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© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_9
9
Historical Aspects of Anal Fissure
Pathology
In her doctoral thesis, Willemsen (1963) quotes Alexis Boyer who points out in his
paper from 1818 on anorectal diseases that fissure-in-ano was first mentioned in
medical literature in 1689. Frey (1943) claims that Boyer’s paper dates from 1825
and confirms that not only Louis Lemonnier in his “Traité de la fistule de l’anus ou
du fondement” (1689) but also Raphael B. Sabatier has mentioned anal fissures in
his “De la Médecine opératoire” (1824). This ostensibly negligible condition
(Czerny 1903) creates “such extreme pain in the patient like no other with such tiny
spatial dimensions” (Peters 1920).
9.1 Signs and Symptoms
Delley (1855) writes about the symptoms: “In such cases, emptying the bowels is
always associated with stabbing pain which in case of an already persistent anal fis-
sure outlasts the act of defecation itself for several hours or even for days and often
radiates into the sacral region. In rare cases, but still frequently enough, there are
even incidents of loss of consciousness and antiperistaltic movements of the stom-
ach. As a consequence, people afflicted with anal fissure try to delay this painful act
as long as possible by deliberately contracting the anal sphincter muscle to reverse
defecation for some hours” (translated from the German original).
Likewise, Peters (1920) summarizes the clinical presentation in particular of the
acute anal fissure: “Severe, increasing and almost unbearable pain during and espe-
cially after defecation, pain which is not restricted to the anus alone but also radiates
towards the back, sometimes dull, sometimes nagging, so that in some cases the
patient is hampered in his professional activity and has to lie down for hours to go
through the same stage of suffering again during the next bowel motion.” Frey (1943)
quotes Alexis Boyer mentioning a patient who had to give up his sedentary job and
had to accept a place of work where he could stand in order to escape pain attacks.
Nevertheless, Fischl (1927) recommends never to miss out local medical exami-
nation, and in case of severe painfulness after prior anesthesia, because “it will keep
92
the physician from ignoring a beginning carcinoma.” According to Passavant (cited
by Delley 1855), pain caused by anal fissure can especially develop in children who
are infected by worms, and one of them creeps into the fissure during the night.
Svehla (1902) describes five cases in which complaints caused by anal fissure were
misinterpreted as coxitis. Delley (1855) never or hardly ever states anal fissure in
children, but quite often in “the prime of life,” and here preferably in females.
Leusden (1925), however, observes anal fissure in twice as many men as in women
and also mostly in middle or older age.
9.2 Etiopathogenesis
Our ancients already recognized and described the polyetiology of anal fissure. For
Delley (1855), “the same causes which induce chronic hyperemia, venous stasis and
varicose enlargement of the vascular ramifications in the rectal skin” are to be blamed
for constipation which could lead to skin cracks in one or more places during the
passage of hard, voluminous feces through the anus. Fischl (1927) quotes Boas
(1878) who states besides habitual constipation the disproportion between the stool
caliber and the lumen of the anus as the most important prerequisite for the develop-
ment of anal fissure. In more than 50% of all patients with constipation, Fischl (1927)
regards anal fissure as the sole reason of their disorder. Rappert (1938) was able to
show in animal tests that anal fissure is at least supported by constipation. Delley
(1855) believes that a further reason for anal fissure is the “act of giving birth, during
which the perineum is pushed forward by the advancing head of the fetus and there-
fore the anal opening becomes considerably lengthened. Furthermore, severe consti-
pation which usually occurs after birth, slight injuries of the anus, for example,
through enemas, cannulas and an unnatural satisfaction of sexual urges” (translated
from the German original). Brown (1864, cited by Willemsen 1963) sees a connec-
tion between female masturbation and anal fissures and showed that stimulation of
the clitoris results in strong sphincter muscle contractions. According to Frey (1943),
Boyer also observed in 1818 an accumulated incidence of anal fissures in patients
with hemorrhoidal disease or patients who had been surgically treated for this disor-
der. Leusden (1925) believes hemorrhoidal patients suffering from severe stooling to
be also predisposed for anal fissure. In his thesis, Rick (1922) finds anal fissure asso-
ciated with hemorrhoidal disease in 22 of 34 patients. He quotes Quenu and Hartmann
who describe such a coincidence in 70–80% of cases. Besides constipation, Rick
(1922) considers also burns, rash, decomposition of sweat, and fecal remains as
causes of anal fissure, and also manipulations to increase lust in masturbating women,
delivery, and backward fall on the buttocks. Likewise, Hirschmann (cited by Fischl
1927) holds traumata responsible for the development of anal fissure that are caused
by passage of abnormally massive stool, introduction or expulsion of foreign bodies,
sneezing or coughing, or by faulty use of instruments. Morgagni (1921) and Orbach
(1928), too, regard traumata as causes for anal fissure. They particularly mention
hard stool, manipulation with foreign objects, pederasty, the birth process, and rub-
bing when afflicted with pruritus ani. Fischl (1927) however, found traumatic anal
9 Historical Aspects of Anal Fissure Pathology
93
fissure to be extremely rare in oriental boys who “professionally” practiced pederasty
because they used Vaseline or other lubricants. Leusden (1925) explains that “the
mucous membrane in the posterior and anterior commissure is more tightly attached
to the anal sphincter muscle below. It is not so movable and therefore more exposed
to strains, stretching and possibly also to injuries through hard stool and foreign
objects” (translated from the German original). Orbach (1928) explains the persis-
tence of anal fissure chemically as a result of passing stool in the sense of a vicious
circle. Blond (1934) attributes the formation of anal fissure to the disintegration of a
thrombosed small-caliber knot of varicose veins.
Fischl (1927) states that anal fissures usually occur individually. “If more than
one is present, this is a sign of a general tuberculous, gonorrheal, syphilitic infection
or a sign of decline of these devastating diseases” (translated from the German
original). Morgagni (1921), too, observes anal fissure together with gonorrhea,
chancroid (ulcus molle) and syphilis. Peters (1920, cited by Willemsen 1963)
assumes a connection between severe itching and oxyuridae, pruritus and anal
eczema. The effects of intense scratching would favor anal fissure formation. Meissl
(1926) saw anal fissure predominantly in neurasthenic individuals. He is convinced
that “the main sign of Fissura ani, namely sphincter muscle spasm, is not the result
of one or more cracks in the anal mucous membrane inside or outside the sphincter
muscle, but rather the cause of them” (translated from the German original).
Rosenbach (1900) concludes from “the fact that primary – not at all or only dis-
tantly connected with local irritations – manifestations of spasms occur in other
organs, (…) that very likely rectal spasm is not identical with Fissura ani” (trans-
lated from the German original). He believes that a “perverse tonic innervation of
the anal sphincter muscle apparatus is responsible” for the rectal spasm (translated
from the German original). Frey (1943) cites Alexis Boyer who said that he has
never observed an anal fissure without spasm, but has observed spasm of the sphinc-
ter muscle without an anal fissure.
Fischl (1927) describes fresh anal fissures, which often show a purulent or
fibrously adhering coating, and old anal fissures (“I was able to pursue them for
twenty years”), which almost always have bulging, indurated, callous edges.
Projecting edematous skin at the outer skin of the anus, also called sentinel tag
(Peters 1920), is characteristic of the existence of (chronic) anal fissure. To English
physicians, this skin tag is known as sentinel pile (Hirschmann 1914). Fischl (1927)
points out that “accumulated secretion in the anal fissure prevents wound healing
unless excision or ligature of the sentinel tag provided an unobstructed discharge of
secretion” (translated from the German original). Leusden (1925) attributes the
poor healing tendency to the fact that “to a certain extent, the deliberate immobiliza-
tion of this opening necessary for healing is not subjected to the owner’s free will”
(translated from the German original).
Clinical histories from 1948 through 1958 are the bases of Willemsen’s thesis.
Her statistical evaluation gives a high percentage (70.8%) of altered blood counts
(in more than 50%, a slight or marked anemia). She discusses a relationship between
iron deficiency and the formation of anal fissure, similar to the formation of angular
stomatitis.
9.2 Etiopathogenesis
94
9.3 Medical Findings
Delley (1855) describes three stages of anal fissure, namely the linear erosion, the
fresh crack in the eroded mucous membrane, and the ulcerous form. Czerny (1903)
observes sometimes only a slight laceration of the mucous membrane between hem-
orrhoidal folds, sometimes rhagades-like ulcers with callous edges. Fischl (1927)
describes the anal fissure as a linear defect whose edges become chronically
inflamed, indurated, and bulging if they have already existed for a longer period of
time. Outside the anus, there is often an inflamed skin fold, similar to a hypertro-
phied anal papilla. According to Fischl, anal fissure in males is found in nine cases
out of ten in the area of the posterior commissure, whereas the rate in females is
60%. The anal fissure in the remaining 40% is found at the anterior commissure or
next to it. The reason for this is “that due to the concavity of the sacrum the rectal
and anal canals are curved in such a way that the greatest force during the expulsion
of stool is directed towards the posterior commissure” (translated from the German
original). Acute anal fissures often show a purulent or fibrous coating, whereas
chronic anal fissures almost always have bulging, callous edges. For Reichle (1940),
too, the posterior commissure is the typical location of anal fissure. In most cases, it
is “a flat, linear ulcer of about one cm in length.”
9.4 Conservative Therapy
Conservative methods comprise the use of warm or cold sitz baths, the application
of enemas and rectal suppositories to obtain softer stool, a diet intended for regular
pulpy stooling (Czerny 1903), and the administration of Scarlet Red 8% (Sudan III)
for quick epithelization (Meissl 1926). Moreover, Fischl (1927) recommends the
application of cocaine Vaseline, whereupon anal fissure healed indeed in five chil-
dren. Hill (1912) recommends stool regulation, primarily through order and diet as
well as nightly enemas with olive oil. Drastic measures should be avoided because
liquid stool irritates and hurts. He also recommends warm sitz baths, after that the
insertion of gauze spread with either calomel or boric ointment, in case of extreme
pain alternatively with cocaine or morphine ointment. During the first consultation,
Hill additionally suggests a slow or careful dilatation with one finger and a light
massage; any existing granulations should be removed by light curettage. For Hill,
another treatment option is the application of Cascara sagrada or liquorice powder
(pulvis liquiritae compositus). Hahn (1928) advocates the administration of
Lenirenin-Belladonna suppositories and ointment. Fischl (1927) reports good
results after the administration of pure Ichthyol and Peru Balsam (Peru-Lenicet).
Some surgeons cauterize with lunar caustic (AgNo3), while others are strictly
against this method. Lapis lazuli, trichloroacetic acid, and lactic acid are also used
for cauterization (Orbach 1928). Fischl himself obtained good results with Jodalcet,
a powder which helps the wound to scab over by forming an elastic membrane.
Heidenhain (1910) recommends the induction of pulpy stools and the insertion
of a hard rubber hemorrhoidal pessary into the anus for 1–2 h. Meissl (1926)
9 Historical Aspects of Anal Fissure Pathology
95
recommends a marked forward movement of the body during defecation when the
anal fissure is located at the posterior part of the anus. Katzenstein (1903) proposes
a gradual stretching (if tolerated by the patient), digitally in the beginning and with
the help of a bougie afterwards. Blond (1934) recommends the injection of 30%
quinine urethane solution (three drops) into the base of the anal fissure. If too much
of this solution is injected, deep necroses and periproctal phlegmon may result
(cited by Rappert 1938). Bensaude (1930) subcutaneously injects the anal fissure
with quinine in 5% urea solution (cited by Rappert 1938). This same solution was
first applied by Terrel (1913) for the sclerotization of hemorrhoids.
9.5 Surgical Treatment
Delley (1855) describes two types of surgery for anal fissure, namely dilatation and
incision. There are three ways to perform dilatation:
1. Gradual dilatation (Fr. dilatation progressive) with the help of charpie swabs
(cotton–wool swabs) of increasing volume to negotiate the contraction of the
anal sphincter muscle.
2. Dilatation in rapid succession (Fr. dilatation brusque) according to Alfred
Armand Velpeau (1795–1867). Here, charpie swabs “of the greatest possible
volume” are used.
3. Instantaneous dilatation (Fr. dilatation instantanée), especially advocated by
J.C.A. Récamier (1838). The dilatation procedure is carried out while the patient
is under chloroform anesthesia. Both index fingers are successively inserted into
the anus. Then the anal sphincter muscle is quickly and vigorously pulled apart.
Baracz (1905) also favors violent anal dilatation, according to Récamier, as the
method of choice. He performed surgery successfully even without anesthesia.
Récamier (1838) prefers deep chloroform anesthesia, because death occurred in
cases of incomplete anesthesia due to glottic spasm and syncope. He pushes dilata-
tion so far until a noise tells him that the anal sphincter muscle has been torn! Alexis
Boyer (cited by Willemsen 1963) was one of the first surgeons to dissect the anal
sphincter muscle as a whole to eliminate the disproportion between the lumen of the
anus and the stool column. Rosenbach (1900) regards “forced dilatation or dissec-
tion of the anal sphincter muscle as cruel, hardly calculable surgery, which at best
can be granted the right of existence only as the last and heroic resource”.
Delley (1855) describes the incision of the anal sphincter muscle, practiced by
Boyer, as laterally open, with vehement contraction in the form of two such inci-
sions, yet without cutting into the anal fissure itself. “Upon a well-oiled finger, a
slender bistoury with a narrow blade and a rounded point is inserted into the rectum.
The cutting edge be directed either to the right or to the left depending on the loca-
tion of the anal fissure. The surgeon now separates the intestinal lining, the subcuta-
neous tissue, and the anal sphincter muscle with one single cut”. To avoid an uneven
joining of the wound edges, a charpie swab is placed into the cut itself.
9.5 Surgical Treatment
96
The second method described by Delley is the subcutaneous incision according to
Philippe Frederic Blandin (1798–1849), obviously the precursor of lateral sphincter-
otomy as practiced by Notaras (1971). Blandin performed the surgery in four steps:
(1) puncturing the skin, (2) insertion of the finger into the rectum and tensing the skin
toward both sides of the anus, (3) advancing the tenotome between the mucous mem-
brane and anal sphincter muscle, and (4) severing the sphincter muscle.
To avoid perforation of the rectal mucous membrane with possible consecutive
fistula formation, tool maker Joseph F. Charrière (1803–1876) invented a particular
tenotome with a blade hidden in a retractable sheath, which perfectly fulfilled its pur-
pose (cited by Delley 1855!). Passavant “advocates an incision into the base of the
anal fissure down to the muscle, yet without severing it”. During this procedure, he
uses a 4-inch speculum for adults, half its length for children (cited by Delley 1855).
Under the assumption that “the continuous contraction of the anus and hard stool as
the most important factors do not allow spontaneous healing of anal fissure,” Delley
also concedes the incision a theoretical right of existence in the therapy for fissure-in-
ano. Philipowicz (1927) performed surgery using local anesthesia. He widens the
anus by means of a speculum, focuses the anal fissure, splits the wound base, and
excises the callous edges after removal of the sentinel tag. He is against the diathermic
treatment for anal fissure as propagated by Zweig (1926). His procedure exactly cor-
responds to the later operation technique published by Eisenhammer (1951).
For Fischl (1927) it is clear that anal fissure does not heal as long as the sentinel
tag is present. Therefore, he removes it by a simple ligature with a silk thread after
having applied ethyl chloride as anesthetic. Czerny (1903) performs surgery accord-
ing to a method specified by Dieffenbach, namely, transversal cut through the scar
and longitudinal closure of the wound. Then, applying general anesthesia, he exposes
the anal fissure with the help of Sims speculum and excises the fissure with a scalpel
in the shape of a lancet or deltoid to such a depth that the ulcerous base is at the same
time removed and the fibers of the external anal sphincter muscle are laid open in the
wound or are excised superficially. He seizes the tip of the mucous membrane rup-
ture with a catgut suture and joins it with the opposite point of the skin wound,
“which is possible without considerable tension because of the easy flexibility of the
rectal mucous membrane. The mucous membrane is attached to the anal skin by two
to four further sutures at both sides of the middle suture to look like lips, and by that,
the old bed of the anal fissure and its irritated nerves are covered up.”
Katzenstein (1903) believes the violent dilatation or surgical sectioning of the
anal sphincter muscle to be indicated only “when other methods desert you,” espe-
cially due to “occasionally occurring Incontinentia alvi with all its disagreeable
attendant symptoms.”
Melchior (1910) strongly warns against dilatation of the anal sphincter muscle
because of the danger of incontinence and assesses the severe incontinence damages
which he had found in the context of a follow-up of dilated fissure patients:
The case histories, which have been just now communicated, hardly need a further com-
ment. Every one of them is an example of serious injury to patients caused by surgery, the
degree of which is hardly proportional to the initial condition. Therefore, these observa-
tions should be suitable to prove the dogma of the harmlessness of anal sphincter dilatation
as untenable.
9 Historical Aspects of Anal Fissure Pathology
97
This statement from the year 1910 still holds true today, without restrictions. A
tabular overview of the history of anal fissure therapy is given in Table 9.1.
References
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anal fissures. Dis Colon Rectum 42:1011–1015
Baracz (1905) Zur chirurgischen Behandlung der Fissura ani auf Grundlage eigener Erfahrung.
Gaz Lekarska Nr. 20–22, 1905. Cited in Zentralbl Chir. 35:934
Bensaude A (1930) Soc Med Hosp Gaz. 6. Cited in Rappert E (1938)
Blandin PF (1798–1849). Cited in Delley LA (1855)
Blond K (1934) Zur Pathologie und Therapie des varikösen Symptomkomplexes des Mastdarmes.
Wien Med Wschr 25
Boas (1878) Cited in Fischl L (1927)
Boyer A (1826) Abhandlung über die chirurgischen Krankheiten und über die dabei angezeigten
Operationen. Zehnter Band. Stahel, Würzburg, pp 119–145 Reprint in Kontinenz.
1995;4:78–85
Brown B (1864) Fissuren des Afters nach Masturbation bei Weibern. Monatschr Geburtsheilkunde.
24:341. Cited in RJ Hiller (1931)
Carapeti EA, Kamm MA, Phillips RK (2000) Topical diltiazem and bethanechol decrease anal
sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum
43:1359–1362
Czerny V (1903) Zur Behandlung der Fissur und des Vorfalls des Mastdarms. Beitr Klin Chir
37:765–769
Delley LA (1855) Die Fissura ani und ihre rationelle Behandlung [dissertation]. Universität
Bern
Eisenhammer S (1951) The surgical correction of chronic anal (sphincteric) contracture. S Afr
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1927; 51:1922–1925
Frey PP (1943) Die Analfissur [dissertation]. Universität Berlin
Table 9.1 The history of anal fissure therapy 1826–2000, a tabular overview
Author (year) Therapeutic procedures
Boyer (1826) Lateral sphincterotomy (open)
Récamier (1838) Manual anal dilatation
Blandin (before 1849) Lateral subcutaneous sphincterotomy (closed)
Hirschmann (1914) Instrumental anal dilatation
Philipowicz (1927), Eisenhammer (1951) Sphincterotomy at the anal fissure base
Bensaude (1930) Subfissural injection with quinine urea
Gabriel (1939) Fissurectomy
Blond (1934) Subfissural injection with quinine urethane
solution
Parks (1967) Open lateral subcutaneous sphincterotomy
Samson and Stewart (1970) Anoplasty
Notaras (1971) Closed lateral subcutaneous sphincterotomy
Jost and Schimrigk (1993) Injection of botulinum toxin
Loder et al. (1994) Local therapy with glyceryl trinitrate
Antropoli et al. (1999) Local therapy with nifedipine
Carapeti et al. (2000) Local therapy with diltiazem
References