A system of practical medicine. By American authors. Vol. 2

by Unknown

Ulceration of the Rectum and Anus.

This is a condition very different from fissure or the painful ulcer of Allingham—much more grave, difficult to treat, and, in chronic cases, much less hopeful of cure. It is not an uncommon affection, Allingham's table of 4000 consecutive cases of diseases of the rectum and anus furnishing 190 of the disease under consideration. An ulcer of the rectum may be partly within, partly without, the internal sphincter, but in most instances is found above that muscle, from an inch and a half to two inches from the anus, situated dorsally.

The symptoms are unfortunately obscure and insidious, misleading not only the patient, but also too frequently his medical adviser, and gaining grave headway before a correct diagnosis is reached. Often the very first symptom is a slight diarrhoea every morning as soon as the patient rises, accompanied with a little discharge resembling coffee-grounds; or, again, the discharge is like the white of an egg; in some rare instances pus is formed. At this stage there is little or no pain, but the patient suffers from tenesmus—which is not followed by relief—and a sense of uneasiness in the part. Several stools of this nature or streaked with blood may be passed during the earlier part of the day, after which the patient feels partly relieved, and no more evacuations occur until the following morning, when he again experiences the same train of symptoms; and this repeats itself daily for a long time. Finally, these discharges occur in the evening as well as in the morning, then at various times during the day: his general health begins to give way; the discharge becomes augmented in amount and contains more blood and pus; and he suffers occasional pain from flatulent distension. Local pain in the rectum is now felt, which is not acute, but is very wearying, is augmented by much walking or by long standing, and which has been described as similar to a dull toothache. These ulcers may be multiple, and not infrequently lead to stricture of the rectum, which condition is indicated by the alternation of attacks of diarrhoea and constipation. As the ulcerative process proceeds, nature makes efforts to limit the process, which causes infiltration and thickening of the submucous and muscular tissues, and produces narrowing of the lumen of the intestine, which in time loses its tone and contractile power and becomes a passive tube, utterly unfit to perform its normal duties. The sphincters give way and the patient loses control over his evacuations. Finally, abscesses form, which, burrowing toward the surface, form fistulæ, and may perforate the bladder, the vagina, or the peritoneal cavity. If one of these ulcers be examined while yet in the acute stage, it will be found to be oval in shape, with well-defined edges: the base will be either grayish or very red and inflamed, the surrounding mucous membrane appearing normal. The rectal glands will be found to be enlarged. Should the ulcer be examined at a later stage, it will be found to be much deeper and more extensive, with great thickening and nodulation of the mucous membrane, and looking in places as though the latter had been torn off. At this stage the ulceration may be partial or may involve the entire lower portion of the rectum. The suffering is now intense, and a constant discharge of fetid pus and mucus takes place. The appearance of the anus at this time suggests malignant disease: it is covered with swollen, shiny, tender, club-shaped flaps of integument constantly bathed in an ichorous discharge. The entire rectum and sigmoid flexure have been involved in some cases, while in others necrosis of the sacrum has occurred. Patients suffering from ulceration and stricture are very liable to a low form of peritonitis, attended by intense abdominal pain.

The causation of these ulcers of the rectum is frequently very obscure: some are of syphilitic, others of strumous, origin. Some are of traumatic origin, but more often the patient was in apparent health up to the time of the appearance of the disease. The experience of Allingham would indicate that neither chronic constipation nor dysentery is a frequent forerunner of this malady. T. Claye Shaw,¹³ in an article entitled "On Some Intestinal Lesions of the Insane," says: "After death are found patches of ulceration sometimes so extensive as to resemble a honeycomb network. The edges are usually slightly raised, and perhaps hardened; but the ulcers are at other times mere local punchings out of the mucous membrane, and there is often a little loose gelatinous material." It is claimed that such disorders are not infrequent among the insane.

¹³ St. Bartholomew's Hospital Reports, 1880.

It is also claimed that the chronic mechanical irritation from foreign bodies, impacted feces, and the like exert a causative influence in the formation of ulcer of the rectum. Like typhlitis, this affection leads to chronic inflammatory changes in the immediate neighborhood (periproctitis), with the formation of fistulæ and crater-shaped ulcerations, and to the extensive destruction of the mucous membrane, followed by wasting and contraction of the rectum. The healing of these ulcers is much delayed by the fact that the ulcerated and undermined mucous membrane is irritated by the fecal masses which are especially apt to accumulate in the lower part of the bowel and around the anus. We find also hemorrhoidal swelling and ulcerations, which may be regarded as partly a cause, partly a result, of the ulcerative proctitis.

Follicular Ulcerations.

In this condition the most extensive ravages are found in the rectum and sigmoid flexure. The causes are identical with those of catarrh of the large intestine, if we except the follicular disease produced by dysenteric infection. In this form of the disease, at least in its earlier stage, the form of these ulcers is always round and funnel-shaped, with distinct thickening of the edges of the mucous membrane around the ulcers. These appearances may be explained by the mode in which the follicular ulcerations originate: "The solitary follicles become swollen, a result of catarrhal irritation, and the cellular elements accumulate in the reticulum, giving rise at first to nodules which project above the level of the mucous membrane: then the newly-formed tissue-elements become necrosed in consequence of the mutual pressure of the cells upon each other; finally, the apices of the follicular nodules give way and the ulcers are formed. The surrounding mucous membrane bends over downward toward the base of the ulcer, so that the orifices of the crypts look down into the same."¹⁴ As the suppurative process extends, particularly in the submucosa, and the tissue surrounding the follicles becomes destroyed, these small ulcers coalesce to form larger ones, and the undermined edges of the mucous membrane project over the base of the ulcers, bleed, and become necrosed. Healing is possible by cicatrization, the borders of mucous membrane becoming applied to the base of the ulcer and gradually drawn together by the cicatricial tissue. Still, this result is extremely rare if the ulcerative process has gained much headway. When, however, a follicular ulcer of some size does heal, cicatricial stenosis may result, followed by chronic constipation, just as in the case of simple catarrhal ulceration. The situation of follicular ulcerations is almost always in the large intestine, and they vary considerably in number: sometimes only a few follicles are thus affected, while in other cases the bowel is crowded with them.

¹⁴ Rokitansky, Path. Anat., iii. 1861, S. 226.

The anus and rectum may become the seat of chancroidal invasion. An ulcer of this character fairly within the rectum is very rarely met with, especially in this country, and could scarcely be produced except by unnatural intercourse. They are of not uncommon occurrence in the anal region, and are met with in this situation more frequently among females than among males. Occurring among the former, they no doubt often arise from accidental contact during normal sexual intercourse. When this condition is found in males, it rather indicates at least an attempt at unnatural intercourse. Of 1271 males affected with chancroids, only 3 were found with the disease in the anal region. Out of 388 females similarly affected, 33 were found with chancroid of the verge of the anus. The table of Debauge gives 23 cases among 206 females having chancroid in various other situations. The destruction of tissue in these cases may be very serious should the nature of the ulcer not be recognized, and stricture of the rectum or cicatricial stenosis of the anus might result. Ulceration of the rectum may occur during chronic proctitis; it may accompany advanced states of prolapse and procidentia of the bowel; it may attack a stricture of the rectum and cause peritonitis by erosion. Ulceration may accompany hemorrhoids, or it may attack them and cause dangerous hemorrhage. Finally, a very intractable form of ulceration may follow the clamp-and-cautery operation upon piles. When this untoward result is seen, it is usually due to the fact that the patient has been allowed to move about too soon. Allingham claims to have seen these ulcerated stumps of piles even ten days after operation.