CHAPTER IX. IS'ON-MALIGNANT ULCERATION. * (Part 2)

DISEASES OF THE SBOTUK AND ANUS. • . The treatment is, therefore, only palliative, though Molli^re* pro- pounds the interesting question whether, if such an ulcer were completely extirpated or destroyed, before general symptoms of tuberculosis nad shown themselves, it might not be possible to prevent the general mani- festation of the disease, as may be done in cases of tubercular testis. He bases the question on a case in which such an ulcer existed nearly four years before any other sign of tuberculosis was apparent. The other variety of so-called tubercular ulcer is a simple sore in a phthisical patient, modified in its course and characteristics by the gen- eral condition. It may result from any of the causes already mentioned, and any of the varieties already described may, under the proper condi- tions, assume its characteristics. It may occur either within the rectum or at the anus, and may vary in size from a mere spot a quarter of an inch in diameter to a sore covering the whole lower part of the rectum. It may extend in depth as well as on the surface; may perforate and cause abscess and fistula, or be attended by thickening of the wall without decrease in calibre. It is often accompanied by numerous polypoid growths; it is generally painful, and the discharge is purulent. It neither extends rapidly nor heals easily, and yet it is surrounded by & healthy reparative action, and, unlike the true tubercular sore, it may be induced to heal, and is one of the causes of grave stricture. The process is essentially a chronic one, and several of the cases of '' chronic ulcera- tion of the rectum*' reported by Curling come properly under this cate- gory. It may easily be distinguished from true tubercle, but may readily be confounded with some of the varieties which are to follow. Scrofula. — Allied to the class of ulcers last named are those in which the scrofulous taint manifests itself, as it may do either in follicular ulcers of the rectum and large intestine, in lupus or esthiomine, and in rodent ulcer. The last two affect primarily the anus and perineum. Follicular ulceration is due to a chronic inflammation and fatty degen- eration of the follicles of the rectum. These which, when first affected, appear as small caseous nodules, break and leave small, deeply excavated ulcers, which, being multiple, may coalesce and leave larger ones of the chronic variety, capable of subsequent healing with the formation of cica- tricial tissue. They may perforate the bowel or form fistulae of the blind internal variety when low down, or cause peritonitis when higher up. They may be only one of many manifestations of the scrofulous tendency in the same patient, and they frequently co-exist with pulmonary disease. Under the title of esthiomine (lupus exedens of the ano-vulvar region) a number of phagedenic ulcerations, complicated with more or less hyper- trophy of the nature of elephantiasis, have probably been described; but, in spite of the confusion of statement, this would seem to be a rare manifes- * Op. cit., p. 651. NON-MALIGNANT ULOEBATION. 166 tation of scrofula, which may precede any others in its development. It commonly starts from the external organs of generation in the female, and invades the anus, rectum, and vagina secondarily. It is almost never seen in men. Its favorite starting-point is in the perineum, and instead of being superficial, it may be perforating and produce great loss of tissue, turning the rectum and vagina into one cavity. At this stage other ulcers are apt to appear in the rectum and colon, causing diarrhoea and flometinies peritonitis; but whether these are of the variety just described as follicular, or are due to further deposits of lupus, has not yet been positively decided. The ulcer is in'egular in outline, with a granular base of a violet-red color; and there is a slight sanious discharge. The edges are but little elevated, and are not undermined, and there is more or less hypertrophy of the surrounding tissue which, in some cases, is exceedingly well marked. The ulcer may cicatrize in part, the cicatrix being thin and white, at the same time that the ulcerative process is extending in the opposite direction. At a little distance from the ulcer there is often a pathognomonic appearance of slight, reddish, hard nodules of tubercular lupus, separated from the primary sore by healthy skin. With this amount of disease the constitutional disturbance is often not sufQcient to confine the patient in the house. The diagnosis is not generally difficult, though the disease may be confounded with cancer, phagedenic chancroid, and with elephantiasis with secondary ulceration. It is best distinguished from cancer by the cicatricial bands which it leaves behind in its ineffectual attempts at heal- ing; and from chancroid by the surrounding tubercles which in lupus develop in the thickness of the derma, and ulcerate secondarily; while the ulcers which sometimes surround a chancroid are ulcerous from the first, being due to secondary inoculation. Van Buren advances the theory that most of these ulcerations are due to the grafting of the syphilitic poison upon the scrofulous diathesis in women of improper lives. The duration of the disease is indefinite, and it seldom leads to fatal results. It is best treated by destructive cauterization and reclage.* Rodent Ulcer is very closely allied to epithelioma, and may, in fact, be considered one of its varieties ; but it is distinguished from it clini- cally by the fact that it does not infiltrate surrounding tissue, does not involve the lymphatics, and does not become generalized. It is the same disease met with upon the face, and is exceedingly rare at the anus, being seen only twice in four thousand consecutive cases at St. Mark's Hospital* According to the classical description of AUingham, it is found by preference at the verge of the anus, and extending from this point up- 1 See also Huguier, M6tn. Acad, de MM., 1849; Harday, Scrofule et Scrofa- lides, p> 80; and Pean et Malassez, op. cit. 166 DISEABB8 OF THB KBCTUM AND ANUS. wards into the rectum. It is irregular in shape, and its edges end ab«* ruptly in healthy tissue. Its surface is red and dry ; it destroys superfi- cially^ attacking mucous membrane rather than skin, and undergoes. rapid but only partial cicatrization under proper local and constitutional treatment. It never entirely heals, and is not to be included among tho causes of stricture. It is at first generally mistaken for a late syphilitic manifestation, but is distinguishable from it by the powerlessness of all treatment to prevent its steady progress. It is one of the most painful of all the ulcerative affections of this part, and ends fatally, unless some other disease cuts short the history. It is best treated by complete exci- sion, and this, in one case of AUingham's, secured immunity for a period of four years during which the patient was under observation. Dysentery. — In dysenteric ulceration, the diseased portion of the lower bowel becomes infiltrated with fibrinous exudation, and, as a result of tho compression which this exercises, is necrosed and sloughs. When the slough is cast off, there results a loss of substance, and if this is superfi- cial, the membrane may regain its former state ; but, if deep, the usual callous cicatrix is produced in its place, and stricture is the result. The ulcers resulting from this proces vary much in size, location, and appearance. They may be minute circles, but are generally large, and, though their favorite site is the rectum or sigmoid fiexure, they may be found anywhere in the large intestine. They may extend so as to coalesce and leave only islands of mucous membrane between the ex- tensive patches. The process usually involves only the mucous coat, but may extend in depth, and result in perforation and its attendant evils. The coats of the bowel may become sinuous abscesses, so that, on divid- ing the prominent portion of mucous membrane between two ulcers, several drachms of pus may escape (Habershon). Although all the symptoms of dysentery may result from ulceration due to other causes, as in Annandale's case,* there is no doubt that in this country the disease is one of the causes of chronic ulceration and stricture, and Habershon con- cludes that the disease is more common in our climate than is generally supposed. In the Medical and Surgical History of the War of the Sebellion,* Dr. Woodward remarks that stricture resulting from dysenteric ulcera- tion seems to have been much rarer than might have been supposed, and that no case has been reported at the Surgeon-General's office, either during the war or since; that the Army Medical Museum does not con- tain a single specimen ; nor has he found in the American medical jour- nals any case substantiated by post-mortem examination which this con- dition is reported to have followed a flux contracted during the Civil War. In the Amer. Journal of the Medical Sciences, for April, 1881> 'Brit Med. Joum., 1872, p. 681. 'Part ii.» vol. i., Med. Hist. NON'MAUGNANT ULCER ATI9N. 167 I published a case which I then believed came under that category, and the subsequent history of which has only the more convinced me of the correctness of the diagnosis. Venereal Ulcers. — Gonorrhoea of the rectum has already been spoken of under the head of proctitis. Without attempting to decide upon the ipecific character of the inflammation which may follow the contact of of gonorrhoea! virus, it may be well to call attention to the severity of that inflammation and to the fact that it may cause ulceration and, probably, subsequent stricture. During the height of the process, the rectum is hot, red, swollen and granular, and there is an abundant purulent dis- charge issuing from the anus, from time to time in clots. The irritation of this may cause erosions and fissures which may reach a cohsiderable size; or a previously existing fissure may become inoculated in this way and spread in extent. Chancroids, — One of the most frequent of all the superficial ulcera- tions at the anus is the soft chancre. It is said by P6an and Malassez to have constituted nearly one-half of all the ulcerations in this region ex- amined at the Lourcine in 1868. It is much more common in females than in males, constituting one in nine cases of chancroids in the for- mer and one in four hundred and forty-five in the latter.' To account for this greater relative frequency only two things are neoessaiy: the frequency of accidental contact of the male organ in coition and the facility of auto-inoculation which is due to the proximity of the vulva and vagina. These ulcers are. seen either on the skin around the anal orifice, or just within the canal, and show a decided tendency not to pass above the upper border of the internal sphincter. So marked is this trait that their existence in the rectum proper \ as been denied, and the mucous mem- brane supposed to furnish no suitable ground for their inoculation. They may be single or multiple, may be situated at any point in the anal circumference, or may completely surround it. In one case of my own, the anus was completely surrounded by a group of these sores, and the ulceration extended from the posterior commissure backwarde in the intergluteal fold its whole length, as far as the base of the sacrum, being superficial, however, in the whole of its course. In such a case the pain is apt to be severe ; a careful examination is impossible without ether, and there is often free haemorrhage. The bleeding at the time of defeca- tion was the chief cause of alarm to the patient in the case mentioned. These sores have the same characteristics as the soft chancre in other parts of the body. The class of women in whom they occur is always an aid to the diagnosis, and if suspicion as to their nature exists, the test of auto-inoculation may always be tried. Sores of this variety tend to spontaneous cure with cleanliness, and, if 1 Fomxiier : Diet, de M^ et Chirg. Prat. Art. Chancre, p. 72. 168 DISEASES OF THE BECTUM AND ANUS. necessary, with judicious cauterization; and no matter how completely they may have involved the anus or the skin around it, they seldom leave any traces of their former existence. On the other hand, the cure may be delayed even for months, and the sore may assume a chronic type, due either to the existence of other disease in the rectum, as haemorrhoids, or to a syphilitic or scrofulous taint in the patient. They may be complicated by a chronic oedema of the surrounding parts, and resemble the lupus exedens already mentioned, or by the gangrenous process known as phagedsena, generally of the chronic variety, and advancing in one place while healing in another. And now we come to the debatable ground upon which so much has been said and written, and about which much still remains to be learned. Do these soft chancres ever cause stricture of the rectum, and are they the most common cause of those grave strictures so often met in women who have had syphilis, and which are generally known as syphilitic? In the light of our present knowledge, and yet subject to such modifications of opinion as future experience may teach^ we shall answer yes to the first of these questions, and no to the second. That a soft chancre may extend into the rectum and cause great destruction of tissue, cicatrize, and leave stricture, is beyond doubt. Van Buren says, " I have certainly seen this in several cases, but only in women;" Bumstead and Taylor* speak in the same way; MoUiere* says, " Nevertheless, the soft chancre of the rectum does exist, and has even been seen to assume frightful proportions in this deep region;" and Bridge's* case is generally considered as conclusive, though its authority tests much more upon the well-known character of the men who pro- nounced judgment upon it than upon its history as it stands recorded; for there is at least a strong suspicion of syphilis, and there is no account of the crucial test of auto-inoculation. Dr. Mason's* paper to prove the chancroidal nature of this kind of ulceration and stricture has this great advantage over the similar one of Gosselin/ that he leaves the reader in no doubt as to what he means by chancroid, and unhesitatingly adopts the dualistic theory. That this is not the case in the latter article, the reader may readily convince himself by a careful perusal; and, for my own part, I am unable to see where in this justly-celebrated article the non-syphilitic nature of the affection in question is taught, for the author leaves us m absolute ignorance as to which of the two at present well-known varieties of ** chancre " is, in his »Op. cit., p. 243. «- Venereal Dis.," Phila., 1879. 'Op. cit., p. 677. ^ Arch, of Dermatology, Jan., 1876. * Amer. Joum. of the Med. Sci. Jan., 1878 • Arch. Geul. de Med., 18.54. NON-MALIGNANT ULCEBATION. 169 opinion, the primary cause of the stricture; and it is rather by inference than otherwise that his " chancre " is interpreted to mean chancroid. The idea left on the mind of the reader is not that the disease is not syphilitic, but that it is neither a primary, secondary, nor tertiary man- ifestation of syphilis, as such are generally understood, but something developed in the neighborhood of the primary sore. Gosselin, though he comes nearer to it than had ever been done before, just missed enunciating the chancroidal nature of these strictures, though Bassereau had distinguished between the two chancres two years before. What he does assert is, that they are not to be considered as manifestations of constitutional syphilis, but that they are of local character, " due to a special modification of the vitality of the tissues contaminated by the virus of the chancre, comparable to the lengthening and hypertrophy of the prepuce with contraction of its orifice, which follows a chancre on its under surface, in which the disease is evidently neither an oedema, nor a specific induration, nor a constitutional affec- tion, but a local lesion, due to the presence of the chancres, and con- secutive to the inflammation which they have caused.'' In the same class of lesions, he places hypertrophy of the labia, condylomata, and other vegetations. The weight of the evidence, then, is decidedly in favor of the occa- sional causation of stricture by the chancroid. But that all of the many so-called syphilitic strictures are not due to this cause is rendered certain by the fact that many of them occur in women above the scf^picion cither of a chancre or a chancroid, and many more are developed late in the course of true syphilis, but are not preceded by any ulceration, chancroidal or otherwise, at the anus, and have their starting-point well above the sphincter muscle. Of the true nature of these we shall speak later. Chancre. — ^True chancre at the anus is not very uncommon. Though P£an and Malassez saw only one case at the Lourcine in 1868, they explain the fact by the slight local disturbance which the sore causes — so slight that the sufferers do not seek treatment. They give the propor- tion in this place as compared to chancres in other parts of the body as one in sixty-eight, and as much more frequent in women than in men (one in thirteen in the former, to one in one hundred and seventy-seven in the latter). These are about thia same figures reached by Jullien. In the female, a sore in this locality*is easily accounted for by accidental inoculation; in the male, it means sodomy.