ULCERATION AND FISSURE OF THE ANUS
Both of these conditions are usually associated in the same case, and for this reason are generally considered together. I think the rule, as far as I have been enabled to observe, will be found that while they may exist together, they have not a very close etiological relationship.
Ulcers are found of all kinds and varieties in the rectum, situated either just within the verge of the anus, or extending over so that part of the sore will be in the skin, and part in the mucous membrane. Whatever the form may be, traumatic, specific, carcinomatous or scrofulous, they are nearly always the seat of much pain, more particularly when partly cutaneous.
In depth they vary greatly; sometimes appearing as a shallow excoriation, at others penetrating to the muscular tissue. The form, as a matter of course, varies greatly, as also does the number, although they are more frequently single. My experience leads me to conclude that there is no uniformity in respect to semiology, nor are the bowels similarly affected. In some cases diarrhoea is a concomitant, in others an obstinate constipation; but more frequently there is a mixture of these characters, the first part of the stool being hard and dry, from the inflammation in the rectum and anus-while the latter portion is either normal or diarrhoeic. Under all circumstances, however, the act of defecation is accompanied by much pain, of a burning and smarting character, continuing for sometime afterwards.
Frequently there is no pain except during stool, and then more after the act than during. When the ulcer is situated on the anterior surface of the rectum, in male subjects-the prostate may become affected by an extension of the morbid process, and some symptoms of irritation of the bladder or urethra results. In some cases of a sloughing or deeply penetrating character, in the female subject, recto-vaginal fistula may form, although it cannot be common. Under either circumstances, however, rectal fistula may be produced in this way, but not, I should infer, very frequently.
It will be utterly impossible to make an accurate diagnosis without ocular or digital examination, or both combined. On passing the finger into the rectum, should an ulcer be present, it will be detected as a velvety feeling elevation, which on being touched will give rise to a severe burning, smarting pain, of a peculiarly pungent character, which continues for some moments after the irritation is removed. There will be more or less discharge, purulent, bloody, or otherwise, as in the case of ulcers elsewhere-which should be submitted to the microscope in cases of suspected specific disease. On passing in a speculum, the mucous membrane will usually be found thickened, of a darker colour, and the ulcer can be accurately inspected. In cases which are complicated by fissures, the probability of the sore is non-specific or at most of strumous origin. If the outline is irregular, particularly like a horse shoe, with hard edges and base, not much pain and shallow, syphilis may be suspected. When the outline is irregularly annular, with eroded edges and somewhat deep, carcinoma is among the possibilities.
Fissure of the anus, is a condition very closely allied with ulcer, and presenting many of the same subjective phenomena, excepting that they are much more severe and unbearable. The trouble will be found to consist in a crack or rhagade through the skin and mucous membrane, extending from the anus upwards across the sphincter for a distance varying from half an inch to an inch. The depth of the fissure varies greatly, sometimes being a simple groove or furrow, at others extending down to the subcutaneous cellular tissue. The surrounding parts are usually highly inflamed, and the sphincter spasmodically contracted. The pain attending stool is described by GROSS as being horrible, and the dread of its recurrence causes the sufferer to delay emptying the bowels as long as possible. The pain is more or less constant, walking, riding, sitting in a hard chair, sexual indulgence, or the pressure and friction of the clothing particularly aggravate it, but the sufferings are as nothing compared to the positive agony of defecation. The bladder becomes irritable, the bowels irregular, the sleep disturbed, and indigestion soon becomes established; the patient becomes week and pale and the expression is one of much suffering.
The causes are variously given by by different authors; some asserting struma, others indigestion, and others again a chronic diarrhoea, piles, ulcers, or laceration of the parts from hard difficult stools or others traumatic agencies. Probably all of these condition may prove causative in different cases, but trauma alone can never produce a rent that would remain open and take in these characters without some constitutional taint, operating as a maintaining cause. On examining such a fissure, the edges will be found everted, and the surrounding parts much inflamed, which would not but the case in an ordinary accidental lesion. There can be no question, however, that in both ulceration and fissure, the existence of chronic diarrhoea must oftener be considered a cause, or a symptomatic accompaniment than an effect.
Treatment.-Perhaps more than in any other form of surgical disease, we must pay more attention to cause, in treating fissures of the anus. When trauma, pure and simple, is the cause, which we have seen must be of very rare occurrence, securing rest to the parts will be that is needed, with perhaps the local application of
Calendula. In cases complicated by the existence of an ulcer, remedies alone can be indicated. When the fissures are purely symptomatic, the same consideration must be given to remedies. In cases so-called idiopathic, perhaps mechanical treatment will be more successful. Still the sufferings are so great that if a reasonable employment of remedies does not produce some marked relief, resort must be had to harsher methods, viz. forcible dilatation of the sphincter.
I think ulcers of all kinds, will do better when treated by remedies, and the exclusion of all local applications. There must be exceptions to this rule, as one case now occurs to me in which a distinguished and competent practitioner had spent months in treating such a case without making the least impression, which was speedily, and apparently radically cured by a single applications of strong Nitric acid by a gentleman of the other school.
The remedies more frequently employed are as follows:
Aconite.-Acute cases, with much fever, pain in the anus, with frequent transient contraction of the sphincter.
Antim crud.-Much mucus discharged from the anus; the parts are swollen, smooth and shining, and there is much Pruritus.
Arnica Mont.-Traumatic cases, with aching, or stiff, sore feeling in the parts.
Belladonna.-Spasmodic constrictions of the sphincter ani., acute, and violent; intense pain on motion, and exquisitely sensitive to the touch; the parts are much inflamed.
Calcarea carb.- Strumous cases, with much fetid mucus discharge, and the ordinary signs of struma; blood is passed at every stool, from further laceration of the fissure.
Carbo veg.-Intense burning in the anus, as from the application of a coal of fire; much moisture about the anus and perineum, but more of a relaxation of the sphincter than a contraction.
Causticum.-Acrid, thin, bad-smelling discharge; the anus and perineum are sore and excoriated, and there is most persistent long-lasting, and violent pruritus; the excoriation is so great that the patient can scarcely walk.
Colocynth.-No pain or constriction except on going to stool, when the anus becomes painfully constricted, the pain running up the back, and of a sharp cutting or lancinating character.
Graphites.-Deep, long, and numerous fissures about the anus, no evertion of the edges, and no inflammation; the fissures look like clean cuts, and are not very sensitive. Discharge of an offensive odour, like herring brine.
Ignatia am.-Stitches from the anus up the rectum; itching and creeping in the anus as from ascarides; constant urging to stool which causes smarting pain.
Nitric acid.-Frequent contraction of the anus, with much odourless mucus discharge, and the characteristic pricking pain, as if from a piece of glass or a splinter.
Nux vomica-In persons afflicted with piles of sedentary habits, or who are habituated to intoxicating drinks, or high livers generally. Stools are hard, dry, infrequent, and passed only after many efforts, with headache in the morning, and dullness of intellect.
Paeonia.-Very painful ulcer, partly in the integument, round, sharp cut edges, and exuding much moisture.
Plumb. acet.-Continuous painful contraction of the sphincter, felt like an ivory ring; almost impossible to pass a stool.
Sulphur.-For chronic rhagades, not very painful, accompanied by much moisture, and constant pruritis; cold water is unbearable, and causes intense smarting, followed by a scalding feeling and much itching.
OF IOWA, CHICAGO. Author of - The homoeopathic treatment of surgical diseases, Published 1873. Surgical emergencies and accidents, Published 1884. The elements of surgical pathology : with therapeutic hints, Published 1896. Surgical diseases and their homoeopathic therapeutics, Published 1880.