The references regarding parikartika are found in sushruta samhita in nidana sthana, chikitsa sthana, and uttaratantra.
In charaka samhita reference regarding parikartika are seen in the siddhi sthana.
In Astanga sangraha parikartika is seen in sutra sthana and nidana sthana.
In bhela samhita parikartika word is seen in the siddhi sthana.
In laghu trayees reference about the parikartika is not seen.
Acharya Kashyapa has mentioned about parikartika in Chikitsa Sthana.
“Parikartika” is not being described in Vedas even tough Vedas have a rich description of various diseases and their management.
All the three authors of Bhrihatrayee have dealt about it.
Nirukti
Pari = Sarvato Bhaavaha.
Kartika = sharp shooting pain (especially in rectum).
Parikrit = Krintati = to cut off, cut round, clip.
Kartana = to cut off.
Vyakhya
“Parisarvato bhavena krintateeva chhinateeva bastyadeeni iti parikartika”.
According to Monier Williams Sanskrit – English dictionary, the words carry the meaning as
Krintati = to cut off, cut round, clip.
Chinna = Chedanam6, again is to cut off, cut, divide.
Parikartika is a condition where the person experiences excruciating pain, which is,cutting type in the guda, Basti Pradesha and surrounding areas.
NIDANA
In Ayurvedic literature parikartika word is seen in virechana vyapat contexts, avruta vata contexts, vataja atisara contexts ect so it is a basically symptom rather a disease, which is a very pain full condition, all the causes which are responsible for virechana vyapat, avruta vata, vataja atisara ect are all the causes for the parikartika. All the available matter is collected here and divided in concise form.
Ahara viharaj –
Sushruta while explaining vamana virechana vyapat he tells that a debilitated person with Mridu Koshta or Mandagni, who intakes the Ati-Rooksha, Ati-Teekshna, Ati-Ushna, Ati-Lavana Ahara or ingestion of Virechana Oushadhi causes the Dooshana of Pitta Dosha and Vata Dosha and leads to Parikartika.
He also mentioned that Parikartika is a Vyapath of Virechana while Kantha Kshanana is a Vyapath of Vamana.
According to Charaka, if a strong Virechana Oushadhi is given in a Snigdha Kaya, Guru Koshta, in Saamavata, in Krusha or in Mridu Koshta and in worn out weak individual, it can cause extensive painful condition, Parikartika.
Vyadhi Nimittaja –
Condition that which is produced after a disease or during the diseased stage, that is vyadhi nimittaja. And Charaka has described Parikartika in Atisara Vyapath chapter, where he mentions clinical features of Vataj Atisara. According to him there is scanty hard stools, with froth and along with sounds, with gripping and cutting type of pain in Guda, and prolapse may follow later even.
Again in case of Jwara where there is generalized Rookshata of the body, even a small amount of Rooksha Pureesha, which passes, may be enough to result into a Parikartika.
Vaidhya Nimittaja :
The procedure which is produced by an inexperienced Vaidhya can also leads to condition parikartika. Sushruta has described 15 different kinds of complications, which may result from an injudicious use of Basti and Virechana owing to the ignorance of the Vaidhya. Parikatika is one such disorder. Parikartika is such a condition, which is produced by improper conduction of a therapy. According to Sushruta, it develop after incorrect administration of Basti using a rough and thick Basti Netra.17 This is true as it invariably produces a tear in the anal margin due to local damage.
Even Acharya Charaka, 18,19,20 Vagbhata 21 and Sharangadhara are also having the same opinion.
OTHER CONDITION
In Ayurvedic literatures Parikartana and Parikartika are the two terms used interchangeably as in , they have been used on numerous occasions as symptoms of various diseases. So it appears that they have been used for the same meaning. Parikartika is seen in the following contexts.
· Apana avruta udana. A.H.Ni - 16/52.
· Vyana avruta apana. Ch.Chi – 28/211.
· Heena dosha apahrita vyapath. Su.Chi - 38/4.
· Pureesha avruta vata. Ch.Chi - 28/70.
· Pureesha avruta vata. ; A.H.Ni - 16/40.
· Sahaja Arshas. Ch.chi - 14/8.
· Sahaja Arshas. A.S.Ni - 7/9.
· Pureesha nigraha. A.S.Su - 5/4.
· Pureesha nigraha. ; A.H.Su - 4/3.
· Pureesha nigraha. ; Ma.Ni - 27/3.
· Vatika grahani. Ch.Chi – 28/221.
· Vatika atisara. Ch.Chi - 19/5.
· Vatika atisara. A.S.ni - 8/8.
· Vatika atisara. A.H.ni - 8/7.
· Udavarta.Ch.Chi.19/5;A.H.ni.7/48.
· Udavarta. A.H.ni.7/48.
CHIKITSA
Sushruta is the one author has given a much description and strong consideration to Parikartika than any other authors, who have mentioned the Chikitsa for this in a brief manner. It is true that none of them have described any surgical intervention thereby showing that there was no need of surgery as the disease was completely cured by the conservative method itself and were much satisfied with the management.
According to the use of medicines the management was divided into general management and local management.
General management :
The oral preparation has many fold objectives like some drugs are used for the correction of Annavaha Srotas, while some for Deepana - Pachana etc. the Shamana of Tridosha is also mentioned.
Sushruta has advised Parisheka of cold water and drinking milk as oral administration.22
Even Charaka for the same has mentioned drinking of milk and intake of Amla Dravya.23
Both these treatments have the property of Vata Shamana and they improve digestion, which in turn mitigates both pain and constipation. He says if Parikartika is present along with fever, one has to take Yavagu prepared of Bala, Kokum etc. Hence in this context the treatment is more focused towards alleviating Vata Dosha and Pitta Dosha and to correct the altered Agni.
Local management :
This is basically attributed to the Basti Karma. Most of the drugs, which are used in the Basti Karrma, are Vata-Pitta Dosha Shamaka and Vrana Ropaka.
There are mainly two types of Basti.
Asthapana.
Anuvasana.
The Basti, which consists of excessive of Sneha Dravya, is called as Anuvasana Basti. It is so called for the fact that it doesn’t injure the system even in the event of it being retained in the body for a whole day or for the fact that it can be adapted to daily application.
Sushruta mentions that in Sneha Basti, the dose is ¼ to that of Niruha Basti, which is decided according to the age.
Dalhana while commenting upon the above verse mentions that Uttama Matra of Sneha Basti is of 6 Pala, Madhyama Matra is of 3 Pala and Kaneeyasi Matra is of 1 ½ Pala.25
Chakrapanidutta on commenting upon Matra Basti describes that the Sneha used in Sneha Basti is 6 Pala that in Anuvasana is 3 Pala and that in Matra Basti is 1 ½ Pala of Sneha.26
It is obvious from the above reference that Acharyas have sub-classified Snaihika Basti into 3 types depending upon the dosage.
Charaka advises that the dose of Hrisiyasi Sneha Pana should be the Sneha Matra in Matra Basti.
Sushruta mentions that Matra Basti is applicable in all cases and is an alternative to Anuvasana Basti, but should be administered with oil only a half part of Sneha of that used in Anuvasana. 28
According to Dalhana, Madhuyasti Siddha Ghrita is indicated in Pittolbana Parikartika while Madhuyasti Siddha Taila is indicated in Vatolbana Parikartika.
MODERN REVIEW
Anal fissure is the second most common condition seen in a rectal clinic and is by far the most common cause of anal ulceration, about 90% of anal fissure occur in the posterior midline the remaining 10% are found in the anterior midline, it is being considerably for its cause, pathology, clinical features, and management, males are more prone to this than females
Anatomy of the Anal Canal 30
The short or anatomical anal canal (2 cm) extends from the anal valves to the anal verge, and the surgical or long anal canal (4 cm) extends from the anorectal ring to the verge. The surgical anorectal junction seems to be more physiological. In the upper part of the anal canal, the mucosa is thrown into a series of longitudinal folds called the columns of Morgagni (10-12 in number). Distally these columns are joined by the anal valves of Ball. The anal glands arise from the dentate line and open into the apex of the crypts of Morgagni. The dentate line is an important guide in the anatomy of the anal canal. The mucosa above this line is made of a cubical epithelium and is entodermal in origin, while the mucosa below is squamous in nature and ectodermal. The area above the dentate line is supplied by autonomic nerves and drains into the portal venous system; the area below is supplied by the sensitive spinal nerves and drains into the systemic veins.
However, the attachment of the anal membrane undergoes differential rapid growth and enlarges to become in the adult the whole of 15 mm or so — the anal transitional zone (ATZ). This whole ATZ represents the ectoderm-entoderm boundary. From about 10-15 mm above the valves down to the boundary with hairy skin, the epithelium has a rich sensory supply made up of both free and organised nerve endings. The sensory endings in the hairy perianal skin are similar to the hairy skin elsewhere in the body.
Sphincters
The anal canal is surrounded by two sphincters, voluntary and involuntary, which have coordinated action. The external sphincter (voluntary) has three parts—subcutaneous, superficial, and deep but functionally, it works as a single unit. It has also been regarded as a series of three loops. The top loop is made up of the deep part of the external anal sphincter and puborectalis attached to the pubis, the middle one is the superficial sphincter attached to the coccyx, and the base loop is attached to the perineal body.
The internal sphincter (involuntary) is the condensation of the circular muscle coat of the rectum. It is 2.5 cm long and 2-5 mm thick, commencing where the rectum passes through the pelvic diaphragm and ending at the anal orifice.
Arterial supply
The superior rectal artery, continuation of the inferior mesenteric artery, descends posteriorly to the rectum where it bifurcates to supply the rectum and the upper part of the anal canal. The right branch again divides into anterior and posterior branches. The final termination of the superior rectal artery corresponds to 3, 7, and 11 o'clock positions in lithotomy; these correspond to the positions of primary internal piles. The middle rectal arteries arise from the anterior division of the internal iliac artery on each side and enter the lower portion of the rectum inferoposteriorly at the level of the levator ani muscles. The inferior rectal arteries on each side arise from the internal pudendal arteries and traverse the ischiorectal fossae on each side to supply the anal sphincter muscle. These three vessels anastomose freely in the anatomical transitional zone. The median sacral artery, a branch from the aorta, supplies only a very small part of the posterior wall of the lower rectum.
Venous drainage
There are two systems of veins — portal and systemic. The superior rectal vein drains the rectum and upper part of the anal canal into the portal system via the inferior mesenteric vein. The middle rectal veins drain the lower part of the rectum and upper part of the anal canal to the internal iliac vein. The inferior rectal veins drain the lower anal canal to the internal pudendal veins.
Lymphatic drainage
There are free communications between the submucosal and intramuscular lymphatic vessels. The usual drainage flow is upwards and to a limited extent, laterally and downwards. The superior rectal nodes are an important group of nodes situated on the back of the rectal ampulla above the levator ani muscle; they are also known as pararectal lymph nodes of Gerota. The middle rectal nodes lie close to middle rectal arteries and pass to the lymph nodes around the internal iliac arteries. The upper part of the anal canal may drain into the superior, middle, or inferior rectal lymph nodes. However, the part of the anal canal below the dentate line drains into the inguinal lymph nodes. The presacral lymph nodes lie in the hollow of the sacrum along the median sacral vessels; these are involved in growth of the posterior wall of the rectum and are palpable rectally when enlarged.
Nerve supply
The sympathetic nerve supply to the rectum comes from the hypogastric plexus. The parasympathetic supply comes from the 2nd, 3rd, and 4th sacral nerves (pelvis splanchnic).
The presacral nerve and pelvic plexus come very close in the dissection of the pelvis during excision of the rectum and they need careful protection. The internal .sphincter, apparently responsible for about 85 per cent of the resting anal canal pressure, has dual (sympathetic and parasympathetic) excitatory control. The motor fibres to the external anal sphincter travel in the inferior rectal nerve (S2 and S;3) and the perineal branch of S4.
PHYSIOLOGY
The colon has three main types of movements—segmental, propulsion, and retropulsion—which help in absorption and faecal movement. Out of approximately 1.5-2 liters of fluids taken orally per day, the colon absorbs water and electrolytes leaving only 100 ml of fluid to pass into the faeces. The proximal (ascending) colon is called the absorptive colon and the distal (descending) one is called the storage colon. The latter secretes copious amounts of mucus rich in potassium. The colonic muscle tone is maintained by prostaglandin.
The rectum is not only a simple- tube for the passage of faeces. In addition to being a reservoir of flatus and faeces, it plays an important role in the maintenance of continence. The rectum also absorbs water and sodium and secretes mucous, rich in potassium and bicarbonate. The rectal ampulla normally remains empty and the contraction of the puborectalis maintains the anorectal angle at 80-90 degrees. When the intraabdominal pressure rises and the puborectalis is functioning, the anterior wall of the rectum is forced against the upper anal (anal like a flap valve) —-the most important mechanism in the maintenance of faecal continence. A flutter valve mechanism also works where flattening of the two walls in the pelvic slit occurs due to raised intra-abdominal pressure.
The mass movement forces colonic contents into the upper rectum. Here, the distension caused by the faeces leads to non-propulsive segmental movements and retropulsion and propulsion also occur. Further passage of the contents into the ampulla distends this part of the: rectum; this stimulates the extra rectal stretch receptor to give rise to the sensation of perineal fullness associated with a feeling of impending evacuation—the rectal sensation. This rise in the abdominal pressure is transient; after about a minute or so, due to receptive relaxation of the ampulla, the pressure returns to the pre-distension level. During the phase of increased ampullary pressure, the rectosphincteric reflex is activated resulting in relaxation of the internal sphincter and sampling of the rectal contents by the anal canal mucosa. At this time, voluntary contraction of the external sphincter prevents further sampling. With the accommodative relaxation of the ampulla, the rectosphincteric reflex is suppressed, the internal sphincter contracts, the sampling stops, and the desire to defecate is overcome. Further entry of colonic contents into the ampulla leads to renewal of the same process until the person defecates voluntarily or until the ampulla contains 150-200 ml of material. In the latter case, the internal sphincter relaxes and contraction of the external sphincter is overcome to make the patient incontinent. In the squatting position, the anorectal angle is decreased on straining. However, most of the straightening is due to voluntary relaxation of the puborectalis, the external anal sphincter complex, in response to straining. Now as the person strains, the intra-ampullary pressure is raised; this relaxes the internal sphincter via activation of the rectosphincteric reflex. Due to a prolonged increase in intrarectal pressure, the external sphincter relaxes.
The faecal bolus or the flatus thus raises the anterior rectal wall of the upper anal canal and passes into the relaxed anal canal to be evacuated subsequently. The presence of any matter in the rectal ampulla, be it faeces, flatus, mucous, or growth will lead to a desire to evacuate until the matter is expelled. In ampullary growth, the expulsion is not possible and the patient suffers from tenesmus and a sense of incomplete evacuation. The extensive involvement of the internal sphincter by a low rectal growth and infiltration of the pelvic splanchnic nerves will lead to incontinence. The central mechanism in the nervous system controlling the act of defecation is not understood. Recent experiments suggest that there is a fast-conducting, direct, pyramidal pathway to the sacral anterior horn cells supplying the pelvic floor and external sphincter, illustrating the importance of brain in the normal functioning of these muscles.
FISSURE-IN-ANO
Definition – an elongated ulcer in the long axis of the lower anal canal.
Location – the site of election for an anal fissure is the midline posteriorly (90% overall). The next most frequent situation is the midline anteriorly.
Aetiology -
The cause of anal fissure and particularly the reason why the midline posteriorly is so frequently affected, is not completely understood.
A probable explanation is as follows -
· The posterior wall of the rectum curves forwards from the hollow of the sacrum to join the anal canal, which then turns sharply backwards. During defecation the pressure of a hard fecal mass is mainly on the posterior anal tissues, in which event the overlying epithelium is greatly stretched and, being relatively unsupported by muscle, is placed in a vulnerable position when a scybalous mass is being expelled.
· Possibly some cases are due to tearing down of an anal valve of Ball.
An anterior fissure is much more common in women, particularly in those who have borne children. This can be explained by the lack of support of anal mucous membrane by a damaged pelvic floor and attenuated perineal body.
Some causes of anal fissure are certain - an incorrectly performed operation for hemorrhoids in which too much skin is removed. This results in anal stenosis and tearing of scar when a hard motion is passed.
Inflammatory bowel disease – colitis or Crohn’s disease.
Sexually transmitted diseases.
Pathology –
An anal fissure is either acute or chronic. The upper internal end of the fissure stops at the dentate line. The swollen anal valve at the upper end of the fissure is called ‘hypertrophied anal papilla’. Because the fissure occurs in the stratified sensitive epithelium of the lower half of the anal canal, pain is the most prominent symptom.
Acute anal fissure Acute anal fissure is a deep tear through the skin of the anal margin extending into the anal canal. There is little inflammatory indurations or edema of its edges. There is accompanying spasm of the anal sphincter muscle
Chronic anal fissure is characterized by inflamed indurated margins, and a base consisting of either scar tissue or the lower border of the internal sphincter muscle. The ulcer is canoe shaped, and at the inferior extremity frequently there is a tag of skin, usually edematous. This tag is known picturesquely as a sentinel pile – ‘sentinel’ because it guards the fissure. There may be spasm of the involuntary musculature of the internal sphincter. In long standing cases, this muscle becomes organically contracted by infiltration of fibrous tissue. Infection is common and may be severe ending in abscess formation. A cutaneous fistula may follow.Chronic fissure in ano may have a specific cause – often a granulomatous infection, e.g. Crohn’s disease of syphilis. Biopsy examination is advisable of any tissue removed at operation for a chronic fissure. Specific fissures of this type are often less painful than the appearance of the lesion would suggest.
Clinical features –
The condition is more common in women, and generally occurs during the meridian of life. It is uncommon in the aged, because of muscular atony. Anal fissure is not rare in children, is sometimes encountered during infancy and may cause acquired mega colon. Pain is the symptom – sharp, agonizing pain starting during defecation, often overwhelming in intensity and lasting an hour or more. As a rule, it ceases suddenly, and the sufferer is comfortable until the next action of bowel. Periods of remission occur for days or weeks. The patient tends to become constipated rather than go through the agony of defecation.
Bleeding – this is usually slight and consists of bright streaks on the stools or on the paper. Discharge – a slight discharge accompanies fully established cases. The discharge may cause pruritus.
On examination –
In cases of some standing, a sentinel skin tag can usually be displayed. This together with a typical history and a tightly closed puckered anus is almost pathognomonic of the condition. By gently parting the margins of the anus, the lower end of the fissure can be seen.
Because of the intense pain, digital examination of the anal canal should not be attempted, unless the fissure cannot be seen, or it seems imperative to exclude major intrarectal pathology. In these circumstances, the local application of a surface anesthetic such as 5% xylocaine on cotton wool, left in place for about 5 minutes, will enable the necessary examination to be made. In early cases the edges of the fissure are impalpable, in fully established cases, a characteristic crater, which feels like a vertical buttonhole, can be palpated. The diagnosis must be established beyond doubt, for which a general anesthetic may be required.
Differential diagnosis -
Carcinoma of the anus in its very early stages easily simulates a fissure. If a real doubt exists, the lesion must be excised under general anesthesia and submitted to histological examination.
Multiple fissures in the perianal skin are commonly seen as a complication of skin diseases, scratching and inflammatory bowel disease. Also homosexual practices and anorectal sexually transmitted disease can cause multiple fissures in both sexes.
Anal chancre is becoming more common and may present as a painful rather than a painless ulcer. The serous discharge contains spirochetes. All patients with sexually transmitted disease, and admitted homosexuals, should be tested for a positive serological response to HIV as they may have ADIS.
Tuberculous ulcer has an undermined edge. Proctalgia fugax is characterized by attacks of severe pain arising in the rectum, recurring at irregular intervals and apparently unrelated to organic disease. The pain is described as cramp-like often occurs when the patient is in bed at night, usually lasts only a few minutes, and disappears spontaneously.
MANAGEMENT OF FISSURE IN ANO
Basic principle –
The pain of an anal fissure is so great that usually the patient demands relief, and consequently many patients with an acute fissure present early. The object of all treatment for this condition is to obtain complete relaxation on the internal sphincter. Provided the complications are dealt with, the fissure will slowly heal as soon as all spasm has disappeared.
Conservative treatment –
Simple conservative measures will give relief in cases where the fissure is acute and superficial and where the inflammation is minimal.
1. Conservative dilatation – 5% Xylocaine in a water-soluble lubricant is introduced with a fine nozzle into the anal canal. After waiting a few minutes for the surface anesthetic to act, relaxation may be sufficient to permit the passage of a well-lubricated finger into the canal. Next a small anal dilator may be passed and, if the anesthesia is adequate, the largest dilator may be introduced. The patient is supplied with Xylocaine lubricant and instructed to pass a dilator twice a day for a month, by which time the fissure is usually healed. Laxatives are prescribed to ensure that the motion is soft, but the stools should not be made watery.
2. Injection therapy – a superficial fissure of recent origin can often be rapidly and effectively healed by the injection of an oil soluble local anesthetic. The injection is made both into the superficial tissues subjacent to the fissure thus giving relief from pain, and deeply into the external sphincter so as to allay spasm. Complete anesthesia with the abolition of spasm is produced within a few minutes and should last for 14 – 21 days. By this time the fissure may be found to have healed or further injections may be given. Technique – several preparations are available containing procaine in oily solution to prolong the action of the anesthetic. The viscous solution is warmed by placing the ampoule in hot water, and is drawn up into a 10ml syringe. It is necessary to use a fairly large bore needle. The patient is placed in the right lateral position. A small quantity of 1-2% aqueous solution of procaine is used to raise as intradermal wheal in mid-line posteriorly, 2.5 cm from the anus. The left index finger is inserted into the rectum, and the anal canal is drawn downwards by flexion of the terminal joint. The needle is introduced into the anesthetized area of the skin and is directed deeply into the sphincteric muscle on one or the other side, the finger within the canal serving as a guide to the position of the needle point, and the solution is injected fanwise as far forward as the anterior edge of the anus. The opposite side of the canal is then infiltrated in a similar manner, without withdrawing the needle from original skin puncture, and finally an injection is made into the superficial tissue immediately deep to the fissure. In all, 10-20ml of solution is injected.
Operative measures –
1. Lord’s anal dilatation – this is the simplest procedure, involving a wide forcible dilatation of the sphincter. Under general anesthesia, the index and the middle fingers of each hand are inserted simultaneously into the anus and pulled apart to give maximal dilatation. The patient can go home the same day, but should be warned that there may be some fecal incontinence lasting possibly for a week or 10 days.
Surgical measures are advisable in cases -
· If earlier measures are ineffective.
· If the fissure is chronic with fibrosis.
· Presence of a skin tag or mucous polypus.
General anesthesia is best, though some surgeons use Xylocaine or Lignocaine introduced into the ischiorectal fossa on each side, in order to anesthetise the nerves passing to the rectum. A caudal block is also suitable.
2. Lateral anal sphincterotomy – in this operation the internal sphincter is divided away from the fissure itself – usually either in the right or in the left lateral positions. The procedure can be done by an open or a closed method. Healing is usually complete within 3 weeks. This is done after the anal canal has been stretched and everted. A bivalve speculum is introduced into the anal canal, and is gradually opened to expose the fissure and put the fibers of the internal sphincter under stretch. These fibers are completely divided to just above the dentate line, to expose the smooth conjoined longitudinal muscle lying underneath. The wound is prolonged in the same direction to excise a tag, if present.
This operation is more successful for acute than chronic fissures. 75% of the cases are suitable for this operation. The patient can leave the hospital within 3 to 4 days; the procedure can be done as an outpatient under local anesthesia by an experienced surgeon.
3. Dorsal fissurectomy and sphincterotomy – the essential part of the operation is to divide the transverse fibers of the internal sphincter in the floor of the fissure. If a sentinel pile is present, it is excised. The ends of the divided muscles retract and a smooth wound is left. The after treatment consists of attention to bowels, a daily bath, and the passage of an anal dilator until the wounds have healed; which usually takes about 3 weeks. Despite the presence of the wound, there is little or no pain and the results are good.
The disadvantage of this operation is the prolonged healing time – usually not less than 3 weeks and often more and, occasionally, a mild persistent and permanent mucous discharge. It is now reserved only for the most chronic or recurrent anal fissure, the majority being treated by lateral sphincterotomy.
4. Excision – when the fissure is a chronic one, or shows much induration, it is probable that complete excision is the operative choice. After the sphincter has been stretched, two pairs of light tissue forceps are placed on the muco-cuteneous junction well to each side of the fissure, and are drawn downwards until the entire fissure comes into view. With a sharp knife the fissure is clearly excised by an elliptical incision, which is deepened down to the fibers of the internal sphincter. To ensure free drainage the ellipse, which includes the sentinel pile, should be carried out well on to the perianal skin, where it should be at least 2 cm in breadth. The sphincteric fibers immediately deep to the fissure may be divided at the same time. Thereafter the floor of the wound should be completely smooth and free from ridges and hollows.After treatment – after either sphinctertomy or excision, bleeding is arrested by the application of a gauge swab, a corner of which may be tucked into the anal canal. It is covered with wool and secured with a T-bandage. The dressings are changed daily, but subsequent repacking of wound should not be required. Hot sitz baths are instituted as early as possible, and gentle cleaning with soap and water is carried after each evacuation. There is almost complete relief of pain immediately after the operation, and healing may be expected to be complete in from 10 days to 3 weeks. The bowel motions should be kept soft for several months after operation, since, if constipation is allowed to exist, there is considerable risk that fissure may recur.
