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Fissure in ano
Read before the Surgical and Gynecological Society, at the
Ninety-first Annual convention of the A.I.H., at New York City June 2
to 5,1935.
ORLANDO R. VON BONNEWITZ, M.D.
New York, N.Y.
SINCE anal fissure is such a frequently
occurring disorder in proctology and since in proctology and since the
symptom are so well known, we will devote the short time at our disposal
to discussing the less familiar features, complications and treatment
of cases presenting unusual symptoms.
A simple uncomplicated anal fissure will
usually yield to a casual divulsion of the contracted sphincter muscles,
but when diseased crypts, congested haemorrhoids or hypertrophied papillae
are present, the problem becomes more difficult. Most of you have encountered
cases in which a divulsion or even complete excision of the ulcer left
the patient with an irritable anus although the agonizing pain, burning
or bleeding following defection was gone and no evidence of the original
tear or ulcer could be found. It is this type of anal fissure that will
be considered day, together with the most successful treatment we have
found during the past twenty-five years and in nearly 3,000 cases.
I would like to discuss fist of all what
we undersigned by "divulsion". May years ago the late. DR. Pratt of Chicago
first called attention to this procedure in Chicago first called our attention
to this procedure in the treatment of various diseases of the rectum ,
but especially as a cure for anal fissure. His Procedure was simply a
sketching of the anus by means of a Bivalve speculum which often tore
the muscle at the side of the Fissure, and the healing of the tear and
consequent contraction of the anal canal generally left the outlet more
constricted than before the operation.
In my opinion this was a barbarous practice,
wholly unnecessary. The technic we use is gentle, deep massage of the
submucous structures and levator ani muscles, and we seldom break the
mucosa or produce hematoma. We use very little force in these cases, but
we are careful to pass a dilator or proctoscope on the third day, of course
without an anesthetic, and we seldom break the mucosa or produce hematoma.
We use very little force in these cases, but we are careful to pass a
dilator or proctoscope on the third day, of course without an anesthetic,
and we repeat this on the sixth day also. During this time we devote our
attention to the local treatment of the parts, which practice we believe
is most important to get the best results.
If the crypts are inflamed, or if large
papillae or haemorrhoids are present, they may be removed after the fissure
is healed if the case is a suitable one, under local anesthesia, but in
most of the ones we see in the clinic at Flower Hospital, we prefer to
clear up everything under nitrous oxide at one time.
The most confusing type of fissure occurs
where the ulcer originates in a deep crypt. The patient may gave all of
he distressing symptoms of a fissure but the physician will not be able
to find the tear in the mucous membrane. Many times it is difficult to
locate the ulcerated crypt on account of the agonizing pain, and we find
it much better to administer an anesthetic and operate at the same time.
Divulsion in those cases is inadequate, and it will be necessary to give
careful attention to the local after-treatment to get the best results.
At our clinic, at our first examination
we class all cases of fissure as first, seconded, or third degree, depending
upon the type. The discussion give above cover the first and occasional
the second-degree type, which is amenable to divulsion if the crusts are
not too badly inflamed or other complications exist.
The third-degree fissure is something entirely
different although it frequently involves the second-degree type when
such a case is very bad. We usually consider he third type as one which
has been torn and healed repeatedly, presenting a hard mass of scar tissue
most often found in the posterior commissure and really found in the posterior
commissar and rarely found in the anterior quadrant. This type begins
at the pectinate line at the mouth of the crypt, tearing the crypt down
to the anal margin where it burrows beneath the skin and forms so-called
"sentinel pile of Brodie." This of course is a misnomer since it is not
a varicosity and is in no sense a "pile.".
These cases we excise completely and allow
to granulate, although they may be sutured sometimes with good results.
It depends entirely upon the condition of the crypts and the general health
of the surrounding tissues. Since this involves a tissues. Since this
involves a general anesthetic, any other pathology present is taken care
of also.
In this connection I would like to all
attention to the tendency in recent years, especially by general surgeons,
of destroying all crypts around the anus when operating for haemorrhoids.
I have seen many of these cases several months after, with a very severe
pruritus, which was not present before the haemorrhoidectomy.
I do not believe a crypt should be destroyed
unless it is definitely diseased, and then only enough removed to provide
good drainage and allow proper removed to provide good drainage and allow
proper treatment. Many of these may be restored to health and proper function.
Since Miles published a paper in 1928 calling its tendency to cause trouble,
very little has been written upon the trouble which may be caused by his
fibrous band in certain maladies of the anal canal which they call pectenosis.
Pectenosis is an inflammation of the pecten
band surrounding the anus which becomes infiltrated and often fibrosed,
and since the condition is often complicated with anal fissure if naturally
comes under the title in discussing fissure. There is no doubt pectenosis
plays an important part in anorectal disease. This band can easily be
felt by the examining finger and extends to the lower margin of the columns
of Morgagni and is sometimes spoken of as the dentate line, or margin.
Chronic passive congestion leads to round-cell
infiltration producing fibrous tissue in the submucosa and eventually
a fibrous ring around the anus which destroys the elasticity of he sphincter
muscles. It takes no flight of the imagination to see how such a band
of fibrous tissue acting as a foreign body can cause innumerable symptoms
or even abscesses, ulcers, neuralgias, or other anorectal pain. Since
this inflamed band is so frequently found in severe pruritus ani it is
conceivable that the pressure of this foreign band might be responsible
in some degree to the altered circulation in in the anal tissues. I firmly
believe that further investigation of this band may prove some astonishing
connection with pruritus ani, and certainly we will welcome anything that
will help to eradicate this distressing disease.
We have found divulsion to be of great
benefit in very early, mild cases, but entirely useless if the band is
very wide. Usually the band is about one-fourth to one third inch in diameter
and about as thick as heavy blotting paper. The best results will be had
by dividing the band or by removing a wedge-shaped piece without in the
lower two inches of the anal canal that this matter of pectenosis becomes
of great interest to proctologists, and must be taken into consideration
in all cases of anal fissure of haemorrhoids.
I feel certain you will find pectenosis
has a great deal influence upon those troublesome cases of anal fissure
that do not respond to the usual treatment and we have found that, under
local anesthesia, he mucosa may be dissected up, exposing the pecten band
which may be divided and the mucosa sutured in place.
During the last few years we have been
using more and more homoeopathic medication in proctology and find that
hepar sulphur 30x, graphites 12x, aluminum 6x and the calcareous, all
are useful in the 6x or 12x potencies and have at times given us astonishing
results. These are only a few of the remedies we have found valuable.
The purpose in directing your attention
to the internal medication is because we believe the indicated remedy
is too often lost sight of by most of us in favor of surgery and we believe
you will gain valuable assistance by means of various homoeopathic medicines.
In proctology topical applications following
surgical procedures is absolutely necessary and important if you wish
to obtain the best results for your patient.
DISCUSSION-JAMES D. SCHOFIELD, M.D.
The author has given an excellent account
of a very distressing anorectal condition, which is not thoroughly understood
by those uninterested in anorectal disease.
The first question which comes to mind
is the intended meaning of the terms "fissure in ano" an "anal ulcer"
In this regard also it is not clear to us just what the essayist means
by fissures of the first. second and third degree. A simple crack for
fissure of the anal skin, caused for example by some form of trauma may
be unaccompanied by any other anorectal pathology. This type of fissure,
if it be the cause of anal spasm and consequent distress, usually responds
readily to palliative treatment. It is assumed that this simple fissure
is the first-degree lesion of the authors classification.
The type of fissure which corresponds to
the authors third-degree lesion is in reality a true ulcer as shown by
endoscopic examination. For this reason the term "anal ulcer" is preferred
by us. As the essayist has indicated, this lesion is usually found posteriorly.
However, in our experience, anterior anal ulcer occurs much more frequently
in the female that it does in the male.
The anatomico-physiologic aspect of anal
ulcer is important to the proper understanding of the lesion. The anal
canal bounded above by the anorectal or dentate line and below by the
anus is lined by modified skin, i.e., stratified squamous epithelium nd
not by mucous membrane. The innervation of this anal lining is somatic,
just as it is for skin elsewhere. This is in marked physiologic contract
to the rectal mucous membrane with its visceral nerve supply. An anal
lesion, such as ulcer or thrombotic external haemorrhoid, is decidedly
painful because ordinary pain fibers are stimulated. In the case of anal
ulcer the concomitant anal spasm resulting from contraction of the irritated
anal muscles adds insult to injury. Anal ulcer, which is after all a relatively
insignificant lesion pathologically, causes severe symptoms. A short distance
above the anorectal line, i.e., on the rectal side, a malignant lesion
may develop and grow for some time unaccompanied by warning symptoms,
principally because the gut has a visceral innervation which can be stimulated
only by crushing or by overdistention.
The author has included in his paper the
confusing subject of pectenosis. Miles states that the pecten band does
not exist in a health individual. Hence the term implies inflammation
although it does not passes the usual "itis" ending. Since infection if
the underlying cause of most anal affections, it seems logical to us that
such conditions as cryptitis, papillitis, etc., may account for the pathologic
condition which the essayist and others choose to call pectenosis.
We thoroughly agree with the author in
his attitude toward divulsion but in this connection we should like to
know just what he means by deep massage.
Except in those cases of simple traumatic
fissure we believe in the radical correction of all anorectal pathology.
It is agreed that the removal of normal of healthy tissue elsewhere. We
do not suture these wounds because of our profound belief in the value
of proper surgical drainage.
In closing , the discussed wound like to
ask the essayist what he means by the normal function of a crypt (it has
never been explained surgeons does he thank are fully aware of the significance
of cryptitis.
Dr. Von Bopnnewitz, (closing): The discussors
inquiry regarding the classification of anal fissures I believe was clearly
was clearly set forth in the paper and was for the benefit of my staff
in carrying out the treatment after operation.
I cannot agree that "Pectenosis" is a confusing
subject, since it is well recognized in all the rectal clinics of Europe
and man articles have appeared in magazines in this country, such as the
excellent treatise by Dr. J.W. Morgan appearing in the journal of Surgery,
Gynecology and Obstetrics, November, 1934, and a very lucid discussion
in the May issue of Clinical Medicine and Surgery, by Dr. W.A.Hinckele.
The crypts of Morgagni placed about the
anal canal is for the purpose of lubricating the passage with a bland
fluid, which materially assists the passage of a hard, dry stool. I fully
agree with Dr. Schofield that the general surgeon does not recognize the
importance of diseased crypts in anorectal surgery.