Elements of Surgery

by Robert Liston

The neighbouring parts often swell and inflame. Sometimes one or two tumours only exist; or they occur in numbers, clustered together, and form a large irregular mass, inflamed, and often ulcerated. Acute pain is experienced in the part, when touched and after straining at stool; by straining too, such as are attached within the sphincter are pushed out, together with folds of the mucous membrane, and, if allowed to remain, are constricted by the sphincter, swell in consequence, ulcerate or slough, and discharge blood. The bleeding often is very violent in such cases, or when the tumour is punctured; the blood flowing in great quantity, and in a rapid stream. The hemorrhage is often periodical, both in males and females; in the latter, it would seem occasionally to take the place of the menstrual flux. The soft bluish tumours that are compressible, and fluctuate when large, furnish blood more readily and profusely than the hard and tuberculated.

Much irritation is produced by piles, and some of them are more irritable than others. There are often extensive excoriation of the nates around, and profuse discharge from the raw parts, particularly when the tumours are external. In such cases, flat, hard, warty excrescences often form in the cleft of the nates, and increase the irritation; and these are termed fici, mariscæ, and condylomata.

In internal piles, a frequent desire to go to stool is induced, and more or less of the mucous coat of the rectum is protruded and swollen. The tumour, along with the protruded portion of bowel, may become strangulated if not replaced. By such or other causes inflammation is excited, which often extends to the neighbouring parts, and terminates in abscess; but this is not so apt to occur from tumours seated high in the rectum as from those about the verge of the anus.

The usual cause of piles is obstruction to the return of blood in the hemorrhoidal veins; and this may be occasioned by advanced pregnancy, habitual distension of the colon and sigmoid flexure, with hardened feces, or tumours of the abdominal viscera.

Inflammation of the Rectum is attended with excruciating pain, burning heat, and a feeling of contraction, increased very much when the parts are thrown into action by evacuation of the contents of the bowel, or of the bladder. The heat may be felt on introducing the finger, with the view of examination; by doing so, dreadful torture is produced, and such manipulation should not be had recourse to unless there is a suspicion of foreign matter lodging in the part, by removal of which the action might be cut short. The bladder is often affected sympathetically; there may be frequent desire to empty it, or else retention of its contents: this latter occurrence not unfrequently follows operations on the bowel, as for the removal of hemorrhoids, by ligature or extensive incision, which is neither warrantable nor requisite. The inflammation extends to the cellular tissue round the rectum, with swelling and increased pain; the pain is aggravated by pressure, and the patient is unable to sit erect. As the painful symptoms abate, puriform discharge from the membrane of the gut takes place, and often is very profuse. The morbid action sometimes extends to the other intestines, attended after a time with mucous or even bloody evacuations. When the affection is confined to the rectum, the feces and vitiated secretion are distinct from each other, and the former are usually of their natural appearance; but when the other intestines participate, to a greater or less extent, the feces are fluid, and intimately mixed with the morbid secretion.

Ulceration of the mucous coat, with continued discharge, often supervenes. Sometimes the peritoneal coat of the bowel is affected secondarily, and then the pain is much more acute and more aggravated by pressure.

Patients affected with hemorrhoidal swellings,—the action of whose bowels is irregular, and in whom the vessels about the anus are congested,—are peculiarly liable to inflammation and abscess in the rectum or its neighbourhood, from the application of cold or wet to the surface, particularly that of the lower part of the body. Ascarides often produce violent irritation in the extremity of the rectum, both in children and in adults; and the morbid excitation is communicated to the bladder, as will afterwards be noticed. Not unfrequently the inflammation is induced by a foreign body, either lodging in the cavity of the bowel or imbedded in its coats—as hardened feculent matter, alvine and biliary concretions, bones of small animals, needles, pins.

Effusion often takes place into the loose cellular tissue round the bowel, with hard swelling, followed by unhealthy and extensive suppuration. Rigors generally precede the formation of matter, and violent fever almost always attends, abating, along with all the painful feelings, on evacuation of the fluid. Still the discharge continues, and the patient is kept uncomfortable and unhappy. Resolution can very rarely be produced; suppuration is the almost uniform termination of the action, and in persons of bad habit this sometimes occurs in these parts without any assignable cause, and without previous warning. The purulent collections are often very extensive, both externally and internally, the integuments are all undermined, and in some cases it is difficult to ascertain the depth of the abscess, even with the aid of a long probe.