Fissure of the Anus.

Selected writings of A. Jackson Howe.

Though a surgeon and surgically inclined, Professor Howe favored the application of salicylic acid ointment in many rectal troubles, rather than a resort to operative measures. It was the belief of Dr. Howe that fistula in ano and related rectal lesions occurred oftenest in those of a tubercular diathesis, even though the latter was not detectable at the time. Hence the frequent injunction in such cases to give Fowler's solution of arsenic as an adjunct to treatment—for this was one of his favorite medicines for tuberculous subjects. The flight of time is made apparent in this paper by the reference to the application of Coca as a local anesthetic. Only the previous year had a medical student—Karl Roller—demonstrated the practical value of the alkaloid of coca, which Gardeke had discovered in 1855 and named "erythroxyline," but which was later named by Albert Niemann "cocaine." That it was distinctly a local anesthetic had been noted in 1862 by Moreno y Maiz, and in 1880 by Von Anrep, yet the feasibility of using it generally for local anesthesia was left for Roller to impress upon the astonished but almost unbelieving medical world. Hence the careful and tentative use of coca, as advised in this article, though it possesses but the feeblest of anesthetic powers. Now we rely upon cocaine as the best local anesthetic and one which has proved a blessing to the afflicted and a curse to those who abuse it.—Ed. Gleaner.

FISSURE OF THE ANUS.—At the posterior commissure of the anus, by the side of a pile tumor, a fissure forms, and the defect renders the sufferer utterly miserable.

The difficulty is encountered in middle life, and in both sexes. Possibly it comes from constitutional syphilis and eczema. Constipation favors a localization of the systemic taint. The greatest distress is experienced when an effort is made to evacuate the bowels. As soon as the anal sphincter is pressed upon and forced to dilate, the elongated, irritable, and indurated ulcer causes a reflex action which takes away the ability to strain, and sends a sickening sensation through the entire body. The patient may have no rational idea of what the disease should be called. He may think he has piles, and be treated for hemorrhoids, yet no benefit will be obtained. If a surgeon be consulted he will place the patient on the abdomen and expose the anus in a good light. He will then part the nates with his hands and ask the afflicted individual to strain as if to expel flatus. The pressure will protude the anus to the extent that the lower end of the fissure can be seen. The other extremity of the morbid furrow reaches to a point just within the sphincters. It appears like a raw sulcus with hard borders. A small quantity of blood and pus may be seen, though the fissure is often dry or free from pumlency. A thorough exploration of the difficulty can not be executed unless the patient be under the influence of an anaesthetic. The application of a solution of Coca might deaden sensation to the extent that the anus could be turned outward or manipulated without pain. But, as I am about to advise a course of treatment that does away with a surgical operation, an anaesthetic need not be mentioned.

Indeed, a painful exploration need not be executed. As soon as it be ascertained that anal fissure exists, the topical use of salicylic acid and vaseline is to be commended, thirty grains of the salt to an ounce of the unguent. This is to be pressed into the depths of the anus once a day, and after an alvine discharge. The agent—salicylic acid—produces little pain, but utterly destroys the hard ridges that flank the fissure and obliterates the pile tumor at whose base the sensitive crack is located. In a word the supersensitiveness will soon subside, and all the accompanying aches in hips and back. However, to effect a cure tute et jucunde the internal use of arsenic should be prescribed. Fowler's solution in drop doses, repeated every four hours, is next to necessary in accomplishing the happiest results.

Women suffering from anal fissure will divert attention from the location of the disease and demand remedies for urinary and uterine difficulties. In times past it was customary to cauterize the os tineas under the theory that ulcer of the cervix existed. It may be remarked en passant that dyspareunia and vaginismus are occasional sequences of fissure of the anus. A practitioner of medicine has to be wary in the diagnosis of morbid phenomena of a reflex character.

Formerly I excised fissura ani with curved scissors; and the difficulty of executing the operation well has rendered me all the more pleased with a method that requires no cutting. My experience with salicylic acid in the treatment of malignant ulceration led me to try the agent in fissure of the anus.—HOWE, Eclectic Medical Journal, 1885.

The Biographies of King, Howe, and Scudder, 1912, was written by Harvey Wickes Felter, M. D.