Cripps (op. cit., p. 193) states that the degree of pain experienced is no indica tion of the severity of the disease, the suffering depending on the situation of the lesion rather than on its extent. Generally spealiing, the nearer the anus it is situated, the greater the pain. This is well exemplified in cases of irritable ulcers of the anus. In ulceration involv ing the anus, loss of control of the sphincters often occurs.
The diagnosis will receive due atten tion when the individual varieties of ul ceration will be discussed.
Etiology. — Non-malignant ulcers of the rectum are usually classified into (a) the varicose; (b) the traumatic; (c) the dysenteric; (d) the irritable [the so-called fissure of the anus]; (e) the catarrhal, or follicular; and (f) those arising from general debility occasioned by Bright's disease, phthisis, diabetes, and starva tion; also into (g) the tuberculous; (h) the so-called rodent ulcer; (i) the chan croidal; and (j) the syphilitic.
The existence of the varicose and the traumatic varieties seems to be unques tioned by all authorities. It it true that varicose veins of the legs are often fol lowed by ulceration, and that a similar condition of the htemorrhoidal plexus of veins is the precursor of ulceration of the rectum, which should be classed in the category of the predisposing causes of all ulcerations in this region. In all con ditions which lead to ulceration pri marily, the condition is attended by vari cosity of the rectal vessels, which in duces a stasis of the blood-supply, fol lowed by congestion. Under these cir cumstances it is not likely that an ulcer of the bowel will occur without some form of traumatism.
The traumatic ulcer may be produced in a variety of ways, as from the intro duction of foreign bodies through the anus; but much more frequently the initial laceration or abrasion is occa sioned by hardened frecal masses, pieces of bone or wood, nut-shells, or some similar substance. Pressure of the foetal head during childbirth is a not un likely cause. Retarded union following operative interference upon the rectum for the removal of haemorrhoids, polypi, etc., is another factor in producing ulcer ation.
The dysenteric variety, in the opinion of J. M. Mathews, is rare. He states that "if a long-continued irritation is kept up in the rectum from any cause, the result would be, of course, an inflamma tory exudate, resulting, perhaps, in ul ceration and stricture," but he states that, in searching for this as a cause, the evidence has not been such as to enable him to place it in the list as a cause at all for stricture of the rectum. What
this distinguished author has to say upon the subject of dysentery as a cause of rectal stricture applies with equal force to ulceration. An attack of dysentery may, and often does, act as a predis posing factor in causing an ulceration of the bowel, but that we have a class of ulcers to which we can apply the term dysenteric I very much doubt.
The irritable ulcer of the rectum, known more commonly by the term "fissure of the anus," has been thor oughly reviewed.
Follicular, or catarrhal, ulceration may, according to Ball, occur in any part of the colon, but the seat of election is undoubtedly in the rectum and the sig moid flexure. The solitary follicles be come inflamed and disintegrated, and finally open upon the surface of the bowel, owing to the necrosis of the swol len tissue. Though small at first, these openings gradually enlarge, and small ulcers are formed, which do not tend to heal, but spread, and finally involve the submucous tissue. These ulcers also spread by uniting. In some instances the muscular coat of the bowel has been perforated and the ulceration has ex tended into the bladder and the vagina.
Ulceration involving the rectum and arising from the general debility occa sioned by Bright's disease, diabetes, and starvation requires no special description, as it presents no special characteristics.
The true tubercular ulceratim of the rectum may be a primary process, but in the majority of instances it is a secondary manifestation of pulmonary consump tion. These ulcers are caused by the disintegration of small tuberculous nod ules deposited in the mucous and the submucous coats of the bowel. They are sometimes scattered and sometimes closely packed together. Such ulcers are usually of considerable size and are found in the rectal ampulla or at the anus. They are irregular in outline, more or less ovoid, with their long axis parallel to the vertical axis of the bowel and corresponding to the direction in which the vessels in this locality run. They have a peculiar appearance, some what difficult to describe. They do not secrete pus, but a thin watery discharge, and are usually surrounded by a mucoid material.