rectum are tubercular, this portion of the bowel, when
examined after death, presenting precisely similar conditions
to those which are found in other parts of the intestine well
known to be thus affected. The ulcers are deep, and spread
at the edges, joining others, and undermining the mucous
membrane, leaving broad or narrow bridges. In this form of
ulceration, as a rule, pulmonary phthisis does not co-exist, or
at all events, only shows itself very late in the disease. In
the case of a young gentleman I saw several times with Sir J.
Paget and Sir William Gull, the ulceration was very marked,
and extended high up the rectum, but no chest affection
became apparent until three years had elapsed from the com-
mencement of the bowel disease. In the many cases of phthisis
I have seen, in which Astula formed, there has been no
diffused ulceration of the rectum, possibly because the disease
spent itself mainly upon the lungs ; and in the case of tubur-
culous ulceration of the rectum, anal fistulas are not common.

The rule, in my opinion, is, that fistula in patients who
have a predisposition to pulmonary consumption commences
by a breaking down of the connective tissue beneath the
mucous membrane of the rectum ; thus a small abscess is
formed, and this makes its way into the bowels very rapidly,
leaving a large, patulous aperture. Therefore, I think we
may safely say that the same condition of health or constitu-
tion which renders a patient liable to pulmonary affections
generally, renders him also prone to fistula. These people
are usually thin and ill-nourished, and have very little power
of resistance against injurious influences ; inflammation,
which in robust individuals would result only in the effusion
of plastic material, in them terminates in the production of
numerous and very perishable cells, which readily form them-
selves into purulent collections, especially in lax tissues. Pro-
bably, I should say, the want of fat in the ischio-rectal fossa



58 FISTULA IN CONJUNCTION WITH PHTHISIS.

and its neighborhood dispones to the formation of an abscess
there. The veins have to sustain a considerable column of
blood, and they are, moreover, exceedingly ill supported, so
that local congestions and feeblensss of circulation must be
a common condition. I am inclined to think that these
general causes are usually sufficient to explain the phenomena
without any reference to tuberculous depositions.

Fistulae in persons of a phthisical tendency are marked by
certain peculiarities which 1 think important to notice. Some
have been already casually mentioned, but I will here state
them clearly.

They have a disposition to undermine the skin and mucous
membrane with remarkable rapidity, but not to burrow
deeply.

The internal aperture is almost always large and open; on
passing your finger into the bowel you can feel it most dis-
tinctly, often the size of a threepenny piece.

The external opening is also frequently large and ragged,
not round ; it is irregular in form, and surrounded by livid
flaps of skin ; when you pass your probe into this aperture
you can swxep it round over an area of more than an inch,
and not infrequently the skin is so thin that you can see the
probe beneath.

This is a very different condition from that of the external
orifice of a fistula in a healthy persbn, which is usually small
and pouting, and the skin is not detached, to any extent,
from the underlying structures.

The discharge is thin, watery, and curdy, very rarely really
purulent.

The sphincter muscles are almost invariably very weak.
When you introduce the finger into the bowel you are hardly
sensible of any resistence being offered. I think this a most
important indication of constitutional weakness, and from it
I derive this practical lesson : When operating upon a patient
with phthisical proclivity interfere as little as possible with
the sphincter muscles, especially the internal. If you divide
the spincter, much incontinence of faeces will almost cer-
tainly result.

It is common to observe, in these patients, much longish,
soft, silky-looking hair around the anus.

WitYi any of these peculiarities strongly marked, I am
always suspicious of my patient's strength; with all of them
or several of them present, I feel certain of his condition
and act accordingly.



FISTULA IN CONJUNCTION WITH PHTHISIS. 59

I should say, from my experience, if you have a phthisical
patient suffering from a fistula which gives him much pain or
inconvenience, by taking certain precautions you may relieve
him of it without running any risk of damaging him. When
a case of this kind comes to me, I am never in a hurry to
operate. I like to watch the patient for a little while, and
observe whether the lung disease is advancing, and also to
find out if the cough is constant ; often these patients will
assert that they cough very little, when their friends notice
that they do so almost perpetually. Wait, if you can, for
genial weather, when your patient need not be confined to
a close room. As to the operation, I«have already said that,
although it must be thorough, you should interfere with the
sphincter as little as you can, and, fortunately, it is not
usually necessary to cut deeply, as the sinuses are mostly
superficial. After the operation let the patient have good
diet ; by all means, plenty of cream and milk ? if he can
take it^ he may have a little cod-liver oil and steel, and
quinine, separate or combined ; do not confine him to bed ;
let him lie on a mattress ; if you can manage it, let the bed-
room face south or west, and get plenty of fresh air into the
room, the patient lying, well covered up, on a couch by the
open window, for hours, in fact, nearly, all day. Do all you
can to keep him amused and cheerful ; avoid poulticing the
wound ; disturb it as little as possible, keep it clean by
gently syringing with a solution of carbolic acid (i in 50),
night and morning, and well dry afterward; dress with wool;
ointments, as a rule, do not suit, but ^astringents are useful ;
the compound tincture of benzoin agrees very well with
these wounds. Do not be in a hurry to get the bowels open,
and manage this rather by diet and laxatives than a purge ;
if you set up a diarrhoea in these patients it will give you
trouble, and delay the healing of the wound. Unless there
is furring of the tongue, headache, or loss of appetite, 1 do
not think the bowels need be relieved more than once in
three or four days. All these matters may appear trivial as
to be almost unworthy of mention, but I am sure that atten-
tion to apparent trifles will make just the difference between
success and failure with the patients about whom I have been
writing.



6o HAEMORRHOIDS.

CHAPTER VII.

HiEMORRHOIDS.

Almost from time immemorial haemorrhoids have been
divided into two varieties, viz.: the external and the internal,
often also popularly called blind piles and bleeding piles,
and this classification is founded upon a true pathological
distinction ; for, although it may be correctly said that exter-
nal piles may and do encroach upon the mucous membrane,
and so are partially internal, and further, that internal piles
by reason of frequent prolapse, become more or less external
yet in the majority of cases the difference is well marked,
and precludes the slightest doubt as to the diagnosis.

In the external form the observer will perceive that they
are either the true hypertrophies of skin, exaggerations of the
natural rugose state of the anus, or rounded and elongated
venous-looking tumors which pass up into the bowel.

In the internal kind he will observe that they are tumors
originating within the anus, but which have been forced down
outstde,and even may have put on a pseudo-cutaneous appear-
ance, from exposure, having been, for more or less time, sub-
ject to the same conditions as the skin. In addition to this,
he will notice that there are also, in very many cases, cuta-
neous excresences accompanying the internal piles. Should
the surgeon still have any doubt as to the kind of hsemorrhoid
he has to deal with, let him return all the protruded part
that he can within the sphincter ani, by gentle pressure at
the same time directing the patient to retract or draw up the
lower part of the gut. He will then find out what is redun-
dant skin and what is internal hsemorrhoid and prolapsed
mucous membrane of the anus ; should the whole mass be
irreducible, it must be treated as a case of internal haemor-
rhoids. I have been rather particular in these introductory
observations, because I have so often seen considerable
doubt in the minds of practitioners as to the character of the
affection they had to combat, and a correct conclusion
is all-important, especially if any operative procedure be
meditated.

EXTERNAL H/EMORRHOIDS.

These affections are so prevalent, that very few persons, either
male or female, arrive at middle age without having in some



HEMORRHOIDS. 6l

degree suffered from them. They occur almost equally in
the robust and the weakly, in the rich and the poor, in the
active and sedentary. No doubt some occupations and
modes of life conduce to the'production of external haemor-
rhoids more than others, still I repeat, there is no class of
society or state of constitution which can be said to be entirely
exempt. The skin around the anus and the mucous mem-
brane at the verge of that aperture are remarkably delicate
in structure, they are also profusely supplied with nerves and
small vessels; from these facts it arises that anything tending
to irritate that region may readily cause congestion and
inflammation of the part and result in an attack of piles. To
certain anatomical peculiarities of structure in the rectum
and its viens, supposed to be the predisposing and also the
active cause of haemorrhoids, I shall refer further on. Again,
obstructions of the liver or portal system, fecal accumulations
or anything rendering the return of blood from the rectum
difficult, are likely to conduce to the same end. From this
we can readily imagine that a great variety of causes may
bring on an attack of piles; the following may be mentioned:
Constipation, often associated with chronic spasm of the
external sphincter muscle, diarrhoea, too good living, espec-
ially the consumption of large quantities of meat, very coarse
fare, indulgence in alcoholic drinks, excessive smoking,
violent and prolonged exertion, sedentary occupation, expos-
ure to wet or cold, discharges from the bowel, resulting from
internal diseases, the pressure caused by the uterus during
pregnancy, uterine displacement, friction from clothing, and
the use of printed paper as a detergent, especially the cheap
papers, from which the ink comes off on the slightest friction
the neglect of proper ablutions (this is very important; many
persons seem to forget that the anus requires quite as much
washing as any other part of the body), straining, however
induced all these are among the common causes, predisposing
or exciting, of external haemorrhoids.

I have already said that two varieties of external piles may
be recognized; the first ought to be called hypertrophies or
excrescences of the skin ; the second, sanguineous venous
tumors. When you look at either of these in an uninflamed
state, you would think them harmless enough ; in the one
caee you will observe around the anal orifice merely a cer-
tain redundancy of the skin, forming little flaps or tabs, more
or less pendulous, in addition to the small radiating corruga-
tions seen in the normal state ; in the other case you per-



62 HEMORRHOIDS.

ceive blue veins, rather raised above the surface, and running
up into the bowel, resembling indeed, varicose veins. Now,
these conditions, so innocent in their appearance, are prone,
at a very trifling provocation, to take an active inflammation,
and to cause the patient an amount of suffering quite dispro-
portionate to the pathological appearance.

Look at them when inflammation, set up by any of the
causes we have mentioned, has set in. These small tabs of
skin are much increased in size ; they may be very swollen
oedematous, and shiny; they are exceedingly painful to the
touch; sometimes they ulcerate, or suppuration may take
place, if the inflammation runs very high, and hence small
but painful little fistula arise. At times the oedema is so
considerable as to extend into the bowel, and form a
large, swollen ring of skin and everted mucous membrane
all round the anus.

So with regard to the sanguineous venous haemorrhoids, they
are swollen into ovoid or globular, bluish tumors, very hard,
exquisitively painful ; they can be pinched up between the
finger and thumbs from the tissues beneath, and they feel as if
a foreign body were present there. Sometimes, but rarely,
they can, by gentle pressure, be emptied of their contents ;
but this proceeding is not followed by any benefit to the
patient, as in a few hours they become more painful and
larger than before. These tumors may be single, or two or
three may be present at the same time ; by irritation they
set up spasm of the sphincter and levator-ani muscles, so that
they are drawn up and pinched, thus adding much to the
patient's suffering. Just as he is falling to sleep a spasm
takes place, and wakes him up ; in addition, there is a con-
stand throbbing and the sensation as if a foreign body were
thrust into the anus ; this excites the desire, every now and
again, to attempt to expel it by straining, which, if indulged
in, of course, aggravates the pain. Often the patient cannot
sit down, save in a constrained attitude, nor can he walk,
and when he coughs, the succussion causes acute suffering.
When the bowels act, and for some hours afterward, the dis-
tress is greatly increased, and the patient, if not absolutely
confined to bed, is quite incapable of attending to his busi-
ness. Accompanying all this there' is general feverishness,
furred tongue and usually constipation. Such, then, are the
symptoms of an acute attack of external piles, and if not a
serious matter, it is one causing great worry and loss of time,
an important point in these hard-working days. Moreover, one



HAEMORRHOIDS. 63

invasion predisposes to another. I have known many patients
who periodically suffer what I have described.

There is a difference of opinion as to the mode of forma-
tion of these venous tumors; some consider them to be
coagulations of blood in varicose veins, others as extrava-
sations into the connective tissue. It is possible that both
these views are correct. I am certain that I have often
found clots contained in a distinct sac, formed of inflamed
and condensed areolar tissue, without any communication
with a vein that the most careful examination could detect;
and, on the other hand. I have, in some cases been able to
squeeze the blood out of the tumors into the vein. It may
be that in the early stage of the disease the pile is simply a
varicosity of the vein, but soon inflammation shuts the clot
off from the trunk; and after a time, and repeated inflam-
mations the clot becomes enclosed in a sac; but, after all,
the question to my mind does not seem a very impor-
tant one as, it in no way influences the treatment to be
adopted.

It is very desirable to ncftice the earliest, or rather the
premonitory, symptoms of one of these attacks, as by this
knowledge it may possibly be warded off, or at all events,
much mitigated. Not infrequently a little extra eating and
drinking, without any absolute excess, is the exciting cause;
an indulgence in effervescing wines, or full-bodied ports, or
new spirits, being especially dangerous. The earliest symp-
tom is a sensation of fullness or plugging up, and slight pul-
sation in the anus; there is also a tendency to constipation,
inducing a little straining; this is frequently followed by
itching of a very annoying character, coming on when the
patient gets warm in bed, keeping him awake for some time,
and inducing him to scratch the part. In the morning he
finds the anus a little swollen and tender, and if he be an
observant person with regard to himself, he will notice after
a motion a slight stain of blood. Now, this may all pass off
with the simplest care and the slightest medication; but if
the patient neglects himself, it will surely be the precursor of
a more or less severe attack.

The treatment in such a case should be abstinence
from active exercise, rather spare diet, well-cooked vegeta-
bles and fish, not much meat, no beer or spirits, and wine is
not desirable; if the patient must take some stimulant, a
glass of light claret, with Seltzer or Vichy or Vals water, will
be the best beverage. If he is a smoker, he must cut down



64 HAEMORRHOIDS.

his usual allowance; smoking often causes a sympathetic
irritation of the throat and rectum. He may take a warm
bath or a Turkish bath, and should wash the anus night and
morning with warm water and Castile soap; after this, apply
some glycerine and tannic acid, or some calomel ointment,
or a lotion composed of one teaspoonful of the Liq. Plumbi-
Subacetatis, added to a wineglass of fresh milk, which is
very soothing. As to medicines, he may take a Plummer's
pill, with a little taraxacum and belladonna, for two or three
nights, at bedtime; and in the morning, fasting, some effer-
vescing citrate of magnesia, or this draught, which I have
found very useful on many oecasions: —

J^- • Liq. Magnes. Carb 5 ss

Potassae Bicarb 3 j

Syrup, or Tinct Sennae 3 ij

Spt. ^ther. Nit 3 ss

Aquae purae ad | ij.

One-third of a tumbler of Friedrichshall water, taken fast-
ing, with twice as much warm water, or Carlsbad salts, will
also have a good effect.

If the case be neglected, and advice is not sought until
active inflammation has set in, and the symptoms I have
described are in full force, you will save your patient much
time, pain, and after trouble, by snipping off the inflamed,
cutaneous excrescences, or in the case of sanguineous
tumors, by laying them freely open. The tabs of skin may
may be frozen by the etherizer, seized with a pair of
toothed forceps, and quickly snipped off with a pair of
strong scissors; the pain soon ceases and the wounds heal
readily under any simple dressing. Care must be taken not
to recklessy cut away too much skin, or contraction will fol-
low; you must, therefore, not make quite a clean sweep of
it, but take off a portion only; that which is left will con-
tract in the process of healing. The best method of open-
ing the venous swelling is as follows: Pinch up the tumor
gently between the finger and thumb of the left hand, trans-
fix its base with a curved bistoury, and cut out; at the same
moment, by pressure with the finger and thumb, the clot
may be extruded; place a piece of fine cotton wool at the
bottom of the sac, and the operation is completed; the pain
soon subsides, and the patient makes a speedy convales-
cence. The incision should be made in the direction of the
radiating folds of the anus, in order to facilitate the contrac-



HAEMORRHOIDS. 65

tion of the skin. If these sanguineous tumors are not inter-
fered with, the blood in them will, in time, become absorbed,
and they may ultimately form the cutaneous flaps already
described. It is always well in these cases to ascertain, by
means of an injection, whether there be any internal piles
associated with the external; if so, they must be attended to,
or the patient will probably be made worse by any operation
on the external haemorrhoids.

If the patient will not submit to the operative treatment I
have recommended, the swollen parts should be well smeared
with extract of belladonna and extract opium, equal parts,
and a warm poultice applied. This, in many cases, gives
very speedy relief, and, as a rule, is much more efficacious
than cold applications. But sometimes it happens that cold
is found by the patient to be more soothing; in that case a
lotion of Goulard water, with extract of opium and bella-
donna, is useful, or ice may be pretty constantly applied. It
does not answer to freeze the piles with the ether spray, as I
have seen recommended, for as soon as the cold goes off the
pain it worse than ever. I have never seen much benefit
derived from leeching. Some surgeons have insisted that
the inflammation should be reduced before removing
the piles by excision. I do not think there is any need
for this delay; certainly the parts are very tender and
sensitive, but the pain can be overcome by thorough freez-
ing, and I am convinced that convalescence is much has-
tened by the removal of the inflamed and oedematous tis-
sues, and, as far as my experience goes, no danger of any
kind need be apprehended from the operation if it be prop-
erly performed. I much too often see these cases treated
by drastic purges and gall-ointment; this, I am bound to
s.ay, is not good practice; in the active stage it is harmful to
the patient.

I have said that one attack of external haemorrhoids pre-
disposes to another; it is, therefore, very advisable for the
patient so to live as, if possible, to ward off this repetition.
Generally he should eat sparingly; and fish, fresh, well-
cooked vegetables, and ripe fruit should form a considerable
part of his diet; he should avoid spirits and beer, and take
as little stimulant of any kind as possible; strong coffee and
highly seasoned dishes must be abstained from; he should
not smoke, or only very moderately indeed; he should take
plenty of walking exercise, but it should not be violent nor
continued to over fatigue; he should sleep on a mattress and
5



66 INTERNAL HAEMORRHOIDS.

never omit to wash the affected part, night and morning,
with cold water; lastly, he should keep his bowels acting
daily. If this latter object cannot be accomplished without
some medicinal aid, he will find equal parts of the con-
fections of black pepper, sulphur, and senna, a capital
remedy ; of this one or two teaspoonf uls may be taken every
morning ; or night and morning, if required. I have had
great experience in the use of the waters of Friedrichshall
and Carlsbad in these cases, and I think them very bene-
ficial, particularly in persons who are prone to congestion of
the liver. Another remedy I find admirable, /. e., a tea-
spoonful of the compound licorice powder of the German
Pharmacopoeia, taken in wineglass of water, twice or thrice
in the week at bedtime. A steady perseverance in the line
of treatment I have suggested will, in all probability, eradi-
cate the haemorrhoidal tendency.



CHAPTER VIII.

INTERNAL HAEMORRHOIDS.

All those causes I have mentioned as likely to induce
external piles tend also to the production of internal haemor-
rhoids, but in addition we may name hereditary influence,
diseases of the genito-urinary system, and the state of recov-
ery from childbirth.

During pregnancy external venous haemorrhoids are fre-
quent, and these may, and often do, pass away after labor,
in common with varicosities of the legs and labia vaginae ;
but the reverse is the case with regard to internal haemor-
rhoids; these most frequently make their appearance after
parturition, when all the parts are relaxed and uterine invo-
lution is going on. I will not attempt to give any reason
for this peculiarity; I only state a fact I have repeatedly
observed.

Our French confreres, for long past, have not been at all
satisfied with the usually accepted explanation of the eti-
ology of piles, either external or internal. They do not
consider that any causes which are occasional can induce



INTERNAL HAEMORRHOIDS. 67

such an afflux and stasis of blood in the rectal veins as shall
be productive of haemorrhoids.

Neither, say they, sedentary occupation, excesses at the
table, venereal . abuses, passive pederasty, the immoderate
and prolonged use of enemata, drastic purgatives, nor habitual
and severe constipation, can, one or all, initiate true haemor-
hoids. They, therefore, with praiseworthy diligence, sought
for the true predisposing cause in the anatomy and physiol-
ogy of the rectum; and Professor Verneuil, the distinguished
Parisian surgeon, says he has discovered that cause in the
peculiar distribution of the veins and the course they take
in the coats of the rectum a few inches above the anus. The
preparations and dissections M. Verneuil made to illustrate
and prove his views are now in the Dupuytren Miiseum at
Paris; and the correctness of the anatomy, and the deduc-
tions made from it, have, say recent French authors, not
only been supported, but even proved, by the dissections of