Hemorrhoids constitute perhaps the most common and, in some respects, uncomfortable or distressing disease of the rectum. The term implies a varicose condition of the lower veins, sometimes those of one set of hemorrhoidal veins being involved, at other times nearly all of them participating. They are spoken of as external or internal. In the former case it is the external hemorrhoidal veins alone which are involved, and usually only two or three of them, although occasionally one sees outside the anus, as within, a general involvement of the entire venous distribution. A pile, then, is essentially a venous angioma, or a single varicosity, and its peculiar features are due solely to its location.
Any vein thus involved is liable to the same dangers and accidents as veins in other parts of the body. Thus it may undergo dilatation, thrombosis, and suppuration, while the ordinary consequences of the latter condition may follow here, as elsewhere, with this difference alone, that when the middle and upper hemorrhoidal plexuses are involved the thromboseptic process, should it occur, follows the portal vein, and the first metastatic abscess that forms occurs within the liver. Thence it may spread to other parts of the body in classic form.
The hemorrhoidal veins, save those at the verge of the anus, are more or less entangled among the fibers of the levator ani and the sphincter. These muscles are thrown into a condition of more or less spasmodic contraction when the veins are so involved. In consequence more pressure is made upon the veins themselves, and the conditions of spasm and venous engorgement react upon each other in a vicious circle, each tending to make the other worse. Hence the great advantage of stretching the sphincter in any operation save that for a small external pile.
Hemorrhoidal angiomas may appear as single tumors or in multiple form surrounding the lower part of the rectum. The most common cause for their occurrence is chronic constipation. Occasionally the first exciting agent is some violent strain in defecation, or possibly the actual rupture of a small vessel, but such constant overloading of the rectum as obstructs its return circulation conduces to engorgement and the other conditions may easily follow. A small pile may be brought into existence in brief time, but a general hemorrhoidal condition is one of slow development. Chronic cases are always accompanied by further changes involving the surrounding connective tissue and the overlying mucosa, both of which become thickened and infiltrated, while ulcers form frequently upon the latter, and the occurrence of those linear ulcers which are ordinarily called fissures is very frequent. This gives an additionally distressing feature to these cases. As the condition goes on and the angiomas increase in size there is an increasing tendency to prolapse. This may be temporary or constant, i. e., it may occur with the straining effort at stool or it may result in a condition of permanent protrusion at the anus of the engorged mucosa; or, if the sphincter has finally become prolapsed a true prolapse of the rectum may result. A mucous surface thus constantly exposed to irritation will nearly always be more or less ulcerated and tender, while hemorrhages in either variety are common. It is not an infrequent event, then, for a patient to lose a number of ounces of blood with or just after stool, and sometimes the blood loss is even excessive. There is then added to the local condition a secondary feature of anemia and its attendant consequences which are sometimes extreme, and may even make operation somewhat hazardous. The lower inch and a half of the rectum is the portion particularly supplied with sensory nerves, and, under these circumstances, the irritated area becomes erethistic and painful and the patient’s suffering may be extreme. This is the so-called “pile-bearing area,” as it is within it that the hemorrhoidal condition is practically confined. Even a small individual pile connected with one of the little external veins may give rise to a disproportionate amount of discomfort.
There has been so much quack literature upon this general subject that ignorant patients are very likely to say that they have piles, no matter what may be the local condition. A statement to this effect should, first of all, provoke a physical examination with the finger, then with the speculum. The educated finger will easily detect the presence of the rugosities or tumors produced by internal piles, the external being always self-evident. The coexistence of ulceration will be indicated by an extreme degree of sphincteric spasm and of tenderness. It should be remembered that, along with hemorrhoids, there may coexist fissure, ulcer, painful spasm, prolapse, and, in long-existent cases, even cancer. The average patient with cancer of the rectum will go to his physician saying that he thinks he has piles.
Treatment.
—Treatment needs to be something more than merely local in aggravated cases, as it should also be more comprehensive. Patients who have thus long suffered have almost inevitably contracted the constipated habit, postponing defecation whenever possible because of pain and tenderness, and perhaps the hemorrhage accompanying it. The large bowel has, therefore, become weakened, and attention should be given to it as well as to the general digestive process.
Locally very mild degrees of purely temporary disturbance may be sometimes acceptably and temporarily treated by the use of suppositories containing some soothing and anodyne drug, as well as ergotin, the latter being valuable because of its constringent effect upon the bloodvessels. A five-grain gelatin-coated pill of ergotin makes a satisfactory suppository for the young, under these conditions.
A freshly formed, external hemorrhoid, which may attain a size no larger than that of a pea, but which will seem to the patient as large as a bird’s egg, is best treated by open division, turning out the blood or clot contained within the dilated vein, which will quickly obliterate, so that recovery will be complete within two or three days. This may be done under local anesthesia and with prompt relief. There have been methods in vogue, especially among the charlatans and some of the specialists, of treating external and the more localized internal conditions by injection of carbolic acid, either pure or reduced with a little glycerin. A few drops are thrown into the tumor with a hypodermic needle, the effect being to promptly coagulate the contained blood, the intent being to produce a final cure by absorption of the clot and obliteration of the veins. This, in fact, is the secret method long employed by the travelling charlatans and often connected with the name of Brinkerhof. It is uncertain in action, and the production of a clot under these conditions is by no means always free from danger, nor is the relief prompt. What is desired is to empty the vein and turn out the clot rather than to provoke its production. The method is rarely practised by judicious surgeons, who have too often seen serious sloughing and even general septic disturbance follow it.
For the radical relief of distinctly hemorrhoidal conditions there is no satisfactory method save the operative. So many measures have been devised in time past that it is necessary here to be selective and only mention one or two. On general principles every pile is a venous tumor, and there is no reason why it should not be treated like any other tumor, i. e., by enucleation or excision. The same is true of the area which contains a number of such tumors, i. e., the so-called pile-bearing area. Hence, surgeons of the largest experience have practically discarded the more bungling methods and have applied to these conditions the same radical measures which they recommend elsewhere.