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. [Illustration: 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. [Illustration: Fig. 4—Anal Fissure associated with the so-called "sentinel pile" (Bodenhamer).] 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.