how, from the free anastomosis which exists between them, it is improbable that one should be affected without influencing the other to a greater or less extent, andj how, judged by this test alone, it may be impossible to tell whether a particular haemorrhoid belongs to one system or the other. For practical purposes, therefore, the first defini- tion is the better one— an external haamorrhoid is one originating outside of the external sphincter, and an internal one is within that muscle. Other secondary differences which may arise from various causes in the development and location of the tumors will be considered later.
External Hmmorrhoids. — A person of middle age who has not at some time suffered from an external haemorrhoid is indeed a great rarity, so common is this affection. In the majority of cases, it is allowed to run its own course, and only when the pain is unusually severe, or some untoward accident has happened, does the patient consult the surgeon.
External Hemorrhoids may appear in two different forms which bear little resemblance to each other. The first is a small, round or elongated venous tumor; the second is a tag of hypertrophied skin, sometimes improperly spoken of as a condyloma. The second is formed from the first by changes soon to be described.
External Hemorrhoids may arise in either of two ways, by the dilatation of a vein, or the rupture of a vein and the extravasation of blood into the adjacent tissue. The dilatation may not always be of the same character. In one case it may affect the whole calibre of the vessel, in another it may be in the form of a pouch springing out from one point in the circumference. A haemorrhoid resulting from the dilatation of a vessel is of gradual formation; but it sometimes happens, particularly after a violent straining at stool, that the patient will feel a peculiar sensation at the anus, and an examination will reveal the presence of a tense, bluish, smooth tumor, the size of a pea or a grape, situated just at its verge. In this case, a previously dilated and weakened vein has suddenly given way, and the tumor is the result of the extravasation of blood.
Such a bloody tumor as this will cause much pain and discomfort, preventing the patient from sitting down, or even from going round with any ease. It may be freely incised by transfixing its base with a small, sharp, curved bistoury and cutting outwards, the incision being in the direction of the radiating folds of the anus, and this operation is sure to give temporary relief, by allowing the escape of a small clot of blood and putting an end to the tension which is causing the suffering.
<Callout type="tip" title="Pro Technique">The incision itself is extremely painful, and should therefore be done with a sharp knife. Deliberation is better exercised before entering the knife.</Callout>
Again, care should be exercised to empty the clot entirely out of its bed, otherwise a small wound remains which will not readily heal, because the sac is prevented from contracting, and the patient is obliged to wear a bandage perhaps for a week or longer to keep from soiling the linen with a sanious discharge. Under such circumstances also the pain is but little relieved by the operation.
<Callout type="warning" title="Safety Hazard">If the surgeon attempts to remove the clot without emptying it, a small wound may remain that will not heal easily.</Callout>
I have in a few cases seen the incision heal by primary intention, and the sac again fill with blood, thus leaving the patient in the same condition as regards suffering, as before operation. This is best avoided by placing a shred of lint in the cut.
These, however, are untoward accidents which may attend an insignificant operation which usually gives relief to suffering, and allows the tumor to shrivel up and disappear except for a small tag of skin which may remain and form an external pile of the second variety. When left to its own course, a bloody tumor of this variety may gradually decrease in size from the absorption of the fluid elements of the clot, the pain decreasing at the same time; and after a week or ten days of discomfort, it is changed into a cutaneous haemorrhoid.
Or the opposite course may be taken, and the tumor may show all the signs of an abscess, and finally rupture spontaneously with the discharge of a little blood and pus, and with an instantaneous ending to a week of suffering. For during this acute inflammatory process, the pain is often very severe, the discomfort constant, and there may be more or less febrile excitement; all of which will pass away the moment the tension is relieved.
The treatment of such a case where the knife is not used will be described a little later. To return to the haemorrhoid which is due to the varicose vein, but not to the extravasation of its contents. In such a case there may be one considerable dilatation which shall cause a smooth, round, bluish tumor the size of a pea or a grape; or there may be a number of veins included in a new growth of connective tissue which shall constitute a distinct, firm, haemorrhoidal tumor.
For these dilated pouches are themselves causes of irritation, and are subject to irritation from without. As a result an exudation takes place in their vicinity which finally ends in the production of new tissue. It is thus easily understood why on cutting into one external haemorrhoid a single large clot will be exposed contained in a distinct sac; while in another, several smaller clots may be seen imbedded in the surface of the section, and why there is more or less connective tissue in the tumor.
The formation of such a tumor is a gradual process due to the continuous action of the primary cause and to subsequent irritation from without. It may go on with little pain and suffering, so little that the patient will hardly care to ask for relief; and it may undergo a spontaneous cure leaving in its place only an hypertrophied tag of skin.
Generally, however, during its course an attack of acute inflammation will be excited at some time, and this is very apt to bring the sufferer into the hands of the surgeon. At such a time, if the inflammation has occurred in a fleshy pile the tag will be swollen, cedematous, and exquisitely sensitive. Suppuration may occur in it and a small marginal abscess and fistula be the result.
Or, if the inflammation has attacked a sanguineous tumor, it will be found hard and swollen and painful to the touch. The patient will often say that he has tried to replace the little grape-like tumor within the bowel, but has been unable, though the pressure has caused it to disappear for the moment and has given a temporary relief. This is due to emptying the vein of its blood, but the blood returns the moment the pressure is removed.
The pain is constant, often preventing sleep at night. The sufferer is unable to sit or stand and soon finds that he feels better in the recumbent posture. A motion of the bowels is feared and therefore avoided as long as possible. When after two or three days of constipation the call can no longer be delayed, the pain is greatly increased.
Such an attack in a sanguineous haemorrhoid may terminate in three ways: by resolution, by induration, and by suppuration. In the former case the resolution may be complete especially when the inflammation has been of moderate intensity, and no trace of the tumor may remain, or a cutaneous tag may be left to mark its former site.
When the inflammation assumes a chronic type, and the tumor becomes cedematous, and is still somewhat painful on pressure or during defecation, though not to such a degree as during the acute stage, the inflammation is said to have terminated in induration. Such a tumor is always liable on slight provocation to a fresh attack of inflammation.
When suppuration occurs, the tumor discharges its pus and then shrivels up and becomes a cutaneous tag. Treatment. — The surgeon will seldom be called upon to treat a case of external haemorrhoids unless during an attack of acute inflammation; for at other times the annoyance caused by them is comparatively trivial.
A cutaneous tag which is quiescent may as well be left undisturbed by the knife or scissors; for the removal of it will not infrequently cause an amount of suffering disproportionate to the benefit gained. The whole thought of the surgeon may then be turned first to the prevention and second to the relief of an attack of inflammation.
The means of prevention are very simple and yet very effectual. They consist in the avoidance of excess in eating or drinking and in perfect regularity in defecation; for in a person affected with external haemorrhoids a single heavy meal at an unusual hour, an evening spent in smoking and drinking, or, worst of all, the neglect to have a motion of the bowels for a single day, will give rise to a sensation of heat, pressure, and itching about the anus, which warns him that trouble has commenced.
Even under such circumstances the attack may be aborted by rest in the recumbent attitude, a light diet, abstinence from wine or liquor of any kind, and a laxative, preferably one of the mineral waters, repeated every night for three or four days. Should the attack go on and inflammation be actually excited, more active treatment will be required, and this may be either operative or medicinal.
It is my own practice to try the latter first, and if it does not succeed, resort to the former. The medicinal treatment consists in keeping the sufferer on the bed or lounge, and applying a small bladder of pounded ice to the part. This is generally very grateful to the patient and very effectual — much more so than warm poultices or applications of belladonna and opium; but should it not prove so, the latter may be tried.
A good formula is equal parts of the extracts of bella- donna and opium smeared freely over the anus. In most cases the attack will sofcside after forty-eight hours of this treatment, and the use of a daily laxative; but should it not, a sanguineus tumor may be incised in the manner already described, and a cutaneous tag may be seized with a sharp forceps and quickly snipped off with the scissors. Ether is not generally necessary for this operation, which, though very painful, requires but a moment; and I have generally found that attempts at local anaesthesia with the ether spray were very delusive in this part of the body.
If ether be employed at all, it is much better to take advantage of the primary anaesthesia produced by the first few inhalations, the patient holding the towel or bottle in his or her own hand. This is a favorite procedure of my own in this and many other operations about the anus, and one which I cannot too strongly recommend.
<Callout type="tip" title="Pro Technique">Use a rubber bandage for post-operative care to prevent soiling from discharge.</Callout>
The only caution necessary in cutting off an external haemorrhoid is to remove neither too much nor too little tissue. If too much be removed, the wound will take a long time to heal, and if several tumors be removed, contraction to a disagreeable extent may follow; if too little, a tag of skin will still remain after cicatrization and shrinking, and, although this might be considered a matter of no importance in a male patient, I have seen ladies who did not so consider it.
Internal Hemorrhoids. — External haemorrhoids were described as varicosities of the external haemorrhoidal veins; and internal haemorrhoids may also be similarly defined as varicosities of the middle and superior haemorrhoidal veins, but they are more than this. An internal haemorrhoid is often an arterial tumor, as well as a venous, and the arteries may be of large size. Occasionally one will be met as large as the radial.
In describing these tumors, we shall follow the division laid down by Allingham into capillary, arterial, and venous. The capillary haemorrhoid is in reality an erectile tumor, composed of the terminal branches of the arteries and veins and of the capillaries which join them. This form of tumor is never of large size, and never projects very far into the cavity of the rectum.
To the naked eye and under the microscope they strongly resemble an arterial naevus. They maybe situated high up in the rectum or low down by the sphincter; their surface is granular, and the membrane covering them is always of extreme thinness. This accounts for the chief symptom which distinguishes them clinically from the other varieties — the free arterial haemorrhage which follows the slightest bruising of their surface even in the act of defecation.
Such a tumor never appears outside of the anus unless accompanied by some other rectal affection, but it may sometimes be seen by a careful pulling open of the sphincter with the fingers, and from some part of its strawberry-like surface there is pretty sure to be a jet of arterial blood, coming per saltern. The disturbance caused by the gentlest examination is sufficient to start this bleeding, and it always occurs at defecation.
This is the form of haemorrhoid to which the name of 'bleeding' most properly applies. In my own experience it is not as frequently met with as the varieties to be described later; and this probably for the reason that after existing for a longer or shorter period in this form it is changed into one of the others: and that patients do not seek relief till after such change has occurred.
After a time, the mucous membrane covering such a tumor becomes thickened, and as a result of repeated irritation, there is an increase in the submucous tissue. The haemorrhage decreases in frequency and finally ceases as the capillary branches become obliterated by the increase in the connective tissue, and the capillary tumor is succeeded by the arterial or the venous one.
The one symptom of a capillary haemorrhoid is the daily haemorrhage; and as this haemorrhage occurs at the time of defecation, and there is no pain at any time, the patient may be entirely ignorant of the fact that blood is daily lost. This is particularly the case with the class of patients seen in public practice who give little attention to themselves.
In the higher walks of life such a loss of blood seldom occurs without the knowledge of the patient; but unfortunately it is often disregarded, especially in women who are in the habit of losing blood at every menstrual turn and who always shrink from an examination. In his case a single application of nitric acid to the bleeding surface worked a cure which has lasted for several years.
The arterial hemorrhoid. — In this form of tumor the capillary network has disappeared and in its place is found a mass of freely anastomosing arteries and veins bound together by connective tissue. The arteries and the veins are tortuous, often varicose and dilated into sacs and pouches, and the arteries may be of large size, especially the one which enters at the base of the tumor, the pulsations of which may often be distinctly felt by the finger.
Such a tumor is often of considerable size; it is firm to the touch and smooth; it is liable to inflammation, erosion, haemorrhage, and prolapse. The haemorrhage which occurs is arterial in character, and apt to be abundant. When the haemorrhoid has gained a sufficient size to become prolapsed in the act of defecation, the patient suffers the usual symptoms of the haemorrhoidal state.
If the sphincter be not tight enough to strangulate the mass after it has come out of the body, the pain will not be very severe and the <Callout type="warning" title="Safety Hazard">prolapsed hemorrhoid can cause significant discomfort.</Callout>
<Callout type="important" title="Critical Rule">Regular bowel movements are crucial to prevent haemorrhoids from developing or worsening.</Callout>
Key Takeaways
- External hemorrhoids can arise due to the dilatation of a vein, rupture of a vein, or extravasation of blood.
- Treatment options include conservative measures and surgical interventions depending on the severity.
- Regularity in defecation is crucial for prevention and management.
Practical Tips
- Maintain a balanced diet to avoid constipation which can exacerbate hemorrhoids.
- Stay hydrated to ensure soft stools that are easier to pass.
- Use over-the-counter creams or ointments to soothe symptoms of external hemorrhoids.
Warnings & Risks
- Avoiding heavy lifting and straining during bowel movements is essential to prevent hemorrhoid flare-ups.
- Ignoring persistent symptoms can lead to more severe complications such as chronic inflammation.
- Incorrect self-treatment, like using harsh chemicals or improperly applied remedies, can worsen the condition.
Modern Application
While the historical techniques for treating hemorrhoids may differ from modern medical practices, understanding the underlying causes and preventive measures remains crucial. Regularity in defecation, maintaining a healthy diet, and avoiding straining are still key to preventing hemorrhoids. Modern medicine offers more advanced treatments but the basic principles of care remain relevant.
Frequently Asked Questions
Q: What are common symptoms of external hemorrhoids?
Common symptoms include pain, especially when sitting or during bowel movements, itching around the anus, and visible lumps near the anal area. A sudden painful lump may indicate a thrombosed (clotted) hemorrhoid.
Q: How can I prevent external hemorrhoids?
Maintaining regular bowel habits, eating a high-fiber diet to soften stools, staying well-hydrated, and avoiding prolonged sitting are key preventive measures. Regular exercise also helps improve circulation.
Q: What should I do if I suspect an external hemorrhoid?
If you notice any symptoms, it's important to consult a healthcare provider for proper diagnosis and treatment. Self-treatment with over-the-counter remedies can provide temporary relief but may not address the underlying issue.
Q: Can external hemorrhoids be treated without surgery?
Many cases of external hemorrhoids can be managed conservatively through lifestyle changes, dietary modifications, and topical treatments. However, severe or persistent cases may require surgical intervention to alleviate symptoms and prevent complications.
Q: What are the risks of ignoring hemorrhoid symptoms?
Ignoring hemorrhoid symptoms can lead to chronic inflammation, increased pain, and potential complications such as infection or blood clots. Persistent bleeding can also result in anemia over time, highlighting the importance of timely medical attention.