DISEASES OF THE ANUS AND RECTUM by J.G. GILCHRIST, M.D.
HAEMORRHOIDS.
Piles are painful tumours found situated either without or within the sphincters, differing somewhat in structure, as they are acute or chronic and known, with reference to their locations, as external or internal. Some writers make a further distinction between the blind and bleeding piles, but as these symptoms depend upon location, and not on any other peculiarity the distinction has been gradually lost.
External haemorrhoids, occur as small, hard tubercles, situated without the sphincter and are undoubtedly caused, in the first instance, by an enlargement of one or more veins, similar to varix, which ultimately give way, and the blood is poured out into the cellular tissue, soon becoming entirely absorbed, or remaining coagulated in a distinct adventitious sheath. In acute cases, absorption is the rule; but when frequent attacks have occurred the tissues are thickened, the blood is not absorbed, and a permanent tumour remains, hard, not particularly sensitive but liable to sudden attacks of inflammation, when the pain becomes excessive, and strong men become greatly prostrated from its violence. Frequent attacks of this kind results in the continued growth of tumours, which may become of such a size that much annoyance and interference with defecation may result. When inflamed the tumours are some what florid, not very sensitive, and apart from the straining necessary at stool, and the pain attending that process, are not very troublesome, unless of unusual size and in numbers. When inflamed, from any cause, the tumours become hard of a bluish or livid colour, very sensitive to the touch, and cause the most exquisite pain and suffering.
The causes are both exciting and predisposing. The predisposing causes are of two kinds; one dependant upon causes that determines an increased amount of blood to the neighbourhood of the anus, and so frequently repeated that the operation may be considered permanent. Under this head we include all habits, of avocation or otherwise, that induce either determination of blood, or that impedes the return through the veins-as sedentary pursuits, or long standing, as hair-dressers, dentists, school- teachers, and the like; as well as mechanical impediments, such as habitual constipation, tumours, pregnancy, or morbid processes of various kinds.
The other class of predisposing causes, are of a more constitutional character, as hepatic derangements, or any impediment to the portal circulation; and a peculiar hereditary tendency, which is either due to a similarity of pursuits or to causes of a more vital character, dependant upon some functional peculiarity.
The exciting causes are very various. Among them we may include exposure to cold or damp; cathartic medication; frequent employment of enemata; violent exercise on horse back; immoderate sexual indulgence, or in the pleasure of the table. In short any continued habit that either interferes with venous circulation, or produces increased determination of blood to the parts. In acute cases the first attack may be the last, but when there is a constitutional or hereditary predisposition, slight provocation will induce subsequent attacks, which become more severe, last longer, with each recurrence.
Internal haemorrhoids, in every way, are quite different from the external variety. It has been thought that this form of piles is rather more frequent than the preceding, at all events from the greater local and constitutional trouble, and the alarm, occasioned by the frequent haemorrhages, such cases are oftener brought to the attention of the surgeon. The causes are about the same as mentioned above, and need not be repeated here. The symptoms, however, are widely different. The first symptoms observed will usually be a pruritis of the anus and perineum, which is very annoying at night particularly, and from the irritation produced by scratching and rubbing the integument and mucous membrane soon becomes thickened and covered with a squamous eruption, caused by the destruction of the epithelium. Later there will be frequent haemorrhages from the rectum, sometimes very profuse, long lasting, and arterial in colour; and at others not so copious or protracted and of a venous character. There will be pain on going to stool, and the act can only be accomplished after much straining and then with a feeling of incompleteness. The rectum will feel filled up, and there will be much weight and tenesmus, with no defecation on attempting relief. The pain soon becomes more continuous, independent of defecation, and the general health begins to suffer; the patient complains of indigestion, pains in the abdomen are of frequent occurrence, the face looks pale and balanced; he becomes listless and application to business or study requires an especial effort. The sphincter requires an especial effort. The sphincter is now observed to be frequently spasmodically contracted, and when the patient is a woman, the sufferings are not unfrequently “referred to that prolific store-house of morbid phenomena, the womb”. The piles now frequently protrude, at first only when straining at stool; but later on slight provocation, as when walking; sometimes they become strangulated by the constriction of the sphincter, and cause intense suffering, becoming even gangrenous and sloughing off, thus inducing a spontaneous cure. Finally, the volume of the tumours become so great, the pain so excessive, and the bleeding so frequent, violent, and exhausting, that the sufferer applies for surgical relief.
On examining such a case it will be more satisfactory if it occurs immediately after an attempt at stool, when the piles are either completely extruded, or brought down close to the verge of the anus. The appearances vary very much in different cases. In some the tumours are of a blue colour, composed of pouch-like dilatations of the veins; sometimes with effusion into the sub- mucoid cellular tissue; the mucous membrane being attenuated, and spread out over the tumours; or else is spread out over the tumours; or else is much thickened, ulcerated, or roughened. The tumours may be sessile or pedunculated, or like a cluster of grapes. At other times, they will be of a bright crimson colour, bleeding at the slightest touch, and evidently composed of enlarged capillaries and veins, the blood escaping in jets, like from an artery, and of an arterial colour.
In old cases, there is much thickening of the mucous membrane, and occasionally an oedematous condition, with pouching or a `flap-like’ appearance about the anus externally. While the masses of piles are usually closely approximated, and confined to a somewhat restricted area, there are cases in which distinct rows are formed, rarely exceeding three, disposed about half an inch apart, one above the other.
The treatment presents many indications, instrumental, hygienic and mechanical. As regards instrumental, our space, and the plan of our work, will not admit of its consideration at this place, but experience has demonstrated its absolute necessity in many cases.
Common sense would dictate an abstinence from anything that would have a tendency to increase or maintain the causes operating either as exciting or predisposing; and sexual indulgence, immoderate indulgence in the pleasure of the table, use of alcoholic stimulants, and anything of either a stimulating or debilitating nature must be avoided. Cathartics must be avoided, and if proper medication, with careful selection of diet fails to relieve the constipation, the piles must be removed. Sedentary people should take exercise and change their habits of life; and those who are suffering from opposites causes, must take rest. In short a removal of the cause must be the first indication. When a gravid uterus is at fault, the best must be made of the condition until it is removed by natural means; but this I think, constitutes the only instance where no attempt should be made to remove the cause; nevertheless, in exceptionally severe cases, those that may either threaten life or cause its continuance to be almost undesirable, artificial labour may be induced, after due consultation, and careful, enlightened, and serious consideration of the question in all its bearings.
Remedies, to my mind, in all ordinary cases at least, should first occupy our attention, after the removal of the causes as far as possible. In old cases, it is true, the action must be slow and tedious, and the tumours may demand removal, as to all intents and purposes they are neoplastic, and resorption requires much time, more than the sufferings and functional disturbance will warrant us in taking. After removal, however, with a continuance of the same exciting causes or hereditary predisposition, remedies must be given to prevent a recurrence of the tumours. In acute cases I should rely entirely upon the well selected remedy; and in chronic cases, when the tumours are small, the sufferings not intense, and the exacerbations infrequent, medicinal treatment will be attended by results that none unfamiliar with our system of therapeutics can realize or conceive as possible,
OF IOWA, CHICAGO. Author of - The homoeopathic treatment of surgical diseases, Published 1873. Surgical emergencies and accidents, Published 1884. The elements of surgical pathology : with therapeutic hints, Published 1896. Surgical diseases and their homoeopathic therapeutics, Published 1880.