=Definition.=—A dilated or varicose condition of the plexus of veins
lying in the submucous tissue of the lower part of the rectum. The
dilatation of these hemorrhoidal veins may extend into the adjoining
subcutaneous tissues and mucous membrane, and the perirectal plexus and
adjoining venous plexuses of the bladder, uterus, vagina and sacral
canal may become involved.
=Osteopathic Etiology= and =Pathology=.—The chief predisposing cause
of piles is man’s erect position and the absence of valves in the
hemorrhoidal veins. Thus a retardation or stagnation of the portal vein
would cause a backward movement of the entire column. It is evident
that such a downward pressure of the blood in the portal system would
dilate and extend the blood vessels, to the very capillaries in the
rectal region.
This retardation may arise from several causes: obstruction of the
portal vein, from diseases of the liver; diseases of the heart;
obstruction or destruction of the capillaries of the lungs; pressure
from a gravid uterus, tumor, etc.; a general loss of tonicity of the
abdominal walls, as in persons who take but little exercise; the
excessive use of wine, tea and coffee; injuries to the spinal column,
especially in the lumbar, sacral and coccygeal regions; a dislocation
of an innominate bone; lifting; constipation; straining at stool;
carelessness of the calls of nature, etc. Catarrh of the bowels may
cause a congestion of the mucous membrane and consequently piles.
Hereditary influence may be a factor in a few cases.
Hemorrhoids are divided into two classes, =external= and =internal=.
An =external pile= is one that arises from the margin of the anus
outside of the external sphincter muscle. It differs from the internal
pile from the fact that it is always composed either of skin or
hypertrophied connective tissue, forming a mere cutaneous tag, or else
it is composed of a small cutaneous vein enlarged by a clot of blood.
The =internal hemorrhoids= are composed mostly of enlarged veins and
are connected by hypertrophied connective tissue. They have a free
arterial supply and are covered by the mucous membrane of the rectum.
They are due, usually, to an affection of the middle hemorrhoidal blood
supply, thereby being a part of the visceral vascular system. Internal
hemorrhoids, when protruding, can be returned within the rectum, while
the external ones cannot. The venous turgescence varies in size from
a pea to a walnut. They may be single or may surround the entire anal
opening like a bunch of grapes.
Repeated attacks of engorgement of the veins involved, will in time
change the mucous membrane or the submucous tissue, and cause catarrhal
swelling of the mucous membrane, or hyperplasia of the connective
tissue. At first the hemorrhoid is usually a blood tumor, but in
chronic cases it is oftentimes made up largely of connective tissue.
Owing to pressure of the varicose veins, atrophy of the mucous and
submucous tissue may occur. The white or slimy hemorrhoids occur when
these roughened parts of the mucous membrane become inflamed and
thickened, resulting in suppuration.
=Symptoms.=—The symptoms are quite diagnostic and need not be mistaken.
Besides the appearance of tumors, there may be constipation, pain
during stools, indigestion, headache and pain in the back. Hemorrhages
frequently occur, and if suddenly checked, as by cold, other
disturbances may occur, as congestion of the head, lungs, stomach,
liver, kidneys, etc., which may result in hemorrhages from these
organs. Fissures of the anus, contraction of the rectal sphincters and
prolapse of the rectum may occur. Occasionally in old people there is a
varicose state of the veins of the neck of the bladder, and in females,
of the uterus and vagina, which causes hemorrhages of these organs.
The communicating plexus of the spinal canal may be affected, causing
weight, numbness and pain, so as to simulate a lesion of the cord. The
patient may have a hypochondriacal disposition and be disinclined to
work, especially at mental labor.
=Prognosis.=—Depends upon the predisposing and immediate causes, but a
large majority of cases can be cured.
=Treatment.=—A thorough examination of the patient should be made, not
only to ascertain the extent of the local trouble, but to understand
thoroughly the general health of the sufferer, especially the state of
the heart, lungs and liver.
Many cases of hemorrhoids are caused by lesions in the lumbar and
sacral regions, and especially dislocations of the coccyx (usually
anterior) and the innominata. Correcting these lesions will oftentimes
cure the hemorrhoidal disorder. Simple dilatation of the rectum once
a week, in addition to other treatment, is of great aid in curing
hemorrhoids, not a few of the cases being cured by dilatation alone.
It relaxes the tissues about the tumefied vessels. Treatment is rarely
necessary above the second lumbar, (unless there is more or less of a
constitutional disorder) as the superior hemorrhoidal blood vessel of
the inferior mesenteric is given off about opposite the second lumbar.
In cases where the abdominal walls have become relaxed, a treatment
should be given to strengthen the abdominal muscles and viscera.
Particular attention should be given the liver. Treatment should be
given over the abdominal muscles directly, and also to the spinal
nerves of the same region. The diet should be strictly regulated and
the bowels kept loose, and stimulants, indigestible food, full meals
and too much meat should be avoided. Injection of cold water before
stools is a good prophylactic, and applications of cold water to the
protruding pile will be of some help in relieving the congestion. A
squatting position during defecation will relieve considerable strain.
=Hemorrhoids= in the =acute state=, within twelve or twenty-four hours
from the engorgement, yield quickly to treatment. The local technique
is to relax the tissues about the tumor, especially above and along
the line of the vein, then with pressure at its base carefully force
out the engorged blood. Follow this up by another treatment the next
day and continue until normal. The vein wall, not being permanently
stretched, will contract and if the irritating cause is found, there
is little danger of return. Remember, in a case like this, the danger
of embolism and be sure a clot has not formed. Cases of hemorrhage at
stool, during or immediately following evacuation, when not from a
bleeding pile, may be of considerable quantity and the source difficult
to locate. It may be due to ulcerations or easily ruptured capillaries
of the mucosa, but the cause will in many cases be found in the
innominata and a reduction of the lesion give relief.
=Rectal conditions=, associated with piles, and =requiring surgery=
after treatment has failed, are: =hemorrhoids=, which are of such long
standing as to become organized tissue, (these will keep up continual
irritation and cannot be absorbed); =saccules= or pocket, formed by
folds of mucous membrane catching and holding particles of feces,
gradually enlarging and ending with considerable reflex symptoms;
=fistulae=, complete or incomplete, may frequently be healed by
adjusting coccygeal or innominate lesions, but are apt to recur from
the tract not being clean in the center or bottom; =abscesses= in or
about the anus or rectum are usually traced to coccygeal, innominate,
or local interference to circulation; =fissure=, complete dilatation
under anesthesia to insure physiological rest of parts, is probably
the best treatment. It is suggested that a fissure may be healed
by making surgically clean, touching with iodine and coating with
collodium. =Papillae= are small, hard black-capped papules in the lower
rectum, each one involving a nerve terminal and causing much distress.
All these conditions give rise to much discomfort and with surgical
assistance can be cured without much trouble. It is not necessary
to make them a major operation and do uncalled-for things. The less
surgery about the rectal sphincter the better.
=Care= of the =anus= and =rectum= after operation or successful
treatment is a factor in preventing return. First, there should be
soluble, non-irritating stools, which do not tend to bring about
prolapse from straining. Diet and regularity contribute to this.
Second, absolute cleanliness. This can only be obtained by following
the stool with an enema of four or five ounces of cool water and
immediately passing it. It will bring forth a considerable quantity of
feces which would otherwise have been retained for another twenty-four
hours. This procedure following, as it does, the stool does not in any
way interfere with the normal function or create a habit. The anus
should then be thoroughly washed in cool water and as thoroughly dried.
Dusting with borated talcum powder, starch, etc., will prevent chafing.