Reprint from St. Louis Medical Review, October 7, 1893. 
The Pathology, Symptomatology and 
Treatment of Hemorrhoids, Simple 
and Complicated. 
BY THOMAS H. MANLEY, M.D , 
Visiting Surgeon to HarleirrHospital, New York. 
In other contributions under similar titles, I have, at 
length dealt with the subject of hemorrhoidal disease; 
so that at present my efforts will be directed only to- 
wards a review of salient points and the enumeration of 
types, rather an endeaver to analyze the subject in de- 
tail. 
It is unnecessary, at the outset, to enter into the mor- 
bid anatomy or the pathological changes in the vascular 
system and the mucous membrane of the rectum and 
anus, essential to the formation of simple, common 
hemorrhoid-s; therefore the pathology of complicated 
cases alone will be chiefly considered in the present in- 
stance. 
Relative Frequency of Hemorrhoids. 
Hemorrhoidal dilatation of the veins of the rectum, I 
have found so common, in the living and dead subject 
after adult years are attained, that I have come to re- 
gard it as practically physiological. It is a species of 2 
vascular degeneration. In the anus it first presents it- 
self, for many good and satisfactory reasons. When 
devoid of complicating elements, hemorrhoids are in- 
offensive and harmless; so that we may go through life, 
not knowing that a cluster of hemorrhoidal masses, oc- 
cupied the edge of the anus, on the interior of the rec- 
tum. They constitute disease only, when they persue 
the seat of pathological processes, or of an usual type, 
when we have an atypical condition, or we are in the 
presence of complications. 
Anatomical Division.- 
1. Veinous hemorrhoids. 
2. Arterial hemorrhoids. 
3. Mixed hemorrhoids. 
4. Internal hemorrhoids. 
5. External hemorrhoids. 
Pathological Division.- 
1. Thrombosed hemorrhoids. 
2. Inflamed hemorrhoids. 
3. Bleeding hemorrhoids. 
4. Ulcerating hemorrhoids. 
Co-Incident Complications or Sequell^e.- 
1. Anal fissure. 
2. Anal fistula. 
3. Anal stricture. 
Varieties of Hemorrhoids. 3 
Tubercle, syphilis and cancer play an important role 
in many types of piles. 
Hemorrhoids become the seat of pathological changes, 
chiefly through infection, either through the mucous 
membrane, the circulation or the absorbants. 
The great preponderance of hemorrhoids are varicose; 
though the most rebellious types of hemorrhage, from 
so-called internal are often dependent on a papi- 
lomatous or angiomatous state of the arterioles in the 
submucosa, just within the verge. 
A varicose state of the veins of the leg causes cuta- 
neous and muscular atrophy; in the spermatic cord a 
wasting of the testicle. 
In the rectum the sphyncter externus and levator ani 
suffer from the effects of malnutrition, when the walls 
of the afferent vessels give way. A low grade of in- 
flammation supervenes in which there is a free hyper- 
plasia into the inter-fasicular spaces and parenchyma of 
the muscle fiber. This undergoes organization with 
fibrous changes, so that the external sphyncter, in all 
cases of hemorrhoids, undergoing pathological changes, 
will be found greatly thickened of a dense consistance 
and but moderately distensible. 
The Usual Termination of Non-Complicated 
Hemorrhoids. 
In response to an immutable law in the economy, 
Nature in her own time, will dispose of any superfluous 
tissue, or excrescences, by slow but radical processes. 
When the element of malignancy is absent and there 4 
are simple neoplastic varices at the anus, they will in 
time disappear of themselves. 
Modus-Operandi of Spontaneous Cure.-A primi- 
tive hemorrhoid is a tumor like dilatation of a vein with 
■fluid blood. This tumor fills and empties, expands and 
contracts under certain physiological conditions of the 
anus and lower rectum. 
But, when they sustain a pressure from hard, irregular- 
shaped fecal masses, or are passed down through the 
sphyncter at stool, and are strangled by its contraction; 
then congestion and inflammation follow. Microgymes 
penetrate the intima and the first most tangible patho- 
logical change is announced by a coagulation of the 
blood. 
Now should our patient possess a good constitution 
and septic influences are escaped, then the more intense 
the inflammation, the more prompt and radical will be 
the destruction of the hemorrhoids, and in a short time 
no trace of them will remain but their shriveled, atro- 
phied stalks. 
Many, however, do not run the gauntlet so safely. If 
the patient be tuberculous there is a tendency to a low 
grade of inflammation following. The work of resorp- 
tion of the inflammatory products is imperfectly per- 
formed. The walls of the hemorrhoid break down and 
its base is the starting point of an ulcer, a fistula, a fis- 
sure, or an opening into an artery. 
If our patient is syphilitic an inflamed hemorrhoid is 
the nidus from which an annular spread of hyperplas- 
tic changes begin, and should ulceration follow, on ac- 5 
count of its painless character, it may work great havoc, 
or even lead to cicatrization and stricture before one 
is aware of its presence. 
It is not the general opinion of pathologists that 
hemorrhoids are an exciting cause of cancer or epitheli- 
oma, but so many cases have come under my observa- 
tion in which cancerous disease has followed in the 
wake of hemorrhoids and the proliferating tissue has 
maintained the character of piles in the embryonic ele- 
ments that I now no longer have any doubt of the fre- 
quent and direct relation. 
Septic or local processes are more often responsible 
for hemorrhoidal implication than anything else. 
The rectum is the excretory channel and other resi- 
dence of digestive excrementitious substances of the 
body. Therefore when a hemorrhoid becomes inflamed, 
if its surface-epithelium be at all abraded, pathogenic 
germs are certain to enter and excite suppurative 
changes. For this reason too, all operations on the 
anus and lower rectum are inevitably exposed to infec- 
tion after mutilation of the soft parts, as a clean, asep- 
tic wound in this situation is manifestly impossible. 
Symptomatology. 
The recognition of hemorrhoids is not attended with 
any difficulty, for they can be seen and felt. It is only 
in chronic cases of a mixed character that experience 
and tact are required to distinguish each type and com- 
plications. The symptoms of the malady are not uni- 
form, definite or reliable. 6 
A proctitis limited to the verge or the lower third of 
the rectum may simulate piles. But clinically it is 
readily recognized. 
Pain, itching and hemorrhage are the most constant 
symptoms. One will usually be able to determine the 
site of the affected parts by certain signs. 
If, for instance, our patient complains much of tenes- 
mus of the bladder we may be confident that the affect- 
ed tumors are lodged in the anterior wall, and that the 
vesical symptoms are dependent on the propagation of 
inflammation, in the male through the prostate. We 
never have bladder symptoms in the female. 
A patient with acutely inflamed piles derives some 
relief from straining at stool: when he feels them with 
his finger, and can tell how many there are, and give 
their size. Polypoid growths of the rectum may simulate 
hemorrhoids in the symptoms which they give rise to. 
They are very uncommon and almost invariably have 
their origin high up. They are not painful, but they 
frequently have a thick vascular tissue, and by their size 
produce a constant sense of fullness. I saw a case last 
summer of vascular polypi of the rectum which by the 
constant hemorrhage which they kept up reduced the 
patient to a state of the most profound anemia. They 
were fully a finger's length above the verge and all had 
long independent pedicles from the anterior wall of the 
bowel. 
Pain is quite a constant symptom of hemorrhoids. 
Sometimes it is of a most agonizing character. There 
is no affection in the anus except fissure which can pro- 
duce such acute suffering. 7 
Rectal tenesmus is quite pathognomonic of piles in the 
absence of dysentery. This must not be confounded with 
another symptom closely allied to it in malignant dis- 
ease when the patient is the subject of advanced years 
and has a constant desire to empty his bowel because of 
a sense of constant fullness. When one comes to us 
with the latter symptom after middle age it must be re- 
garded a symptom of very serious import. 
Itching.-Varices anywhere situated are sometimes 
the cause of the most furious itching in the legs, the 
vulva, or the scrotum, as well as in the anus. 
Hemorrhoidal itch, however, has characteristics pecu- 
liar to it. It is mostly nocturnal and comes on sudden- 
ly, but generally in short exacerbations. In children 
pin worms may excite this state, and so may pediculi in 
the adult. 
Tubercular ulceration of the bowel is often made manb 
fest, chiefly by a sort of an itchy sensation and a feeling 
of uneasiness. It is never acute, but is constant without 
sharp exacerbations. In those of a tubercular diathesis 
we may suspect the true condition, though when in 
doubt, nothing will decide the matter, except a thor- 
ough inspection. 
Rectal Hemorrhage, Bleeding Piles.-Hemor- 
rhoidal hemorrhage is of two varieties, namely, one, the 
most common veinous, and the other, arterial. The 
former may be recognized by its sparcity in quantity 
and its color. 
But, when blood comes in considerable quantities af- 
ter an evacuation, of a bright red color, it is arterial, 8 
and strictly speaking, is not hemorrhoidal, for it does 
not escape from varices, but papillomata or angiomata. 
But in every case of the type under consideration, the 
common site is low down, near the verge. 
It is well to remember that tuberculous ulcers are a 
common source of rectal hemorrhage, and in elderly 
people blood following a painful stool is strongly sug- 
gestive of cancer. 
In all cases of rectal hemorrhage in those past the 
meridian of life, a rigorous examination alone will re- 
veal its etiology. 
The general symptoms of rectal hemorrhage are the 
same as those which present themselves after the loss 
of blood in other districts. Many times one goes on, 
sustaining a steady depletion, until dangerously exsan- 
guinated before the origin of the leak is discovered. 
In aggravated cases of hemorrhoidal bleeding consti 
tutional symptoms are well marked. Anemia is obvi- 
ous; the heart palpitates on the least over-exertion or 
excitement. The patient suffers from giddiness, has 
flashes of light cross his visual field, with insufferable 
noises in the ears. 
In these serious cases we will find on examination 
that the spleen is more or less hypertrophied. 
Treatment of Hemorrhoids. 
Modern advances in science have greatly simplified 
the operative treatment of piles. In the larger number 
of simple uncomplicated cases, chalogogue cathartics, 
one or two doses, with, rest, local bathing, a soothing 9 
salve, or lotions, will suffice and our patients promptly 
recover. 
As to consider this class and the various measures of 
treatment would occupy more space than is permitted, 
I will pass on to the surgical treatment of aggravated 
cases. A thorough examination of the rectum is an in- 
dispensable preliminary to the treatment in all chronic 
cases. 
The plan of treatment which I have advocated and 
practiced is designated "Pressure Massage." By it 
there is no division of the soft parts with consequent 
danger from secondary hemorrhage or stenosis of the 
passage from cicatricial contraction. 
With the aid of a Paquelin cautery it will succeed in 
every type of hemorrhoids when all its details are fully 
carried out. 
The procedures may be divided into five stages: 
1. Preparation of the parts. 
2. Subcutaneous cocainization. 
3. Complete anal dilatation. 
4. Pressure, torsion and massage. 
5. Irrigation and return of prolapsed parts. 
In all cases as soon as one begins to arrange for an 
operation the patient should be given half an ounce of 
brandy, or its equivalent in wine, every fifteen or twen- 
ty minutes before manipulation of the sphincter is 
commenced; while the parts are being shaved and 
scrubbed and the rectum is being well cleared by an 
efficient lavage. 
Cocainization.-The index finger warmed and well 10 
lubricated is now introduced up to the webbing, being 
pressed gently but steadily in. Now its tip is flexed so 
as to give the digit a hook-shape and the sphincter is 
drawn outward slightly when we take the hypodermic 
in hand (in the right). 
A fresh one per cent solution is safe and of ample 
potency. From sixty to one hundred drops are enough 
for hypodermic use in every case. Now the needle is 
sent in in such a manner and to such a length that its 
point penetrates the seat of each large tumor and two 
or three drops are deposited within it. It is then part- 
ly withdrawn making one hub and several spokes in 
four districts. One anteriorly, one posteriorly and one 
on each side. To make this clearer I may say that the 
point after being sent home is withdrawn to, but not 
through, the integument when it is re introduced and 
withdrawn to the surface until a circular area is 
sprayed. 
Hypodermic cocainization, complete sphincteric dila- 
tation is commenced. In order not to rupture or lacerate 
an old, cord-like contracted sphincter one must proceed 
slowly until all resistance is overcome when the entire 
hemorrhoidal area of the lower rectum rolls out through 
the opening. The parts are now well cleansed and 
dried when they are lightly swabbed with a four per 
cent solution of cocaine, and in a few seconds we com- 
mence the pressure manipulation of each pile. 
Each one is seized between the thumb and index fin- 
ger and first so crushed that all except the external coat 
is reduced to a pulp, then fully extended in its pedicle 11 
or base and twisted. The extent and thoroughness of 
force in each case applied will depend on the size of the 
masses and the thickness of their coats. This part must 
be radical and complete. We will now irrigate with 
sterilized water, return the crushed masses within the 
sphincter, introduce an opium suppository, when our 
manipulations end and dressings are applied. 
Bleeding hemorrhoids demand essentially the same 
technique, only that the bleeding sulci or minute 
papillomata need touching with Paquelin's cautery. 
Conclusions, 
The advantages of the above described technique 
may be summarized as follows: 
1. The total dispensation of pulmonary anesthetics 
which are always attended with more or less danger 
to life in those suffering from functional or 
organic disease. A more complete composure of our 
patient with absence of straining, vomiting, or 
besmearing of the parts with feces during our manipu- 
lations, besides we may succeed with fewer assistants. 
Certainly in highly sensitive or hysterical individuals 
ether narcosis may be required. 
2. Analgesic dilatation is not so apt to be attended 
with rupture of the sphincter because, though the pain- 
sense is annulled, the patient yet preserves sufficient 
sensation to warn us when excessive force is being em- 
ployed. 
3. As there is no mutilation and no hemorrhage, the 
danger of tetanus, infection, ulcerative fistula and sec- 12 
ondary hemorrhage is obviated. Acute aseptic inflam- 
mation follows after the hemorrhoids are replaced, 
which ends in resorption of their contents, so that in a 
short period nothing remains to mark their former site 
but short, atrophied stalks. 
3. Shortened Convalescence.-By this manner, as there 
are no sequellae to be feared, the after-treatment is al- 
most nil. As a general rule our patient may be [about 
in a few days, or a week, though it is always well that 
the body be kept in a state of rest and the parts be 
daily bathed for two or three weeks in severe cases. 
4. This method has something more than speculation 
and theory to support it, for in my hands, in a large 
number of cases of every type of hemorrhoids, during 
the past two years, it has invariably succeeded, and in 
no single instance with which I am acquainted, has it 
failed, or has it been followed by relapse. I may add, 
however, that in females it is not as satisfactory as in 
the opposite sex because they are commonly so refrac- 
tory to the action of cocaine.