THE TEE A TMENT OF A HAL 
FISSURE, OR IRRITABLE 
ULCER OF THE RECTUM. 
—BY— 
LEWIS H. ADLER, JR., M.D. [REPRINTED FROM THE AMERICAN LANCET, MARCH, i8q3-1 
THE TREATMENT OF ANAL FISSURE, OR IRRI- 
TABLE ULCER OF THE RECTUM.* 
LEWIS H. ADLER, JR., M.D.f 
'T'HERE are some general rules that must always form 
1 a part of the treatment of anal fissure, to wit: to 
lessen as much as possible any inordinate action or dis- 
tension of the bowel, and to prevent the ulcerated sur- 
face being irritated and abraded by the passage of 
hardened faeces. 
To fulfill these indications, enemata or mild aperi- 
ents should be employed, and the diet must be regulated, 
the use of bland and unirritating food being enjoined. 
It is not possible to point out a diet that would be 
even generally applicable, as so much must depend upon 
the state of the constitution and the previous habits of 
the patient; but in general the food should be moderate 
in quantity, yet sufficiently nutritious—easily digestible 
and having no tendency to produce constipation. 
The patient should be directed to take moderate 
exercise; and if the bowels are disposed to be costive, a 
* Read at the meeting of the Philadelphia County Medical 
Society, Nov. 23, 1892. 
f Instructor in Diseases of the Rectum, Philadelphia Poly- 
clinic and College for Graduates in Medicine. 2 
daily evacuation should be secured by the administration 
of an enema of warm water, or one of rich flaxseed tea, 
say from half a pint to a pint, to be given every evening 
—preference being given to the night-time, as the pa- 
tient can then assume the recumbent posture, which, 
combined with rest, affords the greatest protection from 
subsequent pain. 
Instead of the enema, or in conjunction with its use, 
the action of the bowels may be regulated by the em- 
ployment of some mild aperient such as the patient has 
found by experience to agree with him. 
All drastic purges should be avoided, as they are 
more or less stimulating and irritating to the extremity 
of the rectum. 
The pain and spasm of the sphincter muscles at- 
tending the evacuation of the bowels are best relieved by 
the use of a suppository consisting of: 
3 Ext. belladonnae grain. 
Cocain. hydrochlor Y~Y grain. 
Ol. theobromae io grains. 
Misce et ft. suppositoria j. 
One suppository to be employed about half an hour be- 
fore the enema is given or a movement of the bowel is 
expected. 
Instead of the suppository, an ointment of extract 
of conium may be used, as recommended by Harrison 
Cripps:* 
* “ Diseases of the Rectum and Anus,” second edition, Lon- 
don, 1890, page 189. 3 
R Ext. conii 3 ij. 
Olei ricini f 3 iij. 
Ung. lanolinii q. s. ad § ij. 
M. 
A small quantity of this ointment should be smeared 
over the parts five minutes before a passage, and again 
after it has occurred. 
The various methods of treating anal fissure may be 
divided into the Palliative and Operative. 
Palliative Measures.—Palliative treatment will 
meet with success in cases in which the fissure is tolerably 
superficial and of somewhat recent origin, especially 
when there is no great hypertrophy of the sphincter 
muscles. 
Allingham* states that the curability of the lesion 
does not depend upon the length of time that it has 
existed, but rather upon the pathological changes it has 
wrought. This same authority states that he has cured 
fissure of months’ standing by means of local applica- 
tions, when the ulcers were uncomplicated with polypi 
or haemorrhoids, and when there was not marked spasm 
or thickening of the sphincters. 
It is essential to the success of the treatment of 
fissure, especially by local applications, that rigid clean- 
liness of the parts be maintained; for this purpose the 
anus and the adjacent portions of the body should be 
carefully sponged night and morning and after each 
*“ Diseases of the Rectum,” fifth edition, London, 1888, 
page 215. 4 
stool with hot or cold water, the temperature being regu- 
lated to suit the patient’s comfort. 
In applying the various local remedies, it is neces- 
sary first to expose the ulcer to view, and to anaesthetize 
its surface with a 4- or an 8-per-cent, solution of cocaine 
hydrochlorate, well brushed in with a camel-hair pencil. 
The application may have to be repeated once or twice, 
at intervals of about five minutes, in order to obtain the 
desired anaesthetic effect. 
If any ointment has been used about the fissure, the 
anus should be subjected to a hot-water douche before 
using the cocaine, as cocaine will not exert its anaesthetic 
influence on a greasy surface.* 
Among the different remedies that have been used 
in the local treatment of fissure of the anus may be men- 
tioned the following: Nitrate of silver; acid nitrate of 
mercury; fuming nitric acid; carbolic acid; sulphate of 
copper; the actual cautery; and chloral hydrate. 
Of these topical applications the nitrate of silver is 
the best. Its effects are various: it lessens or entirely 
calms the nervous irritation which is so important a 
factor in producing spasmodic contraction of the 
sphincters; it coats and shields the raw and exposed 
mucous surface by forming an insoluble albuminate of 
silver; it destroys the hard and callous edges of the 
ulcer, and tends to remove the diseased and morbid ac- 
tion of the parts. 
* W. P. Agnew, M.D., “Diagnosis and Treatment of 
Hemorrhoids, etc.,” second edition, San Francisco, Cal., 1891, p. 
91- 5 
The form in which this salt is usually employed is 
in solution (from io to 30 grains to the ounce). The 
stick caustic may be also used. 
To accomplish the best results, the solution should 
be used once in twenty-four or forty-eight hours, accord- 
ing to circumstances. It may be applied by means of 
cotton attached to a silver probe or to a piece of wood. 
The application is made by separating the margins 
of the anal orifice with the thumb and index finger of 
the left hand, and introducing into the anus the probe 
charged with the solution. The argentic nitrate is to be 
applied to the fissure only; a few drops are all that is 
required. If thorough local anaesthesia has been in- 
duced by the use of cocaine, the application of the silver 
salt produces little (if any) suffering, for by the time the 
anaesthetic has lost its effect the otherwise acute pain of 
the nitrate of silver will have passed away. 
After each application the part should be smeared 
well with an ointment of iodoform (30 grains to the 
ounce). The odor of that drug may be disguised by the 
addition of a few drops of otto of roses. Iodol may be 
used instead and in the same way, but I prefer the iodo- 
form, owing to its anaesthetic qualities. 
After the ulcer has been touched once or twice with 
the silver solution, the effect will be, in the cases that 
are benefited by this treatment, a considerable mitiga- 
tion of the pain from which the patient suffered when at 
the closet and afterward, and the sore will present a 
healthy, granulating appearance, and will slowly con- 
tract in size. Some authorities speak highly of the use of the acid 
nitrate of mercury, fuming nitric acid, carbolic acid, the 
actual cautery, etc.; but their employment, with the single 
exception of carbolic acid, is attended with more suffer- 
ing than follows the use of the nitrate of silver or the 
simple operative treatment presently to be described. 
Furthermore, the application of these remedies is not so 
certain to effect a cure as either of the two procedures 
just mentioned. 
The daily introduction of a full-sized bougie, made 
of wax or tallow, will sometimes act beneficially in cases 
of fissure by stretching the sphincter and producing such 
an amount of irritation as will set up a healing process 
in the ulcer. An application of cocaine or of belladonna 
ointment should be made to the part previous to the use 
of the bougie. 
In children and young persons, unless a polypus or 
polypoid growth or congenital contraction complicates 
the fissure, it is almost always curable without operation. 
In children suffering from hereditary syphilis, 
numerous small cracks round the anus are common, and 
they cause much pain. Mercurial applications and ex- 
treme cleanliness soon cure them, but they will return 
from time to time unless anti-syphilitic medicines be 
taken for a lengthened period.* 
Operative Treatment.—If, after a fair trial of 
the simple measures that have been recommended, the 
fissure does not heal; or if, as described by Allingham,f 
6 
*Allingham, loc. cit., p. 213. 
f Loc. cit., p. 217. 7 
the base of the ulcer be gray and hard, and if on passing 
the finger into the bowel the sphincter be found hyper- 
trophied and spasmodically contracted, feeling, as it 
often does, like a strong india-rubber band with the 
upper edge sharply defined; or if there should be a poly- 
pus, polypoid growth, or any other complication; then 
local treatment will not effect a cure, and operative inter- 
ference will be rendered necessary. 
There are three methods of repute to be considered 
in this connection: incision, forcible dilatation, and a 
combination of these two procedures, viz , dilatation and 
incision. 
Incision: A fissure can be cured by making an in- 
cision through the base of the ulcer and a little longer 
than the fissure itself, so as to sever all of the exposed 
nerve-filaments and muscular fibres along the floor of the 
ulcer. In a certain proportion ot cases this operation 
will meet with success, but it is not so certain and radi- 
cal as the third method to be described. It has the 
advantage over the other two operations, however, of 
being nearly or entirely painless under local anaesthesia 
produced by cocaine; and therefore, when general anaes- 
thesia is contra-indicated or is refused by the patient, 
this method is worthy of trial. 
Forcible Dilatation: This is the operation recom- 
mended by Recamier of Paris, Van Buren of New York, 
and others. It consists in the introduction of the 
thumbs into the bowel, back to back, and then forcibly 
separating them from each other until the sides of the 
bowel can be stretched as far out as the tuberosities of 8 
the ischia. It is well to place the ball of one thumb 
over the fissure, and that of the other directly opposite 
to it, in order to prevent the fissure from being torn 
through and the mucous membrane stripped off. As 
pointed out by Allingham,* it is well to repeat the 
stretching in other directions until the entire circumfer- 
ence of the anus has been gone over. In this manner, 
by careful and thorough kneading and pulling of the 
muscles, the sphincters will be felt to give way and will 
be rendered soft and pliable. This procedure should 
always be practiced with the patient thoroughly under 
the influence of an anaesthetic, and it should occupy at 
least five or six minutes. The operation is a perfectly 
safe one; but as it is no less severe than the method by 
incision, and as it fails to effect a cure in some cases, I 
can see no advantage in adopting it instead of the more 
satisfactory and always successful plan of treatment— 
combined dilatation and incision. It may be found pref- 
erable, however, in some cases on account of the preju- 
dice of patients against the use of the knife. 
Rapid forcible dilatation for the cure of fissure is a 
method now tried by some surgeons, and apparently with 
a fair measure of success. The patient is placed under 
the influence of nitrous oxide gas, and the sphincters 
are quickly stretched either by manual force or else 
with instrumental power. For my part, I do not see 
how a satisfactory dilatation can be accomplished in this 
way. When the cure of fissure by dilatation is attempted 
* Loc. cit., p. 326. 9 
under ether-anaesthesia—the muscular system being com- 
pletely relaxed—the thorough paralysis of the sphincters 
occupies several minutes before they are felt to yield, 
and the strain upon the operator’s thumbs incident 
to the operation becomes very tiresome, to say the 
least. 
With anaesthesia produced by nitrous oxide, we ob- 
tain a suspension of muscular action, but no general 
muscular relaxation; hence, to suspend the function of 
the sphincters to such a degree as to remove the cause 
which prevented the healing of the ulcer—viz., the con- 
stant motion of the muscular fibres,—we must exert a 
force which would be both detrimental and dangerous to 
our patient’s welfare. Therefore I cannot believe that 
this plan of treatment will be commended by the con- 
servative surgeon. 
Dilatation and Incision: This method I believe to be 
a radical and unfailing cure for anal fissure, if skillfully 
and carefully performed. The following are the details 
of the operation: The bowels should be thoroughly 
cleansed by the previous administration of a dose of 
castor oil and an injection; after which, under ether- 
anaethesia, the sphincters should be dilated in the man- 
ner previously described. The resulting hyperdistension 
of the anus not only affords rest to the parts, by the 
temporary paralysis of the muscles, but it also, as pointed 
out by Van Buren, stretches the sensory nerves of the 
anus so that they cease for the time being to convey 
impressions, the result of irritation, to the nerve-fibres 
exposed in the floor of the ulcer; in the same way that 10 
we find that forcible stretching of the sciatic and the 
sensory branches of the fifth nerve relieves neuralgia. 
Chas. B. Ball* states that this theory, of the tem- 
porary cessation of the function of the sensory nerves 
following the hyperdistension of the bowel, receives con- 
siderable support from the fact frequently observed that 
the first time the bowels move after the dilatation there 
is entire immunity from the pain which before was so 
severe. 
The first step in the operation being accomplished— 
the dilatation of the sphincter—we are enabled to obtain 
a complete view of the lower end of the rectum and the 
exact limits of the ulcer. The fissure is now kept 
exposed by the fingers of the left hand; and a probe- 
pointed bistoury is drawn through its base, from within 
outward, so as to incise the subjacent muscular fibres at 
right-angles to their course. It is well to begin the inci- 
sion a little above, and to end it a little below, the ulcer, 
so as to insure its being carried quite through the sore. 
Another method is that advocated by Mr. Syme, 
and is performed by transfixing the ulcer beneath its 
base with a small, sharp-pointed, curved bistoury, and 
cutting from without inwards. With this procedure the 
opposite side of the bowel, unless protected, is in danger 
of being wounded. 
The subcutaneous division of the sphincter, as 
recommended by some authorities, is not a satisfactory 
method, and is mentioned solely for the purpose of con- 
* “The Rectum and Anus,” p. 136. demnation. It is not only uncertain in its results, but it 
is also painful, and in more than one instance has been 
followed by abscesses. 
In cases in which the fissure is situated in the 
median line of the rectum, either anteriorly or poste- 
riorly, care should be observed in making the incision, 
for the reason that wounds towards the coccyx split and 
separate the fibres of the external sphincter only, and 
are difficult to heal, while anatomical considerations will 
deter us from using the knife freely anteriorly—in the 
male because the bulb of the urethra is in close prox- 
imity; and in the female because of the shortness of 
the perineum, and the fact that division of the anterior 
fibres of the sphincter is so frequently followed by incon- 
tinence of faeces.* 
After any of these the patient should keep the 
recumbent position, and it is better to confine the bow- 
els with opium, at least for the first forty-eight hours. 
After three or four days a laxative followed by an enema 
may be given, from which time daily alvine movements 
should be secured. In seven or eight days the patient 
can begin to move about, but for at least two weeks he 
should avoid standing too long on the feet. No dress- 
ing is required, except a small quantity of iodoform, 
which should be dusted over the ulcer; and the parts 
should be bathed well with warm carbolized water night 
and morning, to remove offensive discharges. (Mar- 
11 
* T. J. Ashton, “Diseases, Injuries, and Malformations of 
the Rectum and Anus,” etc., second American from the fourth 
English edition; 1865; pp. 49-50, 12 
chand’s peroxide of hydrogen may be used instead of the 
carbolized water.) 
In the majority of cases of fissure, healing progresses 
with great rapidity; but occasionally, after the wound 
has healed to a certain extent, healthy action stops, and 
the appearances of an anal ulcer are again produced. 
Should this occur, it will generally be found that some 
complication has been overlooked, such as a fistulous 
passage running from the ulcer beneath the mucous 
membrane of the bowel. The presence of such a passage 
might be suspected if the discharge from the part is out 
of proportion to the size of the ulceration.* 
Another complication consists of a small hypertro- 
phied tag of membrane, or polypoid growth, situated at 
the base of the fissure or on some other portion of the 
rectal wall. 
The removal of these complications will aid in the 
patient’s recovery. 
* Harrison Cripps, loc. cit., p. 190.