Hemorrhoids or piles are the terms used to mean a hypertrophy of the tissue and a varicose of the blood vessels at the lower end of the rectum or at the margin of the anal canal. The disease has been recognized as a distinct entity and studied for centuries, in fact long before the Christian era and the history of medicine. There has been no definite theory accepted as to the cause of any but the thrombotic variety.

Classification. Hemorrhoids are classified in general, varying with the ideas of different authors as to their location, into the external, internal, mixed, (internal and external) thrombotic and nae void (capillary). This classification is made broadly with the idea of simplifying the description, the causes, and treatment.

External hemorrhoids are located entirely outside of the anal canal, on the margin of the anus.

Internal hemorrhoids are situated entirely inside the anal canal and are covered by mucous membrane only.

Mixed or intern-external hemorrhoids are partially on the margin and partially in the anal canal, covered both by skin and mucous membrane.

Thrombotic hemorrhoids may be situated externally, internally or intern-externally and consist of a circumscribed blood extravaganza, due to a thrombosis in one or more of the veins.

Avoid hemorrhoids are the same as the nervous found elsewhere on the body and differ only in having a mucous membrane covering etiology. Hemorrhoids are found at all ages, although very seldom during infancy and childhood. At puberty there seems to be a per-disposition to the formation of hemorrhoids. When occurring in childhood they are most probably caused by a catarrh proctorial as the ordinary adult causes given for this disease seem entirely inappropriate, as age, menopause, dissipation, violent exercises, liver, kidney, heart or malignant diseases do not enter into the woes of childhood, and confine us to catarrh and constitutional diseases almost exclusively. Constipation is a most common cause undoubtedly and when associated with severe straining might easily explain the presence of a thrombotic or an inflammatory pile. Diarrhea of a protracted nature may cause hemorrhoids because the irritation following the catarrh inflammation may produce more or less permanent swelling in the form of a hemorrhoid.

Persons not properly clothed are liable to a sudden chilling of the body surface. This may bring about a congestion of the portal circulation and in that manner overload the hemorrhoid veins which may in course of repeated congestion produce hemorrhoids. The disease is most frequent in middle life, next in advanced age, and least in children. Males seem to be more frequently affected than females. Occupations which require severe muscular strains, as heavy lifting, and constant standing or sitting in the erect position as followed by street car conductors, truck men, laborers, desk-workers ; also habits of over-indulgence in food and alcoholic beverages, carelessness in regulating the bowels, and the lack of physical exercise are common causes of this disease. Heredity, given by most authors, seems hardly a cause for hemorrhoids, but we must admit that as each successive generation is liable to the same inherited habits that might be conducive to hemorrhoids, the present generation might escape the affliction were these inherited tendencies omitted.

The disease is more frequent in very hot and very cold climates, due probably in hot countries to the relaxation produced by heat and sedentary habits; while in the colder Countries there is a tendency to violent exercise in order to keep warm, and an over-indulgence in alcoholic drinks. In the spring, the portal circulation becomes congested because the system cannot consume the large quantity of carbohydrates that have been used during the cold weather and when the extreme warm weather suddenly conies on. the diet is too rich in that class of foods, and the result is that the body cannot adjust itself. The erect position of man. and the habit of being in the upright position for the larger part of the day, predisposes him to hemorrhoids more than any of the other animals.

Hemorrhoids are found as frequently in thin, anemic and temperate individuals as in the robust and plethora, probably due to a muscular and nervous exhaustion resulting in a relaxation and dilatation of the venous system. Individuals suffering from disorders of the liver are commonly the subjects of hemorrhoids.

Constipation is probably the commonest cause given for hemorrhoids, as the solid fecal mass irritates the mucous membrane and the reverse pressure exerted upon the upright veins by the feces in the rectum results in their engorgement. This backward pressure strips the superficial veins in the opposite direction to which the venous current flows, producing mechanical strain and irritation of the mucous membrane and venous coats and is a starting point for this disease. The blood vessels of the rectum puncture the muscular wall in button-hole-like slits, about three inches above the anus. These divide into numerous branches distributed to the lower end of the organ. These slit-like holes are supposed to serve the purpose of valves in the veins.

Verne claims that they act as an obstruction to the venous flow and following a spasm or peristalsis in the rectal muscles, cause a constriction of the veins, congestion, and result in the formation of hemorrhoids. The arterial walls are so thick that compression is not so easy and the blood current is almost constant, while its return flow in the veins may be obstructed in this manner.

Fig. 59. Thrombotic hemorrhoids.

Tutti claims that Vernacular’s idea is more than a rational cause, for in order that these muscles act as valves, they would have to be in a state of tonic contraction, which we know is not the case, and that, if they were to act as valves, their efficiency would be doubtful, acting as the only valve between the liver and the rectum. The weight which a fourteen-inch column of blood, when in the upright position, exerts upon the thin-walled veins of the rectum, with the associated ca tarring diseases and constipation, are the most reasonable causes of the varicose dilatation at the lower end of the rectum, which we call hemorrhoids.