SECONDARY DISEASES OF THE RECTUM AND ANUS.
This class of affections depends upon constitutional infection, direct extension of disease by contiguity, by contiguity from disease in neighboring organs, or by abnormal conditions excited by disease of remote origin; and are frequently due to changes in the nervous and vascular supply.
Syphilis of the Rectum and Anus.
True primary syphilitic chancre of the rectum must be an extremely rare lesion, and could have been acquired only by unnatural intercourse. There are syphilographers who deny that the hard chancre has ever been found within the sphincter muscles; but it certainly is not uncommonly found in the anal region, and oftener among women than men. The table of Jullien gives 12 instances of this lesion in males, and 1 instance of chancre of the buttock, out of 77 cases, while among 82 cases occurring in the opposite sex, 21 were of the anus and perineum and 4 of the buttocks. The French authorities give the frequency of this condition in men as 1 case in every 119; in women, 1 case in every 12.
Anal chancres are easily overlooked, as they occupy the puckered folds of the anus, which when not opened out to the fullest extent afford perfect concealment: they may be either in the form of cracks or slight fissures, elongated ulcerations, or firm papules. It has been claimed that the initial lesion has provoked stricture of the rectum, but this is not probable.
The secondary manifestations of this disease which show themselves in the anal region are some of the syphilodermata, moist papules, mucous patches, and moist papillomatous excrescences or condylomata. The statistical tables of Davasse and Deville16 in regard to the occurrence of moist papules and mucous patches in women show that out of 186 cases they appeared about the anus in 59 and on the perineum in 40. Bassereau's17 statistics show that in men these lesions occurred in the anal region 110 times out of 130 cases. These are, of course, very contagious. Besides true syphilitic warts, which sometimes occur in this region, it is quite usual to see the anus surrounded and the entire gluteal cleft filled up with moist, offensive, papillomatous excrescences, which remain obstinately so long as these surfaces are permitted to rest in moist contact. Syphilitic stricture of the rectum is one of the results of a later stage of infection, and occurs oftener among women than men. It is stated by Jullien that of 60 cases only 7 were men, the remaining 53 women. They are invariably formed as follows: A gummatous deposit in the submucosa undergoes ulceration, and the subsequent cicatricial contraction gives rise to the stricture. Whether the stricture will be valvular or annular depends upon the extent of rectal mucous membrane involved in the ulcerative process. The diffuse gummatous infiltration of the ano-rectal tissues and the subsequent deposition of contractile tissue are the most usual causes of these specific strictures. The lower portion of the rectum is commonly the situation of specific ulcerations, usually of the secondary or tertiary stage, which lead to the formation of stricture: this occurs more frequently among women than men, and between the ages of seventeen and thirty years. Gosselin and Mason regard strictures as the result of chancres, and not as the result of constitutional infection; but it is known that ulcerations of secondary syphilis may extend upward from affections about the anus, and also that gummata do commonly give origin to this condition. Gummata, and strictures following them, may be distinguished from other affections on account of the greater distance from the anus at which they occur, chancres or chancroid ulcers being usually within four or five centimeters of the anal orifice. Strictures due to gummata are more apt to occur late in life, but may therefore be easily confounded with cancer. Condylomata at the anus are often associated with syphilitic disease of the rectum.
16 Internat. Encyclop. of Surgery, vol. ii. p. 508.
17 Loc. cit.
Scrofulous and Tuberculous Affections.
There are cases which yield abundant evidence of struma in the form of enlarged glands, chronic abscess in the neck, swelling and abscess in the vicinity of the articulations, and the like, in which ulceration of the mucous membrane of the rectum has been found: this condition may result in fistula in ano by erosion, permitting escape of flatus and excrementitious products into the cellular tissue. A similar result may follow by erosion of the bowel from a strumous abscess in the connective tissue around the rectum; both these forms tend to the production of that class of fistula which has no outlet at the surface, but which has one or more openings upon the mucous membrane of the rectum. Thus concealed (for often there is no marked surface indication of either abscess or fistula), they may remain for a long time unsuspected and acting as a serious drain upon the already impaired constitution. The pus in these cases is watery, curdy, and offensive. These chronic conditions are subject to intercurrent attacks of acute inflammation, due to the lodgment in the abscess cavity or the fistulous tract of fecal matter or indigestible solid substances. Any or all of the abnormalities of this region may be complicated by the existence of tubercular or scrofulous conditions of the system. Tubercular ulceration of the rectum is now a well-recognized condition. Rectal ulceration and tubercular disease of the lungs have not been found to coexist in any marked preponderating number of tabulated cases. The frequent association of fistula in ano and tubercular disease of the lungs has long been recognized, Allingham having found 172 such cases among 1208 cases of fistula in ano.