Scrofulous and Tuberculous Affections

There are cases which yield abundant evidence of struma in the form of enlarged glands, chronic abscess in the neck, swelling and abscess in the vicinity of the articulations, and the like, in which ulceration of the mucous membrane of the rectum has been found: this condition may result in fistula in ano by erosion, permitting escape of flatus and excrementitious products into the cellular tissue. A similar result may follow by erosion of the bowel from a strumous abscess in the connective tissue around the rectum; both these forms tend to the production of that class of fistula which has no outlet at the surface, but which has one or more openings upon the mucous membrane of the rectum. Thus concealed (for often there is no marked surface indication of either abscess or fistula), they may remain for a long time unsuspected and acting as a serious drain upon the already impaired constitution. The pus in these cases is watery, curdy, and offensive. These chronic conditions are subject to intercurrent attacks of acute inflammation, due to the lodgment in the abscess cavity or the fistulous tract of fecal matter or indigestible solid substances. Any or all of the abnormalities of this region may be complicated by the existence of tubercular or scrofulous conditions of the system. Tubercular ulceration of the rectum is now a well-recognized condition. Rectal ulceration and tubercular disease of the lungs have not been found to coexist in any marked preponderating number of tabulated cases. The frequent association of fistula in ano and tubercular disease of the lungs has long been recognized, Allingham having found 172 such cases among 1208 cases of fistula in ano.

The pathology of tubercular ulceration of the rectum is graphically described in Ziemssen's Encyclopædia as follows: "These [ulcerations] begin in the follicular apparatus with swelling of the individual follicles and their vicinity from tuberculous deposit. The newly-formed cells become caseous, the superficial layer of the tubercle breaks down, and thus ulcerations arise of a round funnel shape. The enlargement of these ulcerations is probably produced by the constant formation in the base and edges of the ulcers of new nodules, which themselves caseate and ulcerate. This process of extension, to which these tuberculous ulcerations of the intestines exhibit a marked tendency, takes place chiefly in a transverse direction (girdle-shape), following the direction of the blood-vessels. The infiltration and necrosis may advance longitudinally, and, finally, the individual ulcerations coalesce with each other: in this way may be explained in part the dentate appearance of the edges of these ulcerations. The ulceration extends also in depth, although usually the muscular coat appears to be covered by a thick layer of connective tissue: the destruction advances slowly in the muscularis, but in the lymphatic vessels which pierce the muscularis less opposition is presented to the progress of the tuberculosis; and thus it is not uncommon to find tubercles ranged one after the other, like links in a chain, from the base of the ulcer directly down to the serosa. Healing is extremely rare. The most frequent situation is the lower end of the ileum, but the process may extend upward to the stomach, or downward, involving the rectum. There is almost invariably unmistakable signs of tuberculosis in other organs. It is possibly never primary, but this is a still-disputed point. It usually occurs with tuberculosis of the lungs, and when so occurring it is always secondary. The clinical symptoms of this state are by no means characteristic."

Dwelling upon the subject of intestinal tubercle, it has been suggested by Klebs that the intestinal disease is produced by swallowing morbid products derived from phthisical lungs—an hypothesis supported also by the fact that tubercle in the intestines tends so strongly to spread downward. "The seat of the deposit is the submucous tissue or the corium of the mucous membrane: it is certainly subjacent to the basement membrane, and not contained in the follicles, as Creswell taught."

Jones and Sieveking, London, pp. 593-595.

Woodward, in his article upon diarrhoea, says: "The lesions, whether mild or severe, are most generally seated in the cæcum and colon, but more or less extensive tracts of the small intestine, especially of the ileum, are often involved also." He continues: "Tubercular disease of the lung was noted in nearly one-sixth of the autopsies of fatal cases of forms of flux heretofore described. Possibly the frequency in chronic cases may be explained by the fact that protracted intestinal flux forms the development of lung phthisis in the predisposed."

Med. and Surg. History of the War of the Rebellion, p. 266.

The rectal fissure or painful ulcer may be connected with diathetic causes, as struma or scrofula: it is doubtful if syphilis should be included among its causes.