patient will return the tumor by a little gentle pressure and manipulation. <Callout type="tip" title="Tip">For prolapsed tumors, use a bedpan or lie down to reduce pain.</Callout> The venous AtBmorrhoid. — This form of haemorrhoid may result from either of those akeady named or it may arise de novo. It consists at first of a simple dilatanon of the large veins beneath the mucous membrane of the rectum; later these veins undergo certain changes due to the hyper- trophy and induration of the mucous membrane and submucous connec- tive tissue, until finally a large, bluish, hard tumor is formed which is smooth to the touch, comes out of the body on defecation, and is covered by a mucous membmne which has assumed a partially cutaneous character from exposure. The three varieties of internal haemorrhoids thus described may all be present in the same person, and each be distinguishable from the other. In other cases the line of distinction may not be so well marked. A venous haemorrhoid may contain a considerable number of arteries and 7 98 DISEASES OF THE BECTUM AND ANUS. may bleed per saltern, and it is not certain that a^n arterial haemorrhoid is always a later stage of the capillary variety. But the three forms are well marked and must be distinguished from each other in the matter of treatment. Symptoms, — Usually the first symptom of internal haemorrhoids is the loss of blood during defecation to which reference has already been made. This may be present for a long time before any other symptom is no- ticed by the patient except perhaps an occasional feeling of discomfort in the rectum. Pain Is absent until the tumor begins to descend within the grasp of the sphincter and appears at the anus at each act of defeca- tion. If the sphincter be firm and strong, the pain may be very severe and the tumor may become strangulated, but after the disease has existed for any great length of time, and especially in persons past middle life, there is apt to be alossof power in the muscle which, though it facilitates prolapse, decreases the pain attendant upon it. In ordinary cases, tlie patient will reduce the tumors when they come down on defecation. They may, however, become strangulated, and be entirely beyond the patient's power of manipulation. In such a case, after a period of rest, and after the relief which may follow a spontaneous es- cape of blood from the over-distended vessels, the haemorrhoids may return of themselves or be put back by the patient. If the strangulation be more intense, gangrene may set in and a part of the mass may slough; or a part may suppurate and pus be dis- charged. Under these circumstances there will be great pain and more or less constitutional disturbance, with fever and loss of appetite. The gangrene is. very evident to the eye from the greenish or blackish color and foetid odor of the part, and is rather a good termination to the trouble as it generally results in a radical cure. Diagnosis, — It is not always an easy matter to discover an internal haemorrhoid, even though it be far enough advanced to cause haemor- rhage and more or less uneasiness. When it has become hard, it may be detected by the accustomed finger in a simple digital examination, but when soft and not over-distended, it may escape detection. An examination should be made directly after the rectum has been emptied by an enema of warm water, when the water and the straining have brought it into prominence, and should be made with Van Buren's spec- ulum. Under these circumstances, it may generally be brought plainly iiito view. An examination in a case of internal haemorrhoids should never end at the finding of the tumor. An inch or so higher up there may be a stricture, malignant or simple, which has given no sign of its pres- ence except the haemorrhoids, and this is not a good thing to overlook. Treatment, — The treatment of this most common and distressing malady may with advantage be considered under two different heads — (a) palliative, {b) radical. (a) The palliative treatment of internal hcemorrhoids. In spite of U.£KOBBHOID8. . 99 all that the surgeon may say to his patient of the advantages of a radical cure, and the safety and facility with which it may be accomplished, he will still have many more chances in the way of palliation than will fall to him of using the knife. It is, therefore, of great advantage to know what can be done for a timid and reluctant sufferer without the knife; and, indeed, most patients may be made greatly more comfortable without any surgical interference whatever. The first thing to be done is to secure a daily natural evacuation of bowels, and this without medicine, if possible. The diet should be plain and abundant. Highly seasoned meats^ gravies, salads, old cheese, etc., all alcoholic drinks, and anything approaching excess in tobacco, should be strictly interdicted. If the bowels do not act daily with this diet, and with regularity in the time of going to the closet, a laxative must be added, and this may be either in the form of a mineral water in the morning, or of a small dose of compound licorice powder at night. This powder may now be bought under that name at most drug stores. The formula is however appended for the convenience of any who may desire it: 3 Fol. sennae • 2 parts. Bad. liquiritise ••• 2 parts. Pruct. foeniculi pulv 1 part. Sulphuris depurati 1 part. Sacch. pulv 6 parts. If the haemorrhoids are in the habit of coming down when the patient has a passage, he must accustom himself for a time to the use of a bed- pan, and to having his passages while in the horizontal position. This will be considered a very objectionable remedy by most; but it is one from which great benefit will be derived. The other treatment is local, and consists mainly in the use of astringents and of cold. After each passage, the bowel should be injected with cold water. Even ice- water will do no harm. The quan- tity should not exceed four ounces, and if the case is one attended with bleeding, this will be found a most valuable means of combating that symptom. The number of astringents which have been recommended for use under the circumstances we are now considering is very large. I shall content myself with naming one, the subsulphate of iron, which combines the advantages of all the others. This may be applied in the form of an ointment ( 3 i. — i i.) ^o ^h© hasmorrhoids when prolapsed, or may be given in the form of a suppository (2 gr.) and allowed to remain in the rectum over night. It will be found to act simply as an astringent, causing no pain, and destroying no tissue. By these means, when followed with care and patience, the worst case of haBmbrrhoids may be greatly improved, and when the sufferer will not submit to curative treatment, or when, from any reason, opera- 100 DISEASES OF THE BEOTUM AND ANUS. tive interference is contra-indicated, they should always be tried. Al- though they are given simply as palliative measures, and should be considered as such, I have had some cases where, after a few weeks of this treatment, the patients believed themselves cured, and were, at all events, so far relieved as to disappear from observation. Treatment of strangulation. — The practitioner may at any time be called upon to treat this complication of internal haemorrhoids, and the condition is an exceedingly painful one. He will generally find his patient in bed complaining that his piles are ^'down,'' and that he has been unable to replace them. The.prolapse may have occurred at the time of defecation, or during a momentary mental excitement or physical effort. On examination, the anus will be seen to be surrounded with a mass of haemorrhoids which are swollen, congested, livid, and more or less oedematous, and any attempt to replace them will cause exquisite pain. This is an excellent opportunity for Inducing the sufferer to submit to a radical operation, and should consent be gained, ether may be given, and the usual operation, by the ligature, be at once performed. The opera- tion, under these circumstances, does not seem to be contra-indicated, and I have never had occasion to regret performing it. But should an operation be refused, the mass must be reduced. The patient should be turned on the face, with a hard pillow under the pelvis to raise tiio buttocks and allow of gravitation of the abdominal contents uwayfrom the rectum. The mass should then be well smeared with olive oil, and a gentle effort made to reduce it by the taxis. This may sometimes be done by introducing one finger into the anus and exerting pressure with the others, gradually forcing the tumors, one by one, within the bowel; at other times, the mass may be replaced by a firm and continuous pressure, with the bulbs of all the fingers directly upon it, till the blood has been crowded back, and the diminished piles slip up together. Much gentleness is required for this manoeuvre, which is a very painful one under any circumstances, and one man may succeed where another would fail. At times, however, replacement by the taxis is impossible. Under such 'circumstances, it is a not uncommon practice to resort to leeches; and though I have never done it, I have seen it almost immediately suc- cessful with others; and the patient himself will assure you that, if the piles would only bleed, they could be easily reduced. It is better, however, to apply cold, and to leave the patient in bed on his face, with the buttocks raised. The cold should be in the form of an ice-bag, and this will almost certainly give relief to suffering, and so reduce the oedematous swelling as to render reduction possible on a second attempt. Should this also fail, there is nothing to do but to wait for the condition to subside under the use of cold and applications of belladonna and opium in the form of a soft ointment, with rest in the position named, and the administration of laxatives. After forty-eight hours of H^MOBBHOIDS. 101 this treatment^ the patient will generally succeed hy himself in reducing the mass, (b.) Curative Treatment — Before recommending anything in the way of a surgical operation, the surgeon must consider whether the case before him is one in which such a procedure is justifiable, and this brings us to the consideration of what have been called symptomatic haemorrhoids, as distinguished from those which are apparently idiopathic. Internal haemorrhoids may be symptomatic of disease in a number of the viscera. They often indicate structural changes in the wall of the rectum itself at a higher point, such as malignant and non-malignant stricture ; and under such circumstances, whatever is done in the way of relief must be done to the stricture, and not to the haemorrhoids. Again, they are often secondary to disease of the bladder, to enlarged prostate, or to stricture of the urethra ; and in these cases where it is possible to remove the cause it must always be done. If haemorrhoids are dependent upon a calculus, or a stricture of the urethra, they will disappear when these affections are cured. I was consult^ not long since by a brother practitioner in regards to a very typical external sanguineous haemorrhoid — the size of a large pea— on the person of his four-year old child. The child had an adherent prepuce, and the pile was the result of the straining. The ordinary operation of circumcision cured the haemorrhoid. A man with enlarged prostate is never a very desirable subject for a surgical operation, and if such a man's haemor- rhoids can be rendered endurable by the palliative treatment already de- scribed, the better way will be not to use the knife. In women haemorroids often depend upon disease of the uterus ; and in every female patient this dependence should be carefully inquired into, and if found, removed before operation. The operator in rectal sur- gery may save himself much discredit, by postponing his operation for piles till his patient has been cured of a uterine misplacement or catarrh; for, as a rule, the co-existence of the latter diseases will prevent a favor- able issue to the operation. Either the wounds will not heal readily, or the haemorrhoids will speedily return. It will occasionally happen that a pregnant woman will suffer so severely from this complication as to de- mand surgical aid. Though it is better not to operate, except in a case where the haemorrhage or the pain render it unavoidable, still pregnancy is not an absolute barrier to surgical interference in this more than in many other affections. Haemorrhoids may also be symptomatic of disease of the liver, kidney, heart, or lungs. There are few liver affections which need prevent oper- ative interference in a bad case, but such interference should be preceded by general treatment pointing towards relief of the hepatic circulation. An excess of alcohol in the daily diet should be stopped, and a blue pill may be given with advantage every other day for a week before the •oper- ation. Affections of the lungs, except in a very advanced stage> need 102 DISEASES OF THE BEOTUM AND ANUS. not prevent an operation. The condition which most positiyely stays the hand of the operator is that of albuminuria^ whether dependent upon heart or kidney. Haying decided to attempt a radical cure^ the surgeon finds himself embarrassed with the number of operative procedures from which he may choose. It is safe to say that no one operation is the best in all cases^ and I shall make no attempt even to enumerate all of those which have^ at different times, been advocated, but shall describe several which are to be relied upon, .and which, together, will cover every case. The Application of Caustics. — Chief among the caustics used for this purpose are nitric acid, pure carbolic acid, and Vienna paste. The capil- lary hsemorrhoid may be cured by painting it once or twice with pure nitric or carbolic acid ; but large and old haamorrhoids are not curable by this means, though the haemorrhage from them may be stopped, and for a time they may cease to prolapse. When used upon a capillary growth, a speculum must be introduced. If used in a case of large tumors, they must first be brought outside of the body, carefully dried, and then thoroughly covered with the acid, applied with a small stick. The end of a match makes an excellent brush. The tumors should then be well oiled and replaced. The application is not painful, unless the acid is applied to the wrong surface, viz., the skin. I have used this plan of treatment in many cases ; have seen an exhausting haemorrhage from a capillary tumor stopped forever by a single application, and have benefited old cases to an extent which con- vinced the patients they were radically cured in spite of my own skepti- cism; but it is never saie to promise anything more than temporary re- lief by this means. The capillary tumor is very likely to subsequently become the larger arterial one ; and the old and large haemorrhoid is more than likely to become prolapsed at some future date: so that I no longer use it in these latter cases when the patient will permit me to fol- low my own judgment. There is one danger in the application of a strong acid to an old pro- lapsing haemorrhoid, and that is, the occurrence of a profuse secondary haemorrhage when the slough separates. Such an accident is not com- mon, but it may be a fatal one, and it happens just often enough to worry the surgeon in every case in which he has employed this method in an old and debilitated subject.
Key Takeaways
- Maintain a daily natural bowel evacuation without medicine if possible
- Use a bedpan or lie down to reduce pain from prolapsed tumors
- Apply cold water after defecation and use astringents like subsulphate of iron
Practical Tips
- Maintain a balanced diet rich in fiber to prevent constipation, which can exacerbate hemorrhoids.
- Regular exercise can help improve blood flow and reduce the risk of hemorrhoids.
- Stay hydrated by drinking plenty of water daily.
Warnings & Risks
- Avoid straining during bowel movements as it can worsen hemorrhoid symptoms.
- Do not use strong acids like nitric acid or carbolic acid unless absolutely necessary, due to potential severe side effects.
- Be cautious with surgical interventions; they should only be performed if other methods fail.
Modern Application
While the historical techniques for managing internal hemorrhoids have evolved significantly, understanding these conditions and their management is still crucial in modern survival scenarios. Knowledge of basic hygiene, diet, and non-invasive treatments can prevent complications and improve quality of life during prolonged periods without medical care.
Frequently Asked Questions
Q: What are the symptoms of internal hemorrhoids?
The first symptom of internal hemorrhoids is usually the loss of blood during defecation. Other symptoms include discomfort in the rectum, pain when the tumor descends within the sphincter, and potentially gangrene or suppurative complications if strangulation occurs.
Q: How can I prevent internal hemorrhoids?
Maintaining a balanced diet rich in fiber, staying hydrated, regular exercise to improve blood flow, avoiding straining during bowel movements, and using a bedpan or lying down when necessary can help prevent the development of internal hemorrhoids.
Q: What are the risks associated with applying strong acids like nitric acid or carbolic acid for treating hemorrhoids?
The application of strong acids can lead to severe side effects, including profuse secondary bleeding when the slough separates. These acids should only be used as a last resort and under careful supervision.