They are most likely to be mistaken for simple fissures, but have a hard, raised outline and indurated base, are less painful, and devoid of the healthy surface of the former. In any case of suspicion, constitutional treatment should be delayed till the diagnosis is completed by the appearance of general symptoms. True chancre within the rectum is very rare indeed. Ricord, Foumier, and Yidal de Cassis each report a single case, and in the latter the induration is said to have been so great as to cause stricture. MolliSre carefully analyzes the evidence on this point up to date, and concludes that though a true chancre may exist within the rectum, it never causes stricture, for the reason that it does not produce any great amount of ulceration, and that the induration tends to spontaneous resolution, or at least rapidly yields to the influence of mercury. The difficulties surrounding the diagnosis of such a sore are manifest. Its mere appearance would scarce be conclusive, and in women, the absence of any other sore which might cause secondary symptoms would need to be absolutely proved — a very difficult thing to do.
Secondary and Tertiary Syphilis. — One of the secondary manifestations of syphilis is to be looked for at the anus and rectum — the mucous patch, not an infrequent sign in the former locality, and one liable to assume ulcerative action from local irritation or inoculation with the virus of the chancroid. Generally, however, they are devoid of symptoms, and disappear spontaneously without treatment, or simply with cleanliness and the use of an astringent wash. That the mucous patch may appear in the rectal pouch also is rendered probable from analogy with the fauces, and such cases have been reported; but as they never form cicatrices, they must be counted out of the etiology of stricture.
Tertiary syphilis. — Well marked cases of tertiary syphilitic ulceration in the rectum such as are seen in the mouth and throat are seldom mentioned; and yet that they may exist and may cause extensive destruction is not only probable from analogy, but clinically true. Smith says, 'I am strongly impressed with the view that stricture of the rectum is produced either directly by the specific ulceration in the part affected, or by contact of the discharge from the surrounding parts.' — A sentence of which the last clause weakens the first, for the question is not whether ulceration may be set up in the rectum of a syphilitic person by the irritation of a discharge from the surrounding parts, but whether there is such a thing as true tertiary syphilitic ulceration of the rectum. Curling describes a case presented by the late Mr. Avery at a meeting of the London Pathological Society, which he says clearly showed the connection of the lesion with syphilis.
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