RECTUM AND ANUS, DISEASES OF. (See also ILEMORRHOIDS, volume iii.) Irritable Ulcer of the Rectum, or Fissure of the Anus.
Definition. — Primarily, a superficial breach of the mucous membrane in the anal region, which, if unhealed, finally results in the formation of an ulcer of the bowel. This may involve both the mucous and submucous coats, and give rise to a spasmodic contraction of the parts and paroxysmal pain.
Symptoms. — In the early stages the symptoms are not usually marked or even severe. They are generally experi enced during defecation, when at some point or other there will be an uneasy sensation, consisting of an itching, prick ing, slight smarting, or a feeling of heat about the circumference of the anus. As the disease progresses the discomfort attending the movements of the bowel is greatly augmented; there may be severe pain, of a burning or lancinating character. This is followed by throb bing and excruciating aching, attended by violent spasmodic contraction of the sphincter-muscles, continuing from half an hour to half the day. While the pain lasts the patient is usually incapacitated for work. The slightest movement- some times greatly aggravates the suffering.
After an indefinite period the pain subsides or entirely disappears, the pa tient feeling fairly comfortable or even perfectly well, and to all outward appear ance he would continue so were it not for the knowledge that the subsequent passage of fcal matter will bring with it a recurrence of agony. In consequence of this dread, the act of defecation is postponed as long as possible, with the result that when the evacuation does take place the pain is greatly increased. The faces, when solid, will be passed streaked with mucus and sometimes also with blood, and when more soft will be flattened and tape-like, due to the in complete relaxation of the sphincters. Not infrequently the appearance of such a stool leads to an erroneous diag nosis of stricture of the rectum.
When a fissure is of long duration, the general health becomes greatly im paired as a result of the constant pain, the constipation, and the frequent re sort to narcotics, and the patient is liable to fall into a state of melancholy and ex treme irritability. The countenance, ex
pressive of pain, grows care-worn and sallow; the appetite is poor; and there is more or less emaciation, associated with the general appearance of a person suffering from serious organic disease. Flatulence generally attends severe cases; it is not only troublesome, but painful. the passage of gas being almost certain to bring on a paroxysm of pain.
The ulcer is usually located just within the anus, beginning at the muco cutaneous junction, Hilton's line, and extending upward toward the rectum for a distance seldom exceeding half an inch. It may occupy any portion of the circumference of the anal region, but its usual site is at its posterior, or coccy side. Although this lesion is usu ally solitary, we sometimes find it multi ple, especially when of syphilitic origin.
Diagnosis.—The signs are so charac teristic of the lesion that it is almost impossible for a diagnostic error to be made. The peculiar nature of the pain, the time of its occurrence (either during or some time after an evacuation of the bowels), its continued increase until it becomes almost unbearable, and its gradual decline and entire subsidence until the next evacuation clearly point to irritable ulcer of the anus, and in most instances should be sufficient to establish a diagnosis. Yet in numerous well-authenticated cases mistakes have been made and patients suffering from this disease have been treated for neu ralgia, uterine or vesical affections, stricture, and even hremorrhoids.
This disease is very readily distin guished from neuralgia by the absence in the latter of any breach of surface or of any other disease of the mucous mem brane of the rectum; by the entire want of connection between the pain and the alvine discharge, and by the constant suffering. In neuralgia the pain caused by pressure with the finger in the anus is not confined to one spot, as it is in fissure, but all parts of the bowel are alike tender.