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attending this affection will also have great influence with regard to it. In the quiescent state of the tumours, there will merely be a sense of weight and fulness in the rectum; if inflammation be present, there will be throbbing, heat, and aching, aggravated by defecation; should the complication of fissure exist, there will be smarting at stool, followed by spasm of the sphincter, and aching of an agonizing character continuing from half an hour to several hours. In some cases the pain will extend to the urinary and genital organs in either sex, up the sacrum to the loins, to the hips and down the thighs. I have seen a case where the pain was chiefly located in the heel and under part of the foot, and have observed the same in several patients who had stricture of the urethra : in them it was at first increased by passing the catheter, but subsided as the strictures yielded to treatment. Sir Benjamin Brodie mentions an instance where pain in the foot was the prominent feature of the hæmorrhoidal affection. He says, “A lady consulted me concerning a pain to which she had been for some time subject, beginning in the left ankle, and extending along the instep towards the little toe, and also in the sole of the foot. The pain was described as being very severe. It was unattended by swelling or redness of the skin, but the foot was tender. She laboured also under internal piles, which protruded at the

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water-closet, at the same time that she lost from them sometimes a larger and sometimes a smaller quantity of blood. On a more particular inquiry, I learned she was free from pain in the foot in the morning ; that the pain attacked her as soon as the first evacuation of the bowels had occasioned a protrusion of the piles ; that it was especially induced by an evacuation of hard fæces; and that if she passed a day without an evacuation at all, the pain in the foot never troubled her. Having taken all these facts into consideration, I prescribed for her the daily use of a lavement of cold water ; that she should take Ward's paste (confectio piperis composita) three times daily, and some laxative electuary at bed-time. After having persevered in this plan for the space of six weeks, she called on me again. The piles had now ceased to bleed, and in other respects gave her scarcely any inconvenience. The pain in the foot had entirely left her. She observed, that in proportion as the symptoms produced by the piles had abated the pain in the foot had abated also.”

Hæmorrhage is one of the most frequent of the accessory phenomena of internal piles, and at times the most prominent symptom, and, when excessive, is also the most alarming, from the serious effects thereby occasioned : it usually takes place during the evacuation of the contents of the bowel, occurring after the passage of the fæces, but sometimes preceding them. It is mostly of an active character, but may become passive by the vessels being debilitated, and the blood attenuated, as a consequence of the profuseness of the hæmorrhagic discharge. The colour of the blood evacuated is bright vermilion, and is exuded by the capillary vessels of the mucous membrane of the tumours or excrescences constituting the piles : this will be very evident on examination when they are prolapsed. In other cases the blood will be projected in fine streams, as if from minute vessels or dilated pores ; but we are not able to detect these after the hæmorrhage ceases.

The severity of the concomitant symptoms denoting a loaded state of the hæmorrhoidal vessels is not always an index of the amount of hæmorrhage that may occur, sometimes the discharge of blood being trifling though the preceding premonitory signs have been strongly marked; whilst, in other cases, the loss of blood will be very great, notwithstanding that little discomfort or inconvenience has previously been experienced.

In the commencement of the hæmorrhoidal affection, the bleeding will usually cease after a few days, and the several attendant symptoms then subside; yet not unfrequently the bleeding will continue for a much longer period. Some individuals experience but a single attack during life; while in others, the hæmor

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rhage may return at uncertain intervals of weeks, months, or years; or again, it may assume a periodic character, and return at longer or shorter, but regular intervals. As a general rule, the bleeding increases both in frequency and amount with the duration of the disease. In females it is not unusual to observe the hæmorrhoidal discharge interfering with or becoming vicarious with the catamenial functions, and in some instances these discharges will alternate.

There can be no doubt that the quantity of blood lost in many of the cases recorded must have been greatly exaggerated; and patients are always prone to imagine it larger than it really is, from the alarm created by the sight of blood, by the show it makes on their linen and clothes, as well as from the liability of its admixture with other fluids imposing on their inexperience.

Mr. Du Pasquier informed me a patient of his lost one night, while in bed, eight or nine pounds of blood. Mr. Calvert * adduces the two following cases, which came under his own observation. “A middleaged woman, a patient of the Manchester Infirmary, in whom the hæmorrhoidal discharge had been long suppressed, was seized with colic pains, with a sensa. tion of weight about the loins and sacrum ; an enema was exhibited, which brought away some liquid fæces, and soon after a discharge of bloody fluids, amounting to more than three chamber-pots full in less than two hours. She was dreadfully reduced in consequence, but the pains subsided, and after some time she regained her former strength.” “A young woman, an out-district patient of the same hospital, was affected with pain in the head and loins, symptoms of general fever, with tenesmus and sympathetic irritation of the bladder. In this state she continued for some days, when the hæmorrhoidal discharge to which she had been subject returned, and more than a pint of blood was voided for near a fortnight. The pains in the head and loins, with the other symptoms, disappeared with the recurrence of the discharge, and were succeeded by a small, feeble pulse, ædema of the face and extremities, oppression at the region of the stomach, and great prostration of strength. The discharge was eventually stopped by the vigorous use of spirituous and astringent injections, with such other means as are generally employed when affections of this nature are continued from debility.”

*'A Practical Treatise on Diseases of the Rectum and Anus,' by G. Calvert, pp. 16, 17, London, 1824.

The following are some of the casés quoted by Montègre,* to which, however, credence cannot be given without hesitation. “Montanus,f according to

* Op. cit., pp. 27-30.
+ .Apend. Consilior Montani,' p. 59, Basil, 1588.

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