Intertrigo. — As the result of prolonged exercise, such as walking, there
occurs, notably in fat persons and in those who are not cleanly in their habits,
an acute inflammation of the skin between the buttocks in the vicinity of the
anus. The symptoms produced are a sense of heat, burning pain, ami itching.
rpoti inspection the opposed skin surfaces on either side are found intensely
reddened, frequently moist ami excoriated. The 1 diagnosis is usually entirely
simple.
67
226 THE EECTUM
Furuncles. — Furuncles, large and small, not infrequently occur near the
margin of the anus. They are intensely painful ; their diagnosis is to he made
upon inspection without difficulty. (See Furuncle.)
Pruritus Ani. — An affection which tends to become chronic, the causes of
which are often entirely ohscure and which may render the life of an otherwise
healthy person quite miserable, is known as pruritus ani — itching of the anus.
The condition has been ascribed to a great variety of causes — to constipation,
to a sedentary mode of life, to want of exercise, to articles of diet, to gout,
to the presence of oxyuris vermicularis, notably in children. Oftener than not,
I have seen the disease in individuals otherwise quite healthy, who were careful
of their diet, were cleanly, and led an entirely normal life.
The symptoms are an intolerable itching of the shin in the vicinity of the
anus. Frequently these patients are entirely comfortable during the daytime ;
the itching onlv begins when thev are warm in bed at night. The sufferer is
irresistibly impelled to scratch. Sleep is seriously interfered with, and if the
patient falls asleep, he wakes himself up by scratching. During the earlier
stages of the disease inspection may show no visible changes in the skin ; after
the condition has lasted for some time, the skin between the buttocks over a
semicircular area, upon either side, becomes thickened, furrowed, sometimes
fissured, of a pearly white color, sometimes with papillary outgrowths here
and there upon its surface. The local appearances and the characteristic symp-
toms suffice for the diagnosis. Search should be made for local and general
causes. These patients are often congenitally neurotic individuals.
Acute and Chronic Inflammation of the Rectum — Proctitis. — Acute catarrhal
inflammation of the rectum may be caused, by mechanical or chemical irrita-
tion — as, for example, from the presence of foreign bodies, the use of irritat-
ing substances for injection into the rectum, the use of irritating purgatives,
and it is supposed also from exposure to cold and wet, rheumatism, and other
constitutional conditions. As described under Foreign Bodies and Wounds
of the Rectum, injury of the wall of the canal may produce a catarrhal inflam-
mation. The rectum may also become inflamed as a part of a catarrhal or
dysenteric inflammation of the large intestine. The condition is frequently
observed as a complication of the most varied diseases of the rectum and of the
neighboring organs, hemorrhoids, inflammations of the prostate, the seminal
vesicles, as the result of the rupture of abscess, in either the male or the female
into the rectum — as, for example, abscess of the prostate, ovarian abscess, pus
tubes, occasionally from perforation of the rectum by an abscess originating
in the vermiform appendix. The clironic form of the disease frequently re-
mains after the acute condition has subsided. In the chronic form the mucous
membrane may be thickened or be covered with papillary excrescences or polypi.
In some cases the disease is complicated by the formation of ulcers of greater
or less extent, and such ulceration may lead to infection of the perirectal
structures. In the acute form the disease is for the most part confined to that
dilated portion of the rectum known as the ampulla. In the chronic form the
INFLAMMATION'S OF THE RECTUM 227
destruction "I the mucous membrane caused by ulceration and Hi'- subsequent
bealing "I the ulcers maj lead b^ cicatricial contraction to stricture of the
feet Um.
The symptoms of acute catarrhal inflammation of the rectum are :i sense
(il heat and burning referred to the rectum itself or to the region of the sacrum,
sometimes accompanied by fever and prostration. The pain frequently radiates
into the surrounding parts, the thighs, the bladder, etc. The patient suffers
from continuous or frequently repeated painful attacks of rectal tenesmus,
and during such attacks the attempt to evacuate the bowel is followed by the
escape of a small quantity of mucus or pus, sometimes mixed with blood.
Frequently the straining efforts cause the mucous membrane of the rectum to
protrude through the everted anus. In males there is often frequent and pain-
ful urination, sometimes retention of urine. In the chronic stage the symp-
toms are less intense, the patient suffers from constipation, sometimes from
diarrhea, and the stools contain a certain quantity of thick mucus mixed with
pus. Frequently the patient is obliged upon rising in the morning to have a
movement of the bowels immediately, and such movement consists chiefly of
the mucus and pus which have accumulated during' the night. The discharge
usually causes a chronic irritation of the skin, an eczema and pruritus in the
vicinity of the anus. Upon inspection the thickened, roughened, and some-
times ulcerated mucous membrane renders the diagnosis simple, when taken
together with the history. Such individuals frequently have a relaxed sphinc-
ter. 1 have seen cases of this kind in which the life of the individual was
rendered very wretched indeed. The first two inches and a half of the lower
bowel showed irregularly rounded, rather superficial ulcers, sometimes to the
number of six, eight, or twelve, with bases covered by grayish flabby granula-
tions and more or less indurated borders. In other cases the ulcer has been
of considerable size and solitary. The diagnosis is to be made from the his-
tory in the chronic cases, from a long story of the discharge of pus, mucus,
and blood from the rectum, of diarrhea and the symptoms already described,
and further by inspection through one or other of the forms of rectal speculum.
In the acute cases the symptoms are so characteristic as to be unmistakable.
the only possible difficulties in diagnosis being the determination of the excit-
ing cause, usually possible from the history.
Gonorrhea of the Rectum. — Gonorrheal inflammation of the rectum usually
occurs from inoculation of a gonorrheal discharge from the vulva in females:
occasionally the rectum may be the original seat of the infection. It is much
more common among women than among men, and much more common among
female children than among adults. The cases I have seen have nearly all
been little girls in institutions and in hospitals. The manner of infection has
usually been that the child has acquired gonorrhea for the mosl part in some
inexplicable way, and thai the inflammation of the vulva and vagina have
spread to the rectum. In the hospitals in the city of New York, and in the
institutions where children in large numbers are eared for, outbreaks of iX^u
228 THE RECTUM
orrhea occur quite frequently ; sometimes a large proportion of the children
in such an institution will he infected at the same time, and that in spite of
every possible precaution taken to prevent the spread of the disease, and under
these circumstances gonorrhea of the rectum is by no means rare. The symp-
toms and signs of gonorrhea of the rectum among children are much more
severe than is the case with adults. The child suffers with the symptoms of
acute inflammation of the rectum — pain, straining, rectal tenesmus, and the
discharge of pus and mucus, sometimes mixed with blood. Frequently the con-
stant straining produces a certain degree of prolapse of the mucous membrane.
The diagnosis is to be made from the examination of the discharge under the
microscope for the gonococcus. These children are frequently quite ill ; they
suffer from severe pain, from fever, prostration, loss of sleep, and sometimes
from one or other of the complications of gonorrhea. In adults the symptoms
of gonorrhea of the rectum are apt to be less severe. The patients have the
symptoms of a moderately severe catarrhal inflammation of the rectum, occa-
sionally with the production of superficial erosions, fissures, or ulcerations.
The diagnosis is to be made from the presence of gonorrhea of the genital tract
and from an examination of the discharge for the gonococcus. The disease
may assume in certain cases a chronic form, ending in thickening and indura-
tion of the mucous membrane of the bowel, and sometimes, it is stated, in
stricture of the rectum. There is no means of differentiating gonorrheal in-
flammation of the rectum from simple catarrhal inflammation except by the
discovery of the specific organisms of the disease.
Chancroid of the Anus and Rectum. — Chancroid of the anus and rectum,
as is the case with gonorrhea, occurs much more frequently in women than in
men, and usually from autoinoculation from a chancroid of the vulva, occa-
sionally as a primary infection. As is the case with chancroid elsewhere, the
disease is characterized by a short period of incubation or none, by the forma-
tion of multiple, acutely inflamed, progressive ulcerations with reddened edges,
yellowish-white sloughy bases, a purulent discharge, marked pain and tender-
ness, and frequently painful enlargement of the inguinal lymph nodes. The
ulcers occur for the most part outside of or just within the anus, rarely in the
rectum proper. In debilitated persons, or if the poison happens to be par-
ticularly virulent, the disease may take on the phagedenic type. From time
to time one sees in the hospitals of New York chancroids of the rectum and
neighboring structures which have existed for years. I recall a case, seen
while I was house surgeon in Bellevue Hospital, of a young negro man who
had suffered from a chancroid for several years. The disease had gradually
become very chronic, and except for the absence of marked induration sug-
gested a very chronic form of epithelioma rather than any other disease. The
ulcerated surface extended across the front of the abdomen above the pubes,
involved the perineum, the greater part of the scrotum, had destroyed half of
the penis, and extended up the rectum a distance of two inches. After a
number of operations of a very extensive character this man was finally cured.
INFLAMMATIONS OF THE RECTUM
229
Chancroidal ulcerati t' the rectum may, of course, I"- followed bj cicatricial
contraction and stricture.
Syphilitic Lesions of the Anus and Rectum. — The initial lesion of syphilis
is rather rarely observed in the anus and rectum, more frequently in women
than in men, and rarely within the rectum itself, but usually at the muco-
cutaneous junction of the anus. The chancre possesses the ordinary charac-
ters described elsewhere. The lymphatic enlargements affect the inguinal
lymph nodes.
Secondary Syphilitic Manifestations of the Aims— Moisl papules and the
so-called broad condylomata are very frequently observed around the margin
of the anus. They occur as mucous papules having the characters already
described, nol in the sulci between
the folds of skin, but along the in-
tervening ridges, thus distinguishing
them from simple fissure. They
usually become covered with sofl
crusts of a pearly white appearance.
When these mucous papules are nu-
merous they frequently coalesce to
form the so-called broad condylom-
ata, whose true home is in this re-
gion. Very considerable tumors
may be formed in this way, which
might even lie mistaken for cancer
by the inexperienced (see Fig. 32).
In the later stages of secondary or
in tertiary syphilis there sometimes
develops a dry and brittle condition
of the mucous membrane and skin
bordering the anus. Under these
circumstances more or less painful
fissures may occur, usually covered
vith pale and sluueish granulations.
Pain and the symptom of itching are
frequently present. Tt would he
carrying me too far afield to describe at length all the possible secondary
syphilitic lesions in this vicinity.
Tertiary Syphilis of the Rectum. — Isolated gummata occur only very rarely
in the rectum. Diffuse syphilitic inflammation of the rectum, on the other
hand, is a very common lesion, and regularly leads to the subsequent produc-
tion of stricture of the rectum. Indeed, a very large proportion of all the
strictures of the rectum are due to tertiary syphilis. The patients are nearly
always females. The disease begins with the formation of multiple syphilitic
nodules in the mucous membrane, usually just within the rectum proper above
)
Fig. 32.— SKcoNn.vHv Moist Papules (Syphilitic,
Flat Condylomata <>k the Am s). (New York
Hospital, out-patient department.)
230 THE RECTUM
the external sphincter, and tends to spread upward, sometimes as far as the
sigmoid flexure or even higher. As the disease progresses the nodules break
down and gradually form ulcers, which coalesce. Infection of the raw surfaces
takes place from constant exposure to intestinal contents, and there are added
the symptoms of ordinary catarrh, sometimes of suppurative inflammation,
with the formation of abscesses in the vicinity of the rectum, fistula 3 , etc.
Later in the disease inflammatory infiltration of the entire rectal wall takes
place with the formation of abundant cicatricial tissue. Instead of ulcerated
surfaces and pockets in the mucous membrane the rectal wall becomes con-
verted into scar tissue, so that upon inspection one sees a dense, firm, white,
rough or ridged, uneven surface, often completely surrounding the rectum, and
extending a variable distance upward. In the earlier stages of the disease
the symptoms are those of acute, or more commonly chronic, catarrh of the
rectum, sometimes associated with pyogenic infection, fistula?, and abscess, as
already described. The disease may be very painful in a certain proportion
of cases. During its earlier stages tertiary syphilis of the rectum often runs
a somewhat latent course, and we do not see these patients until they come
to us suffering with the symptoms of stricture of the rectum. A large part
of the rectum may be converted into a rigid cicatricial canal. The diagnosis
is to be made from a history of syphilitic infection, from the presence of other
manifestations of tertiary syphilis, from the absence of the signs of malignant
disease, and the fact that these individuals are usually younger than the can-
cerous age, although not always. (For further details, see Stricture of the
Rectum.)
Tuberculosis of the Anus and Rectum. — Tuberculosis of the anus and of the
rectum may occur in three forms: The first two are very rare, the third is
exceedingly common. Infection may occur through the ingestion of tuber-
culous food — milk from tuberculous cows, for example — or from the swallow-
ing of tuberculous sputum in cases of chronic phthisis, or occasionally from
inoculation by scratching with infected finger nails. The first form of tuber-
culosis is lupus. This occurs upon the cutaneous margin of the anus and its
vicinity. It does not differ in clinical characteristics from lupus in other
situations, as already described. (See Lupus.) The second form, also ex-
tremely rare, is the warty or papillary form of tuberculosis. It consists of
the formation of papillary outgrowths upon the skin and mucous membrane
near the anus, consisting of tubercle tissue. The diagnosis must be made by
the recognition of tubercle bacilli under the microscope. The disease may
be confounded with beginning epithelioma of the anus, or possibly with acumi-
nate warts. The coxcomb appearance of acuminate warts is absent, and the
base of the papillary outgrowths does not show the characteristic induration
of cancer. The third form, true tuberculous ulceration of the rectum, quite
rarely occurs alone, but is nearly always associated with infection of the peri-
rectal structures, and the formation of tuberculous fistula in ano. I have,
however, personally seen a number of these cases, and have operated upon
INFLAMMATIONS OF THE REC1 i'\l 231
several in which qo fistula was present. They are nearly always associated
with tuberculosis of the lungs. The diagnosis of the tuberculous ulceration
of the rectum Is to be made by the history of diarrhea, the discharge of mucus
and pus, sometimes mixed with blood from the rectum, from pain, and from
inspection of the rectal mucous membrane through a speculum. The appear-
ance of tuberculous ulcers of the rectum does no1 differ from that of tuber-
culous ulceration in other mucous membranes. The ulcers are usually irregu
lar in shape, their margins are frequently scalloped and undermined: the base
of the ulcer is covered with pale flabby granulation tissue, exhibiting here and
there small yellow dots, representing caseating tuberculous nodules. Sometimes
areas of tuberculous infiltration may be seen in the surrounding mucous mem-
brane nol yet broken down. They have an inflamed border and a white or
yellowish center. The diagnosis can usually be made from the presence of
tuberculosis of the lungs or of other organs. In cases of doubl scrapings from
the nicer mav be examined for tubercle bacilli, or inoculation of animal- may
be tried, the difficulty in these cases being that the animals are apt at the
same time to be inoculated with the pyogenic germs and to die of septicemia.
(See also Tuberculosis of the Intestine.) The question of surgical treatment
of these cases will depend very largely upon the general condition of the indi-
vidual and the extent and severity of the other tnherculous lesions, if such
he present.
Painful Fissure of the Anus. — Small superficial ulcers, cracks or fissures in
the mucous membrane or muco-cutaneous junction just within the grasp of
the anal sphincter, situated in the sulci between the radiating- fold- of shin
at the anal margin, are exceedingly common; their most frequenl position is
in the posterior commissure, and for the apparent trifling nature of the lesion
these fissures give rise to symptoms of extraordinary severity. The causes of
fissure of the aims are usually mechanical, and are due to injuries of the
mucous membrane produced often by constipation and the passage of large
fecal masses which mechanically injure the delicate epithelial covering. The
disease is frequently associated with hemorrhoids, or it may he produced during
labor; sometimes it is due to the passage per rectum of some small, sharp for-
eign body which has heen swallowed accidentally — a fish hone or the like. It
is sometimes associated with gonorrhea, syphilis, or chancroid of the aim-.
The disease usually affects adults, and women more commonly than men: no
age is exempt, 'hhe nicer is quite superficial in character, and usually lies hid-
den between the mUCO-CUtaneOUS folds of the 1 anal orifice; it is linear or oval in
shape. The base may consist of a grayish-white raw surface which show- no
tendency to heal; the edges are slightly inflamed; randy much thickened and
not indurated. It is usually impossible to see these 1 ulcers without obliterat-
ing the folds of skin ahont the anus by traction on either side and asking the
patient to hear down. Occasionally it is necessary to introduce a short tubular
speculum, rarely to dilate the sphincter, before the tissnre or nicer i< visible,
I pen digital examination the presence of an exceedingly tender spot near the
232 THE RECTUM
anus becomes evident. The mere effort to introduce the finger causes violent
spasm of the sphincter muscle, so that without a local or general anesthetic
such introduction may be impossible. If the finger is introduced the patient
will complain of intense pain, referred to the point of ulceration. The exami-
nation may be followed by the escape of a drop or two of blood. The symp-
toms produced by painful fissure of the anus are absolutely characteristic. The
patient suffers intense pain when the bowels move, and this pain is more marked
when the movements are large and hard. Following the movement of the
bowels a continuous or intermittent spasm of the sphincter muscle occurs, last-
ing for minutes or hours, after which the patient is again comfortable until
the bowels move again. The movement of the bowels may be followed by the
escape of a few drops of blood. Sometimes the pain is not felt so much dur-
ing the time the bowels are moving as afterwards. It is an intense and most
annoying pain, attended by sudden acute exacerbations, caused by the invol-
untary spasmodic contraction of the sphincter muscle. The pain is described
as being such as might be produced by the passage of a red-hot iron or a knife
into the bowel. It is sharp and often agonizing. In bad cases it may be
so severe as to produce syncope. The pain may be confined to the vicinity
of the anus or may radiate in the back or thighs. In certain cases the pain
is continuous, the individuals are constantly in a state of suffering and dis-
comfort. These patients often fall into a neurasthenic or hysterical condition
and become extremely wretched. When the ulcer consists of a mere superficial
crack in the mucous membrane, it may, if the individual keeps the bowels freely
open, last only for a few days or for a week or two, and get well of itself.
In other cases the condition goes from bad to worse. The diagnosis is to be
made from the very characteristic history and from the examination of the
rectum and anus, if necessary under a general anesthetic ; during the anes-
thesia the very simple curative measure of dilating the sphincter or incising
the base of the ulcer may be performed.
Suppuration of the Tissues Surrounding the Rectum — Periproctitis. — One of
the most frequent, if not the most frequent, diseases connected with the rectum
is suppuration of the perirectal tissues. The causes are in the majority of
instances infection through the mucous membrane of the bowel which invades
the perirectal structures. Such may be caused by wounds or lacerations of
the mucous membrane produced by the passage of hardened feces or by for-
eign bodies. Further, any one of the processes already described producing
ulceration of the bowel. The infection and suppuration may occur in one of
three situations. In the subcutaneous connective tissue in the vicinity of
the anus which is continuous with the submucous tissue between the sphincter
ani muscle and the mucous membrane. Second, in the ischiorectal fossa,
a somewhat pyramidal space, which is bounded on the inner side by the
external sphincter, above by the levator ani muscle, and on the outer side
by the ischium. This space is filled with loose connective tissue containing
much fat, and the spaces of the two sides are more or less completely separated
INFLAMMATIONS OF THE RECTUM 233
liv a septum of connective tissue. The third space lies above the levator ani
muscle, surrounds the rectum, and lies between the peritoneum above ;m<l 1 1 1 * -
levator ani muscle below. This space is more or less completely divided by
connective-tissue septa into an anterior and posterior recta] Bpace. It i
stiitc.l, separated from the ischiorectal fossa by the levator ani muscle. Peri-
rectal suppuration may be diffuse or circumscribed. The diffuse form occa
sionally runs an acute and fatal course. It follows extensive operations upon
the rectum or accidental injuries, notably severe lacerated wounds. It is
that sudden violent form of septic phlegmonous inflammation already de-
scribed in the chapters devoted to the diseases of wounds. Following an oper-
ation or an injury in the vicinity of the rectum; the tissues of the ischiorectal
fossa or, if the wound or injury extend above the levator ani muscle, the retro-
peritoneal tissues; sometimes also the skin of the buttocks, the perineum, the
scrotum, etc., undergo a rapid, progressive, septic, and necrotic destruction.
The patients do not survive this condition, and die, with progressive septic
symptoms, exhausted, in from two or three days to a week. This form of
inflammation is occasionally seen after the operation of prostatectomy in old
and feeble men. The streptococcus, and occasionally the staphylococcus, are the
organisms ordinarily concerned in the process. Another form of septic inflam-
mation of the perirectal structures was especially described by Kraske, caused
usually by the Bacillus coli communis, and attended by the production of gas