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CHAPTER X.

ENLARGEMENT OF THE HÆMORRHOIDAL VEINS.

THE hæmorrhoidal veins are liable to dilatation quite distinct from, and not to be confounded with, the morbid condition of the several tissues constituting piles. They assume precisely an analogous condition to the veins of the testicle forming varicocele, and to the branches of the saphena vein constituting the troublesome affection generally known as varicose veins of the leg.

There are certain physiological causes that predispose to the enlargement of the hæmorrhoidal veins, and others that are pathological. It will be remembered that the portal system, which commences in the veins of the rectum, is destitute of valves, consequently the radical branches are subject to the pressure of the entire column of blood. Impediments to the venous circulation are very liable to occur from congestion of the liver, from pressure on the venous trunks by overloaded and distended intestine, by the pregnant womb, by ovarian and other abnormal abdominal tumours.

ENLARGEMENT OF THE HÆMORRHOIDAL VEINS. 213

Generally there appears to exist a predisposition to venous dilatation in those who have the hæmorrhoidal veins enlarged, it being not unusual to observe it associated with varicocele and a varicose condition of the branches of the saphena veins.

The symptoms are a sensation of weight and distension about the rectum, uneasiness in the loins, a feeling of sinking and general lassitude, and the same mental depression which is observed to attend dilatation of the veins of the leg and testicle. The dilated veins may be felt on either side of the rectum like a bundle of earth-worms, the same as in varicocele. They sometimes form tumours, projecting internally or externally to the sphincter, but their appearance is very different from those caused by hæmorrhoids.

Since the publication of the first edition of this work, through the kindness of my colleague, Mr. Hulme, I had an opportunity of examining a very aggravated case of this disease occurring in a female, a patient of his, at the Blenheim Dispensary. The veins formed large tumours around the anus, and as far as the finger could reach were felt extending up the rectum; the veins of both labia were also greatly dilated, and conveyed to the touch the feeling that has been described. In other cases which have come under my notice, the veins have not formed tumours external to the sphincter ani muscle, but

could be distinctly felt within its margin, and were attended by the symptoms above mentioned.

Surgery will be of no avail, either in the cure or in the relief of this affection; but by judicious medical treatment the symptoms and distress arising therefrom may be much mitigated. It is most essential that attention be paid to the proper performance of the chylopoietic organs, that constipation be not permitted to exist, and that the skin and kidneys should duly perform their functions. Moderate exercise will be beneficial, as the venous circulation is thereby facilitated the patient should avoid standing for any long period, as the erect posture favours gravitation of the blood. The subjects of venous dilatation being generally of lax fibre, they will be much benefited by the use of tonics, more especially the mineral acids. Six or eight ounces of cold water may be injected into the rectum twice or thrice a day with advantage: the cold bath, and ablution in cold water night and morning, will afford great relief, as also will a jet of cold water directed against the anus.

CHAPTER XI.

PROLAPSUS OF THE RECTUM.

INDEPENDENTLY of the eversion of the mucous membrane that frequently attends internal hæmorrhoids, and which has been considered in the Chapter on Hæmorrhoidal Affections, the rectum is subject to protrusion from other causes.

Prolapsus or procidentia ani, are the terms by which this form of disease is familiarly known; an error in nomenclature very evident from the fact that the anus is merely the terminal aperture of the alimentary canal, and cannot therefore itself be protruded. Prolapsus recti is now very properly used by several recent writers, and conveys a correct idea of the affection.

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Two forms of prolapsus recti occur in the one the whole of the tunics of the rectum descend, in the other the mucous membrane alone is prolapsed. By many former writers it was maintained that the muscular coat of the intestine was never extruded; but

preparations which are to be seen in King's College and other

museums, incontestably show the opinion to be erroneous in the large majority of instances, particularly where the eversion does not take place to a great extent, it is the mucous and submucous areolar tissue only that descends; the firmer attachment of the muscular coat to the surrounding parts and its function render it less liable to be prolapsed than the mucous membrane, which is more voluminous, and but very loosely connected. Mr. Copeland* doubted the protrusion of the muscular coat: he says, "In almost every case of prolapsus ani, it is the internal membrane only of the intestine which descends through the sphincter muscle. The connection of the external surface of the rectum is so firm with the surrounding parts, that it is almost impossible the whole should be protruded together; a separation or elongation of the union between the coats of the intestine must therefore precede the disease, and form its essential character; whether it be produced by the effusion of blood between them, or by the continued tenesmus, or efforts to pass the fæces, or peculiarity of structure, or any other cause."

From anatomical causes, children are more subject to protrusion of the bowel than adults: thus in them the sacrum is less curved, the coccyx is not ossified,

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'Observations on the Principal Diseases of the Rectum and Anus,' by Thomas Copeland, third edition, 1824, p. 73.

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