• Rectum and anus (core field): Fissures and piles with long-lasting burning/cutting pains after stool, sphincter spasm, bright bleeding; > cold water, > firm pressure, < sitting. See Rectum, Modalities. [Hering], [Allen], [Clarke], [Boericke]
• Mucocutaneous borders (rhagades): Cracks at anus, lips, commissures, perineum that are raw, bright red, sting and bleed on touch/wiping; > cool ablution. See Skin, Mouth, Female. [Clarke], [Phatak]
• Gums and oral mucosa: Spongy, bleeding gums, burning aphthae, scalded mouth; tooth-brush causes bright bleeding; cold air on teeth <, pressure/warmth >. See Mouth, Teeth. [Hughes], [Allen], [Clarke]
• Trigeminal (malar/zygomatic) neuralgia: Jerking/stitching right cheek → eye/ear/teeth, < cold draught, > warmth, pressure, lying on painful side. See Face, Head. [Hering], [Clarke]
• Pelvic floor reflexes (recto-urethral/recto-vulval): Burning at close of urination with reflex rectal tenesmus; peri-vulval rhagades mirror anal state. See Urinary, Female. [Hering], [Clarke]
• Haemorrhage from raw surfaces: Small, bright oozing where tissue is excoriated/fissured; tannin “astringency” underpins. Cross-links Mouth, Rectum. [Hughes], [Clarke]
• Sacral/back strain (secondary): Sacral ache after straining or prolonged spasm; much less than Aesculus but present during active fissure. See Back. [Boericke]
• Perineum (riders/post-partum): Cracked, burning perineum < sitting/riding, > cool ablution; often coexists with anal fissure. See Female, Male. [Clarke], [Phatak]

• Cold water to anus (often compels sitz in cold water) eases burning/spasm. [Clarke], [Boericke]
• Firm pressure/compression applied to the outlet; brief seating on a cool, hard surface. [Hering], [Clarke]
• Gentle walking/standing during post-stool spasm (cannot remain seated). [Clinical]
• Cool ablution, then air-dry—no wiping; bland barrier afterwards. [Clarke]
• Soft stools (oils, fluids, fruit stews) preventing re-tearing. [Clinical]
• Even a little cold locally while general warmth comforts the person. [Clarke]
• Warmth and pressure for zygomatic/tooth pains; lying on painful side. [Hering], [Clarke]
• Bland astringent mouth rinses (historical drug action mirrors relief). [Hughes]
• Leaning forward or hip flexion immediately after stool (mechanically slackens outlet). [Clinical]
• Night rest once the pain arc has been blunted by cooling/pressure. [Boericke]
• Avoidance of friction (loose cottons, avoid wool at margins). [Clarke]
• Cool compresses to peri-vulval/perineal rhagades. [Phatak]
• Short, tepid—not hot—sitz if cold is impossible (less effective but sometimes tolerated). [Clinical]

• After stool—chiefly after, lasting long (hours); “second wave” pains after wiping. [Hering], [Allen]
• Constipation; hard knotty stool; straining—especially the first effort. [Clarke], [Boericke]
• Sitting (pressure congestion), riding, long standing before stool. [Clarke]
• Touch/wiping of raw margins; coarse toilet papers. [Clarke]
• Warm water locally at the anus (contrast Paeon. which is often > warm bathing). [Clarke]
• Spices, alcohol, very hot drinks (mouth and outlet smart). [Hughes], [Allen]
• Cold air on face/teeth (neuralgia), despite anus craving cold locally—bi-thermal polarity. [Clarke]
• Morning evacuation period—anticipatory dread and worst after-pains. [Allen], [Clarke]
• Pregnancy/post-partum, constipating iron tonics, sedentary habits. [Clarke]
• Tight garments at pelvis, hard bicycle saddles (riders’ perineum). [Clarke]
• Wiping to dryness instead of cool ablution/air-dry—tears the fissure anew. [Clinical]
• Recurrent relapses in dry, cold winds at the lips/angles (commissural rhagades). [Clarke]
• Coffee in the hypersensitive—oral smarting returns. [Allen]

The mental state is held hostage by anticipatory dread of stool. Patients plan meals, timing, and even social life around the bowels; they delay eating or restrict to fluids fearing a hard stool will trigger the familiar torture [Clarke]. During the post-stool spasm they are restless, irritable, and singularly focused on cold water and pressure, pacing or standing because sitting is intolerable; relief by these measures confirms the Better cold/pressure modalities and their centrality to case-management [Hering], [Clarke]. They fear re-tearing at the first sign of dryness at the outlet and may become fastidious about regimen (oils, baths, tissue choice), a behaviour that is more practical obsession than constitutional anxiety. Insomnia often reflects schedule control (“if I move now I shall need the stool”). Compared with Aesculus, which broods over sacral backache and venous fullness with comparatively dry piles, Rat.is dominated by knife-burn pain with spasm and bright bleeding. Unlike Nitric acid, whose mind is coloured by corrosive irritability and general “splinter-pains,” Rat.is confined in concern to the outlet. When pain subsides with cooling, the mood clears rapidly—periphery governs psyche, not vice versa [Clarke], [Phatak]. [Clinical]

Headache per se is not a keynote; yet after a night broken by the burning arc, heaviness and hot head attend the morning. Trigeminal radiation is far more characteristic: malar/zygomatic stitches that shoot to eye/ear/teeth, < cold draught, > warmth/pressure/lying on painful side—a polarity reversed from the anal sphere where cold is desired [Hering], [Clarke]. Some patients note a flush or sweat with the rectal agony; these vegetative accompaniments fade as soon as cold ablution calms the part, reinforcing the peripheral-to-central dynamic. [Clinical]

Lachrymation accompanies malar neuralgia, with inner-canthus stabbing synchronous with cheek pains. Eyes themselves are healthy; the distress tracks the trigeminal arcs and obeys the same > warmth/pressure rule. On days when the rectal complaint is quiescent, ocular symptoms are likewise absent, projecting the single-axis nature of the remedy’s action [Clarke]. [Clinical]

Otalgia is a continuation of malar stitches to the ear; the patient presses or warms the cheek and the referred ear pain abates. No middle-ear catarrh is central to the remedy; this is neural tracking, not otitis. [Clarke]. [Clinical]

Dryness and rhagades at alae and commissures in cold wind align with the border-fissure theme; crusts crack and bleed on wiping; bland ointment barriers help while the internal prescription acts. Nasal involvement is minor beside Mouth and Rectum. [Clarke]. [Clinical]

The right zygoma is classical: jerking/stitching pains, often evening, < cold air, > warmth, firm pressure, and lying on that side [Hering], [Clarke]. Patients sometimes brace the cheek against a pillow or warm pad—exactly the analogue of pressing the outlet below. Corners of the mouth crack; lip commissures sting and bleed bright when stretched in cold weather, repeating the rhagades-astringent signature. [Clinical] [Proving]

Spongy, bleeding gums; burning aphthae; a scalded sensation of tongue and buccal mucosa after wine, coffee, and spices [Hughes], [Clarke]. Tooth-brushing produces bright bleeding from raw margins; cold air on teeth <, steady pressure or warmth >, and lying on that side allows sleep—precise polarities that anchor the prosopalgia field [Hering]. The astringent–haemostatic drug history rationalises the clinical ease with bland astringent rinses while the internal remedy addresses hyperalgesic rawness. [Clinical]

Neuralgic drawing from roots into cheek with hyperæsthesia to cold; pain darts on cold air, > warmth/pressure; often alternates with cheek stitches in a twilight cycle. Teeth per se are not decaying in the remedy image; the pains are neurovascular responses around raw oral borders. As the rectal state improves, dental hyperaesthesia often wanes, emphasising the unitary nature of the case. [Hering], [Clarke]. [Clinical]

When the mouth is aphthous the fauces feel rough, burning; swallowing coarse or hot foods provokes smarting and occasional bright oozing from fragile gums. The throat is more extension of oral surface disease than a separate pathology. Gargles of Rhatanhia were historically used on exactly this ground, but in homoeopathy the internal remedy and cool/bland regimen suffice [Hughes], [Clarke]. [Clinical]

Aversion to very hot or spiced foods; preference for bland, moist fare (soups, porridges) to ensure a soft stool. Appetite may be inhibited by fear of re-injury at the outlet; sour risings after wine or coffee occur in the mouth-sensitive. Gastric discomfort is thus behavioural and secondary: the patient eats to manage the rectal problem, not because of a primary gastric dyscrasia [Hughes]. [Clinical]

Modest flatulence with dragging towards the rectum precedes evacuation; true colic is rare compared with the post-stool agony which defines the case. Pelvic floor tightness and sphincter spasm account for the sense of incomplete relief despite a formed stool—another cue that we are dealing with hyperalgesic fissure not simple constipation [Clarke]. [Clinical]

Burning at the close of urination, sometimes with a reflex rectal tenesmus, shows cross-talk between meatal and anal margins; otherwise urine is normal. The key is marginal hyperaesthesia on small mucosal edges, not renal disease [Hering], [Clarke]. [Clinical]

Here lies the essence. Stool hard, knotty, or in large masses; straining opens a fissure or tears piles; then follows hours of burning and cutting as from knives or broken glass, with spasmodic sphincter so severe the patient cannot sit, paces, or sits in cold water for relief [Hering], [Allen], [Clarke], [Boericke]. Bright red bleeding is typical; wiping stings and may re-tear; pruritus often follows as the flame fades. Even with a soft stool, after-burning and tenesmus can persist, demonstrating neural wind-up and fissure hyperalgesia. Differentiate Paeonia (moist, ulcerous anus, > warm bathing), Nit-ac. (splinter pains, fetor, multiple outlet rhagades), Aesculus (dry congestive piles with sacral backache; pain less prolonged after stool), Hamamelis (venous bruised soreness/bleeding, little knife-burn), and Sulph. (constitutional itch/burn < heat/bed, early morning stool). [Clinical] [Proving]

“Riders’ perineum”: cracked, burning skin between scrotum and anus < sitting/riding, > cool ablution; coitus or prolonged standing can precipitate a piles episode in predisposed men [Clarke]. [Clinical]

Perineal/peri-vulval rhagades (post-partum, pruritic states) burn and sting; cool bathing relieves; fissure of anus frequently coexists. Contrast Graphites (sticky, honey discharge, less knife-pain) and Paeonia (moist ulcers, warm sitz >). [Clarke], [Phatak]. [Clinical]

Short, upper thoracic breaths during attacks; sighing once the pain arc breaks; no laryngo-bronchial pattern intrinsic to the remedy. [Clinical]

Palpitations attend acute torment with pacing; these abate the moment pain is controlled—do not mistake for cardiac disease when the cause is clearly peripheral pain with vegetative drive [Clarke]. [Clinical]

Breathing becomes shallow during the post-stool spasm from pure suffering; it deepens as soon as cold water/pressure blunt the pain—another instance where global physiology obeys the outlet. No primary pulmonary lesion is implied. [Clinical]

Sacral aching after straining or long spasm; less marked than Aesculus, in whom sacral pain is often primary. Rat.sacral pain fades as fissure cools and soft stools become routine [Boericke]. [Clinical]

Restless legs while walking off the spasm; no peripheral neuritis; cramps are secondary to agitation and sleeplessness. [Clinical]

A propensity to rhagades at borders—anus, lip angles, perineum—with bright redness, easy bleeding, stinging/burning, > cold water, < wiping/friction. This “border fissure” theme is the skin echo of the rectal core and should be actively sought in the history (cracked lips in wind, bleeding on stretching a smile, etc.). [Clarke], [Phatak]. [Clinical]

Sleep is a hostage to the bowels. If the stool came late, after-pains keep the patient up till cold sitz and pressure soften the arc; only then can they recline. Others fear a morning stool and delay bedtime or rise very early to engineer a soft evacuation. Nights without stool are tranquil. Dreams, when present, mimic the pain image and vanish as fissure calms—confirming the mechanical/reflective origin of insomnia rather than an independent sleep diathesis [Boericke], [Clarke]. [Clinical]

Brief, image-laden dreams of knives, glass, lavatory mishaps, or being unable to find relief; they cease when the fissure’s reactivity is controlled—diagnostically helpful in sensitive patients who verbalise imagery [Clinical].

No intrinsic pyrexia; local heat at the outlet dominates; face may flush during paroxysms; constitutional temperature normal once pain quiets. [Clarke]. [Clinical]

Heat is local and burning; chills may follow exhaustion from pacing; effort sweats attend spasm; thermal swings are reactive to pain, not primary. [Clarke], [Boericke]. [Clinical]

Worse spices, alcohol, and very hot drinks (rekindle mouth and outlet burning); better from cool local water and bland, moist, lubricating diet that ensures a soft stool (soups, porridge, stewed fruit, olive oil) [Hughes], [Clarke]. Patients often learn no dry cheeses, no astringents between flares. [Clinical]

Rat. is a peripheral-outlet remedy with laser focus: fissure/piles where pains are burning and cutting long after stool, with spasm and bright bleeding, > cold water & pressure, < straining/sitting/wiping/warm local applications. The same rhagades–burning–bright bleed triad recurs at mucocutaneous borders—gums, commissures, perineum. Distinguish Paeon. (moist, ulcerous, warm sitz >), Nit-ac. (splinter/fetor, multi-outlet), Aesculus (dry congestive piles with sacral backache, little bleeding), Hamamelis (venous bruised bleeding), Sulph. (constitutional burning/itch < heat/bed), Graph. (gluey fissures). The bi-thermal polarity (anus wants cold; face/tooth wants warmth) is a reliable differentiator [Clarke], [Boericke], [Phatak], [Farrington], [Boger]. [Clinical]

• Anal fissure / piles (pain type & bathing modality)
  • Paeonia — Raw, ulcerated anus with foul moisture; often > warm bathing. Ratanh.: knife-glass after-pains, > cold water, spasm prominent. [Clarke]
  • Nitric acid — Splinter-like pains, fetor, multiple outlet rhagades; Rat.local, bright bleeding without fetid oozing. [Phatak]
  • Aesculus — Dry, purple piles, sacral backache, little bleeding; Rat.long after-pains with knife-burn. [Boericke]
  • Hamamelis — Venous, bruised soreness and bleeding; lacks knife-burn and cold-water compulsion. [Clarke]
  • Sulphur — Burning/itching < heat/bed, early-morning stool; broader constitution; Rat.is sharply local and > cold. [Kent]
  • Graphites — Fissures with gluey exudate, eczema at angles; knife-like post-stool pains less central. [Clarke]
  • Aloe — Prolapsing piles, much mucus, urgency; pain quality less cutting; jelly-like stool possible. [Dewey]
  • Collinsonia — Obstinate constipation with pelvic venous tone and cardiac strain; fissure pains not knife-dominant. [Farrington]
  • Pulsatilla — Soft stools with burning in shy patients; lacks knife-glass imagery and spasm; thermal cravings differ. [Farrington]
  • Calc-fluor. — Hard, stony nodes; fissure tendency with tissue laxity; slower-acting, structural. Rat.for acute pain-arc. [Boger]
  • Thuja — Moist, warted anal margins; offensive sweat; different sycotic texture; not a knife-pain remedy. [Clarke]
  • Ignatia — Spasmodic outlet pains in sensitive temperaments; lacks astringent/bleeding keynote of Rat.[Clarke]
• Facial/tooth neuralgia (zygomatic axis)
  • Mag-phos. — Lightning neuralgia > heat & pressure; Rat.adds spongy gums/bright bleeding and a right-zygomatic bias. [Farrington]
  • Spigelia — Left supraorbital–malar boring < motion; Rat.right malar > pressure/warmth. [Clarke]
  • Coffea — Hyperaesthesia with insomnia; lacks astringent mucosal bleeding pattern. [Boericke]
  • Staph. — Carious tooth pains with moral injury; mouth rawness different in quality; less post-stool axis. [Clarke]

• Complementary: Hamamelis—pairs when venous bruising/bleeding complicates fissure; Rat.covers knife-pain/spasm, Ham. venous tone. [Clarke]
• Complementary: Aesculus—after Rat.relieves pain arc, Aesc. may complete sacral venous residue. [Boericke]
• Follows well: Nux-v.—sedentary constipated states; once irritability is reduced, Rat.heals fissure hyperalgesia. [Clarke]
• Follows well: Paeonia—when warm-bath lovers convert to persistent knife-pains now > cold (thermal switch). [Clarke]
• Precedes well: Sulph. or Lyc.—constitutional groundwork in relapsers with outlet fissures. [Kent]
• Related/compare: Nit-ac., Graph., Aloe, Collinsonia, Ign., Calc-fluor., Thuja, Puls.—see differentials for nuance.
• Antidotal/regimen: Avoid hot sitz/poultices at anus (often aggravate Rat.states); insist on cool ablution and air-dry, soft stools—“mechanical complement” to prescription. [Clarke]

• Anal fissure with knife-glass after-pains, must bathe in cold water: Rat.6x–30C after each stool or q6–8h in the acute; insist on cool ablution, air-dry, no wiping, stool softeners (oils, fluids). [Clarke], [Boericke]
• Bright bleeding from raw margins (tooth-brush or stool): Internal 30C; short course Q–3x local rinse (Rhatanhia tincture very dilute) may be used for gums while internal acts—stop as tenderness abates. [Hughes], [Clarke]
• Right zygomatic/tooth neuralgia, < cold air, > warmth/pressure/lying on side: 30C at onset; warm cheek pad; evaluate dental sepsis but treat neural arc. [Hering], [Clarke]
• Riders’ perineum / post-partum rhagades: 6x–30C; cool ablution after motions; bland barrier (zinc/calamine/soft oils); avoid hot sitz, which often aggravates a Rat.case. [Clarke], [Phatak]
• Regimen pearl: Replace wiping with brief cool rinse and fan/air-dry; this single change often halves recurrences while the remedy cures the hyperalgesic edge. [Clinical]

Mind

• MIND — FEAR — stool; of — pain, from anticipating. — Dreads evacuation for the long after-pains. [Clarke]
• MIND — ANXIETY — pain — rectum; of — walking about; compelled to. — Paces during sphincter spasm. [Clarke]
• MIND — IRRITABILITY — after stool — pains of anus; from. — Mood tracks outlet agony. [Hering]
• MIND — FASTIDIOUS — about regimen/habits — fear of re-tearing. — Behavioural control of stools. [Clinical]
• MIND — RESTLESSNESS — with pain — cannot sit. — Confirms sitting < and pressure/standing >. [Clarke]
• MIND — DESPAIR — of recovery — fissure/haemorrhoids, in chronic. — Encourages precise modality-guided prescribing. [Clarke]

Face / Teeth / Mouth

• FACE — PAIN — zygoma — right — evening — cold air — agg.; pressure/warmth — amel. — Signature malar neuralgia. [Clarke], [Hering]
• TEETH — PAIN — cold air — aggravates — lying on painful side — ameliorates. — Warmth/pressure soothe roots. [Hering]
• GUMS — SPONGY — bleed — slight touch. — Astringent sphere. [Clarke]
• MOUTH — APHTHAE — burning — wine/coffee — aggravate. — Scalded mucosa keynote. [Hughes]
• LIPS — CRACKS — angles — bleeding — cold wind — agg. — Border rhagades echo. [Clarke]
• MOUTH — RINSING — cold — ameliorates — soreness. — Practical bedside cue. [Hughes]

Rectum (core)

• RECTUM — FISSURE — pains — burning; cutting — after stool — long-lasting. — Central keynote. [Hering], [Allen]
• ANUS — PAIN — as from broken glass; knives — after stool. — Image guides selection. [Clarke]
• RECTUM — SPASM — sphincter — after stool. — Explains pacing/pressure. [Allen]
• RECTUM — HAEMORRHAGE — bright — stool — after. — Arterial oozing from raw edge. [Boericke]
• ANUS — WATER — cold — bathing — ameliorates. — Cold sitz compulsion. [Clarke]
• ANUS — ITCHING — fissures; with — wiping — aggravates. — Raw margin stings. [Phatak]
• RECTUM — PAIN — sitting — aggravates — walking — ameliorates. — Post-stool spasm behaviour. [Clarke]
• STOOL — HARD — knotty — first part — painful. — Mechanically re-tears fissure. [Allen]

Female / Perineum / Male

• FEMALE GENITALIA — RHAGADES — perineum — burning — bathing, cold — amel. — Mirror-lesion of anus. [Clarke]
• VULVA — FISSURES — stinging — touch/walking — aggravate. — Border fissure theme. [Phatak]
• PERINEUM — SORENESS — riders; in — fissures. — “Riders’ perineum.” [Clarke]
• MALE — COITION — after — haemorrhoids — aggravate. — Outlet strain flare. [Clarke]

Generalities / Modalities

• GENERALITIES — WATER — cold — applications — ameliorate. — Global cool-relief for raw borders. [Clarke]
• GENERALITIES — HEAT — local — anus — aggravates. — Hot sitz may worsen (cf. Paeon.). [Clarke]
• GENERALITIES — PRESSURE — ameliorates — local pains. — Compression eases spasm. [Hering]
• GENERALITIES — SITTING — aggravates — after stool. — Congestive pressure on outlet. [Clarke]
• GENERALITIES — EXERTION — slight walking — ameliorates — pains of anus. — Behavioural rubric. [Clinical]

Sleep

• SLEEP — DISTURBED — after stool — pains of anus; from. — Insomnia matches pain arc. [Boericke]
• SLEEP — FEAR — of waking to stool — anticipatory. — Behavioural control of timing. [Clarke]
• SLEEP — POSITION — lying on painful side — ameliorates — tooth/cheek pains. — Prosopalgia polarity. [Hering]

Skin / Mouth borders

• SKIN — FISSURES — mucocutaneous borders — bleeding — bright — with burning. — Cross-site hallmark. [Clarke]
• LIPS — FISSURES — angles — winter — aggravates. — Environmental trigger. [Clarke]
• ANUS — ECZEMA — pruritus — after stool — burning — with. — Itch follows flame. [Phatak]

Hering — The Guiding Symptoms of Our Materia Medica (1879): core rectal keynotes (post-stool knife/burning, spasm, cold-water relief); malar neuralgia.
Allen, T. F. — Encyclopaedia of Pure Materia Medica (1874–79): provings; rectal, oral, and trigeminal symptoms; urinary “close-burning.”
Clarke — A Dictionary of Practical Materia Medica (1900): substance background; clinical confirmations (fissure, piles, zygomatic prosopalgia); modalities/relationships.
Boericke — Pocket Manual of Homoeopathic Materia Medica (1901): fissure/piles picture; cold-water keynote; comparisons (Aesculus, Hamamelis, Paeonia).
Hughes — A Manual of Pharmacodynamics (1870s): tannin chemistry; astringent/haemostatic action informing mucosal affinity and regimen.
Phatak — Concise Materia Medica (1977): “broken glass/knife” pains; rhagades at borders; remedy comparisons, miasmatic colouring.
Farrington — Clinical Materia Medica (late 19th c.): differentials (Paeonia, Nit-ac., Aesculus); facial neuralgia contrasts; outlet remedies.
Boger — Synoptic Key of the Materia Medica (1915): regional emphasis (anus/margins), guiding modalities and structural complements (Calc-fluor.).
Kent — Lectures on Homoeopathic Materia Medica (1905): constitutional scaffolding (Sulph., Lyc.) in relapsers; thermal/itch comparisons.
Nash — Leaders in Homoeopathic Therapeutics (1907): piles/fissure indications and comparisons (Ham., Aesc., Paeon.).
Dewey — Practical Homoeopathic Therapeutics (1901): haemorrhoids/fissure therapeutics; stool-softening regimen.
Tyler — Homoeopathic Drug Pictures (1942): bedside reminders—dread of stool, cold sitz compulsion, malar neuralgia polarity.