DIAGNOSIS.
There is not much probability of confounding hemorrhoidal tumors with any other abnormality in the vicinity of the rectum. The different varieties of internal hemorrhoids, a description of which is given on page 7, may confuse, but as stated before, no discrimination is necessary in applying the treatment for the purpose of effecting a radical cure, the one great object to be attained. Where several distinct tumors exist, they are usually arranged in rows on either side, not up and down, but antero-posteriorly, with the long diameter of each tumor at its base, parallel to the antero-posterior diameter, or, if the muscles were dilated, to the circumference of the rectum.
If situated on the upper margin of the internal sphincter there may be several isolated tumors thus arranged on one side, while they may have all coalesced, or originally have formed into one continuous hemorrhoidal mass on the opposite side, [Fig. 1]. Or there may be one continuous hemorrhoidal mass on either side, separated only by an anterior and posterior commissure, [Fig. 2]. In some instances when the bowel is prolapsed and constricted by the external muscle, the branches of the middle hemorrhoidal veins that anastomose and encircle the upper part of the internal sphincter, may be so dilated and distended as to present an unsightly appearance, reminding the anatomist of the circle of Willis; at the same time a few capillary or sessile tumors may be seen studded around at different points.
Fig. 1.—Internal hemorrhoids prolapsed and held out by the constriction of the sphincter. J. Junction of skin with mucous membrane. E. Everted bowel.
There can be no mistake in discriminating between a large hemorrhoid and the bowel, but to distinguish a small, blanched hemorrhoid, located on the upper margin of the internal sphincter from an irritated and saggened portion of the bowel, when looking through a speculum, is more difficult. The bowel presents a more smooth and continuous surface, while the hemorrhoid is more uneven and irregular, and bleeds freely when scratched. Sometimes a victim of piles will call and speak of his piles having come down and are hanging out. On inspection a large fold of mucous membrane will be seen protruding on one side, which has been mistaken by physicians for a hemorrhoid, but the tumor will be found immediately above and possibly on the opposite side.
From polypi hemorrhoids may be distinguished by their spongy like texture, easy to bleed when scratched, more painful, history, shape, manner of arrangement, etc. Polypi are considered as a hypertrophy of the normal elements of the mucous membrane and the sub-mucous connective tissue. If originating from the former they are soft, if from the latter hard and fibrous, are often pediculated or club-shaped, sometimes grow rapidly, not painful unless within the grasp of the sphincter, may arise entirely above the sphincters, and are rarely of a glandular, villous or bleeding surface. Should a mistake be made and a polypus thoroughly injected, the result would be nothing more than a permanent removal of the offending growth.
Fig. 2.—Prolapsed internal hemorrhoids, showing a continuous hemorrhoidal mass on either side, with an arterial pile on the left, all completely eradicated by two operations.
The external hemorrhoid does not elicit the thought or command the dignity of his neighbor, the internal pile, but usually makes himself known more forcibly in his incipient stage of formation, caused by the rupture of a venule of the inferior hemorrhoidal vein, allowing extravasation and infiltration, which may lead on to inflammation and suppuration, or the clot absorb and result in an external cutaneous tag, subject to œdema, itching, induration, etc. On pulling down the mucous membrane at the verge of the anus, sometimes a slight fullness or bulbous-like expansion of an exposed part of a superficial vein will be seen, which should not be mistaken by the novice for an incipient hemorrhoid.