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7. Haemorrhoids / From elongation of the with prolapsus I internal membrane

(Cum proci- | From invagination of dentia ani) I the intestines

With dysuria

8. Haemorrhoids with irritation of the bladder ( (Cum irritatione vesica? urinariae)

Strangury
Haematuria

Although this classification is very complete and comprehensive, and clearly shows the various characters and phases of haemorrhoidal tumours, the most practical and important to bear in mind, as influencing the treatment, is the division adopted by most English authors into internal and external haemorrhoids; the former being those which occur within the margin of the anus, and involve the mucous membrane of the intestine, and the latter those which are situated external to the sphincter ani, and are covered by the thin integument of the anus.

The nature and structure of hamiorrhoidal tumours have not been clearly understood till within recent times. By the older writers they were considered to be dilatations of veins, the same views being adopted by many modern authors; and at the present time a very general opinion prevails that they are simple varices, and analogous to that morbid condition observed in the spermatic veins constituting varicocele, or to the dilatation of the superficial veins of the legs, which causes so much distress, and so often gives rise to a very troublesome form of ulceration.

External haemorrhoids.—These tumours occur at the verge of the anus, and are covered by the thin integument of that region; but occasionally they will be observed to extend a short distance within the anal orifice, and will then be partly covered by the integument, and partly by the mucous membrane of the intestine. In form they are mostly globate, and have a broad extended base; they are of a livid colour at first, but lose that as their active state subsides. They are tense and elastic to the touch, and exquisitely painful when inflamed, the anguish then being so great that the patient is unable to walk or take any exercise—in some cases even sitting is impossible. They consist of the integument and cellular tissue into which blood has been extravasated, as a result of congested state of the haemorrhoidal vessels and determination of blood to them, produced by causes to be hereafter mentioned: generally, the blood is encysted in a central cavity, having a smooth glistening surface; in some cases there are several of these cavities filled with blood.

After the acute stage attending the development of these tumours has subsided, the blood that has been effused into their interior becomes absorbed, and if they have not been distended to any great extent the skin contracts, and the parts resume their natural condition; but if the tumours have attained the size of a cherry, or larger, the elasticity of the integument will have been destroyed by over distension, and upon absorption of their fluid contents pendulous flaps remain, prone to take on increased action, and form excrescences which may attain a considerable size, and occasion as much or more suffering than the primary disease.

Mr. Howship * describes another form of external pile, which he terms the serous haemorrhoid; he thinks the difference in structure depends on the strength of the constitution; the sanguineous haemorrhoidal tumour occurring in the strong, and the serous in those of low vital powers. He very justly dwells on the necessity of drawing a distinction between the two kinds, as our treatment will thereby be influenced. This serous haemorrhoidal tumour is pale, elastic, shining, semi-transparent, and more frequently forming a ring round the verge of the anus than appearing as a distinct tumour. I have many times observed these swellings, but cannot agree in considering them as a separate variety of haemorrhoidal tumour, but as an oederaatous distension of the loose cellular tissue and thin skin of the parts, depending on irritation in the immediate vicinity. This state is more frequently seen as an effect of inflamed internal haemorrhoids than from any other cause, though I have witnessed it occurring from fissure of the anus, acrid intestinal secretions, and similar conditions.

* 'Practical Observations on the Symptoms, Discriminations, and Treatment of some of the most important Diseases of the Lower Intestine and Anus,' by John Howship, 1824, p. 208.

Internal hemorrhoids.— The tumours constituting internal piles, consist of a morbid alteration in some portion of the mucous membrane of the rectum, and submucous areolar tissue, with an augmented and abnormal development of the capillary vessels. Like the external variety, they were formerly considered to be a dilatation of the veins. It appears somewhat surprising that this opinion should have been retained by many of the later writers; for when speaking of the character of the haemorrhage, they describe it as florid and bright, and more nearly resembling arterial than venous blood, which it would not if it were poured out from veins, particularly when they are in a dilated and debilitated condition: in them the circulation must necessarily be slow, and consequently the blood would acquire a deeper colour. But examinations on the living subject, and dissections on the dead, clearly demonstrate a different condition. A varicose state of the haemorrhoidal veins is not unfrequently met with; however, they form tumours very different in character, and in the symptoms they occasion, from those now under consideration.

By dissection, internal haemorrhoidal tumours will be found to consist of both arteries and veins, the latter capacious, not in a diseased condition, but merely of abnormal development; the areolar tissue of the mucous membrane is hypertrophied, and if the tumours have existed long, and been subject to repeated inflammatory attacks, it will also be condensed. The surface of these tumours is frequently villous, presenting to the unassisted eye a granular appearance: they generally bleed freely if rudely touched, or accidentally scratched by the nail during an examination, the blood being of a bright red colour. Dr. Bushe states, he has been able to rub off an exceedingly vascular and fragile adventitious membrane from their surface, and is of opinion they may thus acquire an increase in magnitude. To the touch they have a spongy elastic feel, and by some authors are considered to resemble erectile tissue in structure; had they compared them to those abnormal developments of the vascular system termed aneurism by anastomosis, the analogy would have been more correct.

Internal haemorrhoids vary much in size and number, but the accessory phenomena attending them, such as pain, haemorrhage, &c, are not increased in proportion to either, and cases are met with in which

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