Tuberculous ulcers are not infrequently primary, usually the accompaniment of advancing and ulcerative infection of the intestine above, or secondary, as frequently occurs when the more innocent forms suffer a secondary tuberculous infection, becoming thus converted into lesions of pronounced type.
Typhoid ulcers in the rectum are rare, but those connected with dysentery are common, especially in localities where tropical or other forms of the disease prevail. The innocent tumors within the rectum, such as polypi and adenomas, etc., tend to break down because they are kept continually macerated and exposed to contamination. Even innocent hemorrhoidal tumors are extremely prone to suffer in this way because their epithelial covering is thin and they are exposed to both external and internal contamination. Finally every malignant tumor which grows into the rectum tends to break down, and sooner or later to present an ulcerating surface. The causes of rectal ulceration are then seen to be various. Nearly everyone of them may be an exaggeration of a condition first producing an acute proctitis.
Ulcers occupying the anal region are usually compressed into a linear form and present rather as cracks or linear abrasions. These are known as fissures and are spoken of as fissures in ano or rectal fissures, according to their situation. These fissures occupy the most sensitive portion, i. e., the lower inch and a half of the rectum, and become in time irritable, erethistic lesions, whose sensibility is constantly enhanced by the reflex spasm of the sphincter which they produce. An essential part of the treatment of every such case is dilatation of the sphincter, as well as the destruction of the irritable surface, even the former alone often sufficing for the milder cases. Anal fissures, like corneal ulcers, give rise to exquisite pain and annoyance, and produce irritability and general distress. Their treatment is so simple that there is no excuse for allowing patients thus to suffer.
To a peculiar form of combined infiltration and ulceration involving the lower part of the rectum, the anus, and, in females, more or less of the vulva, the French have given the name esthiomene. It has been considered due to more or less mixed forms of infection, including those of chancroid, syphilis, tuberculosis, and other undescribed types. It is a mixed infection, and not necessarily of the same type in all cases. It is usually seen in old syphilitic subjects or in prostitutes. It produces more or less deforming lesions, and sometimes such active and protuberant granulations as to cause it to be mistaken for epithelioma or condyloma. It is essentially chronic, and its most striking characteristic is the combination of ulcerative and hyperplastic processes which it presents. Clinically it is a chronic ulcer, with thickened and deformed base and with all the possible consequences or complications of ulcer in this region.
The other forms of ulcer above mentioned appear singly or multiply in any and every possible location, pronounced types presenting extreme pictures of an ulcerated, inflamed, partially destroyed tube, which needs only to be seen before recognizing the advisability of a colostomy for the purpose of rest of the inflamed surfaces.
Symptoms.
—The symptoms of rectal ulceration are essentially those of proctitis, mild or severe as the case may be, with local pain, and escape of pus and blood. Much depends upon their location, i. e., whether within the sensitive area or not. Ulcer low down in the rectum, no matter how produced, will always cause a disproportionate amount of suffering, because of the reflex sphincteric spasm which it produces. On the contrary, ulcers high up give rise to little or no suffering, and may be discovered only after a history of discharge of blood or pus prompts a thorough local examination. Therefore, without reference to the feature of pain, every statement that mucus, pus, or blood is discharged from the rectum should lead to an examination, sufficiently thorough to detect and expose the cause and permit of proper treatment. Should local anesthesia prove unavailing for this purpose a general anesthetic must be administered. Thus the non-specific, the syphilitic, and the tuberculous ulcers may be scraped and cauterized, care being taken not to perforate. If ulcerating tumor is found it should be operated upon at once. Sometimes, however, by these examinations unsuspected conditions are revealed such as to give the case a serious aspect. In this event a second anesthetic, with operation, will be necessary. For all ordinary purposes, however, sufficient specula, curettes, the actual cautery, and applicator, by which suitable local treatment can be made to the affected surfaces, should be provided.
Treatment.
—As indicated above in the treatment of proctitis there is need also for various local anodynes and soothing applications. Physiological rest for the inflamed bowel is imperative. Finally, in extreme cases, it has been shown that it is best to open the colon above the seat of the principal disturbance, doing this even on the right side should the whole large intestine be involved, and by thus relieving it of its duties enable more complete physiological rest and local treatment.