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tumours before them; when situated higher up in the intestine, they do not descend at so early a period, but, by the pressure and elongation they are subject to from the passage of the fæces, they at length protrude externally. At first the piles are retracted within the anus by muscular action alone after the bowels have been 'relieved; but in process of time this no longer occurs, and it becomes necessary to return them. Another source of distress from the prolapsus of piles, is their liability to strangulation, either by the spasmodic contraction of the sphincter, or by sanguineous engorgement: under these circumstances the assistance of a surgeon will be required to effect the replacement of the extruded parts. If the patient delays seeking the necessary aid, mortification takes place, endangering his life should the constitution be impaired by any cause, or the vital powers be naturally feeble : if the contrary condition exists, and the general health be good, the tumours will slough off, and a cure will thus be effected, but at the expense of much suffering.

The converse condition of the anus to the preceding will cause serious distress to some, as a consequence of the sphincter having lost its tone, and becoming greatly dilated by the frequent protrusion of the piles, by their size, and by the long persistence of the disease, the patient will not only be subject

to the annoyance of prolapsus of the bowel with its attendant miseries, but will be unable to retain his fæces.

In addition to the complications and consecutive effects which have already been considered, others will arise : thus, in the female, by the contiguity of parts, the vagina and uterus are liable to be affected; whence arises leucorrhæal discharge more or less profuse in quantity, accompanied by pain and distressing bearing-down sensations. In the male, from the same cause, and the free anastomosis which exists between the prostatic plexus of vessels and those of the rectum, the prostate gland may be affected, inflammatory action excited, inducing enlargement and other evils; the neck of the bladder will not unfrequently be sympathetically involved, and strangury or retention of urine result. By the long continuance of chronic inflammation from hæmorrhoidal disease, stricture of the rectum sometimes occurs.

Numerous causes tend to excite hæmorrhoidal disease. In some cases we shall be able to trace it to hereditary predisposition: age has its influence ; sex, climate, and period of the year, also have effect. Plethora, particularly when combined with sedentary occupations and indulgence in the pleasures of the table, strongly predisposes to the disease ; mechanical and pathological obstruction to the venous circulation

of the intestine is another cause ; irritation within the bowels, as from ascarides ; diarrhoea, dysentery, irritating enemata, the injudicious use of mercury, certain stimulating purgatives, highly-seasoned dishes, and certain alimentary substances; diseases existing in contiguous parts, as of the prostate gland, stricture of the urethra, stone in the bladder, &c., will give rise to hæmorrhoids; and, lastly, : may be mentioned, excessive venery and masturbation.

It will be desirable to trace how far, and in what manner, the several causes that have been mentioned operate in inducing the disease.

Hereditary predisposition sometimes promotes the establishment of the disease, not so much by any local tendency to the formation of piles, as by a similarity of constitution and general organization. Thus we shall find both parents and children to be of a bilious temperament, of lax muscular fibre, the venous system of an augmented state of development, and the nervous sensibility exalted, whereby the depressing passions have a greater influence. This hereditary aptitude to hæmorrhoidal affections has been traced by many authors: Bushe* has observed it in several families in connection with similarity of organization, and also where that did

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not exist. A French author* mentions an instance of a family of nine people who were thus afflicted.

From several circumstances we do not often meet with hæmorrhoids till after the age of puberty ; diseases from sanguineous engorgement more frequently in early life attacking the head and chest than the abdominal organs : however, at the Blenheim Dispensary, I had a child of two years of age under my care suffering from external piles. One author mentions two cases occurring in his practice, in which one patient was between six and seven years of age, and the other five; the latter also had stone in the bladder. Other practitioners have met with the disease at an early period, but this is very far from being commonly the case. In the middle period of life we find all diseases of the abdominal organs more frequent, owing to the peculiar susceptibility then existing to vascular repletion and engorgement of this region ; the circulation is less rapid in the adult, and that portion of the vascular system returning the blood to the heart is more fully developed in mature life. It is after the age of puberty that the various affairs and occupations of life engage the attention ; then the habits become sedentary : depressing passions and the influence of temperament appertain also to the middle period of existence.

* M. J. B. de Larroque sur · Les Hæmorrhoïdes,' Paris, 1819.

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Females who have enjoyed immunity from hæmorrhoidal affections during that portion of their lives when the menstrual functions were regularly performed, not unfrequently become the subjects of them at the climacteric period, especially those who are plethoric; and, in such cases, the hæmorrhoidal flux may be regarded as salutary, by diverting those congestive affections from the several important organs, that so often succeed the cessation of the catamenia.

Great diversity of opinion prevails as to the relative frequency of hæmorrhoidal affections in males and females. Much will depend on the circumstances in which both are placed. Montègre thinks them more common in females in an occasional or accidental form; and to occur in males in a more regular and constitutional form. The experience of Mr. Syme and Dr. Bushe tends to confirm their greater frequency among men: the latter writer supposes the menstrual function should sufficiently relieve the system of sanguineous repletion; certainly, in the majority of cases of hæmorrhoids occurring in females that have come under my observation, the catamenia have either been suppressed, or the functions more or less deranged, but in some cases this will be rather an effect than a cause. Females who are plethoric are very liable to be the subjects of hæmorrhoids at the turn of life, when the menstrual flow ceases ;

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