Another affection which very frequently occurs in connection with hemorrhoids is anal fissure. The latter consists of an oblong tear of the mucosa of the anus and gives rise to severe pain and spasmodic contractions of the sphincters. Fissures or ulcers of the anus vary in depth and size. Some are mere abrasions of the mucous membrane, others are quite large and deep so that the muscular fibres are laid bare. The edges of the fissure may be in a healthy state or they may be inflamed, callous, and indurated. Fissure of the anus is usually caused by an injury or tearing of the mucous membrane at the verge of the anus. This may result either from excessive straining or from the passage of very dry hard scybala. The affection is more often found in women than in men. The posterior portion of the anus is the point of 13 predilection, although the fissure may occur at any other place. It is usually situated parallel to the external sphincter, although in some instances it may lie higher up, parallel to the internal sphincter or even above it.

The symptoms consist in intense pains in the rectum on defecation, sometimes persisting afterward. The pains are often of a very excruciating character. The size of the fissure does not seem to be of so much importance with regard to the severity of the pain as its position. A small crack situated at the anal orifice over the external sphincter and involving the skin causes much greater pain than a large ulcer situated higher up in the rectum. There may also be a discharge of blood and pus.

The diagnosis of anal fissure is made by the symptoms just mentioned and by local examinations. The patient lying on his left side should be told to bear down, and the anus opened with forefinger and thumb as gently as possible. An elongated club-shaped ulcer will be seen within the orifice. Its floor may be very red and inflamed, or if the ulcer is of long standing, of a grayish color, with well-defined and hard edges. Often the introduction of the finger into the anus is so painful that before making the examination a suppository containing one grain of cocaine has to be applied. Sometimes even this procedure is insufficient, and then chloroform anaesthesia will be required. For a fissure situated higher up above the internal sphincter examination with the speculum will have to be made.

Fissures of recent origin can often be cured without any operation. Rest in the recumbent position should be adopted as much as possible. Mild laxatives are to be recommended, but no drastic remedies employed. If the patient can manage to have a movement at night time be-fore retiring, it will be of advantage. Locally, the fissure should be touched off and on with a ten-per-cent solution of cocaine or with a ten-per-cent solution of nitrate of silver. Still better is the application of the following salve recommended by Allingham:

Fissure Of The Anas 39

Hydrarg. subchlor.........

gr.

iv.

Pulv. opii..........

gr.

ij.

Extr. bellad..........

gr.

ij.

Ung. sambuci............

3i.

M. f. ung.

If these palliative remedies are not sufficient, a free incision through the fissure should be made. The cut should be rather deep and should reach the sphincter muscles.