Fissure of the Anus and Fistula in Ano

In Short

Published in 1892 as part of "The Physicians' Leisure Library," this brief medical treatise systematically demystifies anal fissures and fistulae. Dr. Lewis H. Adler, Jr. outlines their anatomical causes, diagnostic signs, and clinical management. He addresses how patient modesty, hygiene oversights, and medical neglect allow these painful conditions to progress. Through clear clinical guidelines, Adler details conservative topical remedies alongside definitive surgical techniques like dilatation, incision, and elastic ligatures. The book remains a remarkable window into late nineteenth-century surgical precision, showing how structured physical examination and local anesthesia transformed patient care.

The Story

The text develops an authoritative argument for structured clinical intervention over neglect. Adler opens by confronting a pervasive medical problem: both patients and physicians routinely ignore rectal disorders. Patients delay care due to false modesty, poor hygiene habits, or fear of examination, while practitioners frequently misdiagnose anal lesions as uterine or bladder ailments. To resolve this, Adler establishes a baseline of local anatomy, focusing on the external and internal sphincters and "Hilton's white line." This precise border marks where pudic nerve branches exit, explaining why even minute mucosal cracks produce intense, agonizing pain and reflex spasms.

From this foundation, the narrative turns to anal fissure, or irritable ulcer. Adler describes its etiology—ranging from constipation and local trauma to syphilitic lesions—and walks through the steps of physical exploration. He stresses the necessity of proper lighting, positioning, and local anesthesia using cocaine solutions to prevent diagnostic pain. Treatment advances from conservative, palliative methods to direct surgical solutions. Palliative care centers on regulating the bowels with semi-fluid evacuations and applying topical silver nitrate solutions to destroy callous edges and form a protective albuminate layer. When palliative care fails, Adler details operative measures: simple incision of the ulcer base or a combined method of sphincter dilatation and incision, which he presents as an unfailing cure.

The second half shifts to fistula in ano, tracing its origin back to unhealed peri-anal abscesses, foreign bodies like swallowed bones or seeds, or local inflammation. Adler emphasizes that treating a threatened abscess early with free incisions and proper drainage prevents complex fistulous tracks from developing. He categorizes established fistulae into complete, external, and internal varieties, detailing diagnostic methods using probes, specula, and dye injections like milk or iodine to map hidden channels.

Adler then systematically evaluates non-operative and operative treatments for fistula. While palliative methods like curetting the sinus wall and injecting stimulating agents can succeed in mild cases, complete or complex fistulae require surgical division of the intervening tissues. He warns against cutting through sphincters in multiple locations, which risks the dread complication of fecal incontinence, and outlines specialized operations for complex "horseshoe" fistulae. For patients terrified of the knife or prone to bleeding, he presents the elastic ligature technique as a reliable alternative that slowly strangulates the tissue. The text concludes with explicit post-operative regimens, advocating recumbent rest, controlled bowel movements, and careful wound hygiene to ensure complete recovery.

How It Unfolds

Laying the anatomical foundation Adler details the muscular mechanics of the inner and outer sphincters, highlighting how sensitive nerve endings exiting along Hilton's white line cause severe pain when exposed by mucosal ulcers.

Mapping the irritable ulcer The author outlines the visual signs of anal fissure, including the "sentinel pile," and details how to conduct pain-free digital and ocular examinations using local cocaine applications and proper positioning.

Executing fissure therapies Adler moves from palliative topical applications of nitrate of silver to surgical intervention, demonstrating why combined dilatation and incision offers a definitive cure.

Tracing the origins of fistula The text explores how peri-anal abscesses, trauma, and swallowed foreign objects form fistulous tracts, stressing that immediate evacuation of pus prevents extensive tissue burrowing.

Navigating complex fistulous tracks Using probes, specula, and liquid injections, the surgeon learns to distinguish between complete, external, and blind internal fistulae to map out hidden sinuses.

Dividing the tissue safely Adler guides the operator through delicate cutting procedures to unroof the fistula, warning strictly against multiple sphincter cuts that cause fecal incontinence, while presenting the elastic ligature as a non-cutting alternative.

The People

Because this text is a clinical treatise rather than a narrative, its central figures are the diagnostic concepts, anatomical structures, and surgical instruments that drive Adler's clinical reasoning.

• Anal Fissure (Irritable Ulcer): A small, highly sensitive ulcer located at the anal verge, often hidden within mucosal folds. It demands relief from constant sphincter spasms through topical nitrate of silver or precise surgical incision.
• Fistula in Ano: A persistent, discharging sinus track resulting from an improperly healed abscess. It strives to burrow deeper into cellular tissues and requires mapping and complete division to heal from the bottom up.
• The External and Internal Sphincters: The dual ring muscles controlling the anal outlet. They stand as both a cause of suffering—by clamping down in painful spasms—and a crucial structure that the surgeon must protect to prevent fecal incontinence.
• Cocaine Hydrochlorate: The newly adopted local anesthetic agent that allows painless physical examinations and minor operative procedures, provided it is used cautiously to avoid systemic toxicity.
• The Elastic Ligature: A solid india-rubber cord introduced through the fistulous track and clamped tight, serving as an effective non-cutting alternative for patients who refuse the knife.

In Its Own Voice

"While the two subjects treated in this volume have been ably written on at various times and by different authorities, it is undeniable that no organ of the body is more neglected by both the laity and the profession than is the rectum."

Adler opens his preface by identifying the social modesty and clinical carelessness that allow easily treatable conditions to become chronic sources of suffering.

"The upper portion of the rectum possesses very little sensibility, as the chief nerve-supply of the organ is at its termination and around the anus; hence it is that such grave diseases as cancer or ulceration may exist in the higher parts of the bowel and not manifest their presence by pain."

Here, the author explains the anatomical distribution of nerves that concentrates acute sensitivity at the anal verge while leaving higher structures deceptively silent.

"In opening these abscesses, if possible, ether should be given... When pus is present, the operator should stand out of the line of its exit, for when the cavity is opened it often squirts out a considerable distance."

Adler offers a vivid, highly practical piece of surgical advice for managing pressurized peri-anal abscesses in the operating room.

What It's Really About

Underneath its technical descriptions of scalpels, bistouries, and topical solutions, the book argues for rigorous, uninhibited physical examination as the foundation of proper medicine. Adler wages a quiet war against the false modesty and clinical inertia that leave patients suffering in silence. By showing how reflex pain from a tiny fissure can simulate severe uterine, bladder, or stricture disease, he demonstrates the danger of treating symptoms without a thorough local investigation.

The work also captures a pivotal moment in medical history: the shift toward humane, painless surgery. By integrating newly discovered local anesthetics like cocaine and refined surgical techniques, Adler shows how severe, debilitating afflictions can be cured safely and predictably without unnecessary trauma or permanent loss of function.

Why Read It Today

Medical historians, practitioners, and readers curious about late Victorian science will find this brief manual deeply compelling. It provides a direct, unvarnished look at late nineteenth-century clinical practice before the era of modern antibiotics, where successful outcomes depended entirely on precise anatomical knowledge, clean surgical cuts, and attentive wound management.

The reading experience is crisp, methodical, and surprisingly engaging. Adler writes with absolute clarity, avoiding flowery prose in favor of direct instruction, vivid anatomical descriptions, and practical tips gathered from his clinical experience at the Philadelphia Polyclinic.

While modern readers must navigate historical medical terminology, outdated drug applications like iodoform or carbolic washes, and graphic descriptions of rectal pathology and surgery, the text remains thoroughly accessible. It stands as a impressive artifact of nineteenth-century clinical precision, displaying a dedicated surgeon's commitment to relieving human suffering through meticulous diagnostic care.