On this account, the very plausible 
 theory which he has advanced cannot be examined with 
 too much freedom. It is here important to inquire what 
 the ancients considered fissure of the anus to be, and to 
 compare their description of it with that given it by Boyer 
 himself, so as to be able to determine the difference between 
 them. I will show that the ancients considered it to be 
 precisely what they termed it, or what its name imports — 
 a superficial breach of surface simply, of a peculiar form, 
 situated within or immediately without the anal orifice, and 
 attended with more or less sharp or burning pain. I will 
 also show that what M. Boyer considers anal fissure to be is 
 altogether a much more complicated affair, and that this 
 term, when applied to what he believes this disease in 
 reality to be, is a misnomer and has no significance. Pain- 
 ful spasmodic contraction of the sphincter ani muscle is 
 in reality the anal fissure of M. Boyer ; but it was not the 
 fissure of the ancients, for they do not even name spasm 
 of the sphincter ani when speaking of anal fissure. They 
 doubtless witnessed anal spasm, and when they did so, they 
 considered it as an independent, or a separate and distinct 
 
8 
 
 ANAL FISSURE. 
 
 disease altogether, as I will show some of the moderns 
 have since done and continue now to do. Anal spasm 
 attended anal fissure in the times of the ancients as it does 
 now. The disease has never undergone any change in this 
 respect, being precisely the same now as it was then. The 
 ancients only erred in not recognizing anal spasm as one of 
 the signs of anal fissure, but considered it an entity ; hence 
 they failed to this extent in giving it a full description. 
 Many of the moderns, however, with all their advantages, 
 are no better in this respect, as they have committed and 
 continue to commit the same error. I will show, however, 
 that M. Boyer can have an anal fissure without any breach 
 of surface, without a fissure, for he teaches that the spas- 
 modic contraction of the sphincter ani constitutes the 
 disease called fissura ani, that it exists as an idiopathic 
 affection, whether attended by a fissure or not; and not 
 only so, but that the anal spasm is the primary as well as 
 the principal morbid condition ; and even that it is one of 
 the most remarkable predisposing causes of anal fissure. 
 I have thus briefly stated the main points of difference 
 between the ancients and M. Boyer on this subject, and it 
 will be observed that whilst the former consider the disease 
 to consist merely of a superficial idiopathic lesion, attended 
 by more or less sharp or burning pain, &c, the latter con- 
 siders the disease to consist of a painful spasmodic con- 
 traction of the sphincter ani, whether attended by any 
 lesion or not, &c. 
 
 I will now proceed to the proof. It will be conceded 
 by all who are familiar with the little that is said in the 
 writings of the ancients on this subject, that they included 
 in the term fissura ani every superficial lesion about the 
 anus, or inferior extremity of the rectum, in the form of 
 fissure, chap, crack, rhagade, excoriation, abrasion, &c. 
 The ancients are silent with regard to the spasmodic con- 
 traction of the sphincter ani muscle, a phenomenon which 
 
ANAL FISSURE. 
 
 sometimes attends anal fissure in its advanced or aggravated 
 stage ; but, at best, this spasm of the sphincter is nothing 
 but one of the symptoms, effects, or evidences of the fissure, 
 and not the disease itself. The rationale of the phenomenon 
 is, that the sphincter ani is brought into this exalted action 
 solely in consequence of the irritation of the fissure upon 
 the mucous membrane within the grasp of the muscle, and 
 the influence of reflex nerve action. The ancients, as 
 before observed, doubtless witnessed cases in which this 
 hyper-action of the sphincter existed, and if they did they 
 might naturally enough have come to the erroneous con- 
 clusion that it was a disease of the muscle itself, being 
 spasmodic in character and separate and distinct in its 
 nature ; and this would seem the more especially so, since it 
 was extremely difficult then, under the most favorable circum- 
 stances, to make such an exploration as would result in the 
 detection of a fissure or of any other disease of the anal canal, 
 at least whilst the anal spasm lasted. Now if this supposi- 
 tion in relation to the ancients be true, then they were to a 
 considerable extent excusable for embracing this error, sur- 
 rounded as they were by so many unfavorable circumstances 
 towards making a proper inspection of the parts. Not so, 
 however, those of the present day, with anaesthetics, the 
 speculum and endoscope, who hold precisely similar errors 
 in relation to spasmodic contraction of the sphincter ani. 
 
 The celebrated Grecian, Paulus iEgineta, in his most 
 admirable synopsis of the medical literature of the ancients, 
 says, and very correctly too, that, — "Fissures are occasioned 
 principally by hard fseces, and being slow of granulating, 
 owing to their callosity, must be converted into recent 
 ulcers by paring (excoriating, scarifying, or incising) them 
 with the nails, or a scalpel; when they may be made to 
 granulate by proper applications." — (Libri Septem. Lib. VI., 
 cap. 80, English Version, by Adams. Vol. IL, p. 405. London, 
 1846). 
 
10 ANAL FISSURE. 
 
 Albucasis was perhaps the first who recommended simple 
 incision of the mucous membrane, or of the fissure, as a 
 remedy in anal fissure. As has already been noticed, he 
 advised the fissure or fissures to be excoriated with the 
 nails, or incised or scarified with a cutting instrument. 
 (Chirurgi Methodus Medendi, Lib. IL, cap, 8i,/>. 633, Chan- 
 ning's Edition?) 
 
 iEtius, however, of all the ancients, has given the most 
 comprehensive account of condylomata and fissures of the 
 anus. When speaking of the latter he seems to have 
 already had reference to spasmodic contraction of the 
 sphincter ani. He advises the old fissures to be treated by 
 paring, or by scarifying their edges with a sharp instrument, 
 and then applying suitable dressings, &c. (Medici Graci 
 contracted ex veteribus Medicine 'Tetrabiblos hoc est Quarternio. 
 Tetr. W., serm. 2, cap. 3. Basil, 1542. Folio. ,) 
 
 I would now ask, what have the moderns any better, so 
 far as the treatment of anal fissure is concerned, than the 
 ancients had ? The main indication in the treatment of 
 this disease then was precisely what it now is, — namely, 
 to convert the original fissure into a recent wound. This the 
 ancients accomplished by incising or scarifying the fissure, 
 and by making various applications to it. It is here worthy 
 of remark, that a fresh wound made in the diseased 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. The ancients seem to have made the discovery 
 that such a wound produced at first nothing more than a 
 common soreness, but it at the same time entirely relieved 
 the pain and cured the original disease, — hence they recom- 
 mend and practised incision or scarification of the fissure, 
 the same as now advocated and adopted by many at the pres- 
 ent day. On the authority of the late Sir Benjamin Brodie, 
 the late Mr. Copeland was the first surgeon who, in modern 
 
ANAL FISSURE. 11 
 
 times, advised incising the mucous membrane simply, 
 through the fissure, instead of complete division of the 
 sphincter of the anus, as advised by M. Boyer. The an- 
 cients also used various applications, as before observed, to 
 the fissure, which, by converting the primitive or original 
 lesion into a recent or fresh one, thus ultimately healed it. 
 If the fissure is even attended by a spasmodic contraction 
 of the sphincter ani, 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. 
 
 Now, it will at once be perceived that, if the ancients 
 taught such dogmata in relation to anal fissure as represented 
 by M. Boyer, they were entirely ignorant of the nature, 
 cause, and treatment of this disease. But before passing 
 this severe judgment upon the tenets of our great fore- 
 fathers in medicine, it would be well for us to investigate 
 their doctrines on this subject more accurately than M. 
 Boyer appears to have done in this instance. My opinion 
 is, that the views held by the ancients with regard to the 
 nature, cause, and treatment of this disease, although more 
 or less mixed with error, were more rational than those 
 promulgated by M. Boyer himself. It is true that the 
 ancients do not give so full and so graphic a description of 
 it as he does, but they may have thought that the simpli- 
 city of the disease did not require it at their hands. From 
 what M. Boyer says, he doubtless believed that he himself 
 was the first surgeon who made the discovery, and who 
 subsequently taught the doctrine, that anal spasm always 
 accompanied anal fissure, that it was its characteristic or 
 pathognomonic sign; indeed all his admirers attribute to 
 him the origination of this idea of including spasmodic 
 contraction of the sphincter ani — this sine qua non of his — 
 in the term fissura ani. In this, however, as in some other 
 opinions relative to this subject, he and they are most 
 egregiously mistaken, for I will now show that nearly three 
 
12 ANAL FISSURE. 
 
 hundred years before he promulgated this idea, the disease 
 called anal fissure was described as not only consisting of a 
 painful or irritable ulcer or fissure, but also of a contraction 
 of the anus. Had M. Boyer consulted the works of his 
 own countryman, the celebrated surgeon Pare, who flourished 
 about the year 1 552, he would have found almost as 
 graphic a description of fissure of the anus as that which 
 he himself has given. I regret I have not a French copy 
 of the works of Pare to quote from, but am obliged to 
 use the English translation by Mr. Johnson, which is said, 
 however, to have been translated from the Latin and care- 
 fully compared with the French edition. Pare under the 
 head, — " Chapps, and those wrinkled and hard Excrescences which 
 the Greeks call Condylomata" says : — " Chapps or fissures are 
 cleft and very long little ulcers, with paine very sharpe and 
 burning, by reason of the biting of an acride, salt and dry- 
 ing humour, making so great a contraction, and often times 
 narrowness in the fundament and necke of the wombe, 
 that scarcely the toppe of one's finger may be put into the 
 orifice thereof, like unto pieces of leather or parchment, 
 which are wrinkled and parched by holding of them to 
 the fire. They rise sometimes in the mouth, so that the 
 patient can neither speake, eat, nor open his mouth, so that 
 the Chirurgian is constrained to cut it. In the cure thereof, 
 all sharpe things are to be avoided, and those which mollifie 
 are to be used, and the grieved part or place is to be 
 moistened with fomentations, liniments, cataplasmes, em- 
 plasters, and if the malady bee in the wombe, a dilater of 
 the matrix, or pessary must be put thereinto very often, so 
 to widen that which is over hard, and too much drawn 
 together or narrow, and then the cleft little ulcers must be 
 cicatrized." (The Workes of 'That Famous Chirurgion Ambrose 
 Pare. Translated out of Latin and compared with the French. 
 By Th. Johnson. Book XXIF., Chap. Ixiii., p. 957. London, 1634. 
 Folio.} It is thus seen that M. Pare here furnishes us with 
 
ANAL FISSURE. 13 
 
 a brief, yet a very comprehensive and correct description 
 of anal fissure, consisting of cleft and very long little ulcers, 
 situated in the orifice and canal of the anus, attended by 
 very sharp burning pain, and often by great contraction or 
 narrowing of the anus. M. Boyer has, as I have previously 
 shown, emphatically declared that previous to his time anal 
 fissure, as it was presented to him in the numerous cases 
 which he treated, was unknown; inasmuch as he had 
 sought in vain, in the writings of the ancients as well as in 
 those of the moderns, to find a description of it ; and M. 
 Blandin, one of his admirers, says that spasm of the 
 sphincter ani, one of the varieties of anal fissure, was un- 
 known till lately. M. Blandin also says that M. Lemonnier 
 was really the first surgeon who has given any description 
 of fissura ani. From this it is evident that M. Blandin 
 was ignorant that M. Pare, one hundred years before, had 
 given a much better description of anal fissure. M. 
 Velpeau also, in alluding to M. Boyer's description of fissure, 
 says that fissure of the anus was not in reality known as a 
 distinct disease until after the year 1822. I, however, have 
 shown that M. Pare, three hundred years before 1822, gave 
 as correct a description of anal fissure as M. Boyer or any 
 one else. 
 
 For the treatment of this disease M. Pare recommends 
 various applications to be made to the fissure, the dilatation 
 of the contracted orifice, cutting, and the cicatrization of 
 the ulcer or ulcers. I ask, what more is known of this 
 disease at the present time ; or what more is done to relieve 
 it, than we find briefly stated by M. Pare*? The same 
 disease, says this quaint author, attacks the neck of the 
 womb, and requires the same kind of treatment. I myself 
 have for a number of years adopted the idea which is here 
 singularly enough suggested, that the disease which is im- 
 properly denominated Dysmenorrhea, is in reality nothing 
 more nor less than fissure of the os tinea ; and I have so treated 
 
14 ANAL FISSURE. 
 
 it with remarkable success, — namely, by the application of 
 a strong solution of the nitrate of silver three times a week, 
 and gentle and gradual dilatation with an elastic bougie 
 once or twice a week. That dilatation exerts a powerful 
 influence in curing dysmenorrhoea, is evidenced by the 
 known fact that if the patient could become pregnant and 
 give birth to a child she would be cured. In painful men- 
 struation, there will almost always be found, besides spas- 
 modic contraction of the os tincse, either fissures, abrasions, 
 excoriations, inflammation, or tumefaction. 
 
 Mr. Mackintosh, so long ago as in 1823, gives in his 
 very able work on the " Principles of Pathology and Practice 
 of Medicine" an ingenious theory on dysmenorrhoea. He 
 believes that in this disease there exists constriction of the 
 canal of the cervix uteri, — hence he practised dilatation 
 with much success. I am aware, however, that there are 
 those who look upon dilatation of the os tincse by a bougie 
 with great distrust, considering it as a very dangerous and 
 hazardous operation; yet strange, passing strange, these 
 very same surgeons do not hesitate for a moment to thrust 
 into the os tincse a large prepared sponge tent, which is 
 known to be attended by far greater danger than by the 
 gentle and gradual dilatation of an elastic bougie. 
 
 M. Pinel Grandchamp, on the authority of Mr. F. Le 
 Gros Clark, entertains a similar opinion in relation to the 
 liability of fissure attacking the vulva, that M. Pare did in 
 relation to its liability of attacking the os tincse. Mr. F. 
 Le Gros Clark says that, — " This fissure, connected with 
 painful spasm of the sphincters of the anus, had been ob- 
 served only in the anal region, until M. Pinel Grandchamp 
 remarked a similar condition of the vulva, where the con- 
 striction was so firm that the marriage rites could not be 
 fulfilled. Feeling convinced of the analogy of this case 
 with stricture of the anus, Grandchamp made a deep in- 
 cision, dividing the commissure, the mucous membrane, 
 
ANAL FISSURE. 1J 
 
 and the sphincter of the vulva, to the extent of two inches. 
 The contraction was cured, and the parts resumed their 
 normal condition." {Baron Dupuytren's Clinical Lectures. 
 Translated by F. Le Gros Clark, p. 149. London, 1845.) But 
 I must stop here, as this digression has perhaps already been 
 carried too far. 
 
 For the purpose of the better elucidation of this subject, 
 I would observe here that anal fissure might be distinguished 
 into two stages. In the first stage the idiopathic disease of 
 the mucous membrane, or muco-cutaneous coat of the part, 
 has not yet arrived at that degree of irritation or excitation 
 as to result in communicating its excitability to the muscular 
 coat, or to the fibres of one or both sphincter ani muscles, 
 inducing in them spasmodic contraction; for after the first 
 manifestation of the disease, some time must necessarily 
 elapse before spasmodic contraction takes place, and this 
 period, be it longer or shorter, constitutes the first stage of 
 the disease. In the second stage the primary disease has 
 arrived at that extreme degree of excitability as to induce 
 spasm of one or both sphincters of the anus, after every 
 movement of the bowels, or other disturbance of the parts. 
 Any idiopathic disease of the mucous membrane of the 
 inferior extremity of the rectum, immediately over or 
 within the grasp of the sphinctores ani, is liable sooner or 
 later to become so irritable as to induce spasm of those 
 muscles; indeed, disease in the genito-urinary organs is 
 liable also to produce the same, and often does. The chief 
 error, then, of the ancients consisted in omitting the second, 
 or that stage manifested by anal spasm ; that of some of 
 the moderns, in considering the second or spasmodic stage 
 as the real or idiopathic disease, and so treating it ; whilst 
 the error of other moderns again consists in considering 
 each stage as a separate and independent disease, denomi- 
 nating the first, anal fissure, and the second, spasmodic or 
 gainful contraction of the sphincter ani. 
 
]6 ANAL FISSURE. 
 
 I have already given what in my opinion were the reasons 
 why the ancients omitted anal spasm in describing anal 
 fissure, — namely, that they considered it as a different or an 
 independent disease altogether, as many of the moderns 
 have since done and now do. This, however, is conjecture 
 merely, as there is no positive evidence of it in any of 
 their writings, as far as my knowledge extends. 
 
 Our attention will now be turned to the theory of those 
 of the moderns who teach that anal spasm, the second stage 
 of anal fissure, is itself in reality the idiopathic or real dis- 
 ease, of which the breach of surface, or fissure, if any 
 exists, is but an accidental accompaniment, or consequence, 
 &c. This spasmodic contraction, however, is a phenomenon 
 which may or may not accompany fissure of the anus. It 
 is not the anal spasm that constitutes the disease, for anal 
 fissure may exist without this arbitrary contraction; but 
 such contraction of the sphinctores ani never exists without 
 an irritable fissure, an inflammation, a tumefaction, or some 
 other primary disease of the inferior extremity of the 
 rectum ; or of some disease of the genito-urinary organs. 
 This is the true doctrine, notwithstanding the declarations 
 to the contrary of such highly eminent surgeons as MM. 
 Boyer, Dupuytren, Brodie, and others. Their declarations, 
 however, have never been verified in any one instance by 
 any satisfactory ante- or post-mortem examination, and rest 
 merely upon assertion. I have very carefully examined, in 
 every conceivable manner, a large number, of cases, some 
 under the influence of anaesthetics and others not ; and I 
 have yet to observe the first case of painful spasm of the 
 anus, that could not be plainly traced to primary disease in 
 the mucous membrane of the part, or to some disease in 
 the genito-urinary organs. These authorities seem to fix 
 their whole attention on the local spasm of the sphincter 
 ani, as if that condition of the muscle constituted the 
 essence of the disease of which it is in truth only a symp- 
 
ANAL FISSURE. IJ 
 
 torn ; hence their whole treatment is directed to the meas- 
 ures to remove the spasm, instead of such as would attack 
 its cause, the real disease. On this subject, however, M. 
 Boyer seems to have some doubts, not being so emphatic, 
 so decided, as MM. Dupuytren and Brodie. He says, — 
 "Si nous mettions plus d'importance a suivre un ordre 
 tres methodique, qu' a bien caracteriser une maladie incon- 
 nue jusqu'a present, nous n'aurions pas commence cet article 
 par la description de la fissure. En effet, la gercure de 
 l'anus est constamment accompagnee de la constriction 
 spasmodique des sphincters ; mais cette constriction existe 
 quelquefois sans gercure, peut-etre meme celle-ci n'est-elle 
 qu'un effet ou une complication de la premiere. Nous 
 avons observe bien plus souvent la fissure, ou, si l'on veut, 
 la constriction avec fissure, que la constriction sans fissure. 
 Nous avons trouve entre le nombre relatif de ces deux ma- 
 ladies, ou de ces deux etats de la meme maladie, le rapport 
 de neuf a un : voila notre excuse. II est probable cepen- 
 dant que, lorsque la constriction et la gercure existent, ces 
 deux affections n'ont pas commence simultanement ; ou la 
 gercure a araene la constriction, ou la constriction a precede 
 la gercure ; de sorte que l'une de ces affections serait prim- 
 itive, et l'autre accessoire ou consecutive ; mais je n'ai jamais 
 vu de gercure sans constriction, et j'ai plusieurs fois ren- 
 contre celle-ci sans fissure. L'incision des sphincters fait 
 disparaitre la fissure, sans qu'il soit necessaire de porter sur 
 elle l'instrument tranchant. 
 
 " On pourrait presumer d'apres cela, ce me semble, que 
 l'affection principale est le resserrement spasmodique." — 
 (Traite des Maladies Chirurgicales. ^ome Fl. p. 609. Cm- 
 quieme Edit. Paris \ 1849.) 
 
 On this subject M. Dupuytren says: — "La gravite de 
 cette affection depend done principalement du spasme dou- 
 loureux des constricteurs de l'anus ; la fissure n'est meme 
 
 qu'un accident ; ce qui le demontrerait e'est l'existence de 
 
 2 
 
l8 ANAL FISSURE. 
 
 la constriction douloureuse sans gereure, qui, d'apres des 
 chirurgiens celebres, serait a l'autre cas comme l est a 4." 
 
 And again M. Dupuytren says : — " La constriction spas- 
 modique du sphincter, avons-nous dit, est la lesion veritable ; 
 (l'ulceration alongee, nommee fissure ou gercure, n'est qu'un 
 phenomene secondaire." — (Lecons Orales de Clinique Chirurgi- 
 cale. Tome III. Article X. pp. 51-52. Bruxeltes, 1836.) 
 
 I have presented MM. Boyer and Dupuytren fully and 
 fairly in their own language, and it will be perceived that 
 they both teach that the spasmodic contraction of the 
 sphinctores ani muscles is the primary or real disease, and 
 that the elongated ulcer called fissure of the anus is but a 
 secondary phenomenon. They believed that by curing the 
 anal spasm the disease was cured ; hence M. Boyer pro- 
 posed to remove the constriction by the complete division 
 of the two sphincters of the anus with the bistoury ; whilst 
 M. Dupuytren proposed to fulfil the same indication by the 
 anti-contractile property of belladonna, applied to the parts in 
 the form of his celebrated ointment, prepared according to 
 his favorite formula, as follows : — 
 
 Recipe, Extracti Belladonnae, 
 
 Pulveris Plumbi Acetatis, ana, drachmam unam, 
 -'' ■ Adipis Suillae, drachmas sex. 
 Misce et fiat unguentum. 
 
 It will be observed that whilst the theory of these two 
 celebrated surgeons is nearly identical, the treatment of each 
 differs very essentially; that of M. Dupuytren is the most 
 rational, however, and has in several respects decidedly the 
 advantage, inasmuch as his ointment, while it tends to relax 
 the constricted muscles, at the same time heals the fissure, 
 which is the primary cause of the constriction, is attended 
 with but little danger and leaves no subsequent bad results. 
 
 Sir Benjamin Brodie considered the elongated ulcer, 
 called fissure of the anus, as the result of the spasmodic 
 contracted and hypertrophied sphincter ani; and to the 
 
ANAL FISSURE. K) 
 
 morbid action of this muscle he ascribed the severe suffer- 
 ing and distress which always attend anal fissure. — {Clinical 
 Lectures on Surgery. Led. xxxvi. p. 322. Philadelphia Edition, 
 1846.) 
 
 I will now present the opinions of MM. Blandin, San- 
 son, Quain, and Bushe on this subject, in opposition to the 
 theory of MM. Boyer, Dupuytren, and Brodie. 
 
 M. Blandin makes the following very pertinent remarks 
 on this subject. He says : — " Suivant M. le professeur 
 Boyer, dont l'opinion est d'un si grand poids dans tout ce 
 qui a trait a notre science, et a ce point de chirurgie en par- 
 ticulier, la constriction spasmodique de l'anus precede le 
 developpement des fissures les plus graves, et doit en etre 
 considered comme la plus remarquable predisposition. II 
 est impossible de douter que cet etat de l'anus, lorsqu'il 
 existe, ne dispose a la fissure, mais nous ne pouvons nous 
 empecher de dire ici que nous croyons que le spasme de 
 l'anus est bien plus souvent Peffet que la cause de la fissure 
 a l'anus. La contraction spasmodique du sphincter arrive, 
 parce que l'anus est irrite par l'inflammation de la fissure ; 
 elle est tres-forte quand la fissure est tres-enflammee, surtout 
 elle s'accroit par le passage des matieres fecales pendant les 
 excretions, pour la merae cause. Le sphincter anal se con- 
 tracte sous Pinfluence de l'irritation de la fissure, comme 
 l'estomac, comme l'intestin se contractent lors de l'irritation 
 ou de l'ulceration de la tunique muqueuse qui les tapisse. 
 Que si Ton objectait que certaines fissures seulement sont 
 accompagnees de la contraction spasmodique du sphincter, 
 nous repondrions que la chose ne doit point surprendre ; 
 car le sphincter se ressent seulement de l'influence de l'irri- 
 tation de la muqueuse qu'il embrasse, et que par con- 
 sequent les fissures qui lui sont superieures ou infe- 
 rieures, ne devaient pas etre accompagnees de la con- 
 traction, tandis qu'il en devait etre et qu'il en est autre- 
 ment de celles qui siegent en dedans de lui." — (Dictionnaire 
 
20 ANAL FISSURE. 
 
 de Medecine et de Chirurgie Pratiques. Home Fill. p. 157. 
 Paris, 1832.) 
 
 M. Sanson says : — " Nous croyons au contraire que la 
 fissure ou au moins l'irritation de la partie, precede et pro- 
 voque la constriction spasmodique." — (Nouveaux Elements de 
 Pathologie Medic o-Chirurgic ale. Home III. p. 635. Quatrieme 
 Edit. Paris, 1844.) 
 
 The able and distinguished Mr. Ouain is very clear and 
 very emphatic upon this subject, and his argument is indeed 
 unanswerable. He says : — " The spasm of the sphincter 
 in fissure is no more the actual disease than the spasm of 
 the orbicidaris palpebrarum is that curious and painful malady 
 so often met with among children, strumous ophthalmia. 
 The passage of fecal matter is in the one case, what the 
 stimulus of light is in the other. The muscular contraction 
 is equally intense in both ; and the division of the muscle 
 is no more necessary for the cure of the one, than of the 
 other. Doubtless the spasm very largely aggravates the 
 suffering in both instances. Its cessation, however, in the 
 complaint (fissure) we are especially engaged with, by di- 
 vision of the ulcer and the mucous membrane only, proves 
 sufficiently that the muscle is not the seat of the disease." 
 — (Hke Diseases of the Rectum. Second Edition, p. 176. New 
 Tori, 1859.) 
 
 Dr. Bushe on the same subject says: — '' To me it appears 
 illogical to assert that fissure is the consequence, or a com- 
 plication of spasm, because the fissure is always accom- 
 panied with spasm, and spasm sometimes exists without 
 fissure. Now that spasm may cause fissure, I have before 
 explained ; but that fissure may arise from other causes, is, 
 I think, beyond dispute." — {A Treatise on the Malformations, 
 Injuries, and Diseases of the Rectum and Anus, p. 120. New 
 Tori, 1837.) 
 
 M. Velpeau, in order to reconcile somewhat these several 
 conflicting views, says : — " Perhaps, however, there may be 
 
ANAL FISSURE. 21 
 
 some means of reconciling opinions on this interesting 
 point in the history of fissure of the anus. Thus we can 
 understand how a small fissure, being irritated by the pas- 
 sage of stercoraceous matter, may excite spasmodic constric- 
 tion in the muscular bands underneath it ; and again, we 
 can believe that strong spasmodic contraction of the anus, 
 by inducing constipation, may induce excoriation of the 
 skin about the anus, and thus become a cause of fissure. 
 Under this point of view contraction of the sphincter ani 
 and fissure are two distinct affections which are independ- 
 ent, but have a strong tendency to merge, one into the 
 other." — (Clinical Lecture on Fissure of the Anus, in Provincial 
 Medical and Surgical Journal. April 3, 1841.) 
 
 This highly important subject will receive still further 
 elucidation in the next section, while discussing the highly 
 interesting question of the independent existence of anal 
 spasm, especially as being a separate or distinct disease from 
 anal fissure, as taught by a large number of the moderns. 
 
 I would here remark that some of the authors whom I 
 quote in this work make no distinction between the ex- 
 ternal and internal sphincter ani, but speak of both muscles 
 as one, as all the early anatomists do, which they call the 
 sphincter ani, thus confounding both sphincters. When 
 they speak of spasmodic contraction of the sphincter ani, 
 they mean both muscles, and when they speak of incising 
 the sphincter ani, they mean the same. It will be well for 
 the reader to note this, and recognize this distinction. 
 
 -0- 
 
 SECTION II. 
 
 SPASMODIC CONTRACTION OF THE ANUS. 
 
 1. It is well known that nervous irritation in muscular parts 
 often occasions partial and sometimes obstinate contractions ; 
 
22 ANAL FISSURE. 
 
 and when this effect takes place in the anal canal, it consti- 
 tutes what is generally called spasmodic contraction of the 
 anus. In spasmodic contraction, inflammation and nervous 
 irritation are always present in a greater or less degree. 
 With regard to muscular contraction, I would observe that 
 there are three varieties, which can be plainly distinguished 
 in practice : the spasmodic contraction, which can always be 
 dilated to the full size of the canal in which it exists ; the 
 permanent or organic, which admits of no such dilatation, 
 and the mixed kind, which partakes of the characters of 
 both. The two last can not only be detected in life, but 
 can be demonstrated post-mortem. Of the first, however, 
 nothing can be learned by dissection after death, because 
 the spasm depends entirely upon an active principle which 
 ceases with life. It will be readily conceived how a purely 
 spasmodic contraction may be converted into a permanent 
 or mixed one. I am of opinion that a spasmodic contrac- 
 tion almost always precedes a permanent or organic one, 
 upon the principle that the parts, being held so repeatedly 
 and so continuously in a contracted state, ultimately grow 
 rigid and unyielding. Upon the same principle muscular 
 fibres in other parts sometimes become fixed, of which we 
 have an instance in irremediable trismus. 
 
 2. Anal Spasm as an Entity — A Disease in itself. The in- 
 dependent existence of spasmodic contraction of one or both 
 sphincters of the anus is a theory held and taught by some 
 of the most able surgical writers on the diseases of the rec- 
 tum. But as the principle rests purely upon the evidence 
 of facts, fairly and fully ascertained and set forth, they have, 
 in my opinion, failed to establish it. The recorded cases 
 and examinations which they present for the purpose of 
 illustrating and confirming this doctrine, are not given with 
 the detail and with the precision of language which are 
 essentially necessary to render such evidence in surgery a 
 substitute for personal experience. The confusion and 
 
ANAL FISSURE. 
 
 2 3 
 
 conflict of principles in their practical directions are so 
 obvious that the most superficial observer cannot fail to 
 perceive them; for under the head "Spasmodic Contraction of 
 the Sphincter Ani" they enumerate the features of various 
 diseases, not less different in their appropriate treatment 
 than in their setiology and nature ; consequently their at- 
 tempts at making out a clear diagnosis are a complete 
 failure. 
 
 I will now present the names of a number of able authors 
 who have treated anal spasm as an entity — a disease in 
 itself — and who have made it the subject of special consid- 
 eration; and I will endeavor to prove that the numerous 
 cases they present to illustrate this theory of anal spasm are 
 in reality cases of anal fissure, or of some other disease of 
 the mucous membrane of the inferior extremity of the rec- 
 tum, or of disease in the genito-urinary organs, and not 
 cases of primary or independent disease of the sphincter 
 ani muscle itself; and that instead of the phenomenon of 
 spasmodic contraction in these cases being an evidence of 
 primary disease in the sphincter ani itself, it is merely a 
 symptom, or a manifestation of disease in its vicinity. In 
 extenuation, however, of the want of the proper knowledge 
 on this subject on the part of these authorities, it may be 
 observed that the great difficulty and extreme pain always 
 attending an examination per anam, during the continuance 
 of the spasm in these cases, precluded the possibility of 
 making a minute inspection of the parts, so absolutely 
 essential to rendering a clear diagnosis. This great diffi- 
 culty and this severe pain are at the present day annihilated 
 by the use of anaesthetics, and the now common use of the 
 anal speculum as well as the rectal endoscope. 
 
 Spasmodic contraction of the anus, besides being caused, 
 as before observed, by disease of the mucous membrane of 
 the inferior extremity of the rectum, is in some instances 
 consecutive to disease in the genito-urinary organs, as will 
 
2\ ANAL FISSURE. 
 
 be abundantly shown hereafter. As is well known, the 
 rectum, in its course through the pelvis, lies in close relation 
 with the prostate gland, vesiculcz seminales, bladder and urethra 
 in the male, and with the uterus and the vagina in the female. 
 The association of this organ with so many important viscera 
 of the pelvis is so close, both in consequence of their prox- 
 imity and their combined action in the performance of cer- 
 tain functions, that any unusiial excitement of the latter 
 organs is exceedingly liable to extend itself to the former; 
 then how varied and how great must the sympathies be 
 which result from this extensive and multiplied relation of 
 contiguity. 
 
 The first authority I shall adduce will be that of M. 
 Boyer, as he stands at the head of the roll of eminent sur- 
 geons who, in modern times, advocated the doctrine that 
 anal spasm is an entity, an idiopathic disease, as I have 
 shown in the preceding section. He treats of " Constriction 
 with Fissure " and " Constriction without Fissure" and ascribes 
 precisely the same symptoms to both ; but he makes the 
 diagnosis between them to depend upon the presence, in 
 the first, of fixed pain at some point in the contour of the 
 anus or rectum, together with a breach of surface ; whilst 
 in the last these are entirely absent. To illustrate and 
 establish the doctrine that anal spasm is an idiopathic dis- 
 ease — that is, "Constriction without Fissure" — he reports three 
 cases which came under his own immediate observation. 
 These cases, according to his arrangement or series, are 
 numbered three, four, and five. In carefully reading the first 
 of these, headed " Constriction sans gergure" I find that he 
 makes no mention of having made any examination of the 
 anus and rectum, and without such examination, how, I ask, 
 could he determine whether there was a crevice or not ? He 
 seems, however, simply to have taken it for granted that 
 there was none; at least he presents no evidence whatever 
 of this fact. This case must therefore be laid aside as of 
 
ANAL FISSURE. 2$ 
 
 no value in this controversy. In the remaining two cases, 
 four and jive, M. Boyer did make a digital examination of 
 the rectum, consequently I will present them in full in his 
 own language. 
 
 " Obs. IV. — Constriction sansjissure. Laurent Cisterne eprou- 
 va,a Page de trente et un ans, apres une longue constipation, 
 ( des douleurs vives a l'anus, que les efforts qu'il faisait pour 
 aller a la selle rendaient atroces. Des ce moment, les eva- 
 cuations alvines ne purent se faire qu'avec des souffrances 
 inouies, qui duraient quatre a cinq heures. Lorsqu'il etait 
 debout ou couche, il souffrait peu ; mais assis, les douleurs 
 se faisaient sentir plus vivement : il crut done devoir quit- 
 ter son metier de cordonnier." 
 
 "Pendant trente mois, les laxatifs purent seuls produire 
 quelque soulagement ; tous les autres remedes furent sans 
 effet." 
 
 "II entra a l'hopital de la Charite le 26 novembre, 1809. 
 En explorant l'anus, je decouvris, du cote droit, un peu au- 
 dessus de cette ouverture, un point dur, epais et comme cal- 
 leux ; ce point etait tres-douloureux et le siege principal de la 
 douleur pendant les selles. Le sphincter se contractait forte- 
 ment sur mon doigt, surtout lorsqu'il pressait ce point dur. 
 Je mis le malade a la diete et a l'usage des delayants; je pre- 
 scrivis un leger purgatif, le lendemain un lavement, et le 
 jour suivant je coupai le sphincter en travers sur le point 
 dur, epais et douloureux, dont j'ai parle. La plaie se cica- 
 trisa lentement; pendant quelque temps, les matieres fe- 
 cales causerent, en passant sur la plaie et ensuite sur la cica- 
 trice, quelques douleurs obscures ; mais cette partie cessa 
 d'etre sensible, et lorsque, plusieurs mois apres sa sortie de 
 l'hopital, cet homme vint nous voir, comme nous Ten 
 avions prie, il etait parfaitement gueri." — (Op. Cit., p. 617.) 
 
 " Obs. V. — Constriction sans jissure. Alexis Cuby, age de 
 cinquante-deux ans, eprouvait depuis deux ans et demi en- 
 viron, en allant a la selle, des douleurs qui, peu vives dans 
 
26 ANAL FISSURE. 
 
 le commence ment, et se faisant sentir seulement par in- 
 tervalles, devinrent tellement aigues que le malade les com- 
 parait a un fer rouge qu'on lui aurait introduit dans le rec- 
 tum. L'usage des lavements prepares avec des substances 
 narcotiques ne procura qu'un soulagement passager ; tous 
 les autres remedes furent egalement sans succes. Cuby vint 
 me consulter; je lui disqu'une operation seule pourrait mettre 
 fin a ses souffrances. 11 entra a Phopital de laCharite. L'anus 
 etait tellement serre,que mon doigt ne penetra qu'avec peine 
 et en causant de vives douleurs dans rintestin rectum. Vers 
 le cote gauche, je crus sentir une gergure : c'est la que le 
 malade pretendit eprouver les douleurs les plus aigues. 
 
 " Apres avoir prepare le malade pendant quelques jours, 
 je fendis le sphincter sur le point le plus douloureux, sur 
 l'endroit meme ou j'avais cru rencontrer une fissure ; je fis 
 continuer l'usage des meches pendant quarante et un jours. 
 Cet homme sortit de 1'hopital peu de temps apres, pouvant 
 aller depuis un mois a la garde-robe sans eprouver la moin- 
 dre douleur." — {Op. Git, p. 618.) 
 
 It will be plainly perceived from reading the graphic 
 description given of these two cases by M. Boyer, that 
 they were cases of fissura ani, attended by sympathetic 
 spasm of the sphincter ani muscle or muscles, and not an 
 idiopathic disease of these muscles themselves. It is dis- 
 tinctly stated by M. Boyer, that increased pain was induced 
 in each case by pressure with the finger upon a particular 
 spot in the rectum ; and not only so, but he says he dis- 
 tinctly felt, in one case, an induration at the tender point, 
 and to which the patient referred all his sufferings ; in the 
 other case he thought he felt a fissure, an excoriation, or an 
 ulcer at the tender point, and at which the patient claimed 
 to feel the greatest pain. 
 
 These cases were not examined with the speculum ani ; 
 indeed this was not necessary, as the digital examination 
 was alone sufficient to determine them to have been disease 
 
ANAL FISSURE. 27 
 
 of the mucous membrane. They therefore entirely fail, in 
 my opinion, to exemplify the characteristics of the disease 
 which this distinguished author intended them. 
 
 The late and distinguished Mr. Copeland introduced the 
 subject of anal spasm under the head, " Powerful or Dis- 
 eased Action of the Sphincter Muscle." — {Observations on 
 the Principal Diseases of the Rectum and Amis. Second Edition, 
 pp. 48, 132. London, 1814.) Mr. Copeland considered the 
 powerful or diseased action, as he calls it, of the sphincter 
 ani, as an idiopathic affection of the muscle itself, the source 
 of such action. His views upon this subject, however, are 
 somewhat vague and uncertain, and he fails to make out a 
 clear diagnosis. He fails to prove the independent exist- 
 ence of muscular spasmodic contraction; and he also en- 
 tirely fails to make that necessary distinction between a 
 purely spasmodic contraction of the sphincter ani and a mixed 
 contraction of the same — that is, one partly spasmodic, and 
 partly organic, and a permanent or organic stricture of the 
 anus, or anal canal. I will hereafter show how a purely 
 spasmodic contraction of the sphincter ani may result in a 
 permanent or organic stricture of the orifice and canal of 
 the anus ; and also how the same muscle, from the continu- 
 ance of the same cause, may become hypertrophied and in- 
 durated. I will also show that the same muscle is some- 
 times preternaturally large and active, the result of a con- 
 genital malformation. 
 
 Mr. Copeland reports three cases. The first case was 
 evidently not a purely spasmodic contraction of the sphinc- 
 ter muscle, at the time first seen by Mr. C, whatever it 
 might have been originally. It was doubtless the result of 
 chronic inflammation of the mucous membrane of the in- 
 ferior extremity of the rectum, and the contraction, from 
 being at first purely spasmodic, became more or less organic. 
 The same may be said of his second case. In this case the 
 principal contraction was five inches up the rectum, and 
 
28 ANAL FISSURE. 
 
 the sphincter ani was found to be unusually strong and 
 broad. The third case was that of a medical gentleman, a 
 former pupil of the celebrated Mr. Pott. He describes 
 his own case most graphically, and the agonizing pains he 
 endured ; yet gives not the slightest intimation of what he 
 believed to be the true nature and cause of his intolerable 
 and exquisite suffering, more than remarking that his medi- 
 cal friends considered it spasmodic. This was a case of 
 real fissure of the anus, for a better description of anal fis- 
 sure could not have been given than this medical gentleman 
 gave of his own case. Had there been a proper explora- 
 tion of the rectum made in this instance, the fissure would 
 have been easily detected and as easily cured. Here the 
 spasmodic contraction was not the real disease, but the 
 mere effect or symptom of it. 
 
 Mr. Copeland treated these cases rationally, by dilatation, 
 with more or less success. 
 
 Mr. Baillie reported a case of what he called, " Stricture 
 of the Rectum, produced by Spasmodic Contraction of the 
 Internal and External Sphincter of the Anus." — (Medical 
 transactions of the College of Physicians of London. Vol. V. p. 
 136. London, 1815.) x\fter giving a brief description of 
 permanent organic stricture of the rectum, and before de- 
 scribing the case in question, Mr. Baillie says : — " Another 
 kind of stricture, however, occasionally occurs in the rec- 
 tum, much less formidable in its nature, which is very rare, 
 and has hitherto been taken little notice of by practitioners. 
 This is not attended with any diseased structure of the 
 coats of the rectum, but depends upon a contraction, more 
 or less permanent, of the sphincters of the anus." — (Loc.cit) 
 I do not agree with Mr. Baillie when he says that this kind 
 of stricture (meaning spasmodic stricture) is unattended 
 by any diseased -structure of the coats of the rectum, and 
 that it depends upon a contraction, more or less permanent, 
 of the sphincters of the anus. Mr. Baillie, like Mr. Cope- 
 
ANAL FISSURE. 2Q 
 
 land, does not make that distinction between a purely spas- 
 modic stricture or contraction, a mixed one, and a perma- 
 nent or organic one, which is so necessary to a clear con- 
 ception of the subject. This case of Mr. Baillie was 
 doubtless originally purely spasmodic, but had become 
 mixed. He makes the contraction in spasmodic stricture 
 the primary, the real, or the independent disease. His own 
 case, however, does not bear him out in this respect, for it 
 was evidently a case of either anal fissure, or inflammation, 
 or irritation of the mucous membrane of the rectum, or 
 muco-cutaneous coat about the anus. He made no exam- 
 ination of the rectum in this case, except a digital one, and 
 that under the unfavorable circumstances of the anal con- 
 traction being so great that the index finger was admitted 
 with difficulty. A small fissure, hid in the folds of the 
 canal, however, might very easily elude detection by the 
 finger alone. The evident cause of the spasmodic and sub- 
 sequent more or less permanent or organic contraction of 
 the sphinctores ani muscles, in Mr. Baillie's case^ was the 
 sudden translation of the herpetic eruption from the right leg of the 
 patient to the anus and anal canal. This was the direct cause 
 of the structural disease of the inferior extremity of the 
 rectum in this case, and which gave rise, subsequently, 
 to the spasmodic, as well as the more or less permanent 
 contraction which resulted in this case. I will show here- 
 after that cutaneous affections of the anus, or anal region, 
 are often the cause of anal fissure as well as spasmodic and 
 organic contraction of the anus. 
 
 Mr. Gaitskell reported a case of what he termed " Spas- 
 modic Contractions of the Sphincter Ani Muscle." — {Lon- 
 don Medical Repository. Vol.W.p.$\. London, 18 1 5.) Mr. 
 Gaitskell considered the spasmodic contractions in this 
 case as a disease of the muscle itself; for he says in rela- 
 tion to it, that he was induced to consult the valuable work 
 of Mr. Copeland on the diseases of the rectum, in which, 
 
30 ANAL FISSURE. 
 
 under the head "Disease of the Sphincter Muscle" he found a 
 solution of the difficulties which he encountered in the 
 early treatment of it. His description of this case, however, 
 proves it to have been a clear case of anal fissure, for no 
 one at all familiar with that disease could come to any other 
 conclusion, after reading his plain description of it. His 
 treatment was rational and effectual, not being the division 
 of the sphinctores ani. He says he effected a cure of his 
 patient by passing a large bougie up the rectum, night and 
 morning, for two weeks, and keeping the bowels open by 
 castor oil draughts. At first considerable relief was obtained 
 by passing up the rectum, every evening, a small candle 
 smeared with a liniment of almond oil, lime-water, and 
 laudanum. 
 
 Mr. Blackett reported a case of what he called, " Spas- 
 modic Stricture of the Rectum."-— {London Repository. Vol. 
 Vll. p. 377. London, 1817.) The spasmodic stricture or con- 
 traction in this case was caused by rectitis, which was evi- 
 dently the disease from which the patient suffered ; although 
 Mr. Blackett gives no intimation whatever of this. I have 
 in my practice witnessed several cases of spasmodic con- 
 traction of the sphincters of the anus induced by inflamma- 
 tion of the rectum and anus. 
 
 Mr. White, under the head, " Different Forms of Con- 
 traction," makes the following pertinent remarks : — " The 
 most simple form of contraction which we meet with in 
 the lower part of the intestinal canal, is that produced by 
 spasm, which consists in an inordinate degree of contrac- 
 tion in the muscular coat of the intestine, excited by some 
 irritating cause. It happens, however, in ordinary cases, 
 that the spasm ceases as soon as the exciting cause is re- 
 moved. But when there is a frequent repetition, or a long 
 continuance of the exciting cause, a permanent state of 
 spasmodic stricture may be induced, and remain even after 
 the exciting cause has ceased to act." 
 
ANAL FISSURE. 3 1 
 
 " Though it is evident that any part of the canal may be 
 liable to spasmodic contraction, from the nature of its 
 structure, and the office to which it is destined, yet the 
 complaint is found by experience to happen most frequent- 
 ly towards its lower extremity. Very often a permanent 
 spasmodic contraction occurs at the sphincter ani." — {Obser- 
 vations on Strictures of the Rectum. 'Third Edition, p. 10, Bath, 
 1820.) 
 
 Mr. White is clearly of opinion that the spasmodic 
 contraction of the muscular fibres of the rectum, or of 
 the sphincter ani, is not a primary affection, but induced by 
 some exciting cause, of whatever nature it may be, and 
 that the spasm immediately ceases on the removal of such 
 a cause. What Mr. White means by permanent spasmodic 
 contraction, I cannot so clearly comprehend. I can very 
 readily understand how the long and often repeated spas- 
 modic contraction of the sphincter ani muscle, or of the 
 circular fibres of the rectum, would ultimately result in an 
 organic or permanent stricture or contraction of the anal 
 orifice, or of the canal of the rectum. This contraction, 
 however, would no longer be spasmodic, -but organic or 
 permanent, having through the medium of inflammation and 
 subsequent plastic exudation and thickening become so. 
 In such a case the anus gradually becomes permanently 
 contracted and more or less indurated, and in the exact ratio 
 in which this organic change takes place, the spasmodic 
 character of the case disappears. 
 
 M. Delpech, the eminent Montpellier Professor, like 
 Mr. White, alludes to the same subject. He says: — "Un 
 spasme fixe du muscle sphincter externe de l'anus accom- 
 pagne et peut-etre produit par une ou plusieurs gercures 
 placees dans les rides rayonnantes de cette overture." {Precis 
 J^lementaire des Maladies reputees Chirurgicales. Tome I. p. 598. 
 Paris, 1816.) 
 
 Mr. Howship reports two cases of what he calls "Ex- 
 
32 ANAL FISSURE. 
 
 treme Hemorrhoidal Irritation." I will present a part of 
 his description of the first case : — " November 23d, 1822, I 
 was requested by Mr. Hardy, of Walworth, to visit a young 
 lady, a patient of his, who had previously seen several 
 physicians and surgeons, having for nearly six months suffer- 
 ed the most extreme distress and pain, apparently from some 
 very small hemorrhoidal tumors. To alleviate her misery 
 every internal medicine, capable either of allaying pain or 
 regulating the action of the bowels, and every anodyne, 
 sedative, or astringent local application, had been tried with- 
 out affording the least relief. The tongue was white ; the 
 pulse was one hundred, small and weak ; the strength and 
 flesh rapidly wasting. 
 
 " On examining the parts outwardly, I at first conceived 
 there was a small hard tumor behind the integuments at 
 the margin of the sphincter; but, the finger gently passed 
 into the bowel, it turned out to have been a spasmodic and 
 painfully contracted state of the sphincter, which, once 
 overpowered, became relaxed, thin, and comparatively 
 painless. The hemorrhoidal tumors, as Mr. Hardy ob- 
 served, were too inconsiderable to explain so much distress 
 as this young lady had suffered. 
 
 " The state of this young lady's habit was evidently 
 irritable, and although opiates had failed to relieve, it ap- 
 peared to me probable the temporary suspension of spasm 
 by dilatation of the sphincter might be useful, and perhaps 
 do more than was expected." — (Practical Observations on some 
 of the Diseases of the Lower Intestines and Anus. 'Third Edition, 
 p. 240. London, 1824.) This interesting case of Mr. How- 
 ship was no doubt a plain case of anal fissure accompanied 
 by anal spasm and condylomata or anal excrescences, and 
 not a case of haemorrhoids. Had a careful examination of 
 the anus and rectum been made in this instance, a fissure 
 would doubtless have been discovered. The treatment of 
 this case was by dilatation, perseveringly carried out by the 
 
ANAL FISSURE. 33 
 
 use of wax tapers and a metallic bougie five-eighths of an 
 inch in diameter. This treatment succeeded in relieving 
 the spasm, and to a great extent the pain. 
 
 Mr. Calvert, under the head, " Morbid Contraction of 
 the Anus," introduces the subject of spasmodic contraction 
 of the sphinctores ani muscles. — (A Practical treatise on 
 Hemorrhoids, Strictures, and other important Diseases of the 
 Rectum and Anus, p. 210. London, 1824.) 
 
 Mr. Calvert considers spasmodic contraction of the anal 
 sphincters to be an idiopathic, or a substantive disease ; but 
 he entirely fails to establish a correct or satisfactory diag- 
 nosis ; indeed, he appears much confused and undecided 
 respecting the nature, cause, and treatment. He says : 
 " With regard to the mode of treatment of cases of spas- 
 modic contraction of the sphincter muscles, it is very un- 
 certain in the result, unless when it is evidently connected 
 with inflammation ; nothing that is decidedly advanta- 
 geous and generally applicable can be gleaned from past 
 experience ; and amongst the very few who have noticed 
 this complaint, a considerable difference of opinion exists. 
 As it is frequently connected with fissures of the inner 
 membrane of the anus, it has been supposed by some prac- 
 titioners that these are the cause, whilst others have con- 
 sidered them to be a consequence of the contraction, and 
 have been influenced accordingly with regard to the 
 means of cure most likely to be attended with success." 
 — (Of. cit. p. 226.) And again Mr. Calvert remarks : 
 " Although this form of contraction of the anus is 
 often connected with fissures, yet as it sometimes 
 exists separately, it is evident that these, when present, 
 cannot with any degree of certainty be considered as 
 the cause, and that we cannot conclude the complaint 
 will disappear if these are cured." — (Op. cit. p. 229.) 
 From this conclusion of Mr. Calvert I dissent in toto. 
 We can most certainly conclude that if the fissures, die 
 
 3 
 
34 ANAL FISSURE. 
 
 cause, are cured, the spasmodic contraction, the effect, will 
 sooner or later cease. 
 
 Mr. Mayo, under the head, " Stricture of the Rectum," 
 introduces the subject of spasmodic contraction of the sphinc- 
 ter ani, which he says is a kind of cramp; and from the 
 fact of presenting it under the above head, and not under 
 that of "Fissures of the Rectum," he considers it a separate 
 and distinct disease from rectal or anal fissure. — {Obseroations 
 on Injuries and Diseases of the Rectum, p. 184. London, 1833.) 
 
 It is remarkable that so acute an observer as Mr. Mayo 
 should have entirely overlooked the phenomenon of spas- 
 modic contraction of the sphincter ani when treating of 
 "Fissures of the Rectum," in the previous part of his 
 work. He reports three cases of fissure, in the last of 
 which there existed positive spasm of the sphincter ani ; 
 yet in his description of fissure he does not mention spasm 
 as ever attending that disease. His treatment of rectal 
 fissures, as he termed the disease, consisted in the applica- 
 tion of the solid nitrate of silver, or mercurial ointment, 
 and on these failing, then division of the sphincter ani 
 muscle. — (Op. cit. p. 2.) 
 
 Chelius introduces the 'subject of anal spasm, under the 
 head, " Narrowing and Closure of the Rectum." — (Hand- 
 buck der Ckirurgie, Band 11, S. 34. Heidelberg und Leipzig, 1827.) 
 He does not treat of anal fissure at all, only in connection 
 with spasmodic contraction of the anus, of which he believes 
 the anal fissure to be the exciting cause when present, and 
 that it is almost always present. Although he presents spas- 
 modic contraction of the anus as an idiopathic disease, yet he 
 seems to have strong doubts of it; says its causes are very 
 obscure, and that he has ascertained by experience that it 
 is oftener the consequence of seemingly insignificant causes 
 — such as small ulcers, fissures, excoriations, and small ex- 
 crescences, than is generally believed. In this I fully agree 
 with him. He also says that he has ascertained that by 
 
ANAL FISSURE. 3_J 
 
 curing the fissure, or by removing the excrescences, &c, 
 the anal spasm will at once cease. This is precisely my 
 experience too. But he says that if such treatment is too 
 long delayed, nothing short of the complete division of the 
 anal sphincter will cure the complaint. In this I by no 
 means agree with him. 
 
 Mr. Salmon reports a case of contracted sphincter ani, 
 the subject of which was a medical officer of the British 
 army. This case is reported in the language of the patient 
 himself — (A Practical Essay on Stricture of the Rectum, Fourth 
 Edition, p. 81. London, 1833.) 
 
 This was evidently a case of anal fissure, complicated 
 with condylomata and anal fistula, a not unusual complica- 
 tion, as I will show in numerous instances in subsequent 
 pages of this work. Had the attendants of this patient 
 examined carefully the base of the external hemorrhoid 
 (excrescence), which he names in describinghis own case, they 
 would have detected the inferior extremity of an anal fissure, 
 which would have led them at once to the true source: of 
 all his agonizing and protracted suffering. Mr. Salmon 
 considered the anal spasm, or contraction, in this case to be 
 an idiopathic disease of the muscle itself; entertaining the 
 erroneous belief that the whole of this patient's suffering 
 originated in the morbid condition of the sphincter externa s 
 itself; hence he advised and executed the irrational and 
 mischievous operation of the division of the sphincter exter- 
 nus. It is true, the patient says that this operation relieved 
 him of his present suffering ; yet it is equally true that he 
 might have been entirely relieved by a milder, safer, more 
 certain and more rational treatment. 
 
 Our late distinguished fellow-citizen, the lamented Dr. 
 Bushe, treats spasmodic contraction of the sphincter ani as 
 an idiopathic disease, considering it, in some instances, sep- 
 arate and distinct from anal fissure, and from neuralgia of 
 the inferior extremity of the rectum ; but his diagnosis is 
 
36 ANAL FISSURE. 
 
 too vague to be appreciated. He says he has demonstrated 
 that spasmodic contraction of the sphincter ani may be 
 produced by fissure, and that he has proved it to be occa- 
 sionally the consequence of neuralgia; but, says he, ** be- 
 sides these there are two other species of spasmodic con- 
 traction of the sphincter — namely, that which depends upon 
 functional or structural disease of the genito-urinary organs; 
 and that in which we cannot trace any other primary affec- 
 tion, either in the rectum or elsewhere." He then reports 
 six cases of spasmodic contraction of the sphincter ani, in 
 which the genito-urinary organs were primarily affected. 
 He next reports four cases, in which he says he could not 
 discover any other primary disease, and then concludes by 
 saying that, "as these four cases now related are the only 
 substantive forms of spasmodic contraction of the sphincter 
 ani that I have observed, I am disposed to consider it as a 
 rare disease." — (A treatise on the Malformations, Injuries, and 
 Diseases of the Rectum and Anus, f p. 119, 128. New Tori, 
 
 18370 
 
 Dr. Bushe rests the question of the independent existence 
 of anal spasm entirely upon these four cases. But where are 
 the proofs of the substantive form of the muscular spasm 
 in these cases ? It is not by any means a necessary conse- 
 quence that, because he failed in these cases to trace the 
 anal spasm to any primary affection, no such affection 
 existed ; or that on this account the spasmodic contraction 
 must necessarily be the primary disease itself. The pre- 
 sumption is that anal spasm is always the result of some 
 primary disease of the mucous membrane of the rectum, 
 or muco-cutaneous coat about the anal orifice ; or of some 
 primary disease in the vicinity of the rectum and anus, 
 whether we can trace or detect such primary affection or 
 not; indeed, the spasmodic contraction of the anus is a 
 positive evidence that such is the fact. To show how 
 valueless are the assertions of Dr. Bushe, he made no 
 
ANAL FISSURE. 37 
 
 examination whatever of the anus and rectum in the first 
 and second cases ; consequently these two cases prove no- 
 thing. In the third case he admits that the anus was 
 closed so firmly that the finger could only be entered with 
 great difficulty; consequently no fair or satisfactory exam- 
 ination could be made under such circumstances. In the 
 fourth and last case Dr. Bushe says that an examination was 
 made carefully, but no structural disease could be discover- 
 ed, as the pressure with the finger in the rectum produced no 
 more pain in one part than in another, as all the parts touch- 
 ed were painful alike. But was not this diffused pain upon 
 pressure evidence of disease of the mucous lining of the 
 whole circumference of the inferior extremity of the rec- 
 tum; and was not the spasmodic contraction in these two 
 cases merely consecutive to it*? I have no doubt whatever 
 of this. A proper examination of the rectum with the 
 speculum in these two cases, the patients having been under 
 the influence of an anaesthetic, would doubtless have re- 
 vealed this condition of the mucous membrane. Dr. Bushe 
 in the exploration of these cases used no speculum ani, and 
 no surgeon should affirm positively that no disease of the 
 mucous membrane of the lower portion of the rectum 
 exists, because he fails to detect it with the finger ; for 
 such disease may sometimes exist, and the surgeon entirely 
 fail to detect it with the finger alone, several examples of 
 which have come under my own observation. These 
 cases, then, of Dr. Bushe, which were presented to show 
 that there was no primary disease either in the rectum or in 
 the genito-urinary organs to account for the spasmodic con- 
 traction, entirely fail, in my opinion, to do so. They fail 
 to exemplify the characteristics of the disease for which they 
 were adduced. They are indeed examples, not, however, of 
 an idiopathic affection of the sphincter ani muscle, but of 
 some primary disease of the mucous membrane of the part, 
 or some primary disease in some of the adjoining organs, 
 
38 ANAL FISSURE. 
 
 attended merely with sympathetic spasmodic contraction of 
 the sphincter ani muscle. Well may Dr. Bushe then say 
 that he considers as rare the spasmodic contraction of the 
 sphincter ani, as a substantive form of disease. 
 
 Mr. Curling introduces the subject of spasmodic contrac- 
 tion of the sphincter ani muscle under the head, " Irritable 
 Sphincter Muscle" Although he presents it as an idiopathic 
 disease, his diagnosis is anything but clear. This is evident 
 from the conclusion to which he arrives. He says : " Irrita- 
 bility of the sphincter occurs commonly in hysterical 
 females, or in nervous, susceptible women who are accus- 
 tomed to watch and to intensify every sensation. I have 
 seldom met with it in other persons independently of 
 some local source of irritation, as an ulcer, or an inflamed 
 internal pile; and I believe that in men, simple irritability 
 of the sphincter muscle is a rare complaint. The investi- 
 gation of such a case is seldom satisfactory without an ex- 
 amination of the rectum with the speculum ; and in most 
 instances of irritable sphincter, I am convinced that some 
 direct cause of irritation may be discovered by this means." 
 — {Observations on the Diseases of the Rectum, tfhird Edition, 
 p. 15. London, 1S63.) With some of the sentiments of 
 this very able and distinguished surgeon on this subject, as 
 expressed above, I most cordially agree; but I believe that 
 not only in most instances, but in every instance, if 
 thoroughly examined and investigated, a direct cause, out- 
 side of the sphincter muscle itself, can always be found to 
 account for the phenomenon of the spasmodic contraction. 
 
 Mr. Malyn, under the head, "Spasm of the Anus" intro- 
 duces the subject of spasmodic contraction of the sphinctores 
 ani muscles. His views are interesting, and deserve candid 
 consideration. He says : " Spasm of the anus, it seems 
 probable, is mostly the consequence of some preceding 
 morbid irritation, situated either in the gut itself, or in some 
 of the organs with which it is interested; and it conse- 
 
ANAL FISSURE. 39 
 
 quently ceases when that irritation is removed. Such is the 
 case when the urinary or genital organs are excited ; for 
 though the sphincters, especially the external one, always 
 participate more or less in the disturbance of those organs, 
 their spasmodic action ceases when the others have regained 
 their quiescence." "There appears, however, to be pro- 
 duced sometimes by an insidious and long-continued irri- 
 tation in the intestine, or by the degrading broodings of a 
 licentious mind, a spasmodic condition of the extremity of 
 the rectum, which becomes a cause of its own continuance 
 by reason of the inflammation which has been set up in 
 the parts, and which their state of activity will not allow 
 to subside. In this condition when by removing the cause 
 alone, we do not remove the effect." — (jTke Cyclopedia of 
 Practical Surgery. By W. B. Costello, M.D. Vol. 1. Article 
 Anus, p. 339. London, 1841.) 
 
 Mr. Malyn looks upon anal spasm, occurring under cer- 
 tain circumstances, somewhat in the light of a substantive 
 form of disease, and thinks that on this account it merits 
 separate and distinct consideration ; yet, with all his inge- 
 nuity, he fails to make it appear an independent disease or 
 an entity, a disease in itself. I agree with Mr. Malyn, that 
 in anal spasm the effect may under certain circumstances 
 become more or less a cause, and a cause too of its own 
 perpetuation to a certain extent — that is, it may aid by its 
 long continuance in bringing about a morbid condition of 
 the parts, consisting in inflammation, congestion, and ex- 
 quisite irritability; so that, even if the primary cause should 
 be removed, this, morbid condition, the secondary cause, 
 might still remain to keep up the spasm which aided in 
 bringing it about. Indeed, anal spasm, when caused by 
 fissure of the anus, or any other disease of the mucous 
 membrane of the inferior extremity of the rectum, is to a 
 certain extent more or less of an impediment to restoration, 
 and prevents the cause which produced it from being as 
 
40 ANAL FISSURE. 
 
 speedily removed as it otherwise would be ; hence, although 
 a mere effect, it may require treatment. My method in 
 such cases is to treat both the cause and the effect at the 
 same time. Whilst I consider it unpathological to make 
 anal spasm in such cases the chief object of attention and 
 treatment, as many do, I nevertheless insist upon it that the 
 spasm must not be entirely overlooked and neglected in 
 the treatment, for its reaction may have considerable in- 
 fluence on the original focus of the disease. I, however, 
 by no means agree with Mr. Malyn in the kind of treat- 
 ment which is necessary to be adopted in such cases. I 
 do not consider, as he does, that it is ever necessary to 
 divide the sphincters of the anus, for I have never failed, 
 in the worst cases, to easily and speedily overcome the 
 spasm by the use of belladonna and proper dilatation ; 
 at the same time using proper measures to subdue the 
 inflammation, the congestion, and the morbid irritability of 
 the parts which are the primary cause of the anal spasm. 
 I am aware that Mr. Malyn says that in the aggravated 
 form of anal spasm the introduction of a bougie is unscien- 
 tific in principle and inapplicable in practice. — (Op. cit. p. 
 340.) I, on the contrary, notwithstanding, do maintain that 
 its proper use in such instances is both scientific in principle 
 and highly applicable in practice, for I have successfully 
 treated a number of just such cases. I would say in con- 
 clusion, that the operation of Mr. Malyn in dividing the 
 sphincter ani muscles with the knife, is unscientific in prin- 
 ciple and abominable in practice ; and that it is like cut- 
 ting the " Gordian knot" instead of untying it. 
 
CHAPTER SECOND. 
 
 ANAL FISSURE. 
 
CHAPTER II. 
 
 FISSURE OF THE ANUS. 
 
 Section I. — Name. 
 
 The term fissure is derived from the Latin fissura^a cleft, 
 a slit, a chap, — from findo, to cleave, to slit, to chap. 
 
 Fissure of the Anus — English. 
 
 Fissura Ani — Latin. 
 
 Fissure a VAnus — -French. 
 
 Fissur des Afters — German. 
 There is great disagreement among medical writers with 
 regard to the precise application of the term fissure of the 
 anus. Mr. Mayo includes under it breaches of surface of 
 all forms, whether linear or oblong, located anywhere in the 
 inferior extremity of the rectum, and about the anal orifice, 
 either within or without, and whether irritable and painful 
 or attended by anal spasm or not (Op. cit.). This is apply- 
 ing to the term the most extensive application. M. Mon- 
 tegre classes under the same general head, fissures attended 
 by spasm, rhagades, and simple crevices or chapping of the 
 muco-cutaneous tissue about the anus. He says, under 
 the head, " Des crevasses, fissures ou rhagades a Vanus : " " Ces 
 trois mots ont une meme signification. II s'agit toujours 
 d'une .petite ulceration longitudinale, dont les varietes sont 
 relatives seulement a la cause qui les a produites." — (Des 
 Hemorroides, ou ^raite Analytique de toutes les afjections hemorrdi- 
 dales. Nouvelle Edit, p. 51. Paris, 1819.) Some authorities 
 consider the linear form of the ulcer and anal spasm as essen- 
 tial to the disease, and regard them in the relation of cause 
 and effect; one party of these believing the anal spasm to 
 be the primary symptom, whilst the other party consider the 
 
44 ANAL FISSURE. 
 
 fissure to be the primary disease. There are others again 
 who go still further, and consider the anal spasm as the 
 true, the real disease, and the fissure or linear ulcer as a 
 mere secondary complication. 
 
 The term fissure of the anus, as I have already shown in 
 the previous chapter, has been incorrectly applied by many 
 authors to a phenomenon which sometimes attends the 
 second or advanced stage of anal fissure, but which does 
 not in reality constitute it, but is a mere symptom or an 
 effect of it — I mean anal spasm. I have also shown that 
 others, equally incorrect, have included in the term every 
 superficial lesion situated in the anal canal, and about the 
 margin of the anal orifice, of whatever character, whether 
 idiopathic or not. 
 
 This term in its limited sense, or in its strict application, 
 implies simply a superficial breach of surface, of a lineal or 
 long and narrow shape, located on the mucous lining of 
 the inferior extremity of the rectum ; or on the muco-cu- 
 taneous coat about the anal orifice. The term, however, 
 in its more extended sense is used to express those super- 
 ficial ulcerations in which fissures sometimes terminate. 
 Occasionally, too, superficial lesions are met with in this 
 region, differing in form, yet having all the other character- 
 istics peculiar to fissure ; these must be included in the term, 
 inasmuch as the mere form of the ulcer is not of itself the 
 pathognomonic sign of the disease. The characteristic form 
 of lesions in the inferior extremity of the rectum is no doubt 
 communicated to them by the irregularities of the mucous 
 lining in this locality, disposed as it is into numerous rugae. 
 I have myself particularly noticed, and it is worthy of ob- 
 servation, that, in the lower portion of the rectum, and 
 more especially about the anal orifice, where the radiated 
 duplicatures of the mucous membrane and muco-cutaneous 
 coat are longitudinal, the ulcers are, with scarcely an excep- 
 tion, linear in form ; whereas in the middle and superior 
 
ANAL FISSURE. 45 
 
 portion, where the folds are disposed transversely, they are 
 almost always circular or oblong. But, as I have before re- 
 marked, the true character or nature of the disease cannot 
 be determined by the mere form alone of the lesion, be it 
 linear, circular, or oblong. 
 
 From these several considerations I conclude that the 
 term fissure of the anus, which serves no purpose as a descrip- 
 tive or a distinctive name, is not as good a one to designate 
 this painful affection as might have been adopted ; but its 
 use has now been so long sanctioned by authority, that I 
 do not feel at liberty to venture upon the substitution of a 
 newly created one. The term thus retained as a nosolo- 
 gical distinction, should be strictly confined to superficial 
 breaches of surface in the anal region, of a highly sensitive, 
 irritable, or painful character, whether linear, oblong, or cir- 
 cular, or whether attended by anal spasm or not. 
 
 The talented and ingenious author, Mr. Curling, already 
 quoted, very appropriately denominates fissure of the anus 
 "Irritable Ulcer of the Rectum." This is what it really 
 and truly is, regardless of its form. Mr. Curling objects 
 to the term fissure, because it is so only in appearance, and 
 not in reality. He says: "On examining the ulcer with- 
 out distending the rectum, the lateral edges only being 
 presented to view, the breach of surface has the appearance 
 of a fissure — the term commonly given, but improperly, to 
 this sore, which, though often originating in a rent, is 
 obviously more than a mere cleft or fissure in the mucous 
 membrane of the bowel." And again he says : " With 
 the speculum, the longitudinal folds being stretched out, 
 the ulcer can be fully exposed, and it is then clearly seen 
 not to be a mere fissure, but a superficial sore." — (Op. cit. p. 6.) 
 
 Mr. Ashton, in commenting upon the remarks of Mr. 
 Curling, says : " Although in many instances when the sur- 
 geon is first consulted, it (the fissure) may present the form 
 of an oblong ulcer, yet I have no hesitation in saying the 
 
46 ANAL FISSURE. 
 
 primary condition was essentially a fissure or crack of the 
 mucous membrane." — (The Diseases, Injuries, and Malforma- 
 tions of the Rectum and Anus. Third Edition, p. 45. London, 
 i860.) 
 
 I do not concur with Mr. Curling in the opinion that all 
 lesions about the anus and in the anal canal, presenting a 
 linear form and termed fissures, are only so in appearance 
 and not in reality. That some such by long continuance 
 become more extensive, degenerate into sores or ulcers, and 
 lose their original form, is doubtless true ; but such are 
 the exception, not the rule. As far as my experience 
 extends, in the largest majority of cases of long standing 
 which have come under my own observation, I have found 
 the breaches of surface to be of a linear form ; they were 
 doubtless of this shape originally, and they seemed to have 
 maintained it. These cases were examined carefully with 
 a speculum, and the ulcers did not only appear in the form 
 of fissure previous to its use, but were by its use proved to 
 be so in reality. Distention of the mucous membrane 
 upon which they were located made no change in their 
 form, from the lineal to the circular or oblong. 
 
 Mr. Ouain may be said to object to the term fissure of 
 the anus by implication, inasmuch as he does not use it to 
 designate the disease so called, but treats of it under the 
 head, " Painful Excoriations and Ulcers of the Skin and 
 Mucous Membrane." — (Op. cit. p. 154.) 
 
 Mr. Smith introduces the subject of fissure of the anus 
 under the head, " Painful Ulcer of the Rectum!' From the 
 fact of substituting this term for that of fissure of the anus, it 
 is evident that he considers the latter not as appropriate as 
 his own, the former. — (Hemorrhoids and Prolapsus of the 
 Rectum. Third Edition, p. 1 24. London, 1 862.) 
 
 It will be seen I have given three English authorities 
 who repudiate the term fissure of the anus. 
 
ANAL FISSURE. 47 
 
 Section II. — Physiology. 
 
 It may be premised here that fissure of the anus 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 sphinctores ani 
 muscles. It consists in an idiopathic breach of surface, as 
 a superficial ulcer, an excoriation or abrasion, and, as a gen- 
 eral rule, has a linear, or long and narrow form. The dis- 
 ease is always attended by a peculiar kind of pain, of a 
 sharp, lancinating, throbbing, burning, or smarting character, 
 and sometimes, in the advanced stage, by a violent and 
 arbitrary contraction of the sphincter or sphincters of the 
 anus. The pain may, and often does occur in the act of de- 
 fecation, but it most frequently comes on some time after 
 the parts have been disturbed by this act, and irritated and 
 excited by the passage of faecal matter, or vitiated and stim- 
 ulating secretions. The fissure in this peculiar condition, 
 being thus highly irritated and excited, communicates this 
 irritation and this excitability to the muscular coat and to 
 the sphinctores ani, and causes one or both of them to con- 
 tract violently upon the highly sensitive sore of the mucous 
 membrane within its grasp ; hence the additional or most 
 exquisite pain which immediately follows this mechanical 
 violence of grasping and compressing, and which lasts 
 just as long as this exalted muscular constriction continues. 
 The sphincter ani muscles are sympathetically impressed, 
 or influenced by the morbid state of the fissure, — hence the 
 spasm. 
 
 I would mention here, and facts tend to warrant the con- 
 clusion, that in some morbid conditions of the anus and 
 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, often co-exist as 
 
48 ANAL FISSURE. 
 
 parts of the same disease. When the nerves are rendered 
 morbidly sensitive by the irritation and inflammation 
 existing in the part, the violent pressure made upon them, 
 in this highly sensitive state, by the excessive or inordinate 
 contraction of the muscular fibres of the sphincter ani, must 
 of necessity give origin to additional and excessive sensa- 
 tion. This, and the compression of the fissure by the same 
 muscular fibres, are both causes of additional pain, by anal 
 spasm. Any morbid sensibility of the mucous membrane 
 of the inferior portion of the rectum disposes the muscular 
 coat of the same to resist any distention, or extension, 
 beyond its tonic contraction or quiescent state, or that state 
 in which it is when not distended by fseces, gas, or any 
 other foreign body. Neither will the sphincter ani muscles 
 in this morbid condition of the parts admit of distention 
 without the induction of agonizing pain. It is a question 
 whether this arbitrary contraction of the sphincters of the 
 anus would cause pain without a fissure, or any other dis- 
 ease of the mucous membrane of the part, as in cases 
 in which the spasmodic contraction is caused by disease in 
 the genito-urinary organs, some distance removed from 
 them. It certainly would, but by no means to the same 
 extent, unless firm pressure or distention was made, and 
 then upon the removal of which it would cease. When 
 the pain attending the spasmodic contraction is very intense, 
 it is an evidence that it is owing to a fissure, or to some 
 other disease of the mucous membrane of the part, which, 
 without even being violently compressed by the contraction 
 of the muscular fibres of the sphincters of the anus, would be 
 more or less painful, especially after having been excited 
 by the passage of highly acrid and stimulating dejections. 
 
 ] . 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. 
 When this membrane in such locality is diseased from 
 
ANAL FISSURE. 49 
 
 any cause, there is more or less pain experienced whenever 
 the common function of the part is performed. The canal 
 at this point sometimes contracts spasmodically on the ap- 
 plication even of its own proper and natural contents, and 
 offers more or less impediment to their passage. Indeed 
 such disease of the mucous tissue always diminishes to a 
 greater or less degree the canal it lines, and especially its 
 terminal orifice, and makes any attempt to distend the same 
 both difficult and painful. This is doubtless owing to the 
 fact that the outlets of the body are supplied or endowed 
 with a peculiar nervous influence which is obviously con- 
 nected with their proper functions. 
 
 With especial reference to the terminal outlet of the in- 
 testinal canal and the disease in question, the direct cause of 
 the extreme and agonizing pain is the result, to a great ex- 
 tent, as before remarked, of the violent involuntary spas- 
 modic contraction of the sphincters of the anus upon the 
 already highly painful and sensitive ulcer, thus rendering it 
 if possible still more exquisitely painful, as well as more or 
 less preventing it from healing. This view of the subject 
 is in accordance with the pathology of the disease, as well 
 as with the physiological condition of both sphinctores ani 
 muscles, whose involuntary contraction, both tonic and spas- 
 modic, is entirely owing to the peculiar nervous endow- 
 ment previously named, as the latest pathological and 
 physiological researches tend so strongly to demonstrate. 
 
 2. Tonic and Muscular Contraction of the Anal Sphincters. 
 The sphinctores ani muscl.es may be said to display two kinds 
 of contraction, the tonic and the muscular. The tonic con- 
 traction is that property in virtue of which they constantly 
 tend to resume their natural or quiescent state whenever 
 the cause which distended them and which brought into 
 play their muscular contraction is removed. The normal 
 condition, then, of these two muscles is unconscious contrac- 
 tion of their muscular fibres, and this contraction is increased 
 
 4 
 
^O ANAL FISSURE. 
 
 and rendered more effectual by the voluntary contraction 
 of the levatores ani muscles. It is by the tonic contraction 
 of the sphinctores ani that involuntary discharges of the 
 feces are prevented. In the healthy and natural state of 
 the parts, this contraction does not close the anus or anal 
 canal with any great degree of tightness, for the finger, or a 
 proper sized bougie, warmed and lubricated, may always be 
 insinuated with ease. The internal sphincter, as a general 
 rule, is found to be more firmly contracted than the exter- 
 nal, but not sufficiently so to produce very hard pressure 
 upon the hsemorrhoidal plexus, or upon the mucous mem- 
 brane ; nor is it in turn strongly pressed upon by those 
 fibres of the external sphincter which surround its neck. 
 
 3. Tfe Influence of the Will vpon the Anal Sphincters. The 
 two sphincter muscles of the anus are said to be under the 
 control of the will, but this must be accepted in a limited 
 sense, for they are by no means completely so, especially 
 the sphincter internus. They stand in physiological func- 
 tion between the involuntary and voluntary system of 
 nerves, consequently an evacuation can often be voluntarily 
 effected in concert with the action of the diaphragm and 
 other abdominal muscles; but at other times they must 
 necessarily obey the automatic movements of the organic 
 functions of the intestines alone. 
 
 The expansion or relaxation of the anal sphincters, 
 especially the external, which precedes the expulsive effort, 
 is, to a certain extent, an act of the will, a circumstance 
 which makes the resistance of these muscles more easily over- 
 come. Contraction of the same, however, is always invol- 
 untary, and not at all under the control of the will. 
 
 The supposition that a special nervous influence is neces- 
 sary to govern the relaxation and contraction of the anus, 
 has been entertained by several eminent physiologists. The 
 ingenious and talented Italian, Professor Bellingeri, held this 
 view, and endeavored to demonstrate it by experiment. 
 
ANAL FISSURE. 51 
 
 In his experimental inquiry into the functions of the spinal 
 marrow, he believes he has proved that the posterior col- 
 umns of the spinal marrow give nerves to the external 
 sphincter which endow it with the power of contraction, 
 whilst branches from the anterior columns bestow upon it 
 the faculty of relaxation. — (Experimenta Physiologica impedul- 
 lam Spinalem. Lecta die 13 Junii, 1824. From Memorie delta 
 Reale Accademia detle Scienze Di Torino XXX. Turin, 1826. 
 Analyzed in the 'Journat des Progres des Sciences, &c. 'Tome I, 
 p. 125. Paris, 1827). 
 
 The result of the experiments of this learned but fanciful 
 author, is by no means conclusive upon the point in question. 
 Many important objections could be urged against his ex- 
 periments ; and the invalidity too, of his deductions could 
 be easily demonstrated, but this is not the proper place to 
 do it. 
 
 The fibres of the sphinctores ani muscles may be stimu- 
 lated to action directly by the will ; or indirectly by reflex, 
 irritation, the one action being voluntary and the other in- 
 voluntary. 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. This 
 theory, when applied to the disease in question, appears in- 
 deed most highly probable, for it would seem reasonable 
 enough that any irritable or painful condition of that part 
 of the mucous membrane of the rectum, or muco-cutane- 
 ous coat about the anal orifice, within the immediate grasp 
 of the anal sphincters, would, through the medium of reflex 
 action, highly increase the intensity of the nervous influence 
 which causes or stimulates this spasmodic contraction. 
 
 It is stated by Mr. W. P. Alison that when any stimulus is 
 applied to muscular fibres, either directly by the will, or in- 
 directly by reflex irritation, the filaments which are directly 
 stimulated are thrown into action, then contractions very 
 
52 ANAL FISSURE. 
 
 generally and rapidly extend to many others in their vicini- 
 ty, frequently to the whole muscle of which they form a 
 part. But he considers the contractions of individual fibres 
 to be feeble and of short duration. — {Cyclopedia of Anato??iy 
 and Physiology. By R. B. fodd, M.D. Vol. /., p. 719. London. 
 
 1836.) 
 
 4. Nervous 'Endowment of the Rectum. The rectum is the 
 only portion of the intestinal canal which receives addition- 
 al nerves from the cerebro-spinal system ; consequently it is 
 endowed with much greater sensibility, and subjected to a 
 much greater number of influences, both healthy and mor- 
 bid, than any other portions of the canal ; — hence its func- 
 tions too are of a mixed character, partaking, in part, both 
 of voluntary and involuntary motion. Were the rectum 
 not thus suitably endowed with nerves like telegraphic wires, 
 to put it in relation, or in communication with other organs, 
 and enable it to receive and to respond to impressions made 
 upon it, the organ would fail to fulfil its offices as such. 
 But, as before remarked, the rectum, in addition to the or- 
 ganic sensibility with which it is endowed in common with 
 all parts of the intestinal canal, by nerves from the gangli- 
 onic system, is also endowed with animal sensibility, by 
 nerves from the cerebro-spinal system, the peculiar property 
 of which is that kind of sensibility which we can plainly 
 perceive and of which we are distinctly conscious. 
 
 5. Hypertrophy of the External Sphincter Ani. The repeated 
 and long-continued hyperaction of this muscle, consequent 
 upon anal fissure, or from any other cause, ultimately tends 
 to augment both its bulk and its strength, as well as it facili- 
 tates its subsequent excitation of action. This is in con- 
 formity with the general law, that the repeated exertion of 
 living contractile parts is to increase them in size and in 
 strength, which is doubtless owing to a greater flow of blood 
 to them, and consequently with an increase of their nutri- 
 tion. Ii the finger is introduced within the anus in such a 
 
ANAL FISSURE. 53 
 
 case, the external sphincter, in particular, will be found so 
 much altered in respect to size, that it will have more the 
 feel of a thick cartilaginous ring than a band of soft fleshy 
 fibres, and that this sometimes extends as far as the upper 
 margin of the internal sphincter of the anus, several in- 
 stances of which have come under my own observation, the 
 result of long-continued anal fissure. 
 
 This hypertrophy of the sphincters of the anus, purely 
 the result of continued irritation or violent action, is strik- 
 ingly evident in those who have for a length of time suf- 
 fered from this affection, It is interesting in a physiologico- 
 pathological point of view. 
 
CHAPTER THIRD. 
 
 ETIOLOGY, 
 
CHAPTER III. 
 
 ETIOLOGY. 
 
 ] . Constipation as a Cause of Anal Fissure. I have already 
 shown in the first chapter that the ancients attributed fis- 
 sures of the rectum and anus principally to constipation 
 of the bowels, and to the desiccated condition of the ster- 
 coraceous matters incident to such constipated state. Albu- 
 casis and Paulus iEgineta especially impute them to these 
 causes. It will be very readily perceived how constipation 
 of the bowels, with its train of attending evils, — indura- 
 tion of the faeces and the violent action of the expulsive 
 muscles requisite for their evacuation, — maybe causes of anal 
 fissure. Faecal matter in its natural state is consistent, soft, 
 homogeneous and cohesive, but when unduly retained in 
 the rectum, or colon, becomes hard, knotty, dry and friable, 
 changes produced by the absorption of its fluids ; even in 
 its normal condition, when retained but a short time beyond 
 the usual period, it irritates the delicate mucous surface 
 more or less ;. yet how much more irritating must it prove 
 when its characters have become entirely altered by a 
 lengthened stay in the bowels. It is an established fact 
 that the absorbents of the rectum are very active ; conse- 
 quently if faecal matter be retained in it beyond the usual 
 period — twenty-four hours — it becomes consolidated and 
 hard. For example, if a person who is in the habit of 
 evacuating his bowels at a certain hour every morning, 
 
58 ANAL FISSURE. 
 
 should, through the press of anxiety or business, or from 
 any other cause, neglect to perform this highly important 
 act, he will find that the stool which would have been 
 natural and easy in the morning, will be difficult if not 
 painful in the evening or next morning ; that the fseces will 
 be hard and moulded in the bowel, and that the act of de- 
 fecation will be attended with extra straining and with more 
 or less pain, and often with blood. Should he suffer this 
 condition to continue, anal fissure, or some other serious dis- 
 ease of the rectum or anus, would most assuredly be the 
 consequence. In many cases of constipation the difficulty 
 occurs in the rectum, or colon itself, which in such cases 
 seems to have lost its natural tone and action, suffering large 
 accumulations of fseces to take place in its pouch, without 
 manifesting any disposition or power to dislodge them ; and 
 when finally expelled, to produce serious injury to the 
 mucous membrane of the anal canal below, and often cause 
 pains equal in severity to those of labor. Women are 
 especially liable to this torpor and to these accumulations. 
 In some cases of constipation, while the diaphragm and other 
 abdominal muscles act with great energy, the anal sphincters 
 remain more or less contracted, and yield but slowly and 
 reluctantly, so that the indurated fseces contuse and abrade 
 the surface of one or more points of the mucous membrane, 
 which if they do not heal become converted into fissures. 
 In such instances as contemplated above, the hard scybalous 
 fseces being forced through the sphincters of the anus by the 
 abdominal muscles, not only irritate or abrade the mucous 
 membrane of the anal canal, but sometimes lacerate it, and 
 thus directly lay the foundation of the disease in ques- 
 tion. 
 
 This disease is sometimes the result of inflammation and 
 the attendant turgescence of the mucous membrane of the 
 anal canal, by which the intestine becomes narrowed by the 
 tumefaction of its lining coat, and thus forms an obstacle to 
 
ANAL FISSURE. 59 
 
 the free egress of the faecal mass, which, if hard, is liable to 
 abrade, lacerate, or rupture the mucous coat, in its highly 
 delicate and friable condition. 
 
 Anal fissure sometimes results from the excoriations pro- 
 duced by the vitiated and irritating discharges in dysentery, 
 diarrhoea, cholera, and other visceral diseases. 
 
 The anus is liable to a species of chapping, resembling 
 that of the lips in winter, which sometimes results in ex- 
 tremely painful fissures. 
 
 Obstinate fissures are sometimes produced in the fossa, 
 between the two anal sphincters, by the lodgment of faecal 
 matter or other foreign bodies, which here do not always 
 find a ready and easy passage out, in consequence some- 
 times of the contraction, either spasmodic or organic, of the 
 external sphincter ani. More or less of such foreign matters 
 constantly remaining in this pent up situation, become 
 highly irritating in the intervals between the stools, and in 
 this manner lay the foundation of some among the most 
 painful fissures ; a number of such cases have come under 
 my own observation, and will be reported hereafter under 
 the proper head. 
 
 Anal fissure is sometimes produced by a superficial 
 excoriation or ulceration of the anus, similar to that 
 so frequently observed upon the inside of the lips, the 
 tongue, and other parts of the mouth. I have seen several 
 severe cases of anal fissure produced by this kind of aph- 
 thous ulceration in nursing mothers, and one in a young child; 
 they were attended with extreme burning pain, and more 
 or less anal spasm. [Vide Cases xix., xxiii., xxv.] In 
 these cases the ulcerations of the anus were extemporaneous 
 with similar ones of the mouth ; their coexistence at the 
 same time, and the exact similarity of appearance between 
 them, left but little doubt as to their identity. 
 
 2. Severe Straining Efforts a Cause of Anal Fissure, This 
 disease is sometimes caused by the violent straining efforts, 
 
60 ANAL FISSURE. 
 
 consequent not only upon obstinate constipation, but upon 
 those of dysentery, diarrhoea, stricture of the rectum or 
 anus, whether spasmodic or permanent, and stone in the 
 bladder. A laceration or rent of the mucous membrane 
 lining the external sphincter takes place during such efforts. 
 Such a rent being neglected, or suffered to continue without 
 proper treatment, would sooner or later become highly irri- 
 table, and ultimately produce that peculiar morbid condition 
 of the parts which is characteristic of fissure of the anus. 
 Several instances of anal fissure caused by the severe strain- 
 ing efforts consequent upon the violent operation of drastic 
 purgatives, have come under my own immediate observa- 
 tion. Some of these cases will be found reported under the 
 head, " Illustrative Cases" in the last chapter. 
 
 A somewhat frequent cause of anal fissure 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, which were intended by nature to fa- 
 cilitate the passage of the excrement through the anal canal 
 and anus. When this condition of the parts obtains, the 
 mucous lining is often found quite friable, and consequently 
 easily ruptured during the passage of indurated faeces, 
 
 3. Anal Fissure from Mechanical Injuries. Under this head 
 may be included those abrasions and lacerations which are 
 produced by over-distention, or by the passage of hardened 
 faeces in large masses, as before remarked ; or of a foreign 
 body contained in the faeces, as well as those which follow 
 surgical operations, and the careless and awkward use of 
 the pipe of the enema syringe, the speculum ani, the rectal 
 sound, or bougie. The disease is also sometimes the result 
 of mechanical injury consequent upon very violent efforts 
 made in parturition ; several cases of this character I have 
 treated. It is sometimes the result of external violence 
 communicated by falls, blows, &c, upon the anus, the 
 nates, or the coccyx. A case of this kind came under my 
 
ANAL FISSURE. 6l 
 
 own care. [ Vide Case xvi.] Two similar cases are re- 
 ported by Mr. Rouse, as follows : — 
 
 " Case I. — A gentleman, aged twenty-four, was riding a 
 restive horse, when it suddenly bolted. He was thrown 
 with some violence on the hind part of the saddle before 
 he recovered his seat. He felt some pain about the anus 
 at the time, and on changing his shirt he noticed a few 
 drops of blood. For the next few days he experienced a 
 slight burning pain during the evacuation of the bowels, 
 and in about a week the characteristic pain of fissure was 
 established. On examination being made, a small crack 
 was perceived on the posterior surface of the sphincter ; it 
 commenced about two lines within the anus, and extended 
 upwards for about an inch. Various local means were tried 
 without benefit, and an operation to be hereafter described 
 was had recourse to with perfect success. 
 
 " Case II. — A captain in the navy fell off a ladder, and 
 came to the ground on his buttocks with considerable force. 
 He did not observe any particular pain until he went to 
 stool the following morning, when he experienced consider- 
 able smarting, and noticed that he had passed a small 
 amount of florid blood. About a week after the accident 
 he applied for advice. He then, after every evacuation of 
 the bowels, had pain which lasted for several hours. On 
 examination, an ulcer was found on the posterior surface of 
 the lining membrane of the sphincter; the edges were not 
 indurated, and the surface was florid. An ointment con- 
 taing mercury was applied twice a day, and in the course 
 of a week a cure was effected." — (On Ulceration of the Lower 
 Extremity of the Rectum; its Varieties, Diagnosis, and treatment. 
 British Medical Journal. May \ith, i860, p. 356.) 
 
 4. Anal Contraction as a Cause of Anal Fissure. Contraction 
 of the anus or anal canal, either of an organic or of a spas- 
 modic character, by opposing the free egress of the faeces, 
 becomes a proeguminal cause of anal fissure ; in the 
 
62 ANAL FISSURE. 
 
 former by disposing to rupture, and in the latter by con- 
 tusion, excoriation, and abrasion of the mucous mem- 
 brane. Congenital contraction of the anus may lay the 
 foundation of this disease. — (Fide the author's work on the 
 Congenital Malformations of the Rectum and Anus, p. 85. New 
 Tork, i860.) 
 
 Persons who have very large and extensive anal sphinc- 
 ters, or very strong and powerful ones, are very liable to 
 this affection, or predisposed to it. 
 
 5. Anal Fissure from the Frequent use of Enemata. Some 
 authorities are of opinion that it is in consequence of the 
 frequent and indiscriminate use of lavements, so very com- 
 mon on the continent of Europe, that anal fissure prevails 
 so generally in that part of the country ; whilst in England 
 and in the United States, where they are but seldom used, 
 the disease is comparatively rare. The use of enemata, 
 however, is daily on the increase in our own country, and 
 so is anal fissure ; but I doubt whether this increased use of 
 the former has anything whatever to do with this increase 
 of the latter. 
 
 6. Anal Fissure from Hemorrhoids and Condylomata. A very 
 frequent predisposing cause and complication of this disease 
 are hemorrhoidal tumors ; and when this is the case, the fis- 
 sure will often be found between two of them. (Fig. 1 .) 
 Haemorrhoids, by their presence in the anal canal, lessen its 
 calibre, and in the act of defecation are first extruded and 
 then. separated, during which process the delicate mucous 
 lining is, by the forcible passage of hardened faeces, rup- 
 tured. Condylomata, or excrescences of the anus, the result 
 of chronic inflammation or irritation, are quite a frequent 
 cause of anal fissure. They produce the disease by narrow- 
 ing the anal orifice, becoming ulcerated at their base, and by 
 the constant irritation they excite in the parts. I would ob- 
 serve here that these condylomata or anal excrescences are 
 at the present day too often confounded with true hsemor- 
 
ANAL FISSURE. 
 
 63 
 
 rhoids. This is an error that needs correction, for they are 
 not of a hsemorrhoidal character. I have most always found 
 anal fissure complicated with condylomata, having seen but 
 few cases that were not accompanied by one or more of them. 
 
 Fig. 1. 
 
 7. Anal Fissure from Cutaneous Affections. Fissure of the 
 anus is not unfrequently the result of a local variety of one or 
 the other of the following cutaneous diseases : — Prurigo ^Ec- 
 zema, Psoriasis, and Herpes. A thickening of the mucous 
 membrane and muco-cutaneous coat of the terminal por- 
 tion of the rectum takes place in one or the other of those 
 affections, causing deep cracks or fissures, and exciting^viti- 
 ated and acrid discharges, so that ultimately, if not relieved 
 early, that morbid condition of the part takes place which is 
 characteristic of anal fissure. 
 
64 ANAL FISSURE. 
 
 8. Fenereal Origin of Anal Fissure. This disease may 
 arise from the direct application of the venereal poison to 
 the margin of the anus, as in " Unnatural Congress;" or a 
 flow of it may take place from the genital organs to the 
 anus. Females especially are very obnoxious to it from the 
 circumstance that the vaginal discharges can so readily flow 
 over parts of the anus. Or syphilitic fissure of the anus 
 may be consecutive to disease in the genital organs, and 
 then coexist with other secondary symptoms. 
 
 9. Can Anal Fissure be produced Artificially ? M. Velpeau is 
 of opinion that this disease cannot be produced artificially. 
 This, however, is an error, for I myself have witnessed several 
 cases to the contrary. In the removal of hsemorrhoidal 
 tumors by the application of the nitric acid, or the fluid acid 
 nitrate of mercury, if not very careful, sometimes a drop, or 
 even less, may come in contact with the mucous membrane 
 lining the external sphincter, and produce a small superficial 
 ulcer, which in some instances becomes afterwards highly 
 sensitive and irritable, and causes similar suffering precisely 
 to that of anal fissure, and indeed constitutes this veritable 
 disease. [Vide Case xv.] The same disease sometimes 
 follows the excision of hsemorrhoidal tumors, either by the 
 knife or the ligature, when a small ulcer is left from the 
 operation, as I have on several occasions witnessed. [Vide 
 Case xxvi.] Mr. Curling names one or two cases precisely 
 of this nature. " One of the most painful ulcers," says Mr. 
 Curling, " I have had to treat occurred, I was informed, 
 after the excision of a small pile. In another case in which 
 I removed a large pile by ligature, the patient, a gentleman, 
 neglected my injunction to keep at rest afterwards. He 
 returned too soon to active business, and an irritable sore 
 was the consequence. I have also met with one which 
 occurred after the removal of an internal pile by the acid 
 nitrate of mercury in a lady of irritable constitution." — (Op. 
 cit, p. 8.) 
 
ANAL FISSURE. 65 
 
 1 o. Are the Causes of Anal Fissure obscure ? M. Boyer says 
 that the causes of this disease are very obscure ; that he had 
 observed among many of the patients he treated, it had 
 been preceded by a hsemorrhoidal swelling; and that 
 among some of these cases haemorrhoids had been of long 
 standing. Now, in my opinion, the causes of anal fissure, 
 as a general rule, are not obscure, as I have abundantly 
 shown; take for example haemorrhoids as a cause. I am 
 therefore surprised that M. Boyer, -with his extensive know- 
 ledge and experience on the subject, should have made such 
 an assertion. The truth is that all superficial lesions, es- 
 pecially those of a linear shape, located on the mucous 
 membrane lining both sphincters of the anus, are liable 
 sooner or later of becoming so sensitive and irritable, from 
 some of the numerous causes already enumerated, as to 
 produce that morbid state of the parts which I term anal 
 fissure, which is nothing more nor less than a highly sensi- 
 tive and irritable ulcer, located in the inferior extremity of 
 the rectum, and sometimes communicating its irritability to 
 one or both sphincters of the anus, inducing in one or both 
 spasmodic contraction of their muscular fibres. 
 
 I will admit that the disease, in many instances, is so 
 gradually developed, that it is difficult to assign it to its 
 true and legitimate cause. Instances will sometimes be met 
 with in which we will not be able to discover any probable 
 or assignable cause. 
 
 I would here remark in conclusion, that many of the 
 causes of anal fissure which I have enumerated, it is true, 
 produce other abrasions, excoriations, or ulcerations about 
 the orifice and canal of the anus, which cannot for obvious 
 reasons be termed anal fissure ; consequently care must be 
 taken not to confound diseases alike in their cause and ap- 
 pearance, yet very different in their symptoms and in their 
 treatment. 
 
 1 1. Who are the most Obnoxious to Anal Fissure ? It may be 
 
 5 
 
66 
 
 ANAL FISSURE. 
 
 said, so far as temperaments are concerned, that the nervous, 
 bilious, and the leucophlegmatic, are peculiarly susceptible 
 of diseases of the mucous membrane of the rectum. Anal 
 fissure is an affection that does not seem confined to any 
 period of life, but it rarely exists until after puberty. It 
 most commonly occurs between the ages of eighteen and 
 fifty ; but I will presently show, contrary to the opinion of 
 MM. Boyer, Velpeau, and some other eminent surgeons, 
 that children are sometimes the subjects of it. I have my- 
 self observed several marked and unmistakable cases in my 
 own practice. [Vide Cases v., x., xix.] According to 
 the experience of M. Trousseau at the Hospital Neckar in 
 Paris, infants, even during suckling, are liable to this most 
 distressing affection as well as adults. M. Duclos reports 
 two highly interesting cases which came under the immedi- 
 ate practice of M. Trousseau. These cases will be found 
 reported in full in the chapter on the treatment of Anal Fis- 
 sure. 
 
 Mr. Miller says that fissure of the anus has been observed 
 in children at the breast. — {Practice, of Surgery, p. 380. 
 Edinburgh, 1852.) 
 
 " Children, as we have observed," says M. Blandin, " and 
 as it is clear, are not exempt from anal fissure, especially that 
 form of it which is caused by a venereal taint ; and that 
 which is caused by blows or other violence exercised upon 
 the anus." — (hoc. cit!) 
 
 This disease is met with in children whose constitution is 
 feeble, and who have derangement of the digestive func- 
 tions, and who either suffer from obstinate constipation of 
 the bowels, or who have frequent diarrhoea; and in those 
 who without the influence of these circumstances are badly 
 cared for, and imperfectly attended to. The disease in 
 children, as in adults, is caused by the straining efforts re- 
 sulting from constipation of the bowels, and producing a 
 superficial rent of the mucous membrane which lines the 
 
ANAL FISSURE. 67 
 
 sphincter ani ; and in diarrhoea from the irritation and ery- 
 thema of the anus which attend that disease. It sometimes 
 occurs in children who are suffering from aphthse. 
 
 The disease in its worst form, or spasmodic stage, does 
 not as a general rule affect very aged persons, for in them 
 the contractile power of the sphincters of the anus is gene- 
 rally, to a greater or less degree, diminished. 
 
 It is an affection common to both sexes, but women are 
 certainly the most obnoxious to it, especially those who have 
 borne children ; and often occurring in nursing mothers who 
 are subject to aphthse. The principal causes in females, 
 however, are doubtless a want of proper exercise and 
 obstinate constipation of the bowels ; the first a predisposing 
 and the last an exciting cause. Women, both from habit 
 as well as from the usages of society, are sedentary, and in 
 them constipation of the bowels generally prevails, caused 
 in part by habitually neglecting the calls of nature, which 
 they can with greater impunity do than men, in consequence 
 of the greater amplitude of the pelvic cavity, but which 
 sooner or later lays the foundation of the most serious mis- 
 chief to some one or more of the important viscera of this 
 cavity. 
 
 Men of literary pursuits, or those closely engaged in 
 study, as students; or employed at the desk or counter, as 
 clerks, accountants, and salesmen ; or those confined to seats, 
 as tailors, shoemakers, &c, are all liable to suffer from con- 
 fined bowels. The want of bodily exercise generally les- 
 sens the demand for food, weakens the digestive organs, and 
 indigestion and constipation are almost a necessary conse- 
 quence. 
 
CHAPTER FOURTH. 
 
 CLASSIFICATION AND DESCRIPTION OF ANAL 
 
 FISSURE. 
 
CHAPTER IV. 
 
 CLASSIFICATION AND DESCRIPTION OF AN/AL FISSURE. 
 
 Section I. — The Seat, and the Anatomical and Pathological Charac- 
 ters of Anal Fissure. 
 
 i . Seat. To a superficial observer it might seem super- 
 fluous to speak of the seat of anal fissure, since the term it- 
 self implies the locality of the disease, and to such it might 
 also seem of no importance to distinguish and to describe it 
 in accordance with its position. It will be perceived, how- 
 ever, that it is important that the exact locality of the fissure 
 should be pointed out, not only for the purpose of showing 
 the great difference in the ulcer arising from its position 
 within and without the anal orifice, but also to prevent 
 confounding affections essentially alike in cause, but 
 entirely different in nature and in symptoms, and requiring 
 different modifications of treatment. Some authorities 
 attach no therapeutical value whatever to such distinction. 
 MM. Blandin and Dupuytren, however, acknowledge the 
 importance of it. M. Blandin himself divides anal fissures 
 into three divisions, as follows : — 
 
 " l. Les fissures inferieures au sphincter. 
 
 " 2. Les fissures superieures au sphincter de l'anus. 
 
 "3. Les fissures a l'anus qui sont placees au niveau du 
 sphincter." — (Op. cit.) 
 
 2. Classification. I will, for the better elucidation of the 
 subject, point out the different localities, in the inferior ex- 
 tremity of the rectum, which fissures are found to occupy, 
 as well as describe the different character they assume in 
 each of such positions. They may therefore be distinguish- 
 
72 ANAL FISSURE. 
 
 ed into four classes, according to their locality; believing 
 this to be both a natural and a useful distinction. 
 
 First Class. These are the fissures that are situated on the 
 outside of the anal orifice, and immediately beyond the 
 grasp of the external sphincter ani, and affect only the integu- 
 ment, or the muco-cutaneous tissue. They often scarcely 
 exceed four or five lines in length, and occupy the grooves 
 between the duplicatures of the fine and delicate skin 
 about the verge of the anus, and may be readily seen by- 
 separating those folds. They sometimes appear in the form 
 of excoriations or abrasions, consisting merely in the removal 
 of the epithelium ; or in the form of narrow chaps, or oval 
 or circular ulcers, having a red, but more frequently a yel- 
 low or ash-colored base. They frequently penetrate through 
 the epidermis, rete mucosum, and sometimes through the 
 true skin, and are often attended by a slight oozing of a 
 sub-acid discharge, and are very similar in appearance to 
 those fissures or cracks that occur on the lips and angles of 
 the mouth in some persons affected with herpetic com- 
 plaints. The fissures of this locality, as a general rule, do 
 not affect the external sphincter, so as to induce spasmodic 
 contraction of that muscle, not being immediately within 
 its grasp. Cases, however, of fissures in this locality do 
 sometimes occur in which there will be violent spasmodic 
 contraction of the external sphincter. Several such cases 
 have fallen under my own observation. 
 
 The fissures of this locality are always, however, attended 
 with more or less intense smarting and burning pain, either 
 while at stool, or some time afterward, and only occasionally 
 by sympathetic spasm of the anus ; consequently they are 
 justly entitled to the appellation, anal fissure, ox exquisitely ir- 
 ritable ulcers of the anus. It must be distinctly understood, how- 
 ever, that many of the abrasions, excoriations, and super- 
 ficial ulcers of this region, produce nothing but an irrita- 
 tion or soreness of the parts like that caused by a common 
 
ANAL FISSURE. 73 
 
 sore, or like that caused by chafing or galling. Any and all 
 such deserve not the appellation, fissure of the anus. 
 
 Second Class. The fissures which belong to this class are 
 situated immediately within the anal orifice, and affect the 
 mucous membrane lining the sphincter externus, and are 
 situated opposite to or on a level with this muscle. They 
 are considered by some of the most able authorities to be 
 the only true and genuine fissures. In these cases the in- 
 ferior extremity of the fissure may be brought in sight and 
 examined, by causing the patient to make expulsive efforts 
 as if at stool ; or by forcibly divaricating the nates and the 
 anal orifice with the hands and fingers, when the lower end 
 of the ulcer will be exposed to view. In order, however, 
 to obtain a complete view of the whole fissure, the anal 
 speculum must be used, which, by rendering the mucous 
 membrane tense, a vivid red line with a sharply defined 
 edge, or a very narrow slit with redden margins will be ob- 
 served. This fissure is more frequently found at the pos- 
 terior part of the anal canal, or posterior surface of the 
 sphincter ani, than at any other locality ; less frequently on 
 the sides, and still less at the anterior part of the anal canal, 
 or perinseal surface of the sphincter. About two-thirds of 
 the cases I have treated, I have found the fissure situated on 
 the posterior surface of the external sphincter. The next 
 point in frequency, so far as my experience goes, is on the 
 sides of the anal canal. I do not think I have treated 
 twenty cases in which the fissure was situated on the peri- 
 nseal surface of the sphincter muscle. The position of the 
 fissure, however, varies considerably, so does also the degree 
 of the morbid alteration. It most generally begins about 
 a line above the margin of the anus, and prolongs itself in a 
 vertical direction, following one or the other of the furrows 
 between the folds or columns of the mucous lining of the 
 anal canal ; and varying in length from the third of an inch 
 to one inch and a third. It is rare that more than one 
 
74 ANAL FISSURE. 
 
 fissure exists at the same time ; yet I have seen as many as 
 three and four very small ones existing simultaneously. In 
 some instances, in the early stage of the disease, one or two 
 bright red granulations sometimes sprout up in the fissure, 
 and give rise to more or less haemorrhage at each evacuation 
 of the bowels. If the disease is suffered to go on without 
 any active treatment, the appearance of the fissure soon 
 changes. When recent, its edges are soft and pliant, and 
 but little raised ; but in the exact ratio in which the ulcer 
 becomes chronic from long continuance, its edges become 
 hard and elevated, or everted, changes which depend upon 
 the interstitial deposition of adventitious matter from the in- 
 flamed capillaries. The surface of the ulcer itself looks 
 pale, like any other indolent sore, and from which there is a 
 little secretion, and sometimes at stool a little blood and 
 mucus are passed. The mucous membrane surrounding 
 the fissure also undergoes changes; for a while at first it 
 retains its natural color, but when the disease is of long 
 standing it often presents an erysipelatous hue ; and then 
 again it assumes a livid aspect, and becomes soft. 
 
 This solution of continuity never extends in depth fur- 
 ther than to the muscular tissue. In the majority of cases 
 it does not even extend through the mucous membrane ; 
 but cases do occur in which the ulceration not only extends 
 through the mucous, but also through the submucous 
 cellular tissue which unites the mucous to the mus- 
 cular coat. M. Merat, if I understand him, intimates 
 that it sometimes does attack the muscular tissue. He 
 says : — " Le tissu affecte est la membrane muqueuse, mais 
 il n'est pas rare que l'ulceration depasse son niveau, et gagne 
 la portion musculaire de l'intestin." — (Dictionnaire des Sciences 
 Medicates. Tome XF. Art. Fissure, p. 544. Paris, 1816.) 
 MM. Dupuytren and Blandin both declare that the ulcer 
 rarely ever extends even through the mucous membrane. 
 M. Dupuytren says : — " Cette ulceration n'atteint que tres- 
 
ANAL FISSURE. 75 
 
 rarement toute Pepaisseur de la membrane muqueuse." — 
 (Op. cit. p. 151.) M. Blandin says: — "Cette ulceration 
 n'atteint que rarement toute Pepaisseur de la membrane 
 muqueuse." — (Op. cit. p. 156.) 
 
 I have seen two cases in which the ulceration had ex- 
 tended itself completely through the mucous and submu- 
 cous cellular tissue to the muscular coat. Mr. Curling re- 
 lates a case in which he could distinctly perceive the fibres 
 of the sphincter ani forming the bottom of the ulcer. — (Op. 
 cit. p. 1 1 .) I have never seen the record of any case in 
 which the fissure is said to have completely invaded the 
 muscular coat. 
 
 The fissures of this class are, as a general rule, the most 
 painful and the most serious of any others met with. They 
 are most always attended with sympathetic spasmodic con- 
 traction of one or both anal sphincters; and even when un- 
 attended by violent anal spasm, they are of the most exqui- 
 sitely painful nature. 
 
 Third Class. The ulcers or fissures of this class are situ- 
 ated above the sphincter externus, in the middle region of 
 the anal canal, in the small space or fossa which exists 
 there, between the two sphincters. They can only be seen 
 by the use of the speculum ani; but may easily be detected 
 by the finger in ano. These fissures are generally of an ob- 
 long or circular form, and are but seldom linear (Fig. 2) ; 
 they vary in size from a half split pea to that of a silver 
 dime, or to the end of the index finger. In cases of long 
 standing the edges of the ulcer are indurated, but the centre 
 generally remains soft and of a grayish or bright red color, 
 and from which a little purulent or sanio-purulent matter 
 passes at each evacuation of the bowels. These ulcers, ac- 
 cording to my experience, are generally situated on the 
 lateral parts of the canal, and but seldom on the posterior 
 or anterior parts. On a digital examination the sensation 
 which the ulcer communicates to the finger is that of an ex- 
 
-6 ANAL FISSURE. 
 
 cavation. This fissure/as a general rule, does not induce 
 sympathetic spasmodic contraction of the anal sphincters ; 
 indeed anal spasm does but seldom accompany it, but as the 
 ulcer is touched or pressed upon by the finger, the muscle 
 instantly grasps it firmly. The pain of this kind of fissure 
 
 Fig. 2. 
 
 is most intensely sharp and burning, commencing either 
 while at stool or a short time after, and continuing for sev- 
 eral hours, often amounting almost to agony, whether being 
 attended by anal spasm or not. In consequence of the ab- 
 
ANAL FISSURE. 77 
 
 sence generally of spasmodic contraction of the anal sphinc- 
 ters, an examination may be made, as well as the treatment 
 carried out with but little suffering to the patient, obviating 
 thereby the necessity generally of the use of anaesthetics ; 
 indeed the external sphincter, instead of being in a state of 
 spasm, is often found quite relaxed. It is in this locality 
 that the excavated ulcer of the late and eminent Mr. Colles 
 is situated, and which he has described in the Dublin Hos- 
 pital Reports. Vol. F.p. 155. Dublin, 1830. Several cases of 
 this peculiar species of fissure, or obstinate ulcer between 
 the sphincters, have come under my own observation. 
 [Vide Cases vin., ix., xxix.] An ulcer not in the form 
 of fissure, but oval or circular, and attended with all the 
 usual characteristics of fissure, is mentioned by Sir. Benj. 
 Brodie in a lecture on the diseases of the rectum, in the 
 London Medical and Surgical Journal, Vol. V. p. 286. London, 
 1834. I rather incline to the opinion that the ulcer of Mr- 
 Colles and that of Sir Benj. Brodie are identical. Mr. Quain 
 also mentions the same kind of ulcer. — (Op. cit. p. 162, case 
 
 53-) 
 
 The ulcer mentioned and described by Mr. Colles is 
 generally situated in the fossa between the two anal sphinc- 
 ters ; it is sometimes, however, situated a little higher up or 
 lower down, and on a level with one or the other of the sphinc- 
 ters. The form of the ulcer, instead of being linear as in 
 the second class, is generally oblong or circular. It is ex- 
 cavated, having raised edges and a deep soft bottom, of a 
 grayish appearance, and attended by a considerable purulent 
 discharge. This kind of fissure is generally accompanied 
 by enlargement of the hemorrhoidal veins ; or by a con* 
 siderable tumefaction about the verge of the anus. 
 
 Fourth Class. These are the fissures which are situated on 
 the mucous membrane lining the sphincter internus, and a short 
 distance above this muscle. They can only be seen by the 
 use of the speculum ani. These fissures are somewhat rare, or 
 
^g ANAL FISSURE. 
 
 perhaps are overlooked. (Fig. 3.) They do not produce the 
 extreme suffering which those of the second and third class do. 
 The pain is not so sharp and burning, but more of a dull, 
 heavy ache or bearing down, and lasts for several hours after 
 an evacuation of the bowels. It is sometimes attended 
 with spasmodic contraction of one or both of the sphincters 
 of the anus, but this is not frequent. Ulcers in this situa- 
 
 Fig. 3. 
 
 tion cause considerable sympathetic irritation at the neck of 
 the bladder, there being often a constant desire to pass urine 
 with but little ability to do so, which is sometimes very 
 troublesome, and a serious addition to the other sufferings of 
 the patient. I have treated two cases of this kind. 
 
 A fissure in this locality is sometimes most difficult to 
 detect. 
 
ANAL FISSURE. 79 
 
 Section II. — The Symptoms and Signs of Anal Fissure. 
 
 The evidences of this disease are of two kinds, — namely, 
 those which have reference to the disturbance of the parts 
 both immediately and remotely concerned, being manifested 
 by numerous and various symptoms ; and those which relate 
 to the appearance of the parts directly involved. 
 
 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 oc- 
 casions. Indeed the very great distress which is experienced, 
 and the nervous anxiety which is often manifested, even by 
 firm-minded persons, are surprising when the insignificant 
 amount of the local malady is taken into consideration. 
 
 1. Symptoms. The characteristic or essential symptoms of 
 anal fissure, are a severe smarting or burning pain in the 
 anus or anal canal, occurring during the act of defecation, 
 or a short time after, attended sometimes with a sympathet- 
 ic spasmodic contraction of one or both sphincters of the 
 anus. The exacerbation of pain does not precede the evac- 
 uation, as it generally does in inflammatory affections of the 
 anus, but most commonly follows, after an interval of a itw 
 minutes. 
 
 The symptoms of this disease at its inception are not very 
 severe, being for a longer or shorter period merely an un- 
 easy sensation, consisting of an itching, pricking, slight 
 smarting, or feeling of heat in a certain point in the circum- 
 ference of the anus, and occurring only during the evacua- 
 tion of the bowels, and for a {ew minutes after. As the 
 disease advances this uneasy sensation gradually increases, 
 and sooner or later gives place to a most severe burning, 
 lancinating, or throbbing pain. The sensation of burning at 
 the time of stooling sometimes exists to such a degree that 
 it produces the most inconceivable anguish, but which in 
 
80 ANAL FISSURE. 
 
 some instances is almost entirely relieved on the completion 
 of the act of defecation ; whilst in others it is only to be re- 
 newed soon afterwards, with, if possible, greater violence. 
 The pain occupies a circumscribed space about the margin 
 of the anus, and is often attended, when very severe, by a 
 pulsation of the vessels similar to that which generally 
 accompanies phlegmonous inflammation. The attack of 
 local pain being at an end the patient feels perfectly well, 
 and apparently would continue so, were it not for the dis- 
 turbing or the distressing effect of the passage of the fecal 
 matter again. In consequence of this, some patients manage 
 to curtail the number of their evacuations, and others reduce 
 the quantity of food to a very small amount for the same 
 purpose, and to avoid increasing the fecal mass, or having 
 large evacuations, being well aware that such cause addi- 
 tional suffering. According to my observation the largest 
 proportion of patients, however, suffer none at all whilst 
 evacuating their bowels; or if they do suffer, it is so trifling 
 as not to attract their serious attention ; but in the course 
 of ten, twenty, or thirty minutes, or one or two hours after 
 the evacuation, they experience the most intense smarting, 
 burning, or lancinating pains, which are often accompanied 
 with violent spasmodic contraction of one or both anal 
 sphincters. The degree of contraction, however, is by no 
 means in proportion to the amount of suffering. As the 
 disease progresses the pain, if possible, becomes daily more 
 aggravated after each evacuation, often conveying to the 
 patient the sensation of scalding, or of a red-hot iron being 
 thrust into the anus, and gradually increasing in intensity 
 until it has arrived at its maximum, when the patient 
 suffers the most excruciating torture, sometimes bringing on 
 a feeling of syncope, or a threatening of convulsions. These 
 sufferings continue unmitigated for a length of time, vary- 
 ing in different cases from two to twelve hours, or even 
 longer, when they either gradually or suddenly abate and 
 
ANAL FISSURE. 8l 
 
 leave the patient in perfect ease, as it were, until a renewal 
 of the necessity for the passage of fseces causes a return of 
 the sufferings, the interim being spent by the patient " in 
 that delicious calm," says Mr. Calvert, " which usually follows 
 violent suffering, and which may be termed, not inaptly, the 
 very luxury of sensation."— (Op. cit. p. 213.) 
 
 In some few instances, provided the patients have a daily 
 evacuation, the pain lasts from one stool to another, requir- 
 ing them to maintain the recumbent posture almost all the 
 time. Others who daily evacuate their bowels, do so just 
 on retiring to bed, as the horizontal posture affords relief 
 generally, and they wish to be enabled on the morrow to 
 attend to business during the day. Some, however, cannot 
 maintain the horizontal posture without the most terrible 
 suffering, being compelled to sleep in a sitting posture, on 
 a hard seat. A remarkable case of this kind came under 
 my own observation. [Vide Case xx.] Some patients 
 are enabled to walk about, sit down, or attend to their busi- 
 ness during the interval between the attacks, but others 
 again are compelled to keep their beds. If the disease is 
 not promptly arrested by treatment, it will progress. The 
 pains will become continuous, and much more easily excited, 
 especially in irritable habits or constitutions, when they may 
 be produced by the slightest causes — such as any sudden 
 movement of the body, as walking, coughing, sneezing, 
 blowing the nose, singing, loud speaking, urinating, strong 
 passions of the mind; or any cause whatever that produces 
 local or general excitement. 
 
 Flatulence is a symptom that generally attends severe cases 
 of anal fissure, and it is very troublesome, as well as painful, 
 the disengagement of gas being almost certain to bring on a 
 paroxysm of pain; and when it is impossible to pass it, as is 
 sometimes the case on account of anal spasm, it is a source 
 of great discomfort and annoyance, by producing a continu- 
 ous kind of colic, and a bearing-down feeling. I do not 
 
 6 
 
82 ANAL FISSURE. 
 
 think I ever saw a severe case in which there was not more 
 or less flatus present. M. Boyer mentions the case of a 
 lady, one of his patients, who was tormented with a contin- 
 ued desire and impossibility of passing flatus. She was 
 compelled to wear continually an elastic canula in her bow- 
 el, so as to let out the gas whenever it reached the tube in 
 ano. I have frequently adopted the same expedient, to the 
 very great comfort of the patient, in cases in which there 
 was violent spasm of the anus. 
 
 Any excess in eating or in drinking will aggravate the 
 pains. In women the presence of the catamenia increases 
 their suffering. The pain is always at once excited by the 
 introduction into the anus of any foreign body, — such as 
 the pipe of the enema syringe, &c, and if the attempt be 
 made to pass up the finger, it will not only occasion more 
 or less suffering, but the finger will be grasped powerfully 
 by the sphincter muscle. In some cases lancinating pains 
 extend to the bladder in the male, and to the uterus in the 
 female, and in both sexes to the hypogastric region. In oc- 
 casional cases of anal fissure the pain assumes a periodical 
 character, depending upon some peculiar state of the con- 
 stitution. 
 
 In this disease, as before observed, the bowels become 
 obstinately constipated, and in some instances evacuation 
 takes place only once in every eight or ten days, unless pur- 
 gatives or enemata are employed. Indeed the very nature 
 of the disease leads to constipation. Such is the dread of 
 having a stool that most patients postpone the act of defeca- 
 tion as long as possible, some for two, three, four and even 
 eight days, during which they are generally comparatively 
 free from pain and nearly all expression of suffering subsides. 
 So complete is the manifestation of health, that it would 
 astonish a person ignorant of the nature of the disease, to be 
 assured that as soon as defecation takes place the disease in 
 all its violence would be renewed The affection is neither 
 
ANAL FISSURE. 83 
 
 retarded nor diminished in the least by this suspension of 
 defecation, but on the contrary its progress is unremitting ; 
 and both the violence of the spasmodic contraction and the 
 severity of the pain are, as it were, regenerated with an in- 
 crease of intensity, proportioned to the duration of time 
 during which they had been suspended by the absence of 
 defecation. The additional suffering caused by the suspen- 
 sion of defecation may be explained by the fact that an ac- 
 cumulation of fseces taking place for several days in the 
 bowel, becomes exceedingly hard, dry, and irritating; and 
 when at length the rectum contracts to expel this indurated 
 mass, its passage tears open afresh the fissure, and contuses, 
 excoriates, and irritates the whole anal canal, — hence the 
 anal sphincters, being highly stimulated and irritated by this 
 increased pain, contract spasmodically ; and in this manner 
 a contention is set up between the anal sphincters on the 
 one part and the muscular walls of the intestine on the 
 other, aided by the abdominal muscles. In some of these 
 cases the efforts to evacuate the bowels are so violent and 
 so prolonged, that respiration is sometimes suspended ; the 
 face becomes injected and purple, and the blood appears 
 ready to start through the skin. Patients for a long time, 
 even after they have been cured of this disease, have a dread 
 or a horror of stooling. 
 
 In the severe cases, the patients, as a general rule, seem 
 at a loss to find words sufficiently expressive to depict their 
 sufferings, and they always speak of them in the superlative 
 degree. They will compare the pain to that occasioned by 
 a red-hot iron thrust into the bowel ; or by scalding water 
 or molten lead thrown into the intestine ; or to a sharp knife 
 run into the anus ; or to tearing or lacerating the margin 
 of the anus. Females will often tell us that the pain is more 
 severe and more intolerable than the pains of labor. The 
 pain and suffering often give rise to loud expressions of 
 agony, even in some of the most determined and resolute. 
 
84 ANAL FISSURE. 
 
 When this disease is severe and of long duration, the pa- 
 tients sometimes fall into a remarkable state of melancholy 
 and extreme nervous susceptibility. In order to avoid 
 stooling, they eat but little ; their digestion is impaired, and 
 they gradually become emaciated and icteric; their counte- 
 nance is expressive of pain, and they have the general ap- 
 pearance of those suffering from serious organic disease. 
 Such patients too, although they may have possessed the most 
 happy, the most amiable and most even temper, or disposi- 
 tion, gradually lose it, and become petulent, peevish, crab- 
 bed, snappish, and unamiable. 
 
 2. Interval of I'ime between the act of Defecation and the Ac 'ces- 
 sion of the Pain. A remarkable circumstance in the nature 
 of this singular disease, is the distinct lapse of time which 
 takes place between the cessation of the act of defecation 
 and the accession of the pain, in all those who suffer most 
 after this act. There is, however, no certainty with regard 
 to the exact time after, when the pain will come on. It 
 may come on immediately after the excretion of the faeces, 
 ten minutes after, half an hour, one or two hours, or even 
 four hours after, according to some authorities. The cir- 
 cumstance of this distinct interval of time, whether of long- 
 er or of shorter duration, is nevertheless so certain and so 
 uniform in these particular cases that it might be considered 
 as the pathognomonic sign of this disease. " There is one 
 symptom," says Mr. Colles, " that will better explain the 
 nature of this disease, than even an examination through 
 the rectum, and it is so constant and so obvious, that I 
 wonder very much it has escaped writers on the subject, — 
 it is, that there is always a distinct interval of time, from ten 
 minutes to an hour or more, between the passage of the 
 fseces and the occurrence of the pain." — (Op. cit. p. 279.) 
 Mr. Ouain, when speaking on the same subject, also says: 
 " It is remarkable that in no small proportion of cases, it is 
 only after the lapse of some time from the act of defecation 
 
ANAL FISSURE. 85 
 
 that the pain begins. The interval that elapses between 
 the evacuation and the occurrence of the pain, varies from 
 about ten minutes to half an hour, or even two hours. I 
 cannot explain at all satisfactorily why an interval of time 
 elapses between the application of the exciting cause and 
 its effect ; nor can I account for the variations in its length." 
 — (Op. cit. p. 169) 
 
 The distinguished Professor Dr. Van Buren of our city, 
 after quoting what Mr. Quain has said upon this subject, 
 attempts to give an explanation of this phenomenon. He 
 says : " To me it seems plain that the dilatation, to which 
 the orifice of the anus is subjected by the extrusion of the 
 fseces during the act of defecation, is sufficient to prevent the 
 fibres of the sphincter muscle from resuming their full tonic 
 contractility, for a short interval, and that the length of the 
 interval depends entirely upon the size and hardness of the 
 mass extruded, and the amount of stretching to which the 
 orifice has been subjected." — (The American Medical Times. 
 Vol. Fill. />. 218. New Tori, 1864.) 
 
 In my opinion, the Professor has failed in the above to 
 give a true, a rational, or a satisfactory explanation of this 
 phenomenon. According to his hypothesis, both the inter- 
 val of time and its length depend entirely upon the size and 
 the solidity of the fsecal mass, and upon the amount of 
 stretching to which the anal orifice has been subjected by 
 such an evacuation. Now a soft or a fluid dejection is fatal 
 to this theory, inasmuch as a fluid stool, for instance, is 
 effected with the very slightest dilatation of the anal orifice, 
 and with no stretching whatever, in the sense in which that 
 word is used in the above ; so small indeed is the amount of 
 dilatation which occurs during such an evacuation, that it is 
 scarcely perceptible, consequently the interval following it 
 should be so brief that it should occur in a moment after. 
 But does it do so? Never. A fluid evacuation, effected 
 without a particle of stretching of the anal orifice, neither 
 
86 ANAL FISSURE. 
 
 obliterates nor shortens the interval, but rather lengthens it. 
 This faet I myself have verified in numerous instances, by 
 noting the exact time when the pain commenced after the 
 patient had passed a large and hard stool ; and on the next 
 occasion for stooling, administering an aperient to produce 
 a fluid dejection ; and then again observing the exact length 
 of the interval occurring between the completion of the act of 
 defecation and the accession of the pain, and I have gene- 
 rally found but little variation in the length of the interval, 
 the only difference, if any, it being in most cases longer 
 after a fluid than after a large and solid stool; so much so 
 that the patients themselves noticed the difference and began 
 to imagine that they would escape the pain altogether. I 
 have observed the same to occur in cases of anal fissure 
 accompanied by diarrhoea. The pain after a soft or a fluid 
 stool, as a general rule, is not as severe and of as long con- 
 tinuance as after a hard one. Another fact should be taken 
 into consideration in this connection, namely, that no incon- 
 siderable number of patients suffer the greatest if not 
 the only pain during the expulsive nisus, and whilst the 
 anal orifice is being subjected to this very dilating and 
 stretching process of which Dr. Van Buren speaks. 
 
 I would also remark here, that, according to Dr. Van Bu- 
 ren, the tonic contraction of the fibres of the sphincter ani 
 muscle is the cause of the pain, for he holds that the pain is 
 suspended until the full tonic contraction takes place. Now 
 the fact is, that the full tonic contraction of this muscle takes 
 place immediately after the evacuation, unless the distention 
 has been so great as to produce paralysis of its muscular 
 fibres ; for let any one then explore the anus, either with the 
 finger or with the bougie, and he will find this muscle has 
 already contracted naturally, and assumed its quiescent state. 
 This contraction, in my opinion, does not therefore produce 
 the pain, for this comes on some time after that has taken 
 place. It requires something more than the mere tonic con- 
 
ANAL FISSURE. 87 
 
 traction of the anal sphincters to bring on the pain. It 
 would be more reasonable to suppose that it was in such 
 cases the hyperaction, or the arbitrary or spasmodic con- 
 traction of these muscles that caused the pain. 
 
 The question before Mr. Quain was, why should there be 
 in anal fissure, an interval of time between the completion 
 of the act of defecation, the exciting cause, and the acces- 
 sion of the pain, the effect ? He answers by saying, that 
 he can give no satisfactory explanation of this circumstance. 
 I also answer in the same language ; consequently I will not 
 attempt an explication of it. The truth is, we are ignorant 
 of the cause of this interval, neither can we account for its 
 length, and we better admit, in the present state of our 
 knowledge, that it is organic, and consequently that it de- 
 pends upon some spontaneous change in the anus or anal 
 canal itself, of which we know nothing. 
 
 Mr. Malyn offers a very ingenious explanation of why, 
 in anal spasm, the pain does not occur at the time of the 
 excretion of the fseces ; and why it does occur some time 
 afterwards. The question before him was, why should the 
 pain take place after, instead of at the time of stooling ? The 
 following is his explanation of this matter : " The inflamma- 
 tory congestion of a part (the anus) possessing such strong 
 and numerous sympathies, explains at once the fearful 
 symptoms which attend it. The language of the patient 
 appears to be exaggerated, and when he compares the sen- 
 sation to that produced by the lodgment of a red-hot iron 
 in the gut, or to the tearing it out with fish-hooks, it may 
 seem strange that such should be the case, more after than 
 at the time of the expulsion of the fseces. But we must 
 remember that it is only to the most urgent calls of nature 
 that he attends, and that the solid feces in their descent, a 
 descent accomplished by violent abdominal contraction, 
 stun or blunt the energy of the nerves, and so effect their 
 exit with comparatively little pain. When, however, they 
 
88 ANAL FISSURE. 
 
 are expelled, reaction takes place, the nerves re-acquire their 
 sensibility, which is for a time exalted proportionally to its 
 previous depression, and, until this state subsides, the parox- 
 ysm endures." — (Op. cit.p. 339.) 
 
 This explanation of Mr. Malyn is no less specious than 
 that of Dr. Van Buren. They both, however, require large 
 and indurated faeces to sustain them ; the former to produce 
 the stunning or the blunting of the nervous energy, in order 
 to suspend the pain at the time of stooling, and for some 
 time afterwards ; and the latter to produce the stretching of 
 the anal orifice, so that some time must elapse before the 
 full tonic contraction of the stretched muscular fibres can 
 take place, and the pain begin. A fluid evacuation, how- 
 ever, in such a case, followed some time afterwards by the 
 usual pain, is fatal to both hypotheses. Such a stool is 
 effected without any stunning or blunting of the nervous 
 energy whatever, — hence, according to Mr. Malyn, the pain 
 should take place during the defecating act ; yet it does not 
 do so, but comes on as usual some time after, and in the 
 same manner as if the nervous energy had been stunned or 
 blunted by the passage of a hard stool. 
 
 The anus and anal canal being so much narrower 
 than the rectum just above, the expulsion of faeces through 
 this narrow passage is of course attended with more or less 
 difficulty, in proportion to their size and solidity ; sometimes 
 requiring all the power of the sphinctores ani, as well as that 
 of the diaphragm and other abdominal muscles. When the 
 faeces are fluid, the contraction of the muscular fibres of the 
 inferior extremity of the rectum is alone sufficient for their 
 expulsion, without the intervention of the anal sphincters. 
 The gases are more easily expelled than faecal matter. Like 
 fluid faeces, they can be disengaged by the action of the in- 
 testine alone ; though the diaphragm and the other abdo- 
 minal muscles generally co-operate with the intestinal circu- 
 lar fibres in their disengagement. 
 
ANAL FISSURE. 89 
 
 3. Symptoms and Signs of Anal Fissure in Infants. The 
 symptoms of this disease in children differ somewhat from 
 those manifested in the adult. In children or infants the 
 pain occurs only whilst straining efforts are taking place ; the 
 pain apparently ceasing in a few minutes after the passage of 
 the faeces, only to reappear on the bowels being again moved. 
 It is universally the case when infants are the subjects of this 
 disease, that their sufferings commence and terminate with 
 the act of defecation. Nothing appears to indicate the 
 slightest pain after the excretion of the fsecal matter. Dur- 
 ing the expulsive nisus the child manifests the acute pain it 
 suffers by its actions, and by the sharp and piercing cries it 
 utters. The pain appears to begin with the very first effort 
 of defecation, and to be very severe during the passage of 
 the faeces through the anus. When there is considerable 
 constipation, which is sometimes the case in these instances, 
 defecation is more painful, and often attended with violent 
 spasm of the anus ; and there is also, at each and every evac- 
 uation of the bowels, an escape of several drops of blood, 
 consisting simply in an oozing, or a true stillicidium ani, but 
 which immediately ceases on the cessation of the straining 
 efforts. In adults extensive and very painful anal fissures 
 often exist without the slightest haemorrhage. 
 
 The fissure in infants is generally perceptible to the eye 
 when the child is making straining efforts to evacuate the 
 bowels, and the anus is everted ; but even in the absence of 
 this ocular demonstration, the seat of the pain, the mode of 
 its manifestation, and the slight haemorrhage which invariably 
 accompanies each alvine evacuation, would leave but little 
 doubt in the mind of the observer, as to the true nature of 
 the case. 
 
 Such are some of the rational symptoms and the signs of 
 anal fissure, both in the adult and in the child, and they are 
 quite sufficient to furnish a tolerable diagnosis. But in this, 
 as in all other affections of the inferior extremity of the 
 
90 ANAL FISSURE. 
 
 rectum, we must depend mainly upon the actual exploration 
 of the parts, in order to determine its character positively. 
 Such exploration requires considerable tact and dexterity to 
 conduct it successfully. 
 
 -o- 
 
 Section III. — Physical Exploration, Diagnosis, and Prognosis. 
 
 l. Ocular and Digital 'Examination. Preparatory to a 
 thorough inspection of the rectum, and a few hours previous 
 to making it, the bowel should be completely emptied by 
 either a dose of castor oil, or a relaxing enema. Should 
 there exist much pain and anal spasm immediately after the 
 evacuation of the bowel, the following suppository should 
 be administered a short time previous to making the ex- 
 amination, unless it should be considered preferable to use 
 an anaesthetic instead : — 
 
 Recipe, Extracti Belladonnas, granum unam, 
 
 Morphias Sulphatis, granum dimidiam, 
 Butyri Cacao, scrupulum. 
 Misce et fiat suppositorium. 
 
 The rectum and the bladder being completely evacuated, 
 the patient should be placed on his left side, on the edge of 
 a bed, if high enough, or on the edge of a table, in front of 
 a strong light; his head and shoulders depressed, his pelvis 
 elevated, and his nates widely separated by an assistant. 
 
 The first object of attention will be the external appear- 
 ance of the anus itself, which in anal fissure is most always 
 in a highly contracted state, and more or less infundibuli- 
 form; indeed, in such a case the observer will be struck 
 with the very considerable depth to which the anus is 
 retracted, producing a quite unnatural appearance of it. 
 Sometimes, however, in cases in which the fissure is 
 located in the fossa between the two sphincters, the anus, 
 instead of being firmly contracted, its external margin will 
 
ANAL FISSURE. 
 
 9i 
 
 present a peculiar laxity, and a bulging or jutting of one or 
 the other side like a swollen lip. Another object that will, 
 if it exists, attract the attention of the observer in this dis- 
 ease, is a pendulous projection or polypiform body (Fig. 4), 
 
 Fig. 4. 
 
 varying in length from two to eight lines, and of different 
 forms, composed of the integument at the margin of the 
 anus, and existing in most all cases of any considerable 
 duration. This condyloma or anal excrescence is always 
 located at the base, or inferior extremity of the fissure, and 
 is an unerring guide to it. I look upon this excrescence as 
 being almost the pathognomonic sign of anal fissure ; and I 
 
9 2 
 
 ANAL FISSURE. 
 
 have seen but few cases indeed in which it was not present. 
 By placing a finger on each side of the tumor, and pressing 
 it out and down (Fig. 5), the fissure will be seen. 
 
 
 Fig. 5. 
 
 M. Velpeau mentions this excrescence. He says : " It is 
 not unfrequent, in fissure, to find a hsemorrhoidal tuber- 
 cle forming, as it were, its root, and receiving, so to speak, 
 its tail." — {Loc. cit.) Mr. Syoie also notices it : " There is 
 generally," says he, " a small, firm, red-colored pile, like a 
 pea in size and form, at the base or outward extremity of 
 the fissure, which tends not only to conceal the sore but to 
 render its exposure more painful. To a practised eye, 
 indeed, the peculiar form, consistence, and color of this 
 
ANAL FISSURE. 93 
 
 little swelling render it a good guide to the seat of annoy- 
 ance ; but it much more frequently misleads to the idea 
 that there is no local complaint, or only an external 
 hemorrhoid." — (Op. cit. p. 126.) Mr. Smith, in speaking 
 of the same, says : " Not unfrequently a small tumor or 
 hsemorrhoidal excrescence will be found at the verge of the 
 anus ; on well exposing this, the fissure or ulcer will be seen, 
 hid as it were behind it. In fact the existence of this small 
 tumor is a pretty correct indication of the presence of the 
 ulcer." — (Op >. cit. p. 128.) 
 
 On proceeding to search for the fissure, which is often 
 difficult to find, being hidden in the folds of the anus, the 
 nates, as before observed, should be well divaricated by the 
 assistant, while the surgeon should forcibly separate the sides 
 of the anus with his thumbs, when the inferior extremity of 
 the fissure will be brought into view, its edges will diverge, 
 and its true character may be ascertained. 
 
 When, however, the fissure is situated above the external 
 sphincter of the anus, this proceeding will not suffice to 
 bring it in sight, but a resort must then be had to the dila- 
 tation of the anus by the use of the speculum ani, or by the 
 introduction of the finger, in order to detect it. The exam- 
 ination either with the finger or the speculum should not be 
 made immediately after the evacuation of the rectum, if 
 pain and anal spasm exist ; better wait for the effect of the 
 suppository, or for a few hours until the pain and spasm 
 shall have measurably ceased. Of course, if either ether or 
 chloroform is employed, it is not essential to observe this de- 
 lay. The existence, the exact situation and character of the 
 fissure, may often be indicated by the finger alone introduced 
 into the anus and anal canal, especially in a case of long 
 standing. The lesion will be detected by the sensation com- 
 municated to the finger, of roughness of its surface, or hard- 
 ness of its edges ; or by a feeling of something like a hard 
 wrinkled cord. Pressure should be made in every direction 
 
94 ANAL FISSURE. 
 
 around the periphery of the canal. If the fissure is touched 
 or pressed upon by the finger, its existence will also be con- 
 firmed by the sensations of the patient, if not made insensi- 
 ble by an anaesthetic, who will experience the most severe 
 pain, as M, Dupuytren truly says when describing this dis- 
 ease, " la pression fait ressentir beaucoup de douleursT — (Loc. cit?) 
 The index finger of the right hand being warmed and 
 well lubricated with either cacao butter, the simple cerate of 
 the French pharmacopoeia, glycerine, the white of an egg, 
 or olive oil, should be gently and gradually insinuated into 
 the anal canal. Any attempt to penetrate roughly or rapid- 
 ly will be very liable to excite resistance from the muscles, 
 and the passage of the finger or other instrument would 
 occasion more or less suffering and after-distress, and greatly 
 interfere with the progress of the examination. I always 
 use the butter of cacao for lubricating or besmearing the fin- 
 ger, the speculum, the sound, the bougie, &c, in making 
 an examination of the rectum, the vagina, the uterus, 
 and the urethra. There is nothing better for this purpose, 
 as it is soothing and relaxing, and not readily absorbed. 
 I usually make the digital examination first, before using 
 the speculum; the finger dilates the anus, and prepares the 
 parts for the easy entrance of this instrument. The instru- 
 ment I most use in anal fissure is the small bi-valve specu- 
 lum ani, represented by Fig. 6. It, like the finger, should 
 
 Fig. 6. 
 
 be warmed and well lubricated before being introduced ; it 
 
ANAL FISSURE. 
 
 95 
 
 should then be gently and slowly passed up into the rectum, 
 and opened and rotated until the whole mucous surface of 
 the lower end of the bowel is clearly brought into sight. 
 Should the view be obstructed in the least, by either mucus, 
 blood, or fseces, a small mop made of fine sponge and at- 
 tached to the end of a rod should be at hand to remove any 
 of these matters. The instrument should be carefully with- 
 drawn with the blades partially open. The only objection 
 that can be urged against this valvular speculum, is that in 
 instances, in which there is a superabundance of integument 
 and mucous membrane at the anal extremity of the rectum, 
 it too readily permits their protrusion between its blades, 
 and thus more or less prevents an accurate inspection of the 
 parts. The instrument is made of polished steel, or silver- 
 plated. 
 
 I have found the tri-valve trellis speculum ani, represent- 
 ed by Fig. 7, a very valuable instrument for the purpose of 
 
 discovering a certain kind of fissures or ulcers of the rectum. 
 I devised it a number of years ago, as an instrument to be 
 used in detecting the bleeding vessel in case of traumatic 
 hemorrhage of the rectum. It is small when closed and 
 easy of introduction, and when introduced admits of exten- 
 sive expansion by simply revolving the handle. As an anal 
 spec alum, especially in cases of fissure of the anus, I have 
 
96 anal fissure. 
 
 also found the simple and highly polished steel instrument, 
 in the form of a large blunt gorget, as delineated by- 
 Fig. 8, very efficient and valuable. It is passed up into 
 
 Fig. 8. 
 
 the rectum upon the finger, with its concavity looking to- 
 wards the seat of the disease, and when in to the depth of 
 two and a half or three inches, the mucous surface of the 
 canal at that height can be plainly seen reflected on its pol- 
 ished concave surface ; at the same time the lower portion 
 of the canal can be most accurately examined by the eye, 
 by causing the patient to evert the anus as much as possible. 
 By passing this instrument gently and slowly around the 
 canal, the whole internal surface of it may thus be accurately 
 inspected. It requires a strong and bright light. The idea 
 of using an instrument of such a form was first suggested 
 by Mr. Colles, who objected to the various kinds of anal 
 speculse in common use, and employed for this purpose the 
 large blunt gorget, and found it superior to any other. He 
 subsequently made an improvement on it. In order to 
 introduce it with greater facility he accurately fitted it to 
 one side of a conical piece of polished box-wood, represent- 
 ing in its transverse section a full ellipse, so that when both 
 were joined they presented a perfectly smooth outline. 
 After the instrument thus united was introduced to the pro- 
 per depth the wooden plug was withdrawn. — {hoc. cit?) 
 
 The instrument I designed is easy of introduction upon 
 the finger, without the use of the plug. 
 
ANAL FISSURE. 
 
 97 
 
 On a dark day, or whenever a strong light is required in 
 making rectal examinations, I always use the portable 
 apparatus depicted in Fig. 9. It consists of a gas or oil 
 lamp, with a reflector and a lens attached. 
 
 G.TLEMANN & CO, 
 
 Fig. 9. 
 
 My son, Dr. W. H. Bodenhamer of Chicago, in examining 
 the rectum in case of anal fissure, is in the habit of employ- 
 ing the cylindrical speculum used for examining the condi- 
 tion of the membrana tympani, with a prism attached to it. 
 He considers this instrument preferable to any others for 
 this particular purpose. 
 
 2. Examination with the Probe, The method which I 
 generally adopt in making the examination for anal fissure, 
 obviates the necessity of distending the anus, — hence the 
 extreme suffering consequent upon such dilatation is entirely 
 avoided. No anaesthetic generally need be employed. I 
 make the examination with a silver probe seven inches 
 
 7 
 
98 
 
 ANAL FISSURE. 
 
 long and slightly curved at its distal end (Fig. 10). The 
 probe should be dipped in glycerine or olive oil, 
 jf and gently introduced some distance up the anal 
 II canal ; then it should be brought down gradually, 
 
 with its curved point pressing upon the side or wall 
 of the canal, and as soon as it comes in contact 
 with the fissure the patient will at once manifest it 
 by the sensation of pain he will experience. This 
 exploration with the probe may be continued 
 around the whole circuit of the canal until the fis- 
 sure, if any, is detected. 
 
 3. 'The Diagnosis. Apart from the confusion that 
 surrounds the subject, there is no disease of the rec- 
 tum or anus in which the diagnosis is more easily 
 established than in* anal fissure. The surgeon can 
 always, by a physical examination, determine at once 
 its presence or its absence in all doubtful cases. 
 Indeed the manifestation of the disease is such that 
 even the symptoms alone are, in most instances, 
 IG * ia sufficient to establish the diagnosis beyond all doubt. 
 The peculiar character of the pain ; the time of its access, 
 either during or some time after an evacuation of the bowels ; 
 its continued increase until it becomes agonizing ; and its 
 gradual or its sudden decline and entire subsidence until the 
 next evacuation, are circumstances which unmistakably char- 
 acterise it. In describing this pain, the patients too generally 
 use the most hyperbolic terms. In short, the question is not, 
 Is the breach of surface of a peculiar form ? or is it attended 
 by spasmodic contraction of one or both sphincters of the 
 anus "? but it is — If the breach of surface of an exquisitely sensitive, 
 or highly irritable and painful character ? This is the chief 
 diagnostic ; and this is always easily decided by the sensations 
 produced by touching the ulcer with the finger or the probe, 
 or by the passage of the faeces over it in the act of defecation. 
 I consider, too, that the peculiar time of the accession of the 
 
ANAL FISSURE. Q9 
 
 pain is very important in the diagnosis of this disease ; 
 though some may think it speculative, and of no real value. 
 Nothing, however, should be neglected that would in the 
 least tend to dispel the confusion in which this ingular 
 affection has been involved. As far as it relates to spasmod- 
 ic contraction of the sphincter or sphincters of the anus as a 
 symptom of anal fissure, I would observe as before, that 
 when it is caused by fissure, the pain is infinitely more acute, 
 more intense, than when caused by any other disease of the 
 mucous membrane of the inferior extremity of the rectum, 
 — such as inflammation, irritation, tumefaction, haemorrhoids, 
 etc. ; and also much more severe than when produced by 
 disease in the genito-urinary organs. This purely spasmod- 
 ic contraction of the anal sphincters, too, must not be con- 
 founded with permanent or organic contraction of the anus, 
 as is frequently done. The first consists of a spasmodic and 
 accidental contraction only of the sphincter or sphincters of 
 the anus; whilst the second consists of a permanent narrow- 
 ing, thickening, and hardening of the orifice and canal of 
 the anus. The second, however, is often the result of the 
 first. 
 
 Neuralgia of the Anus. Anal fissure is often'mistaken and 
 treated for neuralgia of the anus, or inferior extremity of 
 the rectum ; and, of course, with entire failure of affording 
 any permanent relief A number of such instances have 
 come under my own observation, and will be found report- 
 ed in this work under the head, " Illustrative Cases." Dr. 
 Bushe committed this error. He reports three cases, which 
 he describes as neuralgia of the inferior extremity of the 
 rectum ; but not one of them, in my opinion, was a true, 
 genuine case of neuralgia; for the evidences of structural 
 disease of the mucous membrane, at the exquisitely sensitive 
 points described, are too clear, from which to draw any 
 other conclusion. The complete success attending the 
 operation of Dr. Bushe in one of the cases, tends to prove 
 
lOO ANAL FISSURE. 
 
 that it was not neuralgic ; and in the third case the bloody 
 and mucous discharge proved that in it there was some 
 structural disease of the canal. — {Op. cit., p. 112.) 
 
 Anal fissure is very readily distinguished from neuralgia, 
 by the absence in the latter of any breach of surface, or of 
 any other disease of the mucous membrane of the rectum ; 
 by the entire w T ant of connection between the pain and the 
 alvine evacuations ; and the constant suffering. In neuralgia, 
 the pain caused by pressure with the finger in ano is not 
 confined to one particular spot, as it is in fissure; but all the 
 parts around the anus are tender alike. In anal neuralgia, 
 too, instead of its being qften attended by spasmodic con- 
 traction of the anal sphincters, the muscles will be found in 
 a too relaxed condition. The pain of neuralgia is severe, 
 but quite independent of contact. 
 
 It is true that the morbid sensibility of the rectum and 
 anus caused by a fissure, and that caused by neuralgia, are 
 often so intimately blended, that it is sometimes no easy 
 matter to distinguish between them; nothing but the detec- 
 tion itself, in some cases, of the fissure, which can now 
 always be discovered by a proper examination, will clear the 
 diagnosis. 
 
 Hemorrhoids. Anal fissure is often mistaken and treated 
 for internal haemorrhoids. It is surprising how often this 
 error is committed by practitioners, otherwise intelligent. 
 The contrast between the two diseases is so great and so 
 obvious, that it appears strange that such a blunder should 
 ever be made; it is doubtless in consequence of the neglect 
 of a proper examination. I will in the proper place report 
 a number of examples of this error in diagnosis. Anal fis- 
 sure and haemorrhoids are often associated, and when they 
 are so, they are frequently treated simply as piles; — several 
 examples of which will also be given hereafter. 
 
 Uterine Affections. The symptoms of anal fissure in women, 
 who are more liable to the disease than men, are generally 
 
ANAL FISSURE. 
 
 101 
 
 more severe and more complex, and very often simulate so 
 closely uterine disease, that they are consequently well cal- 
 culated to mislead the surgeon, and cause him to overlook 
 the real seat and the true nature of the disease. A careful 
 inspection, however, of all the parts concerned, will at 
 once remove all errors in diagnosis, and dispel all doubts. 
 
 Occult Fistula and Sacculi of the Anus. Anal fissure is liable 
 to be confounded with blind internal fistulse, or with sacculi 
 of the anus, as some of the symptoms of these two diseases 
 somewhat simulate those of the former; that is, there is 
 sometimes a more or less dull, heavy, aching pain after stool- 
 ing, which, however, is by no means so severe and unbear- 
 able, neither does it observe that regularity in coming on 
 and in continuing to increase as the pain does in anal fis- 
 sure, nor is it present at every evacuation, but several days 
 may supervene and several evacuations may take 
 place without its appearance, yet it may come on 
 at the very next stool. These two diseases are 
 never attended by anal spasm ; but there is always 
 a more or less discharge of pus, which but seldom 
 occurs in fissure. Blind internal fistulse and pre- 
 ternatural pouches of the rectum are easily detected 
 by a physical examination of the canal. It should 
 be explored by means of a hooked probe (Fig. 1 1), 
 as recommended by Heister (Institutions Chirurgica. 
 Part //., Sect. V., Chap. CLXFlll. Amstelcedami, 
 1739) and Dionis (Cours d* Operations de Chirurgie 
 demonstrees au Jar din du Rio. Tome /., p. 405. 
 Huitteme Edit. Par de la Faye. Paris, 1782). About 
 half an inch of the distal end of the common silver 
 probe should be bent back upon itself, so as to form 
 a kind of hook, somewhat like that already recom- 
 mended for examining anal fissure. The probe 
 thus bent should be passed up the canal five or six F*g. n. 
 inches, and then brought slowly back with the point bearing 
 
 n 
 
102 ANAL FISSURE. 
 
 successively on the different parts of the circumference of 
 the rectum. Should an occult fistula or a sac exist, the 
 reverted point of the probe will pass into its orifice and 
 cavity, and render its existence and character at once 
 sufficiently obvious. 
 
 Syphilitic Sores about the Anus. Venereal ulcers in this locali 
 ty, in the form of fissures, clefts, rhagades, etc., contrast re- 
 markably with the real irritable and genuine anal fissure 
 They are chiefly confined to the integument, or muco-cu- 
 taneous coat about the anus, and seldom extend to any dis- 
 tance within the anus. The edges are somewhat elevated 
 and thickened, and the surface secretes an abundance of 
 adhesive pus which forms crusts or scabs. These sores, as 
 a general rule, are attended with but little pain at or after 
 defecation, and by no spasmodic contraction of the anal 
 sphincters ; and thus again contrasting greatly with genuine 
 fissure of the anus. The characteristic appearance of the 
 ulcer, its painless nature, the absence of anal spasm, and the 
 class of persons affected, remove all doubt as. to the nature 
 of the complaint. 
 
 4. Complications of Anal Fissure. Fissure of the anus will 
 often be found complicated with haemorrhoids, with condy- 
 lomata about the verge of the anus, or with anal fistula ; or 
 all these combined in the same case, several examples of 
 which will be reported elsewhere in this work. It often co- 
 exists with disease in the genito-urinary organs. Anal fissure 
 is very liable, from the continued irrita:ion it produces in the 
 parts, to result in fistula in ano. A number of such exam- 
 ples will be found reported in this work. It also gives rise 
 sometimes to spermatorrhoea, several cases of which I have 
 met with in my practice ; also, to permanent organic con- 
 traction of the anus, etc. 
 
 5. The Prognosis. As a general rule, anal fissure is by no 
 means an immediately dangerous disease ; yet it is one which 
 is often accompanied by so much severe suffering, that it is 
 
ANAL FISSURE. 
 
 10 3 
 
 of the highest importance to afford as speedy relief as pos- 
 sible. If the disease should be left to the resources of na- 
 ture, it might continue for an indefinite period before the 
 patient would finally succumb; as nothing authentic has 
 been ascertained of its ever having been cured spontaneously, 
 or without the aid of art. The general health of the patient 
 is at first but little affected ; but when the disease has pro- 
 gressed for some considerable length of time, his constitu- 
 tion begins to fail, and he grows pale, sallow, and listless, 
 and from continued suffering he becomes exhausted, falls 
 into a state of gradual decay, and thus succumbs ; or he ulti- 
 mately becomes attacked by some incurable organic disease, 
 which carries him off. 
 
CHAPTER FIFTH. 
 
 THE TREATMENT 
 
CHAPTER V. 
 
 THE TREATMENT. 
 Section l. — Precautionary and Palliative Measures. 
 
 It is a source of regret that anal fissure, which is gener- 
 ally the production of a slow morbid alteration of the parts, 
 should receive so little attention from patients, except in its 
 considerably advanced stage. The surgeon is scarcely ever 
 consulted until the disease is fully developed. 
 
 Constipation, if not the immediate cause of this affection, 
 is nevertheless almost always an accompaniment of it, and is 
 a constant source of its continuance. It is therefore highly 
 important to the success of any treatment, that this condition 
 of the bowels should be corrected, by securing their daily 
 evacuation, and thereby preventing faecal accumulation. It 
 should also be a primary object in these cases 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. This must be 
 effected by enjoining the most bland and unirritating diet, 
 and by the use of emollient enemata or mild aperients. 
 Purgative medicines, however, should be avoided as much as 
 possible, as the mildest of them more or less stimulate and 
 irritate the inferior extremity of the rectum. To accom 
 plish the certain evacuation of the bowels every day, and 
 the easy transmission of their contents, I generally recom- 
 mend an enema of rich flax-seed tea, say from half a pint to 
 a pint, to be administered every morning immediately after 
 
108 ANAL FISSURE. 
 
 breakfast ; or I use the following, which is more effi- 
 cient : — 
 
 Recipe, Olei Ricini vel Olivae, unciam, 
 
 Infusionis Seminum Lini tepidas, uncias octo. 
 Misce et fiat enema. 
 
 The enema should be repeated in half an hour, if the 
 first should fail to produce the desired efFect. In the 
 administration of enemata in these cases, in order to 
 avoid as much as possible pain or injury to the high- 
 ly sensitive parts affected, I use the gum-elastic jets, 
 applied to the nozle of the enema syringe (Fig. 12). 
 They are easily adjusted over the bone, wood, or metal 
 enema pipe ; and being soft and elastic, are not so lia- 
 ble to cause pain or do harm. 
 
 If the persevering efforts in the use of enemata 
 should fail to regulate the bowels, some mild laxative 
 should occasionally be given to aid the injections. 
 Great care, however, must be taken in the choice of 
 such laxative ; the object being not to purge, but to 
 render the fseces soft, so that as little stretching of the 
 fissure as possible should take place. I often use the 
 following aperient in such cases, with most excellent 
 effect : — 
 
 Fig. 12. Recipe, Sulphuris loti, 
 
 Magnesia calcinatae, 
 Saccholactin, ana, unciam. 
 Misce et fiat pulvis. 
 
 A teaspoonful of this powder should be taken in a little 
 simple syrup an hour or two before breakfast. If it should 
 fail to produce the desired effect, the same quantity should 
 be taken night and morning. One stool only is required in 
 twenty-four hours ; more than one aggravates the case. 
 
 During the treatment of this disease, in order to lessen 
 pain, it may be necessary to use fomentations to the anal 
 region as hot as can be borne, applied in the form of either 
 
ANAL FISSURE. 
 
 IO9 
 
 flannel cloths or sponges saturated with plain or medicated 
 hot water; or a large flax-seed poultice applied as hot as can 
 be borne, and often renewed. When there is much inflamma- 
 tion, congestion, and tumefaction, as in instances of long 
 standing, the application of leeches, together with the fo- 
 mentations, I have found highly beneficial in relieving the 
 pain and spasm in those cases. Cold applications, however, 
 are sometimes more grateful to patients suffering from anal 
 fissure than hot ones, and may be tried when the others fail. 
 Local anaesthesia is in some cases highly valuable, and may 
 be employed, using for this purpose either sulphuric ether or 
 rhigolene. 
 
 One would suppose, from the locality and character of the 
 large blood-vessels of the inferior extremity of the rectum, 
 that the recumbent or horizontal position of the body, after 
 evacuating the bowels, would relieve the pain, which in some 
 instances it does to some extent, whilst in others it seems 
 only to aggravate it. The horizontal posture, however, as 
 a general rule, does afford more relief than any other position. 
 
 I have recommended to a number of my patients the 
 proceedings of M. Gossement as a palliative measure in anal 
 fissure; who, after several trials, and becoming expert in its 
 execution, have experienced the most happy results. M. 
 Gossement's method, as given by M. Malgaigne, is as fol- 
 lows : — "When the patient feels the desire to go to stool, 
 he should moderately pinch, with two fingers, a portion of 
 skin equivalent to almost one-sixth of the circumference of 
 the anus, and comprising the fissure ; at the same time 
 pushing from within outwards, so as to enlarge the anal 
 orifice, and give a new fixed point, not bearing on the As- 
 sure, to the sphincters; thus hindering the former from being 
 dragged and strained by the passage of the excrements. In 
 this way the pain is almost always avoided." — {Operative Sur- 
 gery. English Version, by F. Brittan, M.D., p. 429. Philadel- 
 phia, 1851.) 
 
] lO ANAL FISSURE. 
 
 Section II. — The Treatment pursued by the Author. 
 
 l. The treatment here laid down has been practised by 
 the author for twenty-five years with invariable success. It 
 will be observed that it consists of topical medication com- 
 bined with dilatation, and sometimes incision or scarification. 
 
 The chief indication in the treatment of anal fissure is to 
 modify the surface of the ulcer, and transform it into a 
 simple or a common sore, which then under ordinary 
 circumstances will heal like any other solution of con 
 tinuity. 
 
 The treatment varies according to the stage of the disease 
 and the locality of the ulcer. If the fissure is recent, very 
 superficial, and not in the grasp of the external sphincter 
 muscle, strict attention to the state of the bowels, and ablu 
 tions with soap and water night and morning, and after 
 each act of defecation, will usually effect a cure in a short 
 time. The soap which I have used for years in such cases 
 is BrecknelPs " Old Tellow English Soap ; " but of Tate I have 
 used as a substitute the " Juniper Tar Soap " of Messrs. Cas- 
 well, Mack & Co., of New York City, and found it very 
 beneficial. Should this course, however, not afford relief in 
 a short time, the following lotion, or the following oint- 
 ment, may be used in addition to the ablutions, etc. : — 
 
 Recipe, Sodae Chloridi, drachmas duas, 
 
 Aquae destillatse, uncias duas. 
 Fiat lotio. 
 
 Pledgets of lint should be saturated with this lotion and 
 kept applied to the anus by the T-bandage, and frequently 
 renewed. Or the following ointment may be spread on lint 
 and kept applied in the same manner : — 
 
 Recipe, Unguenti Plumbi Acetatis, 
 
 Oxydi Zinci, ana, unciam, 
 
 Acidi Hydrocyanici, guttas viginti. 
 Misce. et fiat unguentum. 
 
ANAL FISSURE. 1 1 1 
 
 • 
 
 When the fissure has existed for some time, and its edges 
 are hard and elevated, they should be destroyed down to 
 the bottom of the ulcer or sensitive parts, by the applica- 
 tion of either the nitrate of silver, the acid nitrate of mercu- 
 ry, or the nitric acid. Since 1842 I have used the nitrate 
 of silver as a topical application in this disease with the most 
 uniform and the most signal success. As an application in 
 anal fissure, it is capable of producing several different effects. 
 It lessens or calms the nervous irritation which so power- 
 fully tends to induce spasmodic contraction of the sphinc- 
 ters ; it coats and shields the raw and exposed mucous sur- 
 face ; it removes the diseased and morbid action of the parts ; 
 and it destroys the hard or callous edges. 
 
 The form in which I usually employ this salt is in solu- 
 tion, according to the following formula : — 
 
 Recipe, Argenti Nitratis, drachmam, 
 
 Aquas desdllatae, unciam. 
 Fiat solutio. 
 
 The solution should be applied to the fissure with a silver 
 probe or a camel-hair pencil once in twenty-four or forty- 
 eight hours, according to circumstances. The application 
 is made by separating the margins of the anal orifice with 
 the thumb and index-finger of the left hand, and introducing 
 into the anus the probe or pencil charged with the solution. 
 Should the fissure be more than the third of an inch above 
 the margin of the anus, it would be necessary to use the 
 speculum, especially if the camel-hair pencil is employed; 
 and should there be much pain and anal spasm, it will be 
 necessary to induce anaesthesia. The probe should be dipped 
 in the solution and applied to the fissure only, if possible ; 
 a few drops are all that is required. The first application 
 generally causes very acute pain for twenty or thirty min- 
 utes; this, however, maybe very much relieved by the appli- 
 cation immediately after of glycerine, olive or almond oil, 
 which will not in the least interfere with the good effects of 
 
112 ANAL FISSURE. 
 
 the solution. After the immediate effect of the solution has 
 subsided, it acts like a charm in calming the morbid irrita- 
 bility of the fissure ; and by the third or fourth application, 
 in all ordinary cases, the edges of the ulcer will exhibit that 
 pearly color characteristic of approaching cicatrization. 
 
 I have also employed the liquor potassa with singular good 
 effect in some cases of anal fissure, applied in the same 
 manner. It, like the former, allays the irritability of the fis- 
 sure in an astonishing manner ; but I have noticed that 
 cicatrization does not so readily and so rapidly follow its 
 use as it does that of the nitrate of silver. The following 
 mixture, as a topical application in anal fissure, has been 
 highly extolled by M. Chapelle, of Angouleme : — 
 
 Recipe, Spiritus Vini rectificati, drachmam, 
 
 Chloroformyl, guttas quindecim. 
 Fiat mistura. 
 
 I have used this mixture in several cases recently with a 
 very happy effect. The disease in these cases, however, 
 was not of a very aggravated form. It must be applied to 
 the fissure with either the probe or camel-hair pencil. 
 
 In very aggravated cases, especially those of long stand- 
 ing, I use the nitrate of silver in its potential or solid form. 
 I usually cut a stick of the caustic to a point or angle, and 
 passing it back and forth along the fissure rapidly for a 
 minute, and then applying the glycerine or olive oil; or, 
 what is still better, I coat the end of a silver probe by dip- 
 ping it into the fused nitrate of silver, and applying it to the 
 fissure. It generally requires but two or three applications 
 of the solid nitrate of silver to effect a cure. I have also, in 
 aggravated cases, used the liquid acid nitrate of mercury, and 
 the nitric acid, with the most happy results. Great care, 
 however, must be taken in the use of these powerful agents. 
 They must be applied to the fissure by means of a small 
 glass probe. The probe is dipped in the liquid, and a drop 
 or two adhering to it is quite sufficient. The cure is effected 
 
ANAL FISSURE. 
 
 "3 
 
 frequently by two or three applications, several days interve- 
 ning between each. To aid in destroying the hard and elevated 
 edges of the fissure, besides the other treatment, I sometimes 
 scarify them every few days with a small sharp-pointed lancet. 
 In those ulcers located in the fossa between the two 
 sphincter muscles, in addition to one or the other of the ap- 
 plications already named, I have used with most decided 
 good effect the following ointment : — 
 
 5 Hydrargyri Oxydi cinerei, drachmam dimidiam, 
 
 Cerati Simplicis, unciam unam. 
 Misce et fiat imguentum. 
 
 The ointment should be applied immediately to the af- 
 fected part by means of the suppository 
 tube. The tube should be well lubri 
 cated on the outside with the ointment; 
 then it should be charged with from 
 half to a teaspoonful of the same, and 
 passed into the anal canal to the depth 
 of an inch, an inch and a half, or a little 
 beyond the ulcer, and the piston pushed 
 down. Or the ointment may be intro- 
 duced by means of the valuable breech- 
 loading syringe for administering semi- 
 solid substances, devised by Dr. J. C. 
 Hutchison and improved by Mr. Stohl- 
 mann. This instrument, represented by 
 Fig. 13, is far preferable to the sup- 
 pository tube for this purpose. It is 
 made of hard rubber, and consists of a 
 hollow cylinder and a staff. The staff 
 is nothing more than a tube, the end of 
 which passes through an opening into 
 the chamber, and is attached to a piston 
 having a perforation in its centre corre- 
 sponding to that in the tube. From the shoulder on the 
 
 8 
 
114 ANAL FISSURE. 
 
 staff to the upper portion of the chamber is a spiral spring 
 which draws up the piston to the top of the internal portion 
 of the cylinder, and thus enables the syringe to be easily 
 filled. The lower end of the cylinder has a screw-cap, which 
 can be removed for the purpose of loading it with semi- 
 solid substances, such as ointments and the like. The ad- 
 vantages of the instrument over others of its sort are, that 
 it can be worked easily with one hand, by bracing it in the 
 hollow of the palm and pressing upon its shoulder with the 
 two fore-fingers, and, when ointment is used, the lack of 
 danger in soiling the wristband or coat-sleeve by any re- 
 gurgitation. The principle upon which it works is obvious, 
 the pressure of the piston upon the column of fluid or semi- 
 solid forcing the substance through the tube. The shoulder 
 is provided with a screw on its upper surface, to which can 
 be attached any sized tube for the different canals of the 
 body. It is of course only really useful in those cases which 
 do not require a continuous injection, or more than one 
 charge of the fluid at a time, and hence will answer a good 
 purpose in hemorrhoidal affections where an anodyne oint- 
 ment is indicated ; and in various affections of the urethra, 
 throat, ear, uterus, &c. In most cases the patient can make 
 the application without assistance. — (^The Medical Record. 
 Vol. III pp. 95, 166. New Tork, 1868.) 
 
 The ointment should be introduced shortly after the evac- 
 uation of the bowels, and not more than once in twenty- 
 four hours. As a good substitute in such cases, the follow- 
 ing ointment may be used in the same manner : — 
 
 Recipe, Calomelanos, grana viginti, 
 
 Axungie, unciam. 
 Fiat unguentum. 
 
 The anal excrescence or condyloma which is most 
 always present in this disease, and which is evidently 
 caused by the irritation or inflammation of the fissure, gen- 
 erally gets gradually less as the fissure heals, and the ir- 
 
ANAL FISSURE. 1 l^ 
 
 ritation of the parts subsides, and ultimately disappears. 
 Should it, however, not do so, it must be snipped off with the 
 curved scissors ; or removed by the application of chromic 
 acid, the chloride of zinc, or the potassa fusa. 
 
 2. Distention of ike Spasmed Anal Sphincters. When the fis- 
 sure is accompanied by spasmodic contraction of one or 
 both sphincters of the anus, the healing of the ulcer is more 
 or less protracted in consequence of such constriction, which, 
 although a mere symptom, is nevertheless a source of con- 
 siderable mischief, as it occasions much additional pain by 
 compressing the fissure and preventing the healing of it as 
 rapidly as it would otherwise do. ' This spasmed state of the 
 sphincter ani muscles should therefore be overcome by treat- 
 ment, in addition to, and separate and distinct from that of 
 the fissure itself; not, however, by having recourse to section 
 of the sphincter muscles according to M. Boyer, but by the 
 milder, safer, and equally certain method of distending them. 
 
 The object of employing distention of the sphincters by 
 either the bougie, the fingers, or tents made of lint, is not 
 only to produce relaxation of the constricted muscles, but 
 also, by the firm pressure, to render them less irritable, and 
 consequently less susceptible of the sympathetic impressions 
 of the fissure, which are in reality the cause of the spasmodic 
 contraction. Previous to using the bougie in such cases, 
 I always make a few applications to the fissure of the 
 nitrate of silver, which, by shielding the mucous membrane, 
 and removing the nervous irritability of the parts, materially 
 facilitates the introduction of that instrument, and thus ren- 
 ders the dilating process easy and comparatively free from 
 pain. In cases in which the sphincters are powerfully con- 
 tracted, I administer the following suppository about one 
 hour before introducing the bougie : — 
 
 Recipe, Extracti Belladonnas, granum unam, 
 
 Butyri Cacao, scrupulum. 
 Misce et fiat suppositorium. 
 
Il6 ANAL FISSURE. 
 
 This may be administered by means of the suppository 
 tube, the breech-loading syringe, or it may be rendered fluid 
 by warmth and injected into the rectum with a small syringe. 
 It is invaluable in such cases, as it relaxes to a considerable 
 extent the muscular constriction, and greatly assists in the 
 distention of the anus and anal canal, while it lessens the pain 
 arising from such distention. The effects of the belladonna, 
 however, must be closely watched, as in some instances bad 
 results follow its too free and indiscriminate use. Sir Ben- 
 jamin Brodie, on this account, discarded it altogether. I 
 have never witnessed but one case in which alarming symp- 
 toms presented themselves from its use, and that was a case 
 in which the belladonna ointment had been without judg? 
 ment excessively used. If the dilatation is carefully and 
 gradually made, I have always found that the introduction 
 of the bougie, excepting the first time, is attended with but 
 little pain. Every time it is inserted the pain is less. The 
 bougie should not be used when the patient is suffering 
 severely; better wait several hours after stooling, or just 
 before the evacuation, when all the parts are in a quiescent 
 state. Should anaesthesia be determined on, however, the 
 bougie could be used at any time. 
 
 For the purpose of dilating the anus and anal canal I use 
 wax bougies of gradually increased sizes, commencing with 
 a number three. The English rectal bougie, however, 
 answers very well for this purpose. The bougie must be 
 passed through the constricted portion of the canal, and im- 
 mediately withdrawn ; but it should not be so large, neither 
 should the force be so great, as to lacerate or rupture the 
 mucous membrane or muscular fibres, this not being con- 
 templated by the operation of distention or dilatation. The 
 gradual dilatation of the sphincters, and lower end of the 
 rectum, if judiciously performed, is speedily followed by 
 great relief, and ultimately by complete recovery. 
 
 When anal fissure is caused by aphthse or canker, which 
 
ANAL FISSURE. 117 
 
 is sometimes the case, several marked instances of which 
 having come under my own observation in nursing mothers, 
 as well as in others, I apply to the fissure the nitrate of sil- 
 ver, and at the same time inject from half to a teaspoonful 
 of the following ointment, night and morning, into the anal 
 canal by means of the suppository tube, or breech-loading 
 syringe : — 
 
 Recipe, Bismuthi Trisnitratis, 
 
 Glycerine, ana, drachmas duas, 
 Cerati Simplicis, unciam. 
 
 Misce et fiat unguentum. 
 
 Whilst these applications are being made, I recommend 
 the patient to take a teaspoonful of the following powder 
 three times daily. It should be taken at meal-times, well 
 mixed in as much water as will make it thin enough to 
 drink : — 
 
 Recipe, Pulveris Bismuthi Trisnitratis, 
 
 Acacias, ana, unciam, 
 
 Sodas Bicarbonatis, semi-unciam, 
 
 Zingiberis, 
 
 Sacchari purificati, ana, drachmas duas. 
 
 Misce et fiat pulvis secundum artem. 
 
 I have also used the ftotassa chloras in such cases with a 
 most happy effect. To an adult, from twenty to thirty grains 
 in solution may be given three times daily. To an infant 
 one year old, from three to six grains in solution may be 
 given three times daily. I have found this an invaluable 
 remedy in follicular and in ulcerative stomatitis. 
 
 If this treatment is persevered in for eight or ten days, 
 with strict attention to diet, it will without fail result in a 
 cure of both the aphthae and the anal fissure. 
 
 3. tfhe Author's treatment of Anal Fissure in Infants, In the 
 treatment of the fissure of infants, I first administer an ene- 
 ma of flax-seed tea and olive oil, to empty the rectum, and 
 whilst the parts are protruded in the act of defecation, I ap- 
 
n8 
 
 ANAL FISSURE. 
 
 ply the nitrate of silver in solution to the fissure, which is 
 plainly brought into view by the straining efforts of the 
 child. The application can be made in an instant, and be- 
 fore the parts return. The butter of cacao, glycerine, or 
 olive oil, should at the same time be applied to the fissure, 
 as well as to all the parts. One hour after this is done, I 
 administer the following astringent and tonic enema, which, 
 if possible, is to be retained : — 
 
 Recipe, Extracti Rhataniae, grana quinque, 
 
 Aquas Rosarum, unciam. 
 Misce et fiat enema. 
 
 These measures should be repeated once every twenty- 
 four hours until the cure is completed. If constipation of 
 the bowels obtains, and the relaxing enema does not relieve 
 it, mild aperients should be used in addition. 
 
 In the fissure of infants, caused by and complicated with 
 aphthae, I apply the solution of the nitrate of silver and the 
 ointment of bismuth to the fissure, whilst I recommend the 
 following infusion and powder to be given to the child. A 
 teaspoonful of the infusion should be given every three or 
 four hours to a child six or eight months old ; and three or 
 four grains of the powder should be applied every few hours 
 to the child's tongue, by which it will be carried over its 
 mouth : — 
 
 Recipe, Pulveris Ipecacuanhas, grana sex, 
 Tincturae Opii, guttas quatuor, 
 Olei essentialis Menthae piperita^, guttam unam, 
 Sacchari purificati, drachmam, 
 Aquae bullientis, uncias tres. 
 Fiat infusio. 
 
 Recipe, Pulveris Boratis Soda?, 
 
 Sacchari purificati, ana, scrupulum. 
 
 Fiat pulvis. 
 
 This treatment persistently followed will soon relieve 
 both the thrush as well as the fissure. 
 
ANAL FISSURE. H9 
 
 Anal fissure in children is often caused by erythema of 
 the anus, and when this is the case, all the affected parts 
 should be treated. Attention to cleanliness is of the ut- 
 most importance to bring about a cure of both the erythe- 
 ma and the fissure. Bathing the parts frequently with soap 
 and water, and with the infusion of marsh-mallow or flax- 
 seed, or gum-arabic water, will tend greatly to expedite the 
 cure. It is important to change the linen frequently. In 
 these cases I have found great benefit by the frequent appli- 
 cation of the pulvis lycopodii to the whole diseased surface. 
 It protects it in the most perfect manner possible, for it is 
 not pervious to liquids, and water runs off its surface. It is 
 far preferable to starch, which when moistened forms a crust 
 which is difficult to remove. The bismuth ointment, sim- 
 ple cerate, cacao butter, or fresh lard, are good applications. 
 One or the other should be spread on lint and kept applied 
 to the anal region by the T-bandage or by the diaper. 
 
 By this simple treatment I have never failed to effect a 
 cure in a short time. 
 
 o- 
 
 Section III. — The Different Methods of Treatment. 
 
 The various methods which have been recommended, 
 from the earliest times to the present, for the cure of anal 
 fissure, may be comprised under the following heads : — 
 
 First — Topical applications of numerous and various 
 kinds, including enemata, both simple and medicated, and 
 suppositories. 
 
 Second. — Cauterization, with either the potential or the 
 actual cautery. 
 
 tfhird. — Dilatation of the anal sphincters. 
 
 Fourth. — Incision of the mucous membrane of the anal 
 canal, together with the sub-mucous cellular tissue ; or scari- 
 fication of the fissure. 
 
120 ANAL FISSURE. 
 
 Fifth. — Excision of the fissure. 
 
 Sixth. — Complete division of the sphincters of the anus. 
 
 l. topical Applications. Some authorities say that anal 
 fissure can never be cured by topical applications, that at 
 best they can only palliate ; others again even go so far as 
 to say, that they only aggravate the disease. This, how- 
 ever, is not true, for hundreds of instances can be adduced 
 in which some of the most aggravated cases have been 
 cured by such measures. Even M. Boyer himself, who de- 
 nounced all such treatment as worse than useless, gives an 
 instance in which he succeeded in curing a case of anal fis- 
 sure, accompanied by spasmodic contraction of the anal 
 sphincter, by injecting into the rectum two or three table- 
 spoonfuls, three or four times daily, of the following ad- 
 mixture : — 
 
 Up Expressed Juice of House Leek (Sempervivum Tectorum), 
 
 of Garden Nightshade (Solanum Nigrum), 
 
 Olei Amygdalae, ana, ^ iv. 
 Axungie, I iij. 
 
 Fiat mistura secundum artem. 
 
 This mixture, made moderately warm, was injected with 
 a small syringe. — (Op. cit. p. 612.) 
 
 To those who contend that topical applications are at best 
 mere palliatives, and do not cure the disease, I reply that 
 division of the sphincters is only palliative, and does not 
 eradicate or break up the morbid condition of the parts. 
 
 M. Dupuytren reports a number of severe cases of anal 
 fissure which were cured by his celebrated ointment, intro- 
 duced into the anus on pledgets or tents of lint. The fol- 
 lowing is a report of one of his cases : — " A healthy young 
 woman had been affected for some weeks with very violent 
 pains in the anus whenever she went to stool, especially 
 when the faeces were hard. At first these pains continued 
 only for a few minutes, but afterwards they persisted longer, 
 and finally continued during some hours. When she 
 
ANAL FISSURE. 121 
 
 entered the Hotel Dieuher anus was examined with care 
 by M. Dupuytren, who discovered there a very superficial 
 fissure. The constriction of the anus was very consider- 
 able ; the finger could not be introduced into it without 
 great difficulty and causing great pain. Unwilling to sub- 
 ject the patient to the pain and inconvenience of an incision 
 or cauterization, M. Dupuytren prescribed the introduction 
 into the anus of a roll of lint, besmeared with his belladonna 
 ointment, and renewed every time the patient went to stool. 
 This ointment calmed the pains, and in a few days they 
 entirely ceased, and the patient was entirely relieved of 
 her disease. — {Revue Medicate. Home I. p. 869. Pans, 1829.) 
 M. Beclard, who reports numerous cases of anal fissure, 
 declares most positively that he never failed to cure them 
 by the application of the nitrate of silver in its solid or po- 
 tential form, and at the same time employing dilatation of 
 the anal sphincters by the use of the bougie. — (Archives 
 Generates de Medecine. Home VII. pp. 310, 339, Paris, 
 
 1825.) 
 
 M. Delaport publishes a case of anal fissure of an aggra- 
 vated character, in which he used an ointment of belladonna 
 with the happiest effect, after many other remedies had 
 been tried without avail. The ointment was made by mix- 
 ing one drachm of the extract of belladonna with half an 
 ounce of simple cerate. A roll of lint was smeared with 
 this ointment and introduced into the rectum. The relief 
 was prompt. He prefers this treatment to dividing the 
 sphincters, and does not object to touching the fissure at 
 the same time with the nitrate of silver, by which the. pain 
 is suddenly relieved. He mentions instances in which the 
 operation of dividing the sphincter muscles entirely failed. 
 — {Observations sur Vheureux emploi de ta bettadone dans un cas de 
 fissure et de constriction spasmodique de Vanus. In Journal 
 General de Medecine. Home CX. p. 329. Paris, 1839.) 
 
 M. Laborderie reports a similar case to that of M. Dela- 
 
122 ANAL FISSURE. 
 
 port, in which he succeeded in effecting a complete cure by 
 the use of the following ointment : — 
 
 Recipe, Extracti Belladonna?, drachmam, 
 
 Liquoris Plumbi Subacetatis diluti, semidrachmam, 
 Cerati Simplicis, semiunciam. 
 
 Fiat unguentum. 
 
 (Revue Medic ale de Paris. Juillet 3 1830.) 
 
 M. Pagen speaks in the highest terms of a mixture of 
 opium cerate and the extract of monesia, as being remarkably- 
 successful in the treatment of anal fissure. — {Gazette Medi- 
 cale. 'Tome Fill. No. 4. p. 59. Pans, 1840.) 
 
 M. Lamoureux states that he succeeded in curing anal 
 fissure by employing belladonna. — (Societe de Medecine de la 
 Seine-Infer. Tome IX. fi. 78.) 
 
 M. Descunde says that anal fissure may be cured by ad- 
 ministering the oil of hyoscyamus in large doses by the 
 mouth, at the same time employing mercurial ointment as 
 a topical application. — (Motfs Felfieau. Vol. III. fi. 1112. 
 New York, 1847.) 
 
 M. Mothe cured anal fissure by topical applications, 
 principally in the form of lotions. — (Archives Generates de 
 Medecine de Paris. Tome XFll.fi. 648. Also, Memoires sur 
 les Fissures a VAnus, In Melanges de Medecine et de Chirurgie. 
 Tome 11. fi. 31 . Paris et Lyons, 1827.) 
 
 Chelius reports having cured cases of anal fissure with the 
 ointment of zinc smeared on bougies and introduced into 
 the anus. — {hoc. cit.} 
 
 This disease, according to the testimony of some of the 
 most eminent French authorities, has been most successfully 
 treated by the use of rhatany. The distinguished M. Breton- 
 neau of Tours in France appears to have been the first who 
 employed and recommended this agent in the treatment of 
 fissure of the anus. He was led to try the effect of the 
 rhatany in this disease, trom having observed that constipa- 
 tion was in most cases the cause of anal fissure, and the ob- 
 
ANAL FISSURE. 123 
 
 stacle to its cure. That this constipation was in a great 
 majority of cases attended with an unnatural dilatation of 
 that portion of the rectum immediately beyond the internal 
 sphincter ani, which thus formed a place of lodgment for 
 the feculent matters, which sometimes accumulated there to 
 such an extent as to be expelled with great difficulty. To 
 correct this morbid condition of the pouch of the rectum, 
 whether accompanied by fissure or not, and to restore it to 
 its natural tone and action, was the object which M. Breton- 
 neau had in view in employing the rhatany. In several 
 cases then of this condition of the rectum, attended by anal 
 fissure, he discovered that he effected a cure both of the 
 constipation and the fissure, by administering the extract of 
 rhatany in a fluid state as an enema, with the addition of a 
 small quantity of the tincture of the same. 
 
 After M. Bretonneau had thus introduced and made 
 known this method of treating constipation and fissure of 
 the anus, his celebrated pupil, the late and lamented M. 
 Trousseau, followed it up with great success in the treat- 
 ment of anal fissure. The method in which he employed 
 it in this disease is as follows : — He administered to his 
 patient every morning an enema of the decoction of marsh- 
 mallows, or simply of water, with the addition of olive or 
 almond oil, in order to clear out the rectum. In half an 
 hour after the bowel had thus been emptied, he administer- 
 ed the following enema : — 
 
 Recipe, Extract! Rhatanias, drachmas duas, 
 
 Spiritus Vini rectiiicati, drachmas quinque, 
 Aquae purae, uncias quatuor. 
 
 Fiat enema. 
 
 This injection he required the patient to retain, if possi- 
 ble ; and a similar one to be repeated in the evening. 
 When the pain was once moderated he only administered 
 one daily, and when the cure appeared to be completed, 
 only one every alternate day for about two weeks longer. 
 
124 ANAL FISSURE. 
 
 He says he derived considerable advantage in the treatment 
 of fissure of the anus, by the employment of an ointment 
 composed of one or two parts of the extract of rhatany to 
 five parts of the butter of cacao. 
 
 M. Duclos reports the two following cases of anal fissure 
 in infants which were both successfully treated by M. 
 Trousseau, the first in the Hospital Neckar, and the second 
 in private practice : — 
 
 Case First. This was the case of a little girl one year old, 
 under treatment for a white swelling of the knee. This 
 child had been constipated from her birth, but more especi- 
 ally for the four previous months, the bowels being moved 
 only every third or fourth day. Two months previous, the 
 mother remarked that every time the bowels were opened 
 the child screamed violently. The pain appeared to com- 
 mence with the effort of defecation, to continue during the 
 passage of the faecal matter, and to be prolonged for a few 
 seconds afterwards. For the last month, more especially, 
 defecation had been exceedingly painful, and at each stool 
 the child had voided a few drops of blood, either before or 
 after the fseces, but never mixed with them. Sometimes 
 the child, after a violent effort, would void a few drops of 
 pure blood, scream violently, and make an effort as if to 
 prevent the escape of fseces, in which no stool took place. 
 The general health was very good. On examination of the 
 anus, the following was found to be the state of the parts : 
 — The circumference of the anus was perfectly healthy, 
 but on deeply separating the folds, at the anterior part, 
 and between two folds of skin, a fissure, a millimetre in 
 width, and about five millimetres in length, of a red color, 
 was distinctly perceived. It was the more clearly seen as 
 the child, screaming violently, protruded the anus. The 
 constriction of the anus was so great, that the extremity of 
 the little finger could scarcely be introduced. M. Trousseau 
 prescribed an enema, composed of the extract of rhatany 
 
ANAL FISSURE. 12^ 
 
 one scruple, and water three ounces. The child kept the 
 injection four or five minutes, and passed it along with soft 
 faeces. The injection was repeated daily for five days. 
 Each time the passage of the fseces appeared less painful, 
 and on the sixth day the injection was discontinued. The 
 motions were then easy, free from blood or pus, and 
 unaccompanied by pain. The child left the hospital ten 
 days after, quite cured of the anal affection. 
 
 Case Second. This was the case of a child eight months 
 old, well developed, and in previous good health; had been 
 suckled by the mother until the age of six and a half 
 months. At that epoch it was weaned, and was subsequent- 
 ly attacked with violent diarrhoea, which gave way under 
 the use of emollients. The diarrhoea was followed by 
 obstinate constipation. This state had existed for about 
 eight days, when the child was seized, during defecation, by 
 violent pain at the anus, and the fseces were found tinged 
 with blood. From that time the child suffered great pain 
 on defecation and for some minutes afterwards. The fseces 
 were hard, and generally tinged with a few drops of blood. 
 The child was constipated. General state satisfactory. On 
 examining the anus, around its orifice was found a little 
 erythema and eczema which had been occasioned by the 
 diarrhoea, and were fast disappearing. Behind and to the 
 left, on separating the folds of the anus, a fissure about two 
 millimetres in length and one in depth, of a rosy color, was 
 discovered. It was very distinctly seen on the child's pro- 
 truding the anus in an effort of defecation. The anus was 
 considerably constricted. The same treatment was adopted 
 as in the first case. The fissure cicatrized completely in 
 about ten days, all pain on the evacuation of the fseces dis- 
 appearing. — (London Lancet. Fol.lV.p.\$~]. London, 1846. 
 From the Journal de Chirurgie. Annie 1846.) 
 
 The late and lamented Professor Velpeau rejected the 
 idea of curing a true anal fissure with such a remedy as 
 
126 ANAL FISSURE. 
 
 rhatany. In remarks which he made within a year of his 
 death, on "The Affections of the Anal Region" he says: — 
 " Formerly all ulcerations of the anus were confounded un- 
 der this name (anal fissure), and many practitioners still con- 
 found them. It was exactly in regard to this that M. Boyer 
 made his essay, which has remained one of his remarkable 
 works. He perfectly showed that it was necessary to dis- 
 tinguish on one side the fissure, properly so called, — that is 
 to say, a crack sufficiently cleanly cut, a little indurated, or- 
 dinarily perpendicular to the sphincter; this is never cured 
 without an operation, and all the ointments in the world can 
 accomplish nothing." 
 
 " But on the other side, superficial excoriations also exist 
 near the anus, having no particular characteristic ; these are 
 the ones M. Trousseau cures by rhatany ; and in making 
 use of this word fissure he has brought back to us the con- 
 fusion of the times before Boyer, and against which I wish 
 to guard you." — (Lessons upon the Diagnosis and 'Treatment of 
 Surgical Diseases, &c. Translated by JV. C. B.Fifield, M.D. p. 
 90. Boston, 1866.) 
 
 From the above it is evident that M. Velpeau did not 
 consider that the cases which M. Trousseau treated as fissure 
 of the anus were in reality that disease, but were mere ex- 
 coriations of the anus, &c. In this, however, he has done 
 M. Trousseau great injustice, as I will show. What, I ask, 
 is a true anal fissure? I will let M. Velpeau himself answer 
 the question. He says : — " Three essential symptoms charac- 
 terize fissure at the anus; first, burning pains at the moment 
 of passing the stools ; second, a superficial, narrow, long 
 ulcer, or sort of crevice, at the entrance of the intestine ; and 
 third, a violent and painful constriction of the sphincter." 
 — (Motfs Velpeau. Vol. III. p. 1 ill. New Tork, 1847.) 
 
 Now let the reader. refer to the two cases of M. Trousseau 
 as presented above in full, which were treated successfully 
 by the use of rhatany, and let him compare their descrip- 
 
ANAL FISSURE. \2~] 
 
 tion carefully with the description of anal fissure given by 
 M. Velpeau himself, and he will find them to correspond 
 exactly. If those two cases were not cases of true anal fis- 
 sure, then, I ask, what constitutes a true anal fissure ? I 
 could, in addition to the two cases of children reported 
 above, give a dozen cases of true anal fissure in adults suc- 
 cessfully treated by M. Trousseau by the use of rhatany. 
 These cases would be found to possess all the characteristics 
 of genuine fissure according to M. Velpeau — namely, severe 
 burning pains whilst stooling, or a short time afterwards ; a 
 long, narrow ulcer about the verge of the anus, and painful 
 anal spasm. 
 
 These two pre-eminently great men of our profession, 
 MM. Trousseau and Velpeau, have both lately, and within a 
 short period of each other, rested from their earthly labors, and 
 their works do follow them. These will remain as imperish- 
 able monuments of their genius and industry, and entitle 
 them to a high and distinguished rank among the benefac- 
 tors of mankind. 
 
 M. Marjolin treated a case of anal fissure successfully by 
 the use of rhatany alone. Cabanellas (These de Paris. No. 
 132. Annie 1826). 
 
 2. Cauterization. The indication contemplated by the use 
 of the cautery, either in its potential or in its actual form, in 
 the treatment of anal fissure, is to effect a change in the surface 
 of the fissure or ulcer, and thus to convert it into an ordinary 
 sore. The potential cautery has been employed in the treat- 
 ment of this disease from an early day down to the present 
 time, doubtless with more or less success. The treatment 
 of Guido de Cauliaco and Dionis consisted chiefly in the 
 scarification and cauterization of the fissure. The following 
 articles as caustics have been, and are now, sometimes used 
 in the treatment of this disease — Caustic potash, potassa 
 cum calce, nitrate of silver, sulphate of copper, acid 
 nitrate of mercury, the mineral acids, chloride of zinc, &c. 
 
128 ANAL FISSURE. 
 
 M. Jules Guerin, on the authority of M. Boyer, has the 
 merit, if any, of first recommending and employing the 
 actual cautery in the treatment of anal fissure in modern 
 times. M. Boyer, however, very justly remarks that it can- 
 not be employed without great inconvenience, except in 
 those cases of fissure unattended by spasmodic contraction 
 of the anal sphincters. — (Op. cit. p. 612.) 
 
 3. Dilatation. The object of employing dilatation of the 
 sphincters of the anus in instances of anal fissure, accompa- 
 nied by spasmodic contraction of one or both of these mus- 
 cles, has already been explained in another place. It may 
 be well, however, again to refer to the subject here. I have 
 elsewhere shown that the spasmodic contraction of these 
 muscles not only adds greatly to the pain of the fissure by 
 compressing it, but that it more or less retards the healing 
 of it, — hence the great importance of the distention of these 
 spasmed muscles, which destroys or suspends, for a longer 
 or shorter time, their contractility, without inflicting any 
 permanent injury upon them, and completely relieves the 
 fissure from their grasp and compression, and enables it, by 
 proper applications, to cicatrize so much more rapidly. 
 
 The same object, it is true, is accomplished by the divi- 
 sion of one or both of these muscles with the knife, but not 
 without serious danger and great inconvenience. The same 
 object is also partly attained by the anti-contractile property 
 of belladonna. 
 
 Dilatation of the anus and inferior extremity of the rec- 
 tum, except in organic or permanent stricture of the anus 
 and rectum, was, so far as my reading extends, first alluded 
 to by Ambrose Pare. — (Loc. cit.) In 1815 Mr. Copeland 
 highly recommended it, and successfully employed it in the 
 treatment of several cases of what he called spasmodic con- 
 traction of the sphincter ani muscle. — (Loc. cit?) A short 
 time subsequently Mr. Gaitskell employed it with equal 
 success in a similar case (loc. cit.'), and in 1 824 Mr. How- 
 
ANAL FISSURE. 12 
 
 ship also employed it successfully in a case of the same 
 kind. — (hoc. cit.) These gentlemen denominated their cases, 
 simple painful spasm of the sphincter ani, but, as I have else- 
 where shown, they were without doubt all clear cases of 
 anal fissure. 
 
 The principle of muscular distention and dilatation was, 
 however, in 1838, most thoroughly investigated in a valua- 
 ble paper on " Extension, Shampooing, and Percussion, in the treat- 
 ment of Muscular Contractions" by the able and ingenious M. 
 Recamier, the then distinguished physician of the Hotel 
 Dieu of Paris. In this paper M. Recamier observes that 
 the peculiar functions of all organs of the body may be dis- 
 turbed, either directly or indirectly, — the deviations from 
 health being in many cases dependent upon the state of an 
 organ at a distance from the one which exhibits the morbid 
 phenomena. The contractile functions of the muscles, in- 
 voluntary as well as voluntary, not unfrequently exhibit 
 the truth of this remark. M. Recamier closes this very 
 interesting and instructing paper by declaring the following 
 conclusions : — 
 
 First. It is necessary to discriminate those spasms or 
 
 ,muscular contractions which are not dependent upon, or 
 
 proceed from, an affection of the nervous system, but which 
 
 constitute a direct lesion of the contractile functions of the 
 
 voluntary or involuntary muscles themselves. 
 
 Second. In idiopathic muscular contractions, in wry-neck, 
 in dyspnoea, in spasmodic colic, in spasms of the sphincters, 
 etc., the use of extension, compression, and shampooing, 
 and the application of the cupping-glasses (dry cupping), 
 seem to be by far the most efficacious means of treatment. 
 
 Hhird. Hence it is scarcely ever necessary to have re- 
 course to section of the contracted muscles in torticollis, or 
 in contractions of the sphincter ani ;] except in cases in 
 which there exists an actual degeneration or a morbid change 
 of structure in the part itself. 
 
 9 
 
I30 ANAL FISSURE. 
 
 M. Recamier was consulted by a lady who had long suf- 
 fered severely from a fissure of the anus, for which M. Boy- 
 er had divided the sphincters of the anus. The operation, 
 however, did not prevent a relapse of the disease, and the 
 patient continued to suffer dreadful pain in the rectum, 
 especially when stooling. Dilatations of the sphincters and 
 of the lower end of the rectum, by means of bougies grad- 
 ually increased in size, ultimately succeeded in effecting a 
 perfect cure in this interesting case. 
 
 This eminent physician reported several other cases of 
 anal fissure, accompanied with painful constriction of the 
 anus, and some of them complicated with haemorrhoids, in 
 which the use of gradual distention of the anus and anal canal 
 was speedily followed by great relief, and finally by com- 
 plete recovery. He adds that the operation of dividing the 
 sphincters may be dispensed with in the majority of cases. 
 , — (Revue Medicate de Paris. Janvier, 1838.) 
 
 In the distention or dilatation of the anal sphincters, M. 
 Recamier did not contemplate any rupture, laceration, or 
 tearing of the mucous lining, or any of the muscular fibres of 
 the intestine. 
 
 turunda, or Merits. Dilatation of the anal sphincters and 
 rectum in this disease may be effected by the introduction 
 into the canal of tents made of lint and gradually increased 
 in size. The use of these kind of tents has been attended 
 with the very best results in the hands of MM. Beclard 
 (Loc. cit.), Dupuytren (Loc, «/.), Marjolin (Loc. cit.), and 
 Velpeau (Loc. cit.). The objection, however, that is urged 
 against this method of distention is, that it is sometimes 
 tedious and painful; the pain, however, only attends the 
 introduction of the first and second tent. The tent should 
 be well besmeared with the butter of cacao, or saturated 
 with glycerine, and if possible, suffered to remain in twelve 
 or twenty -four hours ; the patient in the mean time maintain- 
 ing the recumbent or horizontal position. 
 
ANAL FISSURE. I3I 
 
 Tents composed of such materials as become swollen and 
 enlarged by warmth, or by the imbibition of moisture or 
 fluids, might be used with advantage in the treatment of 
 this disease. I employed the sponge tent in two cases with 
 decided good effect, but it was attended with very severe 
 pain. I consider it very certain and efficient. The second 
 tent is generally sufficient, in ordinary cases, to produce 
 adequate dilatation. The gent? ana radix may also be men- 
 tioned for this purpose. I, however, decidedly prefer the 
 bougie I have already named, in all such cases. 
 
 Forcible Dilatation. I remember having seen a number of 
 years ago, in some of the French Medical Journals, a state- 
 ment of M. Maisonneuve, in which that distinguished sur- 
 geon recommended and employed with success forced and in- 
 stantaneous dilatation of the anus and anal canal, as a remedy 
 in fissure of the anus. He performed this operation by in- 
 troducing his right hand through the anus and anal canal 
 up into the pouch of the rectum, then firmly clenching it 
 and forcibly withdrawing the fist. I recollect, at the time, 
 I was forcibly struck with the novelty, the barbarity, as well 
 as the repulsive nature of the proceeding. The operation 
 met with no favor, and has since been justly consigned to 
 oblivion. Subsequently, however, a modification of the 
 operation of M. Maisonneuve was recommended, in which 
 the two thumbs were to be substituted for the fist. I am 
 unable to say who had the merit of introducing this modifica- 
 tion of M. Maisonneuve's operation, more than that the very 
 able and distinguished French surgeon, M. Nelaton, has 
 practised it for a number of years, and is its advocate ; hav- 
 ing, it is said, employed it successfully in a number of cases. 
 
 The operation as performed by M. Nelaton, the patient 
 always being under the influence of an anaesthetic, is as fol- 
 lows : — "The patient being conveniently placed, the two 
 thumbs are introduced into the anus, and the tuberosities of 
 the ischium serving as points-d? appui for the fingers, they are 
 
132 ANAL FISSURE. 
 
 separated until they come in contact with the internal face 
 of the tuberosities. A resistance is felt, when suddenly there 
 is a feeling of an internal rupture, and the two thumbs touch 
 the bones. This is sufficient. There is no dressing neces- 
 sary. When the patient recovers from the effects of the 
 anaesthetic he has some pains, at times quite sharp! but it is 
 not like the kind of pain he felt before, it is of a differ- 
 ent character ; when this pain is over, the patient does not 
 suffer any more. It is sufficient during the first few days to 
 administer enemata to facilitate the stools, and at the end of 
 a week the patient can attend to all his occupations." — (Clin- 
 ical Lectures on Surgery. From Notes taken by IV. F. Atlee, M.D. 
 p. 552. Philadelphia, 1855.) 
 
 Professor Van Buren is the advocate of forcible dilatation 
 of the sphincter ani by means of the thumbs, as a prompt 
 and sure remedy in anal fissure, as well as in some other 
 diseases of the rectum. He prefers this method to, and sub- 
 stitutes it for that of M. Boyer, objecting to the latter mere- 
 ly because it is a cutting operation, and that patients dread 
 the knife. The objections, however, to the process of M. 
 Boyer are surely of a much more grave or serious nature 
 than the patients' dread of the knife merely. Were the 
 patient, however, to be made well acquainted with both 
 operative procedures, and then consulted as to which he 
 would choose, he might perhaps, with all his natural dread of 
 cutting and of the knife, prefer the method of M. Boyer, of 
 having all the fibres of the sphincter ani muscle divided 
 with the knife, to the method of Dr. Van Buren, of having 
 some of the fibres of this muscle torn and the remainder of 
 them paralyzed by violent stretching with the thumbs. The 
 question would simply be, whether the patient would pre- 
 fer cutting with the knife, to tearing and paralyzing by 
 forcible dilatation. Dr. Van Buren reports a number of 
 cases he has cured by this process, without any bad results. 
 — (Loc. citS) 
 
ANAL FISSURE. 1 33 
 
 Those who approve and adopt this measure claim for it 
 entire exemption from danger. I cannot, however, see why 
 it should not be dangerous, as considerable violence is evi- 
 dently done to the parts. Indeed the advocates themselves 
 of this proceeding appear to be surprised that it should not 
 be so ; yet they tell us that no accidents have occurred in 
 the cases upon which they have operated. They must all 
 know, however, that this operation, which is effected by 
 sheer manual force, can never be performed without more 
 or less laceration, tearing or rupturing of the membranes and 
 vessels of the anal canal. A considerable portion of the 
 muscular fibres of the external sphincter, especially, are evi- 
 dently torn or ruptured in this violent stretching process, as 
 witnessed in the relaxed and flabby condition of this mus- 
 cle, the complete inability of the patient to control it, and 
 in the fact that if the finger immediately after is introduced 
 into the anus, quite a gap is felt in the substance of it. Patients 
 who have been subjected to this operation, without having 
 been put under the influence of an anaesthetic, invariably state 
 that it is attended with dreadful pain and a sense of tearing. 
 The operator himself experiences a sensation of tearing, or 
 giving way of something, and the haemorrhage that imme- 
 diately ensues is a positive evidence that a breach has been 
 made. 
 
 The immediate consequences of the injury thus inflicted 
 by this operation, upon the integrity of the mucous and 
 muscular tissues of the canal, are increased irritation and 
 inflammation, and subsequently permanent contractions, an 
 additional source of mischief; for as the union of the torn 
 portions proceeds, the cicatrices become firm and indurated 
 and tend gradually to contract, whilst at the same time the 
 inflammatory action existing in the surrounding parts pro- 
 duces their adhesion, and thus ultimately indurations are 
 formed, involving the proper membranes of the canal in one 
 common mass with the subjacent parts. Under such cir- 
 
134 ANAL FISSURE. 
 
 cumstances it would not be surprising if the patient should 
 at some subsequent period find himself suffering from a firm 
 and hard stricture of the anus or anal canal. 
 
 Furthermore the immediate and forcible distention, or the 
 over-stretching of the external sphincter muscle in this 
 operation, even without producing any laceration, might so 
 far paralyze it, or impair its contractile power, that it might 
 never afterwards be able to resume its function as a sphinc- 
 ter. Three instances of this character, caused by this opera- 
 tion, have fallen under my own observation within the last 
 two years. Two were females, and one a male. They 
 were all operated on by surgeons in this vicinity. I found, 
 upon examination, that in each case the external sphincter 
 was in a relaxed and flabby condition, having to a great extent 
 lost its contractile power. In these cases, for some time after 
 each fsecal dejection, small portions of faeces pass involun- 
 tarily from the anus, compelling the patients to wear a T- 
 bandage and fold of rag, or to wash the parts frequently, in 
 order to prevent soiling the linen. It is true that these 
 persons still have the control of the internal sphincter, and 
 it is fortunate for them that they have. 
 
 These are some of the objections I have to urge against 
 this operation, and in my opinion they should be sufficient 
 to condemn it, and to cause its rejection altogether; for if I 
 believed that it was absolutely and essentially necessary that 
 the whole or a part of the muscular fibres of the anal sphinc- 
 ters should be divided, in order to effect a cure of anal fis- 
 sure, I would decidedly prefer dividing them with the knife, 
 inasmuch as a simple incised wound is, for obvious reasons, 
 far more preferable than a torn, mangled, and irregular one. 
 This operation, so far as my knowledge extends, is princi- 
 pally confined to France, where it originated, and to our own 
 country, in which it has been within a few years introduced. 
 I believe it is neither adopted in England nor in Germany. 
 
 There would not be so serious an objection to this opera- 
 
ANAL FISSURE. I35 
 
 tion, if a smaller distending body than the two thumbs were 
 used, and if the distending force was so controlled as to in- 
 sure the membranes against laceration or rupture. I have 
 myself on several occasions adopted a modification of it 
 with most decided good results. Instead of the thumbs, I 
 introduce into the anus the index finger of each hand, 
 and forcibly dilate the contracted muscle, first, antero-pos- 
 teriorly, and then laterally, at the same time taking great 
 care to preserve the integrity of the membranes. 
 
 A few years ago, I saw an instrument called an anal dila- 
 tor, which worked by a screw. It was invented and intend- 
 ed as a substitute for the thumbs in this operation. This 
 instrument was ingeniously contrived, and beautiful to look 
 at ; but it is entirely too much of an automatic machine ; it 
 leaves no scope for the judgment of the operator. It is 
 impossible by such an instrument to regulate the exact 
 amount of dilatation necessary. The thumbs or the fingers 
 as dilators are far preferable to this, as the operator, having 
 the complete control of them, can regulate the force ac- 
 cording to the effect. 
 
 It is remarkable what a great thirst there is among some 
 surgeons of the present day for operating by new, novel, 
 and extraordinary means — such as crushing, rupturing, 
 lacerating, tearing, etc. One among our able professors of 
 surgery, a short time since, made the remark to a friend 
 that he had rejected the knife in all the surgical operations 
 in which it was heretofore used, except in lithotomy. With 
 him the ecraseur is the instrument par excellence. By it he 
 removes all tumors, all limbs, the uterus, the penis, the 
 tongue, etc., and uses it in the operation for anal fistulse, 
 etc. 
 
 What will be the result of this ecrasement furor, or of such 
 surgery % or what will come next ? are questions. 
 
 4. Incision of the Mucous Membrane. The incision of the 
 mucous membrane alone, or including with it sometimes the 
 
I36 ANAL FISSURE. 
 
 submucous cellular tissue, and even some of the muscular 
 fibres, in the treatment of anal fissure, has been recom- 
 mended by some eminent surgeons as a substitute in certain 
 cases for complete division of the anal sphincters. This 
 limited operation is infinitely preferable to that of M. Boy- 
 er, especially as it is said by some to fulfil every indication 
 claimed for by his; as well as its being entirely free from the 
 dangerous consequences so liable to follow his proceeding. 
 According to the testimony of the late Sir Benjamin 
 Brodie, Mr. Copeland was the first surgeon who, in anal 
 fissure, advised simple incision of the mucous membrane in 
 certain cases, instead of incision of the anal sphincters, as 
 recommended by M. Boyer. — (Op. cit. p. 325.) Upon this 
 subject Mr. Ouain says: "It is now more than fourteen 
 years ago, that being about to perform Boyer's operation 
 upon a female in this hospital (University College Hospital, 
 London), who was lying in bed, and not held with sufficient 
 firmness, having suddenly moved away, I drew the bistoury 
 through the ulcerated membrane only. It occurred to me 
 at the moment to ascertain if that slight incision would be 
 enough to relieve the patient. The success was complete ; 
 and from that period I have used no other operation in 
 ordinary circumstances." In a note, Mr. Quain further re- 
 marks : u At the time I thought that this method had origi- 
 nated altogether with myself, but upon examining various 
 books, with a view to be assured upon this point, I found 
 in a lecture of Sir Benjamin Brodie's a remark which shows 
 that in certain cases the modified operation had been previ- 
 ously performed by another surgeon." — (Op. cit. p. 175.) 
 
 I would here remark, that so far as priority is concerned 
 with regard to this operation, I have elsewhere already 
 shown that it, or a similar one, was practised and recom- 
 mended by Albucasis and others of his time, and conse- 
 quently is not a discovery or an invention of modern times. 
 Mr. Copeland, however, has the merit of re-introducing 
 
ANAL FISSURE. 1 37 
 
 and reviving it, and especially as a complete substitute for 
 the formidable and obnoxious operation of M. Boyer. 
 
 Mr. Curling is of opinion that the simple and superficial 
 incision of the mucous membrane, as recommended by Mr. 
 Copeland, is not sufficient to effect a cure in anal fissure. 
 He says : " I am convinced that on this point Mr. Cope- 
 land is in error ; at any rate this is not sufficient, and that, 
 however slight and superficial the incision may be, a few 
 at least of the fibres of the sphincter must be divided." 
 — (Op. cit. p. 10.) 
 
 Mr. Henry Smith, speaking on this same subject, says : 
 " Thanks to the suggestion of the late Mr. Copeland, 
 surgeons, whilst recognizing the same principle as influenced 
 Boyer, are content with making only a limited incision, so 
 as to fairly cut through the ulcer, and only divide a portion 
 of the fibres of the sphincter muscle. Some surgeons even 
 suppose that it is not necessary to divide any of the fibres 
 of the sphincter, and simply recommend an incision 
 through the ulcer ; but it must be borne in mind that a fair 
 incision to the bottom of the ulcer will of necessity involve 
 some portion of the sphincter. The rule I adopt and would 
 recommend is to carry the incision to such an extent as 
 will produce a sensible dilatation of the anal orifice. This 
 is readily ascertained by introducing the finger after the 
 operation. If the ulcer be fairly divided, and with it some 
 of the fibres of the sphincter, the contraction of the lower 
 part of the bowel will be much diminished when the finger 
 is introduced, and this is a pretty certain indication that the 
 necessary incision has been effected." — (Op. cit. p. 134.) 
 
 Believing as I do that an anal fissure never invades the 
 muscular coat of the rectum, I am consequently of opinion, 
 that even in the worst cases it is only necessary to incise the 
 mucous membrane and submucous cellular tissue to effect 
 all the relief claimed for by it, namely, removing the ten- 
 sion of the parts, and setting the mucous membrane at lib- 
 
I38 ANAL FISSURE. 
 
 erty. I am fully convinced, however, that even this opera- 
 tion is unnecessary, inasmuch as the disease can most cer- 
 tainly be cured by proper topical applications, combined 
 with suitable dilatation ; but I decidedly prefer it to forci- 
 ble dilatation with the thumbs, which is difficult, painful, 
 dangerous, and in some instances impossible. 
 
 Modus Operandi. Previous to the performance of this 
 operation the bowels should be emptied by an aperient, and 
 the rectum afterwards well cleared out by an enema. The 
 patient being placed on the left side, with the knees drawn 
 up to the chin, the surgeon should introduce his left index 
 finger, warmed and well lubricated, into the anus and anal 
 canal, in the direction and beyond the upper end of the fis- 
 sure. He should then introduce a straight probe-pointed 
 bistoury flatwise, along and in front of the finger in ano, until 
 the point has reached a little beyond the superior extremity 
 of the fissure, when the bistoury should be turned round 
 with its cutting edge against the ulcer. The incision is 
 then to be commenced at this point, and carried through 
 the fissure down to the external skin, care being taken in 
 bringing down the bistoury not to cut so deep as to di- 
 vide any of the fibres of the sphincter. The incision may 
 be made either through the fissure, or in the immediate vi- 
 cinity of it. After the incision has been made, a small 
 pledget of lint besmeared with simple cerate may be press- 
 ed into the wound. It is best not to allow any action of the 
 bowels for two or three days after the operation. This may 
 be effected by the patient maintaining the horizontal pos- 
 ture, taking an enema of starch and laudanum, and strictly 
 observing a milk diet. 
 
 G. T I EM ANN k CO. 
 
 Fig. 14. 
 
 This operation I have performed on several occasions 
 with an instrument which I devised and which is represent- 
 
ANAL FISSURE. I39 
 
 ed by Fig. 14. This instrument is founded somewhat upon 
 the principle of the lythotome cache, and consists of a straight 
 narrow-bladed bistoury three inches and a half long, the 
 blade of which is concealed by a guard having a deep slit 
 in it, and which is easily adjusted to the blade, and rests 
 upon two pivots, one on each side of the same. The distal 
 extremity of the guard is blunt, and its proximal extremity 
 terminates in a steel spring which rests upon the back of 
 the handle of the blade. By pressing upon the handle of the 
 bistoury when it is properly adj usted upon whatever is intended 
 to be cut, a portion of the cutting edge of the blade leaves 
 the slit of the guard, and is made to appear. This instru- 
 ment, being small, is easily introduced into the canal without 
 the finger. It should be warmed, well lubricated, and insert- 
 ed into the canal in the direction of the fissure and a little 
 beyond its superior extremity, with the slit in the guard 
 facing the fissure or ulcer ; then pressing upon the handle, 
 the blade will appear, and the instrument thus drawn out 
 will make the incision of the mucous membrane only, as 
 the guard is so arranged that the blade cannot cut deeper 
 than this tissue. 
 
 5. Excision of the Fissure. The operation of excising the 
 fissure instead of dividing the anal sphincters, I believe was 
 first proposed and executed by M. Velpeau. In this opera- 
 tion the integrity of the muscular coat is preserved, neither 
 the muscle nor the muscular fibres being interfered with. 
 M.. Velpeau performed this operation in eight or ten cases, 
 in two of which the fissure reappeared and was never cured. 
 He, however, recommended, in very obstinate cases, the 
 combination of the two methods — that is, both the division 
 of the anal sphincters, and the excision or extirpation of the 
 fissure or diseased part. Care should be taken, in perform- 
 ing the operation, to remove the whole affected portion. 
 
 The operation of excision of the fissure, as performed by 
 M. Velpeau, is as follows : The patient being placed in the 
 
140 ANAL FISSURE. 
 
 same position as that for incision of the sphincters, the 
 surgeon seizes with a tenaculum the point of the verge of 
 the anus occupied by the fissure, and with a few strokes of 
 the bistoury, on the right and the left, completes the exci- 
 sion of the fissured part. The scissors may be employed 
 to remove the fissured or diseased part, but care must be 
 taken to avoid cutting the muscular tissue beneath. The 
 operation is soon done, and attended with but little pain. 
 The wound requires to be dressed for three or four days, 
 and the bowels prevented from acting, as recommended in 
 the operation of simple incision of the mucous membrane. 
 — (Demonge, France Medicate, Home I. p. 46. Also Motfs 
 Felpeau, Vol. III. p. 1115. New Tori, 1847.) 
 
 6. Myotomy of the Anal Sphincters. The merit of first recom- 
 mending and executing the operation of dividing the anal 
 sphincters, in fissure of the anus, is universally attributed 
 to M. Boyer. I have elsewhere shown, however, that it was 
 advised by Ambrose Pare. Be this as it may, M. Boyer 
 was nevertheless the first surgeon who, in modern times, 
 executed it, and gave it a status in surgery as a powerful 
 remedy in anal fissure. 
 
 The operation, as I have elsewhere observed, 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 the real disease. The operation 
 being wrong in principle and most mischievous in 
 practice, cannot therefore be approved of upon rational 
 grounds. All treatment is irrational that is not directed to 
 the morbid condition of the mucous membrane of the part, 
 or that does not immediately tend to heal the fissure, the 
 real disease. It must not be taken for granted that because 
 the operation removes, for the time being, the muscular 
 spasm, that this spasmodic contraction is the real disease or 
 cause of it. At best the operation can only be of service 
 as a temporary amelioration of the real disease. 
 
ANAL FISSURE. I4I 
 
 M. Boyer considered this operation as an infallible remedy 
 in the treatment of anal fissure, yet several most eminent 
 surgeons have reported cases in which it has utterly failed. 
 Among such are MM. Velpeau, Recamier, Beclard, etc. 
 M. Velpeau says of this operation, that it compels us to cut 
 through the deeper-seated tissues beyond the muscles. The 
 wound which results always suppurates for some time, and 
 may occasion dangerous accidents. The inflammation and 
 formation of matter may extend to the pelvis, and com- 
 promise the patient's life. I have seen two cases, says he, in 
 which the patients died after a division of the sphincter, for 
 fissure of the anus. — (Loc. cit.) 
 
 Inflammation from this operation is liable to be produced, 
 and extend to the loose cellular tissue immediately external 
 to the muscular tissue ; from this it may extend to the cellu- 
 lar tissue external to the peritonaeum, and terminate in the 
 destruction of the patient. In consequence of the peculiar 
 anatomical structure of the parts in females, the operation is 
 always hazardous. By this operation, too, the patient is 
 often rendered permanently incapable of retaining either the 
 intestinal gases or his stools, and they pass involuntarily. 
 This truly would be a most deplorable condition to be left 
 in, even if cured of the anal fissure. The operation, too, is 
 by no means free from serious, if not fatal haemorrhage. 
 I therefore consider the operation unscientific in principle, 
 as well as uncertain and unsafe in practice ; but, for the 
 benefit of those who may think and practise otherwise, I 
 will give in full the modus operandi of it, together with a few 
 modifications of it, and conclude with the observation, 
 that to avoid the use of the knife, if possible, in the treat- 
 ment of this disease, should be the rule of the well-edu- 
 cated and scientific surgeon, both in public and in private 
 practice. 
 
 The Proceeding of M. Boyer. The preparatory steps of 
 Boyer's operation are precisely the same as those for inci- 
 
142 ANAL FISSURE. 
 
 sion of the mucous membrane in the same disease. A day 
 or two previous to the operation, the bowels should be 
 emptied by means of a mild purgative, and on the day of 
 the operation the rectum should be completely cleared out 
 by an enema, in order to insure entire quietude for several 
 days after. An injection of thin starch and laudanum should 
 be administered immediately after the operation, and the 
 patient should maintain the horizontal posture, and observe 
 a milk or meagre diet, so that he may remain free from any 
 faecal evacuation for four or five days. 
 
 t i em ann & co. 
 Fig. 15. 
 
 The instruments employed are a straight blunt-pointed 
 bistoury, the blade two inches long and about one sixth of 
 an inch wide (Fig. 15) ; a common bistoury, a large tent 
 made of lint, a T-bandage, and all the minor accessories. 
 The patient being placed on his left side, on the edge of a 
 bed, with his head low, the under limb extended, the upper 
 one flexed, and the nates widely separated by assistants, the 
 surgeon, after anaesthesia is produced, should introduce the 
 index finger of his left hand, well lubricated with cerate, in- 
 to the rectum, and gliding along it the flat side of the blunt- 
 pointed bistoury to a little beyond the superior end of the 
 fissure, the cutting edge should then be turned towards the 
 surface of the canal in the course of the fissure, if it be sit- 
 uated laterally, and the coats of the intestine, the anal 
 sphincters, and the surrounding cellular tissue and integu- 
 ment should be divided by one stroke of the bistoury. A 
 triangular wound is thus made, the summit of which answers 
 to the intestine and the base to the skin. Should it be 
 necessary to extend the external incision, as it sometimes 
 is, it can be done by an additional stroke of the bistoury. 
 In some instances the intestine slides before the edge 
 
ANAL FISSURE. 
 
 H3 
 
 of the knife, and the wound of the cellular tissue is then 
 larger than that of the intestine. Should this occur, it will 
 then be necessary to re-introduce the bistoury, in order to 
 prolong the wound of the intestine ; or this may be accom- 
 plished by a blunt-pointed scissors. Should there be a fis- 
 sure on each side, or should there be excessive spasmodic 
 contraction of the sphincter or sphincters of the anus, both 
 sides must be incised alike. The incision should always be 
 made through the fissure, provided it is located on one or 
 the other side ; but if it is situated in front or behind, the 
 incision of the side is quite sufficient. No operation of the 
 kind should ever be made either anteriorly or posteriorly, 
 because the anal sphincters can neither be safely nor com- 
 pletely divided at either of these points, on account of the 
 shortness of the space between the coccyx and the verge of 
 the anus, the proximity of the bulb of the urethra in the 
 male and the shortness of the perinseum in the female. 
 Another serious objection to the performance of this opera- 
 tion in the median line, is the great difficulty in healing 
 wounds in this situation, in consequence of the friction cre- 
 ated by the motion of the extremities. 
 
 Should the edges of the fissure be hard and elevated, 
 they should be seized with a forceps and removed. Should 
 haemorrhage occur, the usual measures for arresting it must 
 be promptly put into practice. The dressing of the wound 
 is very simple. Dossils of lint covered with cerate should 
 be placed between the lips of the wound, and extend about 
 an inch beyond the superior angle of the incision. The 
 space between the nates should be filled with lint, and the 
 whole supported by a compress and a T-bandage. In 
 four or five days the dressing should be carefully removed, 
 and after that it should be daily renewed until cicatrization 
 takes place. The wound is generally cicatrized in about 
 one month or six weeks ; sometimes, however, the healing 
 is not effected under two or three months. 
 
144 ANAL FISSURE. 
 
 I would observe here that M. Boyer did not consider it 
 essentially necessary to the success of the operation that the 
 incision should be made immediately through the fissure. — 
 {hoc. cit?) M. Velpeau, however, thought differently. He 
 says : " Should the fissure occupy the median line in front, 
 the surgeon must not cut upwards, for fear of injuring the 
 urethra or the vagina. Boyer thought it sufficient to di- 
 vide the sphincter at any point without caring where the fis- 
 sure may be located ; but I am of opinion that the surgeon 
 will do well to pass the blade of the bistoury through the 
 fissure at the same time that the muscle is divided." — (Loc. 
 cit?) 
 
 tfke Proceeding of Boyer as modified by Blandin. To avoid 
 the dangers, uncertainties, and the inconveniences of Boyer's 
 operation, M. Blandin devised, executed, and recommended 
 a modification of it, consisting of the submucous and sub- 
 cutaneous section of the sphincter ani. Blandin's operation 
 is very ingenious ; it is simple, and far less formidable and 
 repulsive to the feelings of the patient, and certainly, in a 
 practical point of view, attended with much less risk. The 
 relief is as instantaneous as it is by Boyer's operation, and 
 no large open wound is left in the intestine, the intestinal 
 membrane and integument being entire. Defecation can 
 therefore be performed without the same amount of irrita- 
 tion; and the cure is materially expedited, inasmuch as 
 the parts are not kept in a state of disunion longer than is 
 necessary for its completion. 
 
 In this operation the same preliminary treatment with 
 regard to unloading the bowels is as necessary as in that of 
 Boyer, and the precautions concerning the impropriety of 
 incising directly forwards in the female, or directly back- 
 wards in either sex, are equally applicable to both methods 
 of operating. The instrument employed for operating by 
 the method of Blandin consists of a sharp-pointed straight- 
 bladed bistoury, with a flat sliding guard upon one side of 
 
ANAL FISSURE. 145 
 
 it. This guard is rounded at the extremity, oval externally, 
 and flat upon the surface lying on the blade. It is com- 
 pressed against the side of the knife by means of a spring, 
 and retained in its position by a slightly projecting pin, 
 sliding in a groove upon the blade. The whole, or a por- 
 tion, of the guard can be retracted within the handle by a 
 button attached to it for that purpose. This instrument, a 
 little simplified and improved by myself, is represented by 
 Fig. 16. 
 
 TIEMANN-CO 
 
 Fig. 16. 
 
 The patient being placed in the proper position, a small 
 puncture with the point of the bistoury is then to be made 
 in the skin, at the distance of from eight to ten lines from 
 the verge of the anus. The index-finger of the left hand 
 is now to be introduced into the rectum, in order to keep 
 the mucous membrane tense, at the same time the skin on 
 each side of the anus being well stretched by an assistant. 
 The guard is protruded beyond the point of the blade, and 
 the tenotome is then carefully introduced through the wound 
 and passed up between the mucous membrane and the 
 sphincter to the requisite height. The cutting edge is then 
 turned towards the sphincter, the guard retracted, and the 
 muscle cut through as the blade is withdrawn. As soon as 
 the section of it is made,- the finger in the rectum feels the 
 solution of continuity between the divided portions of the 
 muscle, which is preceded by a peculiar noise — "une espece 
 de craqiiement." ' If any doubt remains as to whether the 
 muscle is completely divided or not, the tenotome, guarded 
 as before, may be reintroduced, and a second incision made 
 in a similar manner, exactly upon the first. The small ex- 
 ternal wound should then be closed. The after-dressings 
 should consist either of lint covered with simple cerate, or. 
 
 10 
 
I46 ANAL FISSURE. 
 
 lint wet with a cooling lotion, or simply cold water. The 
 bowels should be kept in a relaxed state by mild purgatives, 
 or by enemata alone. A double submucous section of the 
 sphincter may be made if necessary, — one on each side. 
 
 M. Blandin has performed this operation with complete 
 success in several cases of anal fissure. M. Marchal (de 
 Calvi) also performed the same operation on a man suffering 
 from cancer of the rectum, attended with painful spasmodic 
 contraction of the anus. This patient suffered intense 
 agony after each evacuation of the bowels. The operation 
 at once afforded great relief. — {Archives Generates de Medecine 
 de Paris, Avril, 1846.) 
 
 tfhe Proceeding of Boyer as modified by Dr. Hayward. — The 
 late and lamented Dr. Hayward of Boston, late surgeon to 
 the Massachusetts General Hospital, was of opinion that no 
 treatment short of Boyer's operation of the division of the 
 anal sphincters would be effectual in relieving anal fissure. 
 He reports a successful case of fissure of the anus in which 
 he divided the muscles from without inwards, instead of from 
 within outwards, as in the operation for complete fistula in 
 ano. This he considered the best method. A part of this 
 case he relates as follows : — " On examination, I found just 
 within the margin of the anus, towards the sacrum, a narrow 
 ulcer an inch or more in length, quite tender and painful to 
 the touch. The bowels having been emptied by an enema, 
 the operation was performed in the following way: The 
 forefinger of the left hand having; -been introduced into the 
 rectum, a spear-pointed scalpel was thrust in outside of the 
 sphincter till it reached the point of the finger, thus includ- 
 ing the sphincter between the edge of the scalpel and the 
 finger. Both were then simultaneously withdrawn, the 
 scalpel cutting its way out through the fissure. Lint was 
 introduced between the lips of the wound, and a compress 
 and a T-bandage completed the dressing. For two or three 
 . days he had slight spasms about the anus, which were re- 
 
ANAL FISSURE. I47 
 
 lieved by anodyne fomentations. But after this period he 
 had no trouble; his dejections gave him no pain, though 
 the ulcer was not healed, and he was discharged from the 
 Hospital " well " in fourteen days after the operation, in all 
 respects able to resume his ordinary avocations." — {Report of 
 the Surgical Cases that occurred in the Massachusetts General 
 Hospital from \2th May, 1837, to 12th May, 1838.) 
 
CHAPTER SIXTH. 
 
 CONCLUSION. 
 
CHAPTER VI. 
 
 CONCLUSION. 
 Section I. — Illustrative Cases. 
 
 The following cases of anal fissure, selected promiscuously 
 from my case-book out of a large number collected during 
 a practice of thirty years, will illustrate the several phases, as 
 well as the complications under which this disease generally 
 presents itself: 
 
 Case I. — Anal fissure of nine months' standing, caused by obsti- 
 nate constipation of the bowels, and the continued use of drastic 
 purgatives. 
 
 On the nth of September, 1840, Miss S. T- , 
 
 of Jessamine county, Kentucky, set. twenty-six, a very 
 delicate lady of a nervous temperament, consulted me for a 
 disease she had suffered from for nine months, and which 
 her physician, who had frequently examined her, pronounc- 
 ed to be constipation and internal piles, caused by torpor of 
 the liver. To relieve the torpor and the constipation, he 
 was in the habit of giving her an active cathartic about 
 twice a week for a long time. She could only tell me the 
 name of one of the several kinds of drastic purgatives she 
 had been taking, and that was " Cool's Ptlls" a quite com- 
 mon medicine of that day, composed of equal parts of aloes, 
 rhubarb, and calomel. She gradually grew worse under this 
 active treatment, which seemed to have changed the charac- 
 ter of the disease altogether — so much so, that she finally de- 
 termined to abandon both the treatment and the doctor. 
 
 She informed me that for the last three months she had 
 
152 ANAL FISSURE. 
 
 suffered the most intense burning and lancinating pains in 
 the anus whilst stooling, and for three or four hours after, 
 often attended with most violent spasms of the sphincter ani. 
 All these symptoms were much aggravated during menstrua- 
 tion, which was generally quite normal. She had a great 
 dread of stooling, and to avoid it as much as possible, she 
 would almost starve herself, so that she had become quite 
 emaciated. The stools, when hard, were generally streaked 
 with mucus tinged with blood; and when soft, were figured 
 and of small size. 
 
 Upon making an examination, by divaricating the nates, 
 I observed on the left side of the anus a lineal ulcer com- 
 mencing at the verge of the anus, and extending up into the 
 canal about three-fourths of an inch. This crevice was so 
 deep as to extend through the mucous membrane ; it pre- 
 sented a bright red appearance, and its edges were hard and 
 elevated. I could not insert my finger into the anus in 
 consequence of the rigidity of the sphincter, and the severe 
 pain occasioned by pressing on and separating the lips of 
 the fissure. To overcome the spasmodic contraction of the 
 sphincter, I administered as an enema one ounce and a half 
 of an infusion of belladonna, and two hours after repeated 
 the same ; in the meantime the anus was well fomented with 
 cloths wrung out of hot water. The infusion was prepared 
 as follows : 
 
 Recipe, Belladonnas Radicis, drachmam, 
 
 Aquas bullientis, uncias sex. 
 Misce et fiat infusum, macerando horam integram : dein cola. 
 
 By these measures I was enabled in about four hours to 
 introduce my finger into the rectum with ease, and with 
 scarcely any pain, as well as a bougie much larger than the 
 finger. 
 
 This patient was kept in the horizontal position ; took a 
 mild tonic; her diet was chiefly animal broths, rice, arrow- 
 root, etc. ; no cathartic medicine whatever was given, her 
 
ANAL FISSURE. 153 
 
 bowels being entirely relieved every alternate day by an 
 enema composed of the infusion of linseed and castor oil. 
 The edges of the fissure were touched with the solid nitrate 
 of silver on the days on which the bowels were not evacu- 
 ated, and immediately after each application a small pledget 
 of lint besmeared with the simple ointment of belladonna 
 was inserted. The first application caused very severe pain, 
 which continued for three or four hours. The two follow- 
 ing applications were not so severe. The solution of the 
 salt was now substituted for the caustic in its solid form. It 
 was applied to the fissure every day, and the bougie was 
 used immediately after. At the end of the second week 
 an evacuation took place daily, always preceded, however, 
 by the enema ; about two hours after which, the application 
 would be made, and the bougie inserted' for a moment. 
 Under this treatment the fissure completely cicatrized in 
 four weeks. This patient returned home completely re- 
 lieved of the fissure and the constipation. 
 
 Case II. — Hhe lady referred to in the following communication 
 was successfully treated by me for an anal fissure, complicated 
 with hemorrhoids, six months after the date of the letter. 
 
 " , Ky., September 8th, 1841. 
 
 " Dr. Bodenhamer : 
 
 " Dear Sir — My wife is afflicted with a 
 serious disease of the lower bowel, for which she has taken 
 much medicine from several physicians, without any per- 
 manent good effect. Indeed, they do not appear to under- 
 stand her disease. Her physicians all have advised her to 
 
 consult Dr. D , believing that some surgical operation 
 
 might perhaps be necessary. We have come to the con- 
 clusion, before taking this step, to consult you ; and if you 
 think that you can cure her, we will visit you as soon as we 
 get your answer to this. For several years my wife labored 
 
154 ANAL FISSURE. 
 
 under costive bowels, for the relief of which she was 
 compelled, from time to time, to take active purgative 
 medicine. About seven months ago, one day after she had 
 taken a large dose of Cook's Pills, which operated severely, 
 she was taken with such a burning pain while at stool, that 
 she nearly fainted. Ever since, whenever she stools, and 
 for hours after, she suffers the most agonizing pain. These 
 pains extend to her back and down her lower extremities, 
 and sometimes so affect her bladder that she cannot urinate 
 without great difficulty. Her discharges from her bowels 
 are frequently mixed with blood and matter ; and when she 
 has these discharges, the burning is just like hot lead pass- 
 ing down her bowels, as she describes it. She is nearly all 
 the time confined to her bed, a mere skeleton, and so ner- 
 vous at times that we can scarcely do anything with her. 
 Such is the dread she has of an operation on her bowels, 
 that she frequently sheds tears for an hour or two previous. 
 She has no cough, and her digestion is good ; and if she were 
 relieved of this horrid disease, she would, I think, be well 
 otherwise. Some of her physicians call her disease fistula, 
 and others piles. She has had three children, the youngest 
 two years old, and her age is thirty." 
 
 On making an examination of this case, I found on each 
 side of the anal canal posteriorly, a hsemorrhoidal tumor 
 about the size of a hazel-nut, which I caused the patient to 
 protrude as much as possible, when I detected a long narrow 
 ulcer between the two tumors at the posterior verge of the 
 anus, and extending into the canal about two-thirds of an 
 inch. Its edges were thick and hard, and its surface florid, 
 and bled freely when touched with the probe. The at- 
 tempt to introduce the finger gave excessive pain, and 
 brought on a violent spasmodic contraction of the sphincter. 
 
 This lady continued to maintain the horizontal posture ; 
 took as a tonic the muriated tincture of iron and the cold 
 infusion of wild-cherry bark ; lived on nutritious broths, 
 
ANAL FISSURE. 155 
 
 jellies, etc.; and relieved her bowels entirely by emollient 
 enemata. The fissure was touched several times with the 
 solid nitrate of silver, afterwards the solution of the same 
 was substituted. The bougie was also frequently used. 
 After pursuing this course for two weeks, and the fissure 
 having greatly improved, the hsemorrhoidal tumors were 
 then removed by ligature, and the cure completed in two 
 months from the commencement of the treatment. 
 
 Case III. — Anal fissure complicated with a small blind in- 
 ternal fistula. Tfe patient had been treated several months 
 for irritable piles, the true nature of the case not having been 
 understood by the medical attendants. 
 
 On the 10th of October, 1844, I was called to see Mr. 
 
 S. P. W , a commission merchant of Louisville, Ky., 
 
 set. 45, of a bilious and nervous temperament. This gentle- 
 man, for several months previous to consulting me, suffered 
 the most violent and agonizing pain in the anus after each 
 evacuation of the bowels; the pain coming on regularly 
 from within thirty minutes to an hour after each stool, and 
 continuing from eight to twelve hours, when it would 
 gradually, and sometimes suddenly, cease. Such was Mr. 
 
 W 's sufferings, that after having an evacuation of 
 
 his bowels in the morning, he was compelled to remain on 
 his couch all day; and the only time that he could be up 
 and attend to business at all, was in the morning, an hour or 
 two before stooling. 
 
 From the commencement of his illness, Mr. W. had sub- 
 mitted to both medical and surgical treatment; one or two 
 hsemorrhoidal excrescences at the verge of the anus had been 
 removed, with, however, no mitigation whatever of the 
 usual and regular pain. The primary disease having been 
 mistaken for haemorrhoids, was entirely overlooked by his 
 medical attendants. Mr. W. informed me that some con- 
 siderable time previous to the commencement of his present 
 suffering, he suffered from indigestion and obstinate consti- 
 
I56 ANAL FISSURE. 
 
 pation of the bowels, for the alleviation of which he had 
 taken large quantities of drastic purgative medicine, and also 
 various tonics, etc. 
 
 On examining the anus externally, I saw the remains of 
 the principal anal excrescence which had been removed, 
 situated on the posterior margin of the anus, on the left side. 
 By making firm pressure with the finger on this part, great 
 pain was experienced, and violent anal spasm was induced. 
 I also noticed that the pressure caused a slight oozing out 
 of pus at this point. Such were the pain and the rigidity of 
 the sphincter, that the attempts to evert the anus, or to in- 
 troduce the finger, were fruitless ; consequently I adminis- 
 tered an enema of warm flax-seed tea and castor oil, and 
 completely emptied the rectum, and applied to the anus 
 cloths wrung out of hot water for one hour, after which I 
 succeeded, although attended with considerable pain, in in- 
 serting my finger up to the second joint, and sensibly felt a 
 fissure running up the canal from the tender point already 
 noticed. After withdrawing the finger, I carefully intro- 
 duced a small speculum ani, which completely revealed the 
 whole extent of the fissure, which was nearly one inch in 
 length, from the centre of which I discovered a small orifice 
 from which issued a little matter. By using a hooked probe 
 I discovered that the orifice communicated with a small fistu- 
 lous cavity — quite superficial, however. The cause of Mr. 
 
 W 's suffering was now clearly explained. The fistula, 
 
 doubtless, was caused by the fissure. 
 
 The treatment consisted of enemata composed of the in- 
 fusion of flax-seed and castor oil, to relieve the bowels; the 
 daily application to the fissure of the solution of nitrate of 
 silver ; and the frequent touching of the bottom of the fis- 
 tulous cavity with the end of the bent probe, previously 
 thickly coated by being dipped in the fused nitrate of silver. 
 By this treatment this gentleman was completely cured in 
 five weeks from its commencement. 
 
ANAL FISSURE. 1 57 
 
 Case IV. — I'he author of the following letter, three months after 
 its date, was cured by me of an anal fissure of an aggravated 
 character. 
 
 " C , Ohio, June 5th, 1845. 
 
 " Dr. Bodenhamer : 
 
 " Dear Sir — Having heard that you have 
 been successful in treating diseases of the lower bowel, I 
 have taken the liberty of writing you. I have been suffer- 
 ing almost martyrdom for the last year, from a most trouble- 
 some and distressing affection of my lower bowel. I ex- 
 perience the greatest suffering while I am stooling, and 
 then it is often so severe that I am compelled to lie down 
 for several hours. At these times the burning and smarting 
 are so severe, that it appears to me it could not be any 
 worse if a red-hot iron was run into the bowel. I have 
 such a horror of stooling, that I only have a passage every 
 forty-eight hours, at night, so that I do not lose so much 
 time in the day, by lying down. I use Blue Lick water to 
 keep my bowels loose. The sore place is on the right side 
 of the anus, communicating low down, and extending, up 
 about an inch. I can feel it quite distinctly with my finger 
 the introduction of which, however, causes the most intense 
 pain. The only discharge I have noticed from the place 
 is a little matter streaked with blood. I have no doubt 
 this disease was caused by obstinate constipation, under 
 which I labored for years, and for which I have taken large 
 quantities of purgative medicines. 
 
 " The disease did not come on suddenly, but gradually. I 
 am thirty-one years of age, my health good in other respects, 
 and I am by profession a lawyer. You will now doubtless 
 wonder what I did for my complaint. I have done every- 
 thing. I have consulted the best medical men of your pro. 
 fession, and they all have disagreed with regard to my dis- 
 ease, some calling it internal fistula, some piles, some neu- 
 ralgia, and some ulceration. About six months ago I sub. 
 
I58 ANAL FISSURE. 
 
 mitted to the operation of laying all the parts open with the 
 
 knife, by Dr. of - m This operation afforded 
 
 me partial relief for about six weeks ; but I am now about 
 as bad as ever. I have lost all hope, and almost despair 
 of ever being cured. I would much rather be dead than be 
 compelled to live in this condition. Can you cure me ? 
 Can you give me any relief?" 
 
 This gentleman visited me at Louisville, Ky., on the 25th 
 of June, 1845; and upon making an examination of the 
 anus, nothing was visible but a large condyloma situated on 
 the verge of the anus, on the right side posteriorly. This 
 excrescence formed the base, and concealed the inferior ex- 
 tremity of a fissure a quarter of an inch wide, and extending 
 up the canal fully one inch. By everting the anus, almost 
 the whole of the fissure was brought into view; its surface 
 was discovered to be smooth and florid, and its edges were 
 raised and hard. The division of both sphincters of the 
 anus, to which he had submitted, was not made through the 
 fissure, but on the side in its immediate vicinity. The in- 
 cision was but partially cicatrized. 
 
 By the use of the nitrate of silver, the employment of 
 the bougie, and the removal of the condyloma with the 
 scissors, the cure was completed in eight weeks. 
 
 Case V. — Anal fissure in a little boy three years old who had ob- 
 stinate constipation of the bowels, the result of inactivity of 
 the liver induced by intermittent fever. Hypertrophy of the 
 spleen. 
 
 On the 8th of May, 1847, I was called to see Edward 
 
 S , of Louisville, Ky., set. three years and two months, 
 
 a very delicate, nervous, and excitable little boy. He was 
 emaciated, had torpid liver, no appetite, skin dry and sal- 
 low, and obstinate constipation of the bowels. The little 
 patient the year previous had an attack of intermittent 
 fever, which lasted for several weeks, and has now decided 
 
ANAL FISSURE. I59 
 
 hypertrophy of the spleen, which is very apparent through 
 the anterior abdominal wall. Suffers severe pain at each 
 evacuation of the bowels, and for a short time after, as mani- 
 fested by his sharp cries, and the strong tendency to convul- 
 sions. His stools are scybalous, and always followed by five 
 or six drops of florid blood. 
 
 On making the examination of the anal region, I found 
 the anus spasmodically contracted, and upon widely separ- 
 ating the nates and the sides of the anus, I distinctly saw, 
 at its verge, on the right side posteriorly, the inferior ex- 
 tremity of a rent having the appearance of a red line, and 
 observing a vertical direction, which upon close inspection 
 proved to be a superficial fissure of the mucous membrane. 
 This crevice was doubtless the result of a laceration induced 
 by the passage of scybala. 
 
 The little patient's bowels were daily relieved by emol- 
 lient enemata, and an occasional dose of castor-oil. He took 
 as an alterative tonic the third of a teaspoonful, three times 
 daily, of the following mixture : 
 
 Recipe, Syrupi Sarsaparillse compositi, uncias octo, 
 
 Ferri Sulphatis, grana duodecim, 
 
 Tincturas Cinchonae, unciam. 
 Fiat Mistura. 
 
 The fissure was touched once daily with the nitrate of 
 silver in solution, applied with the probe. By this treat- 
 ment the fissure was completely cicatrized in ten days, and 
 at the end of two months the little boy was almost entirely 
 restored to his wonted health. 
 
 Case VI. — Anal fissure complicated -with fistula in ano, s per ma- 
 torrhcea, and ascarides of the rectum. 
 
 Mr. W. S. T , of Greencastle, Indiana, set. 32, of a 
 
 nervous temperament, visited and consulted me at Louis- 
 ville, Ky., on the 1 6th of June, 1847. Mr. T. informed me 
 that for three or four years he suffered from indigestion 
 
l6o ANAL FISSURE. 
 
 constipation of the bowels, intolerable itching of the anus, 
 especially at night, and frequent nocturnal emissions of se- 
 men. His stools were small and hard like marbles, and 
 covered with an inspissated mucus, like skin. For the last 
 three months he says that whenever he has an evacuation 
 of his bowels, and for several hours after, he suffers the most 
 severe and agonizing pain in the anus and anal region, and 
 often accompanied by a violent and painful closure of the 
 anus; and 'that within the last six weeks an abscess formed 
 on the left side of the anus, which was lanced by his medi- 
 cal attendant, and lately pronounced to be a complete fis- 
 tula in ano. 
 
 This patient, from this complication of diseases, was very 
 much emaciated, sallow, highly nervous and excitable, as any 
 one can well imagine. Upon examination, I observed on the 
 left side of the anus the external orifice of a fistulous sinus 
 about half an inch from the verge of the anus, which com- 
 municated with the bowel between the two sphincters. In 
 attempting to introduce my finger into the anus and anal 
 canal, in order to search for the end of the probe which was 
 in the sinus, it encountered considerable difficulty from the 
 firm contraction of the sphincter muscle ; and was attended 
 by severe pain. By withdrawing the finger and everting the 
 anus, I detected a small superficial ulcer in the form of a 
 fissure at the anterior commissure of the anus, commenc- 
 ing immediately within the anal orifice, and extending up 
 about two-thirds of an inch. This patient took as a tonic 
 the muriated tincture of iron; regulated his bowels by mild 
 cathartics and emollient enemata. The fissure and the anal 
 spasm were treated by the nitrate of silver and the bougie. 
 The anal fistula was treated by the use of the ligature. Mr. 
 T.'s health at the beginning commenced improving slowly 
 but decidedly, and at the end of three months I discharged 
 him cured. I would observe that in the early part of the 
 treatment of this case, for the purpose of removing the 
 
ANAL FISSURE. l6l 
 
 chronic irritation and inflammation of the mucous mem- 
 brane of the inferior extremity of the rectum, I ordered the 
 patient to inject two tablespoonfuls of the following mix- 
 ture immediately after each fsecal dejection, and if possible 
 to be retained : — 
 
 Recipe, Balsami Copaibae, 
 
 Tincturas Opii, ana, drachmam, 
 
 Creasotis, semidrachmam, 
 
 Pulveris Acacias, semiunciam, 
 
 Aquas destillatae, uncias octo. 
 Fiat mistura secundum artem. 
 
 About two hours after the injection of the first dose of this 
 mixture, the patient felt so strong a desire to stool that he 
 could not resist it, and he passed into the chamber without 
 effort three balls of what he thought were fsecal matter, but 
 upon inspection he found them entirely composed of small 
 worms and mucus. He at once called my attention to the 
 circumstance, and upon examining the contents of the vessel 
 I found them as he had described. The worms were the 
 maw or thread-worm, — Oxyuris vermicularis of Bremser, or 
 the Ascaris vermicularis. These worms are generally found 
 en troupe in the rectum, and so covered with mucus as not 
 to be easily accessible by anthelmintics. In this instance 
 the creasote in the injection was doubtless the principal 
 agent in effecting their dislodgment. When counted by 
 the patient, he found they numbered three hundred and 
 fifty-four. • 
 
 The continued excitement and irritation of the mucous 
 membrane of the rectum produced by the presence of these 
 worms in this case, were doubtless the cause of the sperma- 
 torrhoea, and may have, been the predisposing cause of the 
 fissure and the fistula. 
 
 Case VII. Anal fissure complicated with a blind internal 
 
 fistula. 
 
 Mr. G. B. W- , a merchant of Buffalo, N. Y., set. 
 
 11 
 
l62 ANAL FISSURE. 
 
 fifty-eight, of a bilious and nervous temperament, visited 
 and consulted me at Louisville, Ky., on the 9th of May, 
 1849. He informed me that for six or seven months he has 
 suffered the most severe burning pain in the anus, commenc- 
 ing a short time after each evacuation of his bowels, and 
 continuing for several hours without intermission, and then 
 entirely subsiding until the next movement of his bowels. 
 These paroxysms of pain were often attended with violent 
 spasmodic contraction of the anus. His bowels were 
 naturally inclined to constipation, and often required the 
 most active purgative to move them. He has noticed of 
 late a slight but constant discharge of a thin matter from the 
 anus, sufficient to soil his linen; sometimes this matter was 
 mixed with blood and mucus. 
 
 Mr. W.'s general health is poor; he is quite emaciated, 
 is easily fatigued, and suffers much from weakness of the 
 back and lower extremities, especially for a few hours after 
 evacuating his bowels, when it amounts almost to complete 
 prostration. 
 
 This gentleman had been treated for ulceration of the 
 rectum by caustic applications, and a solution of the nitrate 
 of silver was used as an injection, with, however, no per- 
 manent benefit. Upon making an examination of the anus, 
 I discovered a condyloma about as large as a common size 
 pea, situated on the verge of the anus, on the right side 
 towards the front. Pressure upon this part detected consid- 
 erable hardness for some distance round, caused much pain, 
 and a discharge of pus from the anus. By the straining 
 efforts of the patient, and the everting or prolapsing of the 
 anus with the fingers, a fissure was plainly visible, commenc- 
 ing a little above the condyloma, and extending up the 
 bowel three-fourths of an inch. It was about the eighth of 
 an inch wide, with hard and everted edges, and a red, soft, 
 and spongy bottom, from which some pus was seen to be 
 issuing. This discharge of pus and the external hardness 
 
ANAL FISSURE. 163 
 
 were plain indications of a blind internal fistula. By means 
 of a bent probe, I at once found the orifice of the fistula 
 just in the track of the fissure, and near its superior extremi- 
 ty. I gave a flexible probe the proper curve, and through 
 the orifice of the fistula conducted it from above down- 
 wards and outwards, until the end could be distinctly felt 
 through the external integument, about half an inch below 
 the condyloma. At this point I made an incision upon the 
 end of the probe into the fistulous cul-de-sac, and thus con- 
 verted the blind and incomplete, into the complete fistula. 
 The diagnosis was plain. The fistula in this instance was 
 doubtless the result of the fissure. 
 
 This gentleman took tonics, regulated his liver and bow- 
 els by diet, emollient enemata, and occasional aperients 
 Daily applications of the nitrate of silver were made to the 
 fissure until the acute sensibility and the severe pain had 
 subsided, when a ligature was introduced into the fistula and 
 daily tightened until it came out, leaving but a small por- 
 tion of the fissure and fistula to cicatrize, which soon after 
 took place. Fie was dismissed cured on the 25th day of 
 June, just forty-six days after the treatment had been com- 
 menced. This patient was not confined for one moment to 
 either his room or his bed by the treatment. 
 
 Case VIII. — Highly irritable ulcer, situated in the fossa between 
 the external and internal sphincter of the anus. 
 
 Colonel J. W , of Woodford county, Kentucky, set. 
 
 sixty-seven, of phlegmatic temperament, consulted me at 
 New Orleans, Louisiana, on the sixth of April, 1850, for what 
 he called a painful affection of the lower bowel. The 
 Colonel informed me that for more than a year he has been 
 suffering most severely from a burning, throbbing, and bear- 
 ing-down pain, seemingly but a short distance above the 
 end of the bowel. The pain would come on either whilst 
 at stool or in a short time after, and continue for several 
 
164 ANAL FISSURE. 
 
 hours, often extending to the neck of the bladder, and 
 causing more or less stoppage of urine, and always at- 
 tended by a slight purulent discharge from the anus, quite 
 sufficient to soil his linen daily. His digestion and appe- 
 tite are good, and his bowels are regular, but from having 
 been robust and healthy at his time of life, this painful 
 affection has reduced him greatly in flesh, and rendered him 
 feeble, highly nervous, and excitable. 
 
 The rectum having been thoroughly emptied by a proper 
 enema, and there being no spasmodic contraction of the 
 sphincter ani, the exploration was made by the finger and 
 the speculum with ease and with but little pain. The fin- 
 ger in aiio soon detected a large, deep, and highly sensitive 
 ulcer, situated on the anterior wall of the anal canal, be- 
 tween the external and internal sphincter of the anus. The 
 sensation communicated to the finger was that of having 
 entered a considerable excavation, with a hard and rough 
 brim, and a deep and soft bottom. Upon the introduction 
 of the speculum this ulcer was fairly brought into view. 
 It proved to be of an oblong shape and somewhat larger 
 than a silver ten-cent piece ; it was of an ash color, and 
 its bottom was soft and spongy, and covered with a tena- 
 cious matter. 
 
 The ulcer was cauterized every fifth day w T ith the solid 
 nitrate of silver, and in the mean time the bowels were daily 
 moved by emollient enemata. Two tablespoonfuls of the bal- 
 samic mixture mentioned in Case vi. (page 161) was injected 
 into the rectum twice daily, first in the morning, after stool- 
 ing and dressing the ulcer, again at night, just before retiring. 
 During the treatment the Colonel was allowed a nourishing 
 diet, and the liberal use of good sherry. 
 
 By pursuing this course for six weeks the ulcer w T as 
 cicatrized, the pains had all ceased, and the Colonel had 
 greatly improved in flesh, in strength, and in spirits. 
 
ANAL FISSURE. 165 
 
 Case IX. — Irritable ulcer of the rectum simulating uterine disease, 
 and a large accumulation of hard and impacted faces in the 
 left colon, simulating a tumor in that region. 
 
 Mrs. J. D , of Oldham county, Kentucky, set. 
 
 thirty-seven, of a nervous and bilious temperament, and 
 mother of one child, consulted me on the 23d of May, 
 1850. She stated that she had been treated a long time 
 for a uterine disease, without, however, any mitigation of 
 her sufferings. She also informed me that she suffered from 
 indigestion, and sometimes from great irritability of the 
 stomach; that her bowels were obstinately constipated, often 
 not having an alvine evacuation for five or six days, and 
 then passing with great pain and much difficulty only a few 
 dry and hard balls of fsecal matter. In about thirty min- 
 utes after such an evacuation she commences to experience 
 a most intense pain in the anus, often extending into the 
 pelvis, and especially to the neck of the bladder, causing 
 ardor urina, and continuing for eight or ten hours, during 
 which she is compelled to maintain the horizontal posture. 
 No anal spasm. Mrs. D. also called my attention to an en- 
 largement of the abdomen, low down on the left side, which 
 had existed for three or four months, and which she said had 
 been pronounced an internal tumor by her physician. Upon 
 making an examination of the region indicated, I distinctly 
 felt at the sigmoid flexure of the colon a nodulated tumor 
 about the size of my fist, dull upon percussion, and the 
 parts tender upon pressure. The left colon could be felt 
 through the abdominal walls, distended with faeces. My 
 opinion therefore was that the tumor was a mass of indu- 
 rated fsecal matter, accumulated in the left colon; and to 
 test the correctness or not of this diagnosis, as well as to pre- 
 pare the patient for the exploration of the rectum, I pre- 
 scribed the following stimulating cathartic : — 
 
 Recipe, Olei Ricini, 
 
 Terebinthinze, ana, drachmas quatuor. 
 
 Misce. 
 
l66 ANAL FISSURE. 
 
 In five hours after taking this cathartic she had a consid- 
 erable evacuation of faecal matter from the bowels, but with 
 no perceptible diminution, however, of the enlargement in 
 the left side. I then administered the following valuable 
 enema, recommended by Mr. O'Bernie in such cases, 
 through an O'Bernie tube, introduced into the sigmoid flex- 
 ure of the colon : — 
 
 Recipe, Tincture Assafoetidas, drachmas duas, 
 
 Olei Olivce, 
 
 Magnesia Sulphatis, ana, uncias duas, 
 
 Olei Terebinthinae, unciam, 
 
 Infusionis Seminum Lini tepidas, octarium, 
 Misce et fiat enema secundum artem. 
 
 In fifteen minutes after the administration of this enema 
 she commenced to discharge large quantities of faecal mat- 
 ter, attended by much pain, vomiting, and prostration, so 
 much so that anodynes, stimulants, and a bandage round 
 the abdomen had to be resorted to. After a few hours, 
 however, she rallied and became quite easy. On making 
 an examination I found the tumor in the sigmoid flexure 
 had disappeared, and upon introducing my finger nearly up 
 to the second joint into the anus, which was quite relaxed, 
 I distinctly felt an ulcer, situated anteriorly in the middle 
 region of the anal canal. On inspection by means of the 
 speculum I observed a slightly excavated ulcer, of an oval 
 form and about one-fourth of an inch in diameter, with hard 
 and raised edges, soft bottom, and of a grayish appearance, 
 and exquisitely painful to the touch or pressure. 
 
 The fissure was treated by the frequent application of 
 the solid nitrate of silver, and the introduction of the fol- 
 lowing ointment on tents or pledgets of lint : — 
 
 Recipe, Pulveris Rhei, grana decern, 
 
 Opii, grana quinque, 
 
 Cerati simplicis, unciam et semissem. 
 
 Misce et fiat unguentum. 
 
 The bowels were relieved by aperients and enemata, and 
 
ANAL FISSURE. 167 
 
 she took a tonic. She was dismissed cured in two months. 
 The ulcer accounted for all her sufferings ; although not in 
 the form of fissure, and unattended by anal spasm, it was 
 nevertheless exquisitely irritable and painful. 
 
 Case X. — Anal fissure in an infant ten months old. Dentition. 
 Persistent diarrhoea, and procidentia ani. 
 
 On the 10th of April, 1852, I was called to see Harriet 
 
 T , of New Orleans, an infant at the breast, set. ten 
 
 months. This child was suffering from dentition, and 
 much debilitated by a diarrhoea, which I was informed had 
 persisted for a considerable length of time, and which resulted 
 in an obstinate procidentia ani. By the application of powerful 
 astringents by the attending physician, Dr. P , the pro- 
 lapsus rapidly disappeared; but ever since the disappear- 
 ance of the protrusion, whenever the child makes efforts to 
 relieve its bowels, it cries, screams, and struggles as if suffering 
 terrible pain. These manifestations of suffering only last while 
 the child is stooling ; immediately after, it is as quiet and as 
 calm as if nothing painful had occurred. A few drops of 
 blood follow each evacuation from the bowels. Dr. P. 
 was of opinion that the diarrhoea was becoming dysenteric 
 in character, and that it was the tenesmusofdysentery that 
 caused the cries of the child during defecation. I dissented 
 from this opinion, and suggested that an anal fissure might 
 be the cause of these manifestations ; that by the use of 
 the active astringents, the anal orifice was constantly kept 
 in a firmly contracted and unyielding state, so that at some 
 time when the child was making powerful efforts to extrude 
 the fseces, as well as the former prolapsus, a rent in the 
 mucous membrane at some point may have taken place. 
 Dr. P. observed that my suggestions were plausible and 
 worthy of consideration, but that he had never heard of an 
 infant having an anal fissure. I proposed to him to make the 
 examination, which he at once proceeded to do in the pro- 
 
i68 
 
 ANAL FISSURE. 
 
 per manner; and we soon discovered a very superficial, 
 yet very distinct fissure, marked by a faint red line at the 
 posterior part of the anaj orifice, on the right side. Whilst 
 separating the orifice with the fingers, a little thin, bloody 
 exudation took place from the posterior commissure of 
 the anus. 
 
 The child took one teaspoonful of the following prepara- 
 tion four times daily : — 
 
 Recipe, Aquas Calcis, 
 
 Lactis recentis, ana, unciam. 
 Misce. 
 
 The local treatment consisted of a few applications to the 
 fissure of the nitrate of silver in solution, by means of the 
 probe, the frequent application of cacao butter, and the daily 
 use of enemata of the infusion of linseed. The cure was 
 completed in ten days. 
 
 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. 
 
 Mr. L. F , a hardware merchant of New Orleans, 
 
 La., £et. forty-three, of a lymphatico-nervous temperament, 
 consulted me January 2d, 1853, ^ or wnat ne called a serious 
 and painful disease at the end of the bowel. He stated 
 that for two or three months past he had been suffering the 
 most agonizing pain at the end of the intestine, brought on 
 and aggravated by each movement of his bowels. The 
 pain is of that intense burning character as if a live coal of 
 fire were in the bowel, and always accompanied sooner or 
 later by violent spasm of the anus. The pain sometimes 
 comes on in the act of defecation, at other times it, together 
 with the spasmodic contraction, comes on half an hour or one 
 hour after stooling, and continues for four or five hours, 
 when it suddenly subsides. During the pain the patient 
 says he is compelled to remain in the horizontal posture. 
 
ANAL FISSURE. 169 
 
 A short time previous to the commencement of these 
 anal pains, Mr. F. had a severe bilious attack and took a 
 large quantity of drastic purgative medicine, the violent 
 action of which he belives gave rise to them, or at least had 
 something to do in the development of the disease at the 
 end of the bowel. His medical attendants treated his case 
 severally as neuralgia, internal piles, and constipation of the 
 bowels, by the use of quinine, iron, drastic purgatives, and 
 ointments. This treatment not being at all suitable to the 
 case, was, as a matter of course, anything but beneficial. 
 Mr. F., from having been, previous to this attack, stout, 
 hearty, and hale, had lost much flesh, looked pale and 
 haggard, and was quite prostrated by his long-continued 
 suffering. 
 
 About two hours after the rectum had been completely 
 cleared out by an emollient and relaxing enema, and the 
 administration of a belladonna suppository, I made, without 
 the use of an anesthetic, a thorough exploration of the anus 
 and inferior extremity of the rectum, employing both the 
 finger and the speculum; and the result of which was 
 the discovery of a long and narrow superficial ulcer, with 
 but slightly raised edges, situated on the mucous membrane, 
 at the anterior part of the anus, on the left side, its inferior 
 extremity commencing about a quarter of an inch above 
 the verge of the anus. The diagnosis was now clear. 
 
 This patient used a nourishing, but unirritating diet; 
 relieved his bowels daily by relaxing and emollient enemata, 
 and immediately after each movement of the bowels two or 
 three tablespoonfuls of the balsamic mixture mentioned in 
 Case vi. (page 161) were injected into the rectum and retained. 
 By these measures, rigidly observed, and by the daily appli- 
 cation to the fissure of the nitrate of silver in solution, and 
 the occasional use of the bougie, the cure was complete 
 in eight weeks. 
 
 What was somewhat remarkable, this gentleman, in the 
 
lyO ANAL FISSURE. 
 
 summer of 1857, was treated for and cured of a com- 
 plete fistula in ano, by me in the city of New York, 
 after he had been cured of his anal fissure more than four 
 years. What gave rise to the anal fistula could not be sat- 
 isfactorily explained. The long time that had elapsed after 
 the cure of the fissure and the appearance of the fistula, 
 would seem entirely to preclude the idea that the former 
 was the cause of the latter. I saw Mr. F. at the St. 
 Nicholas Hotel in this city last November, 1867, when he 
 informed me that he continued to remain free from both 
 the anal diseases, and that his health otherwise was never 
 as good. 
 
 Case XII. — Anal fissure attended by great flatulency, and accom- 
 panied alternately by constipation and diarrhcea. 'The true 
 nature of the case having been overlooked, it was treated 
 severally as dyspepsia, anal neuralgia, and internal piles. 
 
 Mrs. W. F , of Cincinnati, Ohio, set. twenty-four, 
 
 bilious and nervous temperament, married five years, but 
 never had children, visited and consulted me at Louisville, 
 Ky., on the 16th of August, 1853. Mrs. ^- informed me 
 that she suffered from indigestion, with constipation of the 
 bowels, alternated with diarrhcea, and about fifteen or twenty 
 minutes after each evacuation she experienced the most 
 severe pain at the end of the bowel, attended by a firm 
 contraction of the anal orifice. This agonizing suffering 
 sometimes continues for seven or eight hours, and compels 
 her to be in bed until it subsides. In this case the pain and 
 the anal spasm, as well as the time of their accession, were 
 in no manner influenced by the character of the stools, 
 whether hard, soft, or fluid. This patient was much emaci- 
 ated, highly nervous, irritable and peevish, and continually 
 annoyed and pained by flatus, especially low down in the 
 rectum. She had been treated for along time severally for 
 dyspepsia, anal neuralgia, and haemorrhoids, with; however, 
 no permanent benefit. 
 
ANAL FISSURE. 171 
 
 Upon an examination of the anus, a single condyloma, 
 about the size of a small pea, was observed at the posterior 
 verge of the anus, on the left side, and concealed by this 
 excrescence was the inferior extremity of a fissure, which, 
 when the borders of the anal orifice were drawn aside, was 
 plainly seen, and found to be a superficial ulcer, extending 
 up the canal half an inch. This lesion had a smooth, bright- 
 red surface, and slightly raised edges. On introducing the 
 finger, which caused severe suffering, a peculiar rough sen- 
 sation was imparted to the touch. 
 
 For the flatulence, and to calm the irritability of the 
 stomach and bowels, one of the following pills was taken 
 every three or four hours : — 
 
 Recipe, Extracti Hyoscyami, scrupulum, 
 
 Pulveris Ipecacuanhae, grana decern. 
 Fiat massa, in pilulas viginti dividendi. 
 
 Strict diet was enjoined, and the bowels were relieved 
 almost entirely by emollient enemata. The application to 
 the fissure daily of the nitrate of silver in solution, and the 
 occasional introduction of the bougie to dilate the anal ori- 
 fice and canal, effected a radical cure of this case in two 
 months. The excrescence diminished in size as the fissure 
 cicatrized, and gradually disappeared. 
 
 Case XIII. — Anal fissure complicated with hemorrhoids. In this 
 case the fissure, having been entirely overlooked by the previous . 
 medical attendants, was diagnosed and treated by them as 
 irritable piles. 
 
 Mr. W. H , a most estimable gentleman, and citi- 
 zen of Chambersburg, Pa., set. sixty-two, of a nervous tem- 
 perament, came under my care on the 14th of December, 
 1854. Previous to visiting me at New York, Mr. H. 
 corresponded with me in relation to his condition. The 
 following is an extract from his first letter : — 
 
1/2 ANAL FISSURE. 
 
 " Chambersburg, Pa., November 23d, 1854. 
 
 W. BODENHAMER, M.D. '. 
 
 Dear Sir : — I have been afflicted 
 for the last three months with what my physician calls the 
 piles; indeed I have been troubled with them, more or less, 
 for the past ten years, but at no period for more than a few 
 days at a time. For the last three months, however, I have 
 been rendered perfectly miserable. My bowels are regular, 
 and my passages quite natural; immediately upon rising in 
 the morning I have a passage, regular every day, but im- 
 mediately after commences a burning pain, amounting to a 
 torture, continuing for about eight hours, when it subsides 
 like a fire going out. I then have partial rest till next morn- 
 ing, when the pain again commences in the same manner 
 after stooling, so that I am quite prostrated, and am now 
 writing this in bed, unable to be up. The pain I cannot 
 describe ; it is peculiar to itself, and keeps me in bed more 
 than half the time. Please answer this communication at 
 once, and say what you can do for me, and what it will be 
 necessary for me to do myself — if I must come to New 
 York, how long it would require me to remain there — if so, 
 where had I best stay in the city, and any other information 
 it may be necessary for me to know. I am fearful that I 
 could not at present bear the journey," 
 
 I immediately replied to the above, and informed this 
 gentleman that he no doubt had piles, but in addition to that 
 disease he also had an anal fissure, the nature of which I de- 
 scribed to him, and also gave him plain instructions how he 
 or his medical attendant could without fail detect it, etc. 
 
 In a subsequent letter, dated November 28th, 1854, he 
 says : — " You have no doubt taken the correct view of my 
 case. I immediately put your valuable suggestions into 
 practice, and although attended with considerable pain, the 
 result afforded great satisfaction, as demonstrating beyond all 
 
ANAL FISSURE. 
 
 »73 
 
 doubt the true character of my disease. Upon introducing 
 the finger about half an inch, a hard point could be dis- 
 tinctly felt, which was exceedingly sensitive to the touch. 
 The severe pain >I suffered after each stool was supposed by 
 us to have been caused by the lower sphincter (as I believe 
 it is called) grasping the partially protruded piles, and 
 pressing upon them for hours afterwards. Some, however, 
 said it was neuralgia connected with the irritable piles. I 
 have fully made up my mind to place myself under your 
 care, and if I am able to travel, I will leave here about this 
 day week." 
 
 On the arrival of this gentleman I made a careful exam- 
 ination of the affected parts, and discovered a fissure, with 
 slightly raised and hard edges, situated between two hemor- 
 rhoidal tumors, and commencing immediately within the 
 anal orifice, and extending up the canal nearly one inch, 
 with a small condyloma externally forming its base. I also 
 discovered four distinct and regularly organized hsemor- 
 rhoidal tumors, neither of which, however, was very large. 
 The diagnosis in this case was now quite clear, and the 
 indications equally so. 
 
 This patient's bowels were regulated by diet and emol- 
 lient enemata; the fissure was daily touched with the strong 
 solution of the nitrate of silver, and when nearly cicatrized 
 I began to remove the hemorrhoidal tumors by ligature, 
 one by one, until they were all removed. I then removed 
 the condyloma with the knife. This gentleman was dis- 
 missed cured on the 19th of January, 18^5, having been 
 thirty-six days under treatment. 
 
 Case XIV. Anal fissure complicated with hemorrhoids and with 
 
 spermatorrhoea. 
 
 Mr. J. B. D , a notary public of New Orleans, La., 
 
 set. twenty-eight, of a nervous temperament, applied to me 
 for medical and surgical advice on the nth of April, 1855. 
 
J 74 
 
 ANAL FISSURE. 
 
 He complained of indigestion, constipation, and of a severe 
 burning pain immediately after evacuating his bowels, 
 attended by a spasmodic contraction of the anal orifice, 
 which, together with the pain, would continue for several 
 hours with intense vehemence. He also complained of 
 having frequent seminal discharges, and a general weakness 
 of the genital organs. He attributed this entirely to the 
 pain and anal spasm, as he never had anything of the kind 
 before, and never had abused the venereal pleasures. He 
 informed me that he had been suffering more or less from 
 these several complaints for eight months, and that he had 
 been treated severally for anal neuralgia, haemorrhoids, and 
 an affection of the prostate gland — the whole treatment, how- 
 ever, affording but partial relief. 
 
 Examination revealed a highly sensitive but superficial 
 fissure, half an inch long, situated on the anterior part of the 
 anus, commencing immediately within the anal orifice. 
 Two internal hemorrhoidal tumors were also discovered. 
 There was no disease of the prostate gland present, further 
 than sympathetic irritation. The spermatorrhoea was doubt- 
 less the result of the fissure. 
 
 In this case the bowels were made easy by proper enemata; 
 daily applications were made to the fissure of the solution 
 of the nitrate of silver ; the bougie was frequently used for 
 the contraction ; the hemorrhoidal tumors were removed 
 by the ligature, and the cure was speedily effected. 
 
 Case XV. — Anal fissure the result of the application of nitric 
 acid to the mucous membrane of the anal canal. 
 
 Mr. C. A. B -, of No. 16 West 23d Street, New 
 
 York, set. forty-three, of a highly irritable constitution, con- 
 sulted me on the 21st of November, 1855. Mr. B. was suf- 
 fering severely from constipation of the bowels and from 
 haemorrhoids, complicated with a prolapsus recti. 
 
 On one occasion whilst I was treating this patient, after 
 
ANAL FISSURE. 1 J$ 
 
 having freely applied the nitric acid to the protruded mucous 
 membrane, he, in forty-eight hours after, when sloughing had 
 taken place, suffered the most agonizing pain in the anus 
 after each evacuation from his bowels, accompanied with 
 violent spasmodic contraction of the external sphincter ani. 
 His suffering was so great that I was called to see him in 
 the night. Next day, on making a minute examination, a 
 small fresh ulcer, the size of a split pea, evidently caused 
 by the acid, was observed in the fossa between the two 
 sphincters, in the posterior part of the canal. 
 
 The daily application of a strong solution of the nitrate 
 of silver to the ulcer, together with the application at the 
 same time of olive oil, soon cicatrized the lesion, and entirely 
 relieved him of his suffering in six days. He had never ex- 
 perienced anything of the kind before ; neither has he since. 
 I might have said that his bowels, which were obstinately 
 constipated, were entirely relieved by enemata composed of 
 the infusion of linseed and olive oil. 
 
 Case XVI. — Anal fissure from a rupture of the mucous mem- 
 brane of the anal canal, the result of a fall upon the nates. 
 
 On the 28th of May, 1857, Mrs - S - T , of Harlem, 
 
 New York, set. forty, a large and fleshy woman, of a san- 
 guineous temperament, consulted me for a disease of the 
 anal region, from which she had suffered for about three 
 months. She said that two physicians had treated her case; 
 the first for internal and irritable piles, the second for anal 
 neuralgia. Neither of them had afforded her any perma- 
 nent relief. 
 
 In questioning her as to the origin of her anal sufferings, 
 she informed me that she believed they were connected with 
 an accident which had befallen her about three months ago. 
 Whilst in the act of descending a very steep and narrow 
 flight of stairs, when at the top, one of her feet slipped and 
 she fell violently upon the coccyx, and slid in this posi- 
 
Iy6 ANAL FISSURE. 
 
 tion to the bottom of the stairs. Three or four hours after- 
 wards she thought she had sustained no injury whatever; 
 but on the next day, when evacuating her bowels, she dis- 
 covered some clots of blood mixed with the faeces, and 
 about a tablespoonful of fresh blood was passed at the same 
 time, and immediately followed by a smarting and burning 
 pain. From that time to this she says she suffers after each 
 evacuation of the bowels the most agonizing pain, espe- 
 cially when the stools are hard ; sometimes lasting from five 
 to eight hours, and often attended with a firm and painful 
 contraction of the anus, so that nothing whatever could be 
 introduced during the spasm. 
 
 Whilst she was under the influence of chloroform I made 
 a careful examination with the speculum, and observed a 
 narrow slit in the mucous lining, about an inch and a quar- 
 ter long, commencing just within the margin of the anus, 
 at its posterior commissure, and extending up the canal 
 longitudinally. 
 
 Frequent applications of the nitrate of silver in solution 
 to the rent, a large rectal bougie introduced into the rectum 
 every other day, and the bowels regulated by enemata of 
 the infusion of linseed, entirely relieved her in two weeks. 
 
 Case XVII. — Several anal fissures complicated with numerous 
 condylomata, and with permanent contraction of the anus. 
 
 On the 6th of October, 1858,1 was consulted by Mrs. 
 
 G. W. L , of Manhattanville, New York, a married 
 
 lady, of a nervous temperament, set. thirty-five. She stated 
 that she had external piles and constipated bowels; and that 
 in a short time after stooling she invariably suffered the 
 most severe burning pain at the end of the bowel, continu- 
 ing often for three or four hours, attended with more or less 
 contraction of the anal orifice. She said that this pain and 
 contraction, together with a constant exudation of a thin 
 yellow matter from the highly sensitive tumors, together 
 
ANAL FISSURE. 1JJ 
 
 frequently with an intolerable itching, rendered her truly 
 miserable. The contraction of the anal orifice was so great 
 that she could not have a hard evacuation; nothing but 
 fluid faeces could pass. 
 
 Upon making an examination of the anus, I discovered a 
 large number of small anal excrescences around the verge of 
 the anus, and between some of these and the radiated folds 
 were seen several superficial fissures or crevices, from one- 
 quarter to one-third of an inch long, extending from below 
 the anal orifice up into the canal. Many of the excrescen- 
 ces were ulcerated at their base, and produced a permanent 
 narrowing of the anal orifice. 
 
 This lady kept her bowels in a soluble state by proper 
 regimen and by the use of enemata. The nitrate of silver, 
 both in its solid and fluid form, was daily applied to the 
 condylomata and to the fissures. Before making the appli- 
 cations the parts each time were well washed with yellow 
 soap, and afterwards well dried. Pledgets of lint saturated 
 with the following lotion were also kept constantly appli- 
 ed: — 
 
 Recipe, Pulveris Sulphatis Zinci, 
 
 Aluminis, ana, drachmas duas, 
 
 Aquas ferventis, uncias octo. 
 
 Misce et fiat lotio. 
 
 The bougie, together with a relaxing ointment, was also 
 frequently used to break up the hard contraction. The 
 result was that in a few months the anal condylomata, the 
 fissures, and the contraction were all gone, and the parts 
 had become soft and pliant, and performed their functions 
 naturally. 
 
 Case XVIII. Anal fissure complicated with an intolerable 
 
 pruritus of the anus. 
 
 Mr. E. B , of New York, a lithographer by occu- 
 pation, set. thirty-seven, of a bilious and nervous tempera- 
 
 12 
 
I78 ANAL FISSURE. 
 
 ment, consulted me on the 11th of June, 1859. ^ e stated 
 that for a number of years he had been troubled with indi- 
 gestion, flatulence, and constipation of the bowels, together 
 with an intolerable itching of the anus, which came on at 
 night after becoming warm in bed, and continued for an 
 hour or two, and which nothing would seem to appease. 
 He was in the habit of using Brandrettis Pills to relieve the 
 constipation, and various ointments and lotions for the itch- 
 ing, without any permanent benefit. For the last two 
 months, however, in addition to his other ailments he suffers 
 a most severe burning pain in the anus after each operation 
 from the bowels, lasting three or four hours ; attended at 
 first by the passage of about a teaspoonful of blood from the 
 anus. Whilst the pain continues he is unable to attend to 
 his occupation, being confined to his room and the recum- 
 bent position. In order, however, to be able to attend his 
 business, he has'.lately changed the time of defecation from 
 the morning to just before retiring to bed at night; but then 
 he loses several hours of rest in the early part of the night. 
 After the burning pain subsides the itching commences, so 
 that between the two he almost suffers martyrdom. 
 
 By making the proper exploration of the parts, I detected 
 three or four quite small and superficial fissures, both without 
 and within the anal orifice. I also found the mucous mem- 
 brane, as well as the muco-cutaneous tissue about the anal 
 orifice, in a state of chronic inflammation, and both of them 
 much thickened and indurated. The mucous membrane 
 especially, for more than an inch above the verge of the anus, 
 was thickened, dry and friable. In this case I first proscribed 
 Brandreth's Pills, and instead, the patient was enjoined to keep 
 his bowels soluble by a proper regimen and the daily use of 
 emollient enemata. I daily painted the whole diseased sur- 
 face, both within and without the anus, with the solution of 
 the nitrate of silver. The following ointment was also applied 
 to the same parts twice daily : — 
 
ANAL FISSURE. Iy9 
 
 Recipe, Hydrargyri Bichloridi, grana duo, 
 Terebinthina; Venetian, drachmam, 
 Axungie, unciam. 
 
 Fiat unguentum. 
 
 Before each application the patient bathed the external 
 parts well with the yellow soap and water. 
 
 By persistently pursuing this treatment for six weeks, 
 the patient was entirely relieved of the fissure, the pruritus, 
 and the constipation. 
 
 Case XIX. Anal fissure in an infant suffering from aphtha. 
 
 On the 20th of August, 1859, I was called to see Anna 
 
 J. P , of New York, set. thirteen months, a remark- . 
 
 ably fine, healthy looking child. The mother informed me 
 that the child for some time had had the thrush badly, which 
 was entirely confined to its mouth until lately, when it, or 
 something like it, appeared on its fundament, which she said 
 was now quite red, raw, and sore ; and that whenever the 
 child evacuated its bowels, it seemed, from its sharp cries 
 and the agitation of its body, to suffer the greatest agony. 
 A few drops of blood follow each movement of the bowels. 
 On making the examination, I found the anus firmly con- 
 tracted, and otherwise in the condition the mother had descri- 
 bed it. I also discovered two very superficial fissures or cre- 
 vices on the left side of the anus, concealed between the deli- 
 cate folds, commencing about three lines below the verge and 
 extending up into the anus above the verge about two lines. 
 
 The child was ordered a teaspoonful each of aquae calcis 
 and fresh milk mixed, three or four times daily, and the 
 following collutory was applied to the mouth with a mop 
 or brush several times daily : — 
 
 Recipe, Boratis Sodae, drachmam, 
 
 Mellis despumati, unciam, 
 
 Aquae Rosarum, uncias quatuor. 
 Misce et fiat gargarysma. 
 
i8o 
 
 ANAL FISSURE. 
 
 The fissures, and the whole inflamed and raw surface 
 about the anus, were touched every other day with the 
 solution of the nitrate of silver. The parts were frequently 
 washed with soap and water, or bathed with the decoction 
 of marshmallows. Fresh lard on lint was constantly kept 
 applied. 
 
 By this treatment the child was entirely cured in ten days. 
 
 Case XX. Anal fissure complicated with hemorrhoids and an 
 affection of the prostate gland. 
 
 At the request of Mr. R. S. H , of Alleghany 
 
 City, Pa., I visited him at his residence on the 6th of May, 
 i860. He informed me that for several months he had 
 been suffering the most agonizing pain after each movement 
 of his bowels, attended by violent contractions of the anus. 
 He described the pain as being of an intense burning and 
 lancinating character ; that it always commenced from ten 
 to thirty minutes after stooling, and continued from eight 
 to ten, and often to twelve hours without intermission. The 
 pain sometimes extended to the neck of the bladder, 
 and caused more or less retention of urine. What was 
 more remarkable in Mr. H.'s case, he could not lie down 
 during the pain without greatly aggravating it, and, even 
 in the absence of the pain, the horizontal position would at 
 once reproduce it ; consequently he could only sleep whilst 
 sitting on a hard-bottomed chair. During the pain he was 
 alternately sitting on a chair, or walking about the room in 
 the greatest agony. He told me he had not slept in a bed 
 for a number of weeks, as the horizontal posture was most 
 certain to bring on a paroxysm of pain ; indeed, coughing, 
 sneezing, urinating, or any sudden or violent movement 
 would cause a recurrence of the same. His bowels were 
 obstinately constipated, but his appetite, his digestion, and 
 his health otherwise were good. He was much emaciated 
 as. well as prostrated, and had that peculiar sharp expression 
 
ANAL FISSURE. l8l 
 
 indicative of long-continued suffering. Mr. H. is fifty 
 years of age. 
 
 In a short time after the rectum had been completely 
 emptied by a relaxing enema, I proceeded to make the 
 examination. The first thing that attracted my attention 
 externally was the singular appearance of the anus itself, 
 which was so retracted or drawn up that it was almost 
 out of sight; the next was a condyloma, about the 
 size of a filbert, on the left side of the anus posteriorly. I 
 also detected a small internal pile tumor on the same side 
 anteriorly. Upon examining the interior of the canal with 
 the finger as well as with the speculum, I detected an ulcer, 
 two-thirds of an inch long and a quarter of an inch wide, 
 just above the condyloma. Its edges were considerably 
 raised and indurated, and the bottom soft and of a grayish 
 appearance, and exquisitely painful to the touch. There 
 was also discovered a considerable chronic engorgement or 
 enlargement of the third or middle lobe of the prostate 
 gland, which was very tender upon pressure. 
 
 Under these circumstances, I advised Mr. H. to visit me 
 at New York at once, if possible, and after recommending 
 some palliative measures to be observed by him in the 
 mean time, I left. 
 
 On the 12th of May, i860, just six days after my visit 
 to him, Mr. H. came to New York, when I at once com- 
 menced the radical treatment of his case. His bowels were 
 regulated by diet and by emollient enemata. Every morn- 
 ing, immediately after the rectum was emptied by the enema, 
 twotablespoonfuls of the balsamic mixture mentioned in Case 
 vi. (page 161) were injected into the bowel, and retained. 
 The fissure was at first touched every other day with the solid 
 nitrate of silver ; occasionally, however, the acid nitrate of 
 mercury was applied instead. After pursuing this treatment 
 for about twelve days, Mr. H. could sleep in the horizontal 
 posture, which was the first indication he experienced of a 
 
l82 ANAL FISSURE. 
 
 most decided improvement. After this the nitrate of silver 
 was daily applied, in the form of solution, to the fissure, and 
 the frequent introduction of the bougie was adopted to 
 overcome the contraction, which still remained very trouble- 
 some and annoying, as it interfered greatly with defecation. 
 In the mean time the condyloma and the hemorrhoidal 
 tumor were removed by the ligature. Mr. H. continued 
 to improve gradually until the 7th of August, when I dis- 
 missed him cured. For three or four months after he left, 
 he was occasionally troubled with the contraction and slight 
 twinges of pain, which, however, he always relieved himself 
 of by the use of the bougie. 
 
 This gentleman was told by several surgeons, both before 
 and after I commenced treating his case, that he never 
 would be cured of his fissure unless the anal sphincters 
 were divided according to the operation of M. Boyer. I 
 had the pleasure of seeing Mr. H. in this city last Decem- 
 ber, 1867, when he informed me that he still remained 
 entirely free from his anal fissure and contraction, now more 
 than seven years since he was cured. 
 
 Case XXI. — Anal fissure complicated with hemorrhoidal tumors, 
 the fissure situated between two of them. 
 
 Mr. G. A. B , a glass manufacturer of Pittsburg, 
 
 Pa., set. forty, of a sanguine and nervous temperament, con- 
 sulted me on the 11th of December, 1861, for what he said 
 his physician called irritable and painful piles. He informed 
 me that he suffered the most intense pain after each move- 
 ment of the bowels, attended by a rigid spasmodic contrac- 
 tion of the anus. In stooling, a large protrusion would 
 take place on the left side of the anus, which he was always 
 compelled, although attended with severe pain, to replace 
 as soon as possible or suffer the consequence — a prolonged 
 agony. 
 
 Gn making the examination I discovered two large 
 
ANAL FISSURE. 183 
 
 hemorrhoidal tumors on the left side of the anus, and be- 
 tween them a fissure nearly an inch long. 
 
 The bowels were relieved by aperients and emollient ene- 
 mata, the fissure was daily touched with the nitrate of silver 
 in solution, and the tumors were removed by the ligature. 
 A complete cure was effected in four weeks, the patient 
 at no time during the treatment being compelled to remain 
 in his room or his bed for a moment on account of it. 
 
 Case XXII. — Anal fissure caused by chronic irritation of the mu- 
 cous membrane and muco-cutaneous coat of the anus. Error 
 in diagnosis and failure to afford relief by previous treatment. 
 
 The Rev. Dr. P , of Pittsburg, Pa., consulted me 
 
 January 31st, 1862, for a very painful affection of the anus, 
 from which he had been suffering severely for several months, 
 and which almost completely disqualified him from attending 
 to his clerical duties as pastor of a large congregation, as well 
 as those of professor in a theological college. Although 
 two or three physicians had in the mean time examined and 
 treated his case, they afforded him no permanent relief, in- 
 asmuch as they failed to detect the real disease, and conse- 
 quently failed to establish the true diagnosis of the case. 
 As well as I now recollect, the case was treated as neuralgia 
 of the anus or inferior extremity of the rectum. 
 
 The Doctor informed me that he was much troubled with 
 indigestion and constipation of the bowels, and that for the 
 last two or three months, in a few minutes after each fsecal 
 dejection, he experienced the most severe and excruciating 
 pain in the anus and anal region, of a sharp and burning 
 character, accompanied often with a rigid contraction of the 
 anal orifice. These sufferings would continue for several 
 hours, often confining him, during their continuance, to his 
 room and his couch, when they would gradually or suddenly 
 subside, to be again renewed after the next fsecal evacuation. 
 
 After having heard him describe his sufferings, I at once 
 
184 ANAL FISSURE. 
 
 informed him that he had an anal fissure, and that I would 
 demonstrate it ocularly. I requested the Doctor to empty 
 the rectum thoroughly on the following morning by an ene- 
 ma composed of the infusion of linseed and castor oil, and 
 that I would call at his residence afterwards and make a 
 minute physical exploration of the rectum and anus. 
 
 The rectum having been cleared out, I carefully intro- 
 duced my small bivalve speculum into the anus and anal 
 canal, and gradually expanded the blades to their full extent, 
 when I at once detected, in the posterior portion of the anus, 
 a long narrow superficial ulcer, of a bright-red color, com- 
 mencing just within the anal orifice, and extending up the 
 canal about two-thirds of an inch. The inferior extremity 
 of the fissure terminated in a small condyloma at the verge 
 of the anus, which, together with the longitudinal folds of 
 the canal, completely concealed it, until it Was brought into 
 view by the folds being made tense by the expansion of the 
 blades of the speculum. I also observed that there was 
 considerable chronic inflammation and thickening of the 
 mucous membrane and muco-cutaneous coat of the anus, 
 which was doubtless the cause of the fissure. No anaesthet- 
 ic was employed in making this examination. The diag- 
 nosis of this case was now quite clear. 
 
 The treatment consisted in the dailv exoneration of the 
 bowels by enemata of the infusion of linseed; the daily 
 application to the fissure and inflamed surface of the nitrate 
 of silver in solution. The patient took a mild tonic, ob- 
 served an unirritating diet, and daily took moderate exer- 
 cise in the open air. 
 
 By this treatment the cure was completed in four weeks. 
 
 Case XXIII. — Anal fissure in a nursing mother who was suf- 
 fering severely from aphtha. 
 
 Mrs. F , of W , N. Y., mother of two children 
 
ANAL FISSURE. 185 
 
 and nursing the last, applied to me on the 2d of April, 1862. 
 She complained of indigestion, constipation of the bowels, 
 acidity of the stomach, flatulence, and canker sores of the 
 gums and inside of the lips and cheeks, with a constant and 
 copious flow of saliva. She says she has piles, and loses a 
 great deal of blood at each evacuation of the bowels, so much 
 so that she is quite anaemic; she also says that each time 
 the bowels are moved she suffers the most severe burning 
 pain at the anus, extending up the sacrum to the loins, 
 frequently accompanied by anal spasm, and lasting from one 
 to five hours. Paroxysms of these pains are frequently 
 brought on by the passage of flatus from the anus, which is 
 her constant dread and torment; coughing, sneezing, urina- 
 ting, and singing loud, also induce or aggravate the pain. 
 
 I at once intimated to her that she had anal fissures or 
 ulcers, similar in character to those of her mouth, which 
 upon examination proved to be true. 
 
 I applied the strong solution of the nitrate of silver freely, 
 once daily, to the sores of the mouth, as well as to the fis- 
 sures and sores of the anus. She took regularly the bismuth 
 powder mentioned in another part of this work (page 117) ; 
 lived on plain and simple diet, and regulated her bowels by 
 mild aperients and emollient enemata; and in the course 
 of a month she was entirely cured. 
 
 The same patient consulted me again in the fall of 1865 
 for the same affection — in a worse form, however. She was 
 again nursing as before. Leaving in a short time, she was 
 only partially relieved by the same treatment. I have not 
 heard from her since, and do not know the result of her case. 
 
 Case XXIV. — Anal fissure complicated with hemorrhoids , and 
 
 with an anal Jls tula. 
 
 At the request of His Excellency , Governor of 
 
 , I visited him professionally at his residence at 
 
 on the 17th of May, 1862. I found the Governor much 
 
1 86 ANAL FISSURE. 
 
 prostrated, quite emaciated, and highly nervous and excita- 
 ble, suffering from a complication of diseases, any one of 
 which would have been quite sufficient, of itself, to have 
 prostrated any person, not of an extraordinarily strong con- 
 stitution. I also observed that in his official capacity as 
 Governor, he was overtasking his brain by attempting to do 
 the mental work of half a dozen men, it being just then in 
 the midst of the terrible civil war which was desolating our 
 country. 
 
 The Governor informed me that he had suffered more or 
 less from piles for a number of years, but that from the labors 
 and fatigues of the exciting political canvass in which he 
 was engaged during the summer and fall of ] 860, they had 
 become greatly aggravated. Ever since then they appear 
 to have gradually changed their character, so that now, after 
 each movement of the bowels, the tumors are returned with 
 much greater difficulty and pain, and in a short time after 
 they are returned, he suffers the most intolerable acute and 
 burning pain in the anus, continuing for five or six hours 
 without intermission, and frequently attended by paroxysms 
 of violent anal contraction. There is constantly more or 
 less discharge from the anus of mucus and matter, some- 
 times mixed with blood. 
 
 After the rectum had been thoroughly emptied by an 
 enema of the infusion of linseed and castor oil, and before 
 the protruded parts were returned, I made a careful ex- 
 amination, and found four large hemorrhoidal tumors pro- 
 truding, and between two of these, at the posterior part of 
 the anus, I detected a fissure the eighth of an inch wide, 
 commencing at the verge of the anus, and extending up 
 the canal nearly an inch. The surface of the ulcer was 
 florid and its edges were raised and hard. I also discovered 
 the external orifice of a small anal fistula, situated on the 
 left side of the anus posteriorly. Upon probing the fistula, 
 I found it communicated with the bowel. 
 
ANAL FISSURE. 1 87 
 
 In this instance the fissure was doubtless the result of a 
 laceration of the mucous membrane produced at some time 
 during the forcible expulsion of indurated faeces, and the 
 fistula, the result of the continued and combined irritation 
 kept up in the parts by both the haemorrhoids and the fissure. 
 
 The anal fissure was cured in about three or four weeks 
 by my son, Dr. W. H. Bodenhamer, who remained with the 
 Governor in his house. The ulcer was daily touched with 
 the nitrate of silver in some form or other, and the bowels 
 were almost entirely relieved by emollient enemata. 
 
 Subsequently to the cicatrization of the fissure, the Gov- 
 ernor visited me at New York, where I cured the anal fistula 
 by the use of the ligature, and removed the hemorrhoidal 
 tumors by the use of the same means. I have just had the 
 pleasure of a call (this 17th day of June, 1868), from my 
 friend Ex-Governor , who I am happy to say is en- 
 tirely well. He says that he remains entirely free from all 
 his anal affections; that the cure is complete and radical, 
 being now six years since I dismissed him well. 
 
 Case XXV. — Fissures and aphthous abrasions and ulcerations 
 of the anus, in connection with nurses' sore mouth. 
 
 On the 16th of July, 1863, I was called to see Mrs. G. 
 
 R , of New York, set. thirty-eight, mother of several 
 
 children and nursing the last one. I found her suffering from 
 indigestion, frequent sour eructations from the stomach, 
 abrasions of the lips, fissures of the tongue as well as of 
 the anus, and general relaxation. 
 
 On making an anal examination, I discovered a number 
 of superficial fissures and ulcers, both immediately without 
 and within the anal orifice, which were of a bright-red color 
 and highly sensitive to the touch ; and from which she suf- 
 fered the most intense burning pain whenever she evacuated 
 her bowels. The pain would sometimes continue three or 
 four hours, and often attended by firm contraction of the 
 
i88 
 
 ANAL FISSURE. 
 
 anal sphincters. She informed me that she suffered severely 
 from haemorrhoids, but only during pregnancy; and that 
 she always had a sore mouth whilst nursing, but never before 
 suffered from pain at the anus, neither at the time of, nor 
 after evacuating her bowels. 
 
 The treatment of this case was in every respect similar to 
 that of Case xxiii. ; and a complete cure w T as effected in four 
 weeks. 
 
 Case XXVI. — Anal fissure following the ligation and sloughing 
 
 of a hemorrhoidal tumor. 
 
 Mr. H. McC , of Harrisburg, Pa, set. thirty-five, of a 
 
 bilious temperament, consulted me in May, 1864, for a 
 haemorrhoidal affection. On the sixth or seventh day after 
 ligating the last tumor, a quite large one, it became detached 
 during the severe straining efforts at evacuating hard feces, 
 causing at the time a little haemorrhage and considerable 
 burning pain. On the next and subsequent evacuations 
 the burning pain was extreme, and attended with spasmodic 
 contraction of the anus, thereby greatly increasing the pain 
 and making it almost unbearable. Upon examination, I 
 discovered on the left side of the anus, about four lines 
 above its margin, a small oval and angry-looking ulcer at 
 the spot where a portion of slough had become detached. 
 
 A few applications of the nitrate of silver to the ulcer, 
 and dilatation of the sphincters of the anus, relieved him 
 entirely in three days. 
 
 Case XXVII. — Anal fissure in a patient with albuminous urine, 
 whose general health was much impaired. 
 
 E. L , of New York, an Irish servant girl, set. twen- 
 ty-one, very pale, thin, and much impaired in health, con- 
 sulted me on the 20th of May, 1 865. She is very nervous, 
 has a morbid appetite, obstinate constipation of the bowels, 
 constant distressing flatulence, and irregular and scanty cata- 
 
ANAL FISSURE. 189 
 
 menia. About half an hour after each movement of the 
 bowels she says she suffers the most dreadful pains at the 
 fundament, which continue without intermission for several 
 hours, and then subside, to be renewed on the next faecal 
 dejection. She also loses a large amount of blood at each 
 alvine evacuation, but says she has never discovered any 
 tumors. 
 
 An examination disclosed two anal fissures — one in front, 
 and one on the right side of the anal orifice — both extending 
 some considerable distance up the canal. From her appear- 
 ance and general ill health I was induced to examine the 
 urine, and found it albuminous. The condition of this poor 
 girl was anything but flattering, yet in the course of four 
 months her general health was restored ; and long before she 
 had been entirely relieved of her fissures, without either cut- 
 ting or forcible dilatation, for no prudent or educated sur- 
 geon would, in her condition, have performed either opera- 
 tion. 
 
 The bowels were regulated by diet, mild aperients, and 
 enemata, and she took as a tonic twenty drops of the follow- 
 ing solution, three times daily, in an infusion of quassia : — 
 
 Recipe, Citratis Ferri, drachmas duas, 
 
 Sulphatis Quiniae, semi drachmam, 
 
 Acidi Citrici, grana viginti, 
 
 Aquae destillatae, unciam. 
 Fiat solutio. 
 
 Her diet was nourishing, consisting of roast beef, beef- 
 steak, mutton chops, &c. The fissures were treated by 
 the daily application of the solution of nitrate of silver, 
 and were entirely cicatrized at the end of four weeks. The 
 hsemorrhage proceeded from the anterior fissure, and gradu- 
 ally ceased as the healing progressed. This patient improv- 
 ed rapidly, she gained flesh and strength, and her face lost 
 its pallor, by arresting the hsemorrhage, by the use of the 
 nourishing diet and the citrate of iron. 
 
190 ANAL FISSURE. 
 
 When from any cause the operation of incising the 
 mucous membrane, of dividing the anal sphincters, or of 
 forcible dilatation, is contra-indicated, the method of topical 
 applications, as recommended in this work, especially 
 becomes invaluable. 
 
 Case XXVIII. — Anal fissure the result of obstinate constipation 
 of the bowels, and the passage of scybalous faces. 
 
 Mrs. B , of Flushing, N. Y., set. thirty-three, mother 
 
 of one child eight years old, of a bilious and nervous tempera- 
 ment, consulted me on the 10th of September, 1866, by the 
 advice of my excellent and good friend Dr. J. F. Gray, 
 to whom I am greatly indebted for many favors of this 
 kind. Mrs. B. informed me that she has suffered from 
 obstinate costiveness from her earliest recollection, otherwise 
 her health was good, until, within the last year or six months, 
 she commenced to suffer the most agonizing pain in the 
 anal region a short time after each evacuation of the bowels, 
 attended by a firm and violent contraction of the anus. 
 The pain and the contraction on some days would continue 
 as long as six or ten hours, confining her during the time 
 to her bed or couch. It was supposed she was suffering 
 from haemorrhoids. 
 
 On making an examination, I observed a condyloma 
 about the size of a large pea at the posterior verge of the 
 anus on the left side, and on drawing down the borders of 
 the anal orifice, I plainly saw the inferior extremity of a 
 superficial fissure concealed by the condyloma. Upon 
 using the finger and speculum, which was attended with 
 severe pain, no anaesthetic having been employed, I found 
 the fissure extending up the canal about three-fourths of an 
 inch, having a bright-red and raw surface, and slightly 
 raised edges. 
 
 The treatment of this case consisted in the regulation of 
 the bowels by a mild aperient, and by the daily use of an 
 
ANAL FISSURE. I9I 
 
 emollient enema ; by the frequent application to the fissure 
 of the strong solution of the nitrate of silver, and by the 
 occasional use of the bougie. By this course a rapid im- 
 provement soon took place ; but on several occasions, when 
 it was supposed the fissure was cicatrized and entirely well, 
 an evacuation of hard fsecal matter would open the fissure 
 and reproduce the pains ; so that the treatment was unusu- 
 ally protracted, and causing great discouragement. The 
 regulation of the bowels, and a few applications to the fis- 
 sure, however, always promptly relieved the pain. It is now 
 nearly a year since any pain has been experienced, although 
 on several occasions hard evacuations have taken place, so 
 that Mrs. B. considers she is permanently cured. 
 
 » 
 Case XXIX. — Irritable ulcer situated in the fossa between the 
 external and internal sphincter of the anus. 
 
 Mr. Van N , of New York, a student of Bellevue 
 
 Medical College, set. thirty-one, of an atrabilious tempera- 
 ment, consulted me on the 26th of November, 1866, for 
 what he believed either neuralgia of the inferior extremity 
 of the rectum, or anal fissure. Mr. Van N.'s general health 
 is good, but he suffers from indigestion and constipation of 
 the bowels. A short time after each evacuation of the 
 bowels, he experiences the most intense burning pain some 
 little distance above the anal orifice, attended occasionally 
 by a slight spasm of the anus, and by a small purulent dis- 
 charge. This pain on some days, especially when he has 
 very hard stools, will continue for five or six hours after 
 having such an alvine dejection. 
 
 On making an inspection of the parts, I discovered a por- 
 tion of the verge of the anus, on the left side posteriorly, 
 to be red, swollen, and everted, and on introducing the right 
 index finger into the anus a little above the second joint, I 
 could distinctly feel a large excavated and highly sensitive 
 ulcer, with hardened edges and soft bottom, situated on the 
 
1'9 2 ANAL FISSURE. 
 
 posterior portion of the canal, in the fossa between the two 
 anal sphincters. By the use of my small speculum, I discover- 
 ed the ulcer to be about the size of an American silver ten- 
 cent piece, of a grayish appearance, with elevated edges and 
 soft and spongy bottom, answering the exact description of 
 certain ulcers in this locality given by Mr. Colles, and men- 
 tioned in another part of this work. 
 
 The treatment in this case consisted in moving the bowels 
 by emollient enemata, the daily application to the ulcer, 
 made visible by the speculum, of a saturated solution of the 
 nitrate of silver. By this treatment a cure was effected in 
 three weeks. The peculiar laxity and lip-like protrusion of 
 the external margin of the anus in this case, gradually dis- 
 appeared as the ulcej above it became healed. 
 
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 By R. B. Todd, M.D. Vol. 1. Art. Contractility, p. 719. 
 
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ANAL FISSURE. I93 
 
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I96 ANAL FISSURE. 
 
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 de charpie et de preparations de belladone. In Nouveau 
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 1827. 
 
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 by F. Brittan, M.D. p. 429. Philadelphia, 1851. 
 
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 W. B. Costello, M.D. Vol. I. Art. Anus, p. 341. London, 
 1841. 
 
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 No. 132. Annee 1826. 
 
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 the Rectum, p. 3. London, 1833. 
 
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 inburgh, 1852. 
 
ANAL FISSURE. 1 97 
 
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 secours de l'incision ni de la cauterisation. In Revue 
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 T. Johnson. Chap. LXIII. p. 954. London, 1634. 
 Folio. 
 
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I98 ANAL FISSURE. 
 
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 Riverius (Lazarus). The Practice of Physic. Book X. 
 
 chap. 11, p. 316. London, 1658, Folio. 
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 Chirurgicale. Ouatrieme edition. Tome III. p. 634. 
 
 Paris, 1844. 
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 of the Rectum ; its Varieties, Diagnosis, and Treatment. 
 
 In British Medical Journal, May 12, i860. P. 356. 
 
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 Rectum. Fourth edition, pp. 70, 180. London, 1833. 
 
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 co-Chirurgicale. Quatrieme edition. Tome III. p. 
 634. Paris, 1844. 
 
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 November, 1845. P* 21 7* 
 
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 Smith (Henry H.). A System of Operative Surgery. Vol. 
 II. p. 330. Philadelphia, 1856. 
 
 Syme (James). On Diseases of the Rectum. Third edi- 
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ANAL FISSURE. I99 
 
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 Van Buren (W. H.). Certain Points in the Treatment of 
 Diseases of the Rectum. Read before the New York 
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 American Medical Times. Vol. VIII. p. 218. New 
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 Velpeau (Alf. L. M.). Dictionnaire de Medecine. Deuxi* 
 erne edition. Tome III. p. 300. Paris, 1833. Also, 
 Mott's Velpeau, Vol. III. p. 1108. New York, 1847. 
 
 V 1 vent. Dissertation sur la Fissure a l'Anus. These de 
 Paris, No. 132. Annee 1830. 
 
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By the same Author. 
 
 A PRACTICAL TREATISE ON THE 
 AETIOLOGY, PATHOLOGY, AND TREATMENT OE THE 
 
 Congenital Malformations of the Rectum and Anus. 
 
 In One very handsome Octavo Volume of 368 Pages. Illustrated by Sixteen Superb 
 
 Lithographic Plates. 
 
 Bound in Extra Cloth, $4.00. 
 
 William Wood & Co., 61 Walker Street, New York. 
 
 NOTICES OF THE MEDICAL PRESS. 
 
 " This work constitutes one of the most complete monographs with which we are 
 acquainted. In it we have collected, and apparently with accuracy, no less than 
 287 cases from every available source, and also a review of both the medical 
 and surgical treatment in full from the earliest times, with all the improvements 
 down to the present time." 
 
 " The materials collected and introduced into the work are well digested, with full 
 and particular references to their sources ; and in the relation of the various cases, 
 the remarks of the original writers are given in connection with them. The volume 
 is well illustrated by 16 plates, each containing several drawings. Altogether, the 
 book is a complete and valuable compendium on the subject up to the time of its 
 publication, and a monument of industry and patience." — British and Foreign Medico- 
 chirurgical Review. 
 
 " This is a most complete and valuable work, treating in an exhaustive style of a 
 class of affections on which no complete systematic or practical treatise has hitherto 
 been published.- A copious bibliographical index is given, and on the whole the 
 treatise is most complete, ranging throughout almost the whole literature of the 
 subject, and nearly exhausting all that is to be said on it in the present state of our 
 knowledge." " The subject is one well worthy of the labor Dr. Bodenhamer 
 has bestowed upon it, and worthily has he worked it out." — Dublin Journal of 
 Medical Science. 
 
 " The style of this author is concise and agreeable, and his subject interesting; 
 his work will well repay perusal, although its immediate study may not be required. 
 Unfortunately it belongs to that class of books which a physician, having no cases 
 of the kind to treat, feels indifferent in possessing, and scarcely willing to admit as 
 necessary. It shows itself forth, however, in bold relief, as one of the most impor- 
 tant and useful, when he is called to operate on some unfortunate child thrown 
 suddenly in his charge. Glad of the opportunity of examining its valuable pages, 
 he will then agree with us on its extreme utility, and in considering that no medi- 
 cal library can be called complete without it. It is a large octavo of upwards of 300 
 pages, Med with beautiful lithographs ; and, besides, separate and distinct treatises 
 on the different species of malformation and their treatment, containing, in elucida- 
 tion of the subject, upwards of 200 cases, gathered from every reliable source, 
 classified and tabulated. By these we find that of 156 on which operations have 
 been performed, 87 have recovered : this is encouraging, for of 42 for which nothing 
 had been done, all but 12 succumbed. Finally, 50 pages are devoted to the differ- 
 ent modes of performing the operation for abdominal artificial anus, which are plain- 
 ly illustrated by lithographs.''' — Canada Lancet. {Montreal.) 
 
 " To the practitioner who desires to be prepared for every emergency, we 
 commend this volume as an indispensable addition to his library." — American 
 Medical Times. 
 
 " This is a most valuable monograph on subjects on which little knowledge is to 
 be derived from our surgical books. The author appears to have fully elaborated 
 
Notices of the Medical Press Continued. 
 
 and exhausted the subject, having collected from all sources nearly three hundred 
 cases, and illustrated the most remarkable by sixteen plates, which are well exe- 
 cuted, and render the volume an attractive and useful one." — American Medical 
 Gazette. 
 
 " This is an opportune and valuable addition to the means of acquiring a know- 
 ledge of the diseases of the rectum, which the excellent works of Ashton, Quain, 
 Syme, Bushe, and Copeland have so clearly and fully furnished to English and Ameri- 
 can readers. As a practical monograph it is not inferior to either of these, so far as 
 relates to its particular department of the subject ; while it surpasses them all 
 in completeness and extent of illustration, and in the facilities afforded to the student 
 for the purpose of further investigation. The work is no empty compilation, since 
 the author's views are clearly and precisely given upon all practical points, and 
 many useful practical details are pointed out, in a manner which shows them to be 
 the product of much especial thought and observation as well as practical skill and 
 intelligence." — American Journal of the Medical Sciences. 
 
 " The work before us is one that cannot fail to interest all diligent inquirers in 
 the ranks of the medical profession, at the same time that it will add much to the 
 reputation of one of its laborious members. Asa monograph it may be taken 
 almost as a model ; while the subject is one upon which the profession were little 
 enlightened, its literature being principally scattered through the published transac- 
 tions of various medical societies, or appearing in isolated cases reported in various 
 medical journals." 
 
 " In conclusion, we would merely say that the volume which Dr. Bodenhamer has 
 given to the profession is most creditable to himself and to the profession in this 
 country ; and must be considered by far the most valuable, if not the only text-book 
 on this subject." — Boston Medical and Surgical Journal. 
 
 " "We give this work of Dr. Bodenhamers a cordial welcome to our table, both on 
 account of the intrinsic value of the work itself, and our esteem and friendship for 
 the author, who has labored hard, but successfully, for many years in this branch of 
 medical science." 
 
 u The work is unique, being the only complete, systematic, and practical treatise 
 upon the subject ever published. It contains, in addition to his own vast experi- 
 ence, the productions and contributions — to the literature of this subject — of all the 
 eminent surgeons of Europe and America; — thus collecting and combining, in a 
 compact and condensed form, what has heretofore been scattered over the two 
 hemispheres, in brief and detached articles, memoirs, and essays, as presented 
 in the transactions of medical societies ; in brief monographs ; in different periodi- 
 cals. &c." 
 
 " Dr. B. has devoted an immense amount of labor and time in the production of 
 this invaluable work, for which he richly merits the thanks and the gratitude of 
 the entire medical profession." — Eclectic Medical Journal. 
 
 " Congenital vices of conformation constitute many of the most unfortunate dis- 
 orders to which the human frame is liable. Some of them are incurable, either 
 causing early death, or allowing life to be prolonged in suffering and deformity 
 (Spina Bifida, Exstrophy of the Bladder, Deformities of the Limbs, Phocomele, (fee). 
 Others are curable, but demand for their relief the highest resources of the medical 
 art (Hernia, Cleft Palate, Hare Lip, Club Fool). The congenital malformations of 
 the rectum and anus include representatives of both these classes. Although of not 
 infrequent occurrence, they are not sufficiently numerous to permit the general 
 possession of experience in their management among practitioners ; so that a practi- 
 cal treatise on the subject, embodying the requisite details of diagnosis and treat- 
 ment is of great value to the profession. The able work of Dr. Bodenhamer before 
 us has this merit: It is concise, full, and practical; and in addition to this claim, 
 possesses that of being the only complete and practical work on congenital malfor- 
 mations of the rectum and anus which has ever been published in this, or in any 
 other country." — Berkshire Medical Journal. 
 
 " This able work of Dr. Bodenhamer will be welcomed by the profession, as filling 
 a void which has heretofore existed, and as presenting the opinions and' reports of 
 cases that have been made through journals, reports of medical societies, or pub- 
 lished as monographs, and were beyond the reach of the mass of the profession." — 
 Journal of Rational Medicine. 
 
 " We cordially recommend this work to the profession." — Savannah Journal of 
 
 " Is the most complete work of the kind that has ever been published." — Medical 
 Journal of North Carolina. 
 

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