Resinous cathartics are in general known to be the cause of hemorrhoids, as well as drugs which produce congestion of the pelvic veins, such as saccharides, myrrh. ravine apical and ergot; also foods which irritate the mucous membrane and excite peristalsis, such as aromatic spices, mustard, peppers, highly seasoned sauces, tamales, water cress or pickles, are frequently the direct causes of, or aggravate, hemorrhoids. Persons who suffer from idiosyncrasies which result in digestive disturbances accompanied by acute catarrh proctorial frequently suffer from hemorrhoids.

Strawberries and the carbohydrates eaten to excess are common causes. Diseases of the uterus, in the form of retro version or providential, and Benito-urinary diseases are often associated with attacks of hemorrhoids, due to a local congestion of the parts. Persons having heart, liver, kidney or nervous diseases, in which there is a relaxation or stony of the muscular structure, are frequent sufferers from internal hemorrhoids.

Fig. 60. Internal hemorrhoids.

Cases of acute catarrh proctorial have demonstrated the following theory to me as a probable cause of hemorrhoids in many instances and while the theory cannot well be demonstrated by proofs, I have presumed in many instances to follow its dictates in the treatment of these cases where no other causative factor could be thought of as a suitable substitute. When acute catarrh proctorial persists in the form of a low grade or sub acute inflammation, the hemorrhoids exist until the inflammation entirely disappears. Hemorrhoids due to this cause are most satisfactorily treated.

Should this most common course of the disease take place, and sufficient irritability persists to inflame the membrane, a gradual hypertrophy is caused, followed by a separation and sliding down of a small portion inside of the loose cuff of mucous membrane, at some point within the grasp of the sphincter muscles. The mere weight of the redundant membrane is sufficient to initiate the loosening and the subsequent formation of a hemorrhoid. This small hemorrhoid is quickly filled by the serous exudate from the vessels lying within its sub mucous tissue. The upright superficial vessels of the lower rectum acted upon by the descending fecal mass in a reverse direction to the normal current tend to swell up. These vessels temporarily distorted from their engorged condition, tear more of the mucosa and sub mucosa from the surrounding tissue, and they are lifted gradually by the accumulating serum away from the muscular layer.

This condition existing for months or years occasionally becomes edemas from irritation or traumatize in the form of hard fecal movements. The parts are constantly in a state of hyperglycemia This increased blood supply causes hypertrophy of the blood vessels and connective tissue, finally a well-organized hypertrophy mass becomes a recognized hemorrhoid.

Hemorrhoids existing in the presence of an strophic catarrh proctorial are, in my judgment, secondary to this hypertrophy inflammation and their presence is due simply to the serum forced within the meshes of the connective tissue of the sub-mucosa, which, with the blood vessels, remains hypertrophied - the atrophy only affecting the mucous membrane.

The primary etiological factor in the causation of hemorrhoids from this point of view, is most probably a digestive disturbance, either in the stomach or intestine, with the fermentation excreta acting as an irritant, bringing about the inflammation of the mucous membrane. Indigestion in one or another form seems always associated with hemorrhoids.

We may find other well-known and positive causes of hemorrhoids, such as glandular disturbances - meaning the liver, kidneys or pancreas, or heart lesions, traumatizes, pressure due to pregnancy and to tumors, malignant disease of the rectum or adjacent organs, and to specific forms of catarrh proctorial, as tuberculosis, syphilis, etc. These causes are not common. The large number of cases presented for treatment positively refute the assertion that everyone suffering from hemorrhoids also suffers from one of these serious disease.

As a foreword to the treatment of hemorrhoids, the etiological factor or cause should be sought in every instance and then the proper treatment instituted. This word of advice may seem harsh when emphasized, but when we consider the subject as we do diseases in general, how can we expect to accomplish a cure of this malady until the true cause has beenestablished. Hemorrhoids are very often the only manifestation of an organic disease such as nephritis, hepatic or cardiac disease, which may contraindicate operation. One would certainly not advise operation upon hemorrhoids which are the result of hypertrophy cirrhosis of the liver, cancer of the rectum, insusceptible, stricture or loco motor ataxia, examples of which one may see in the ordinary practice of medicine commonly complicating either of these affections. A cure under such conditions could only be accomplished by relief from the primary organic disease.

Most prevalent, as stated before, are the mistakes, so often serious to the patient, of a casual view of the hemorrhoid region, the acceptance of the patient's description and then the prescription by the doctor of some ointment. Nature is expected to do the rest. It is natural to be careless occasionally, probably more so in the disagreeable tasks that appear as simple pathological conditions apparently satisfactory without further investigation in many instances. Often men of unquestionable surgical ability make this mistake, and a hemorrhoid operation is performed when an nucleation of the rectum for cancer would have been the proper scientific treatment. However, we all learn from experience and it is the man who refuses to profit by his mistakes that is open to criticism.

One should examine the rectum, sigmoid, heart, liver and the urine in every case, no matter how simple the hemorrhoid condition appears; then only can the true cause be ascertained.

After having established the proof that no other disease is responsible for the hemorrhoid condition, the question of instituting the proper treatment then presents itself. Very often the regulation of the patient's bowels and diet, the avoidance of violent exercise, and a moderation in all the habits of living, will greatly improve the hemorrhoid condition. This in addition to prescribing an ointment containing belladonna, tannin acid and strontium; the injection of a cup of cold hydrant water into the rectum before a movement and advising the sufferer to avoid straining at stool, will, in a number of cases during the early stages, be sufficient treatment. Thrombotic Hemorrhoids should be simply cut into with a knife or scissors to permit the escape of the clotted blood. Care should be exercised to make the incision in the longitudinal axis of the anal canal, to avoid a transverse caricaturization The after-treatment consists in having the patient bathe the wound frequently with warm water.