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CHAPTER IX.

HEMORRHOIDAL AFFECTIONS.

HÆMorrhoids is a term applied generally to certain tumours occurring at the verge of the anus, or within the rectum. The term, like many others, is not the most appropriate that could be chosen, as it conveys no adequate idea of the nature of the disease ; yet by use it has become familiar both to the profession and the public, and its import generally understood : piles is the popular name under which these affections are known, indeed, by many, and by the working and poorer classes especially, almost every other disease about the rectum and anus receives the same designation.

It is not surprising that the ancients, from a deficiency of knowledge of anatomy and pathology, were unacquainted with the true nature of the disease, that they should have had very erroneous opinions of the structure of the tumours forming hæmorrhoids, and

have entertained the notion that they performed the · function of evacuating black bile and melancholic

humours from the system. After the discovery of the

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circulation of the blood by the illustrious Harvey, a new but equally erroneous theory was generally received; it being conceived that bleeding from external piles depleted the system generally, and that hæmorrhage from internal piles depleted the portal system only.

Montègre* gives the following classification of hæmorrhoidal complaints :

1. Blind or dry Hæmorrhoids (Cæcæ) 2. Hæmorrhoids

White discharge (Albæ), with catarrh of

I the intestines with discharge

Sanguineous discharge | By Exhalation (Fluentes)

1 (Sanguinolente) By Rupture 3. Hæmorrhoids Varicose

Dry with tumours (Variscæ)

Bleeding (Tumentes) Mariscous

Dry (Mariscæ)

Bleeding from

dilated pores 4. Painful Hæmor- Inflammatory rhoids (Dolentes) Nervous

Fissured 5. Hæmorrhoids (Indolent

From induration with constriction

of the tissues of the anus (Cum constric-Painful

Spasmodic. tione ani)

Schirrhous 6. Hæmorrhoids (Superficial with ulceration

(Ulcerate) Fistulous * · Des Hémorrhoïdes, ou Traité Analytique de toutes les Affections Hémorrhoïdales,' par A. J. de Montègre, Deuxième Edition, Paris, 1830, p. 71.

7. Hæmorrhoids (From elongation of the with prolapsus internal membrane

(Cum proci- From invagination of
dentia ani) | the intestines
8. Hæmorrhoids With dysuria

with irritation of
the bladder Strangury
(Cum irritatione
vesicæ urinariæ) (Hæmaturia

Although this classification is very complete and comprehensive, and clearly shows the various characters and phases of hæmorrhoidal 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 hæmorrhoids; 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 hæmorrhoidal 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 vari

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cocele, 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 hæmorrhoids. 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 hæmorrhoidal 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 hæmorrhoid ; he thinks the difference in structure depends on the strength of the constitution ; the sanguineous hæmorrhoidal 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 hæmorrhoidal 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 hæmorrhoidal

* • 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.

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