Synonyms

Phlebectasia hemorrhoidalis. Piles.

Definition

Diffuse or circumscribed varicose dilatations of the hemorrhoidal veins situated either in the subcutaneous tissue of the external surface of the anus or in the submucous tissue of the lower portion of the rectum.

Etiology

The affection under consideration is quite frequently met with. It occurs more often in men than in women and very rarely in children. While in olden times it was believed that hemorrhoids were due to a faulty state of the general circulation or dyscrasia, it is now generally accepted that they are the result of merely local disturbances. The development of hemorrhoidal varices takes place in the same manner as that of varices of other regions of the body, principally by mechanical influences. The reason why these phlebectases are formed so often in the hemorrhoidal plexus is as follows: 1. The hemorrhoidal veins occupy a low position of the body, no matter whether in the standing or in the recumbent posture. 2. They are often unduly compressed by the contraction of the muscles situated in the lower end of the rectum and by fecal masses accumulated here. The circulation is thus at certain times obstructed or altogether arrested. 3. The hemorrhoidal veins are not provided with valves, and thus blood which has passed through them can be easily forced back. 4. The rectal veins are the remotest branches of the portal vein in which there is normally but a low degree of pressure, and in which circulation is easily retarded by disturbances of the liver.

As all these factors exist even under normal conditions it is readily conceivable that phlebectases are found in the majority of people; usually, however, they do not reach a marked development, and for this reason do not give rise to complaints.

All conditions which tend to produce lasting hyperemia of the lower portion of the rectum give rise to the development of hemorrhoids. Too prolonged sedentary or standing occupations predispose to them. In this way hemorrhoids occur in clerks, students, some artisans, for instance, shoemakers, tailors, and cavalrymen, seamstresses and washwomen, etc. High livers and people who are used to strongly seasoned or fatty foods also often suffer from piles on account of the great fulness of the portal circulation under these conditions. Habitual constipation also favors their development. The use of strong cathartics like aloes, colocynth, gamboge, etc., irritates the large bowel in a marked degree and often gives rise to hemorrhoids. Diseases of the uterus which lead to an enlargement of this organ and also pregnancy are predisposing causes. In a similar way affections of the prostate and tumors of the bladder as well as of other organs situated in the small pelvis often produce hemorrhoids. All diseases of the liver which are accompanied by a congestive state of the portal circulation exert a direct influence upon their formation.

Diseases of the heart and lungs frequently cause congestion of the inferior vena cava and indirectly also of the rectal veins, thus predisposing to the affection under consideration.

Hemorrhoids are most frequently developed between the ages of thirty and fifty years. They are extremely rare in infants and children. With regard to frequency the male sex seems to be more often afflicted than the female. Some races show a special predisposition to this disease, depending most probably upon their mode of living and their diet. Whether heredity plays a part in the development of hemorrhoids is yet unsettled.

Morbid Anatomy

In some instances the hemorrhoidal veins are evenly dilated and can be noticed as bluish-red and tortuous vessels encircling the external anal opening. At the same time there may be no special varicose swellings; more frequently, however, besides the general congested condition of the veins there are isolated varicose protrusions which may range in size from a pea to a walnut. They vary greatly in shape: sometimes they are round, sometimes flat, sometimes again irregular. Their size greatly changes from time to time in the same person. After defecation as a rule they grow smaller. Internal hemorrhoids appear as soft nodules of a bluish hue and have thin walls. They often develop to a considerable size and make defecation difficult. As a rule, hemorrhoids occur as multiple nodules, which may cover the mucous membrane at different places, or they may encircle the external surface of the anus, or be situated above the internal sphincter. Internal and external hemorrhoids may also be present at the same time.

Thus Cruveilhier 1 described a case in which there existed a wreath of external hemorrhoids around the anal opening, another above the internal sphincter, and a third a few centimetres farther up.

External hemorrhoids are at first covered with normal epidermis which can be moved over them. Later, however, through inflammatory processes the cutis becomes adherent to the varicose nodule. At the same time the skin covering the nodule grows thinner through the steady pressure to which it is subjected, and it may reach a point when it breaks open after a forced defecation. The same remarks also apply to internal hemorrhoids in which the cutaneous covering of external hemorrhoids is represented by the mucous membrane of the bowel. This also becomes adherent, thinned, and may ultimately rupture.

1 Cruveilhier "Traite d'anatomie pathologique generate, " 1849.