The feces, when solid, will be passed streaked with purulent matter,—possibly also with blood,—and when more soft will be figured and of small size; sometimes they are flattened and tape-like, due to the incomplete relaxation of the sphincters during defecation. Not infrequently the appearance of such a stool leads the inexperienced to make a diagnosis of stricture of the rectum. In this connection it may be well to state that a fissure is sometimes found associated with a stricture, which latter is due to a congenital contracted state of the anus. Serremone, quoted by Ball,[[15]] believes that the stricture is the cause and not the result of the fissure, the narrow outlet being more liable to injury from over-stretching.
When a fissure is of long duration, the constitution becomes greatly impaired as a result of the constant pain, the constipation, and the frequent resort to narcotics, and the patient is liable to fall into a state of melancholy and extreme nervous irritability; the countenance, expressive of pain, grows care-worn and sallow; the appetite is poor; and there is more or less emaciation, associated with the general appearance of a person suffering from serious organic disease.
Flatulence is another annoying symptom that generally attends severe cases of anal fissure.[[16]] It is not only troublesome, but also painful, the disengagement of gas being almost certain to bring on a paroxysm of pain.
Such are the rational symptoms of anal fissure. If, then, a patient comes to a physician, complaining of severe pain lasting for some time after defecation, the presumption is strong that a fissure exists, since no other rectal disease produces this characteristic distress. But in this as in all other affections of the inferior extremity of the intestinal tract we must supplement our investigation by an actual exploration of the parts, in order to determine the true character of the trouble and to exclude the presence of coexisting lesions.
Ocular and Digital Examination.—Previous to making the rectal examination, the bowels should be thoroughly emptied by an enema,—the subsequent pain and anal spasm being prevented by a preliminary local application of a four-per-cent. solution of the hydrochlorate of cocaine to the mucous membrane of the anus, the drug being applied on a pledget of cotton and left in situ for five or ten minutes. Care must be exercised not to use the solution too freely, as otherwise toxic symptoms are apt to ensue when the drug is employed in this region. The rich lymphatic and vascular supply of the part probably accounts for this fact.
Fig. 3—Head Mirror.
The rectum and the bladder being completely evacuated, the patient should be placed on the side in a good light, with the knees drawn up and one hand supporting the uppermost buttock. To condense the light on the parts to be examined the head mirror may be employed (Fig. 3).
Upon inspection, the first thing that attracts our notice, frequently, is a red, somewhat edematous prominence (Fig. 4) close to the verge of the anus, looking not unlike a small hemorrhoid. This excrescence has been termed the "sentinel pile." Upon placing a finger on each side of the tumor and pressing down and out, as recommended by Bodenhamer,[[17]] the fissure will be seen.
