CHAPTER II.

SYMPTOMATOLOGY—PHYSICAL EXPLORATION—DIAGNOSIS—PROGNOSIS.

SYMPTOMS.—The symptoms in the early stage of this disease are not usually severe, and are generally experienced during defecation, when at some point or other there will be an uneasy sensation, consisting of an itching, pricking, slight smarting, or a feeling of heat about the circumference of the anus. As the disease progresses, the discomfort attending the movements of the bowel is greatly augmented, and at a variable period of time gives place to a severe pain, of a burning or lancinating character, which is followed by throbbing and excruciating aching, attended by violent spasmodic contraction of the sphincter muscles, continuing from half an hour to several hours.

From reflex irritation, pains are often experienced in other parts, simulating sciatica or rheumatism; the urinary organs, as has already been mentioned, are liable to be sympathetically deranged, causing attention to be diverted from the real seat of the disease.

The ulcer being fully established, the suffering usually comes on with intensity shortly after the actual passage of the motion, and frequently it lasts for many hours, completely incapacitating the patient for work while it continues. I have known persons affected with this malady who for hours were obliged to maintain one position, or to assume the recumbent posture, for fear that the slightest movement would aggravate the pain.

After an indefinite period the pain subsides or entirely disappears, the patient feeling fairly comfortable, or even perfectly well, and to all outward appearance he would continue so were it not for the knowledge that the subsequent passage of fecal matter will bring with it a recurrence of agony. In consequence of this dread, the act of defecation is postponed as long as possible, with the result that when the evacuation does take place the pain is greatly increased.

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.

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.

An important point, to which Bodenhamer calls attention, is the external appearance of the anus itself, which in these cases is usually in a highly contracted state and more or less infundibuliform; the observer being struck by the very considerable depth to which the anus is retracted, and its unnatural look.

The fissure is sometimes difficult to find, and must be searched for in the folds of the anus. This can be accomplished by drawing the mucous membrane away on each side, by which means we shall usually be able to see just within the orifice an elongated, club-shaped ulcer, the floor of which may be very red and inflamed, or, if the disease is of long standing, of a grayish color, with the edges well defined and indurated. Sometimes the ulcer is quite superficial, while in other instances it extends completely through the muco-cutaneous surface, exposing the subjacent muscular coat. Cripps[18] states that these ulcers are sometimes undermined, so that a probe may be passed for a short distance beneath them, while occasionally a little fistulous channel will run some distance up the anus.

A fact to which special attention should be directed here is that small ulcerations may exist in the sinuses of Morgagni. Kelsey[19] and Vance[20] have met with such cases, the ulceration being completely hidden from sight, and detectable only by the sharp pain caused by the introduction of a small bent probe. This condition is no doubt a rare one, but is none the less important on this account, for its situation is such that it may be readily overlooked.

The next step in the examination of a case of fissure is the introduction of the finger into the rectum,[21] and it should be conducted in the following manner.[22] If the lesion be situated dorsally, pressure should be made by the finger toward the perineum, thus avoiding the fissure and rendering the introduction of the digit as painless as possible. If the fissure be situated anteriorly or laterally, the finger should be pressed toward the opposite side of the bowel.

In cases of fissure the speculum ani is seldom required by those accustomed to making rectal examinations. In the majority of instances the possession of the _tactus eruditus_—education of the sense of touch—will enable the surgeon to form a correct diagnosis without the aid of this instrument, and thus save the patient much pain. If a speculum should be required, the instrument of Aloe (Fig. 5) or of Sims (Fig. 6) may be employed.

It is not an uncommon occurrence, according to Allingham,[23] to find a polypus associated with fissure, it being situated at the upper end of the ulcer, or lying against it on the opposite side of the wall of the rectum. I have met with several such instances. If the polypus be undiscovered, treatment of the fissure will prove useless, for it will not heal until the polypoid growth is removed. In searching for a polypus, it is important to remember that the investigation should be conducted by passing the finger from above downward, as otherwise the tumor may be pushed up out of reach, the pedicle in these cases often being of considerable length.

DIAGNOSIS.—The manifestations of this disease are so characteristic of the lesion that it seems almost impossible for an error to be made in its diagnosis. The peculiar nature of the pain, the time of its occurrence (either during or some time after an evacuation of the bowels), its continued increase until it becomes almost unbearable, and its gradual decline and entire subsidence until the next evacuation, are symptoms clearly pointing to fissure, and in most instances should be sufficient evidence to establish a diagnosis; yet in a number of well-authenticated cases mistakes have been made, and patients suffering from this disease have been treated for neuralgia, uterine or vesical trouble, stricture, and even hemorrhoids.

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 want of connection between the pain and the alvine evacuations; and by the constant suffering. In neuralgia the pain caused by pressure with the finger in the anus is not confined to one spot, as it is in fissure, but all portions of the bowel are alike tender. 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 detection itself, in some cases, of the fissure, which can always be discovered by a thorough examination, will clear up the diagnosis.[24]

The symptoms of anal fissure often simulate so closely those of uterine disease and bladder affections that the surgeon is led astray and overlooks the real seat and true nature of the malady. Occasionally the spasmodic condition of the sphincter in these cases simulates the symptoms of stricture; but a thorough examination will dispel all uncertainty by revealing the presence of the ulcer.

Frequently uterine trouble or hemorrhoids are found associated with the fissure, and in this event the case is treated for either one or the other of the first two complaints, the presence of the other lesion being unsuspected and consequently neglected. In all such instances a careful inspection of all the parts concerned will at once remove all errors in diagnosis and dispel all doubts.

In children, the fact must always be borne in mind that fissures and other erosions about the anal orifice may be due to the scratching induced by the irritation of pin-worms.

COURSE AND PROGNOSIS.—Anal fissure is not an immediately dangerous disease; nor can it be said that it has any tendency toward recovery if let alone. An indefinite time may elapse without any other change than the gradual wearing down of the patient's vitality from continued suffering and nervous strain. With proper treatment, however, this disease can be promptly cured, and practically without risk, the operation usually practiced being one of the simplest of surgical procedures.

Footnote 15:

_Op. cit._, p. 132.

Footnote 16:

Bodenhamer, _op. cit._, p. 81.

Footnote 17:

_Op. cit._, p. 92.

Footnote 18:

_Op. cit._, p. 187.

Footnote 19:

"Diseases of the Rectum and Anus," third edition, New York, 1890, p. 294.

Footnote 20:

Medical and Surgical Reporter, August 14, 1880.

Footnote 21:

In some cases of fissure the irritable condition of the sphincter will cause such contraction of the anus when an examination is attempted that it will be impossible for the surgeon to pass his finger into the rectum without etherization of the patient. In these instances it is best to advise the patient to submit to such operative measures as may be deemed necessary at the same time that the examination is made under ether.

Footnote 22:

Allingham, _op. cit._, p. 212.

Footnote 23:

_Op. cit._, p. 212.

Footnote 24:

Bodenhamer, _op. cit._, p. 100.