A system of practical medicine. By American authors. Vol. 2

by Unknown

Occasionally there is a total inability to urinate, combined with a frequent desire to do so. When an attack such as this ends in suppuration of the tumor a radical cure is effected, but a marginal ulcer of the anus sometimes follows. An unclean and neglectful habit provoking constipation, sexual incontinence, over-indulgence in highly-seasoned food or in stimulating beverages, exposure to cold and wet, and the straining attendant upon dysuria, will provoke an attack. No age or sex is exempt from this affection (Gross). It is claimed that before puberty females are more subject to it than males; after that age the reverse obtains, except during pregnancy.

Internal hemorrhoids are round, oval, or sometimes cylindroid-shaped tumors covered by mucous membrane; they are smooth, granular, or rough to the touch, much less sensitive and painful than the inflamed external variety, and are situated within the rectum it may be an inch or two above the internal sphincter muscle. They occur in groups or scattered over the surface of the bowel. In structure they are soft, spongy, vascular tumors composed of dilated and tortuous blood-vessels, the veins predominating over the arteries, their interstices scantily supplied with connective tissue, and their covering is of mucous membrane. In color they are dark red, but when compressed and strangulated by the sphincters they assume a dusky purple hue. After long exposure they take on a pseudo-cutaneous appearance.

The columns of the rectum are the seat of the cylindroid pile, which is brighter in color and much more arterial in its structure than the ordinary variety, and bleeds very freely. Anything which causes stasis and accumulation of blood in the hemorrhoidal plexus of veins predisposes to this very common affection. Constipation is the usual cause; and among others may be named diseases of the liver which cause portal obstruction, pelvic tumors causing engorgement from pressure, the gravid uterus, labor, prostatic hypertrophy, urinary calculi, stricture of the urethra, stricture of the rectum, and rectal tumors. Among other causes are horseback-riding, the erect posture, violent cathartics, seat-worms, dysentery, diarrhoea, dyspepsia, and a sedentary life, with a diet of rich, stimulating food.

These piles do not usually cause much suffering; they vary in size from that of a pea to that of a pigeon's egg, and cause a sense of weight and stuffing in the bowel; but when they are large and numerous they cause severe pain, tenesmus, difficult defecation, spasm of the sphincters, and prolapse of the anus. When the patient is at stool the tumors are forced down and protrude in a bunch, surrounded and constricted by a collar of prolapsed mucous membrane: under these circumstances the tortuous and dilated vessels of which they are composed give way and free arterio-venous hemorrhage takes place. In some cases this happens at every stool, the patient losing from a few ounces to a half pint of blood almost daily until alarmingly depleted. Usually, the protruded piles are easily restored after a motion of the bowels, and so remain until the next one occurs; but in other cases of longer standing and of more gravity the sphincter loses all tone and the piles remain constantly prolapsed. This affection is very chronic, and the subject of it has to regulate his life with the greatest care, as the least unusual effort or excess may provoke an exacerbation. Excepting in the worst cases the general health is not materially impaired. They occasionally become so strangulated as to slough off, which effects a cure, but this is accompanied by grave constitutional disturbance. The disease is rather rare before the age of puberty, but is very common in both sexes in adult life, and is frequently associated with fistula, polypus, fissure, or carcinoma of this region. In females suffering with piles a free hemorrhage from them sometimes takes the place of the menstrual flow. The presence of internal piles causes a sense of weight and fulness and the sensation of a foreign body or of feces remaining in the rectum, with troublesome and obstinate itching about the anus. These symptoms, with the occurrence of hemorrhage from the rupture, erosion, ulceration, or abrasion of the dilated vessels, render the diagnosis easy. Should the piles not protrude, they can readily be made to do so by directing the patient to sit and strain over a vessel containing hot water. If the piles do not appear, a digital examination should be made. Indeed, it would be better to make one in every case of this kind.

About the margin of the anus the superficial veins are prone to great dilatation, and when presenting form masses of a bluish color, often very dark, covered partly by mucous membrane, partly by integument. These are also commonly known as piles.

Dilatation of the Rectal Pouches, or Physick's Encysted Rectum.

This is an uncommon disease, generally occurring in those advanced in years, and consists of an hypertrophy, and sometimes of an inflammation, of the natural rectal sacs. These pouches are quite small in early life, and enlarge gradually as age advances, this condition being favored by the lodgment in them of extraneous substances, such as indurated fecal matter, inspissated mucus, the seeds of fruit, and other undigested masses. Constipation, so usual with the old, predisposes to this affection, as it keeps the bowel distended with hardened feces. The pouches vary much in size, the largest of them admitting the end of a finger. The disease is insidious and slow, but is capable of producing intense suffering should inflammation, suppuration, or ulceration attack them. Sometimes as many as a dozen are involved.

The symptoms, which are rather misleading than suggestive of the disorder, are a sensation of weight and uneasiness just within the anus and uneasy sensations in the rectum, distressing itching, and, after a time, pain following defecation and lasting often for hours. The pain, which is aching and burning in character, is not confined to the parts affected, but radiates down the thighs, toward the back, and into the perineum. An increased secretion of mucus always exists in these cases, but the discharge of purulent matter is uncommon, and its presence indicates the existence of very active inflammation.

It is said that even in the worst cases no spasm of the sphincters occurs. An exploration of the bowel with a blunt-pointed hook affords the only reliable guide to correct diagnosis: this, as it is moved about in the rectum, engages the rim of a sac, which may thus be drawn down through the anus and examined.