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the report of Schwevcher, saw a patient who had passed two pounds of blood for forty-five successive days, and finally recovered. Cornarius * mentions the case of a gentleman, who, after drinking freely of Hungarian wine, lost two pounds of blood from the nose, and six pounds on each of the four following days from the anus. Nevertheless, he got well without any remedy. Pomme † gives the case of a man, thirty-six years of age, of an atrabilious temperament, who for a long time had been subject to an excessive hæmorrhoidal flux, for which he tried many remedies without obtaining relief. At length, having adopted the idea that it had a venereal origin, he underwent an antisyphilitic course of treatment, in consequence of which the flux disappeared. However, he was soon attacked with distressing symptoms of cholera, when the hæmorrhage reappeared. During a month he lost nearly a pound of blood daily, which was followed by colic, pains of the face and extremities. By a generous diet, nutrient injections, and cold baths, the hæmorrhage was arrested, and exercise on horseback rendered him convalescent. Lanzoni f cites the case of a priest who daily passed a pint of blood per anum. Ferdinand ş says that a girl, twenty years of age, of a sanguineous temperament, sedentary habits, and endowed with much vivacity, in consequence of a violent chagrin, arising from jealousy, became affected with hæmorrhoids, and for many months daily evacuated about half a pint of blood while at stool. The menstrual discharge ceased, her face became pallid and ædematous : under proper treatment she perfectly recovered.”
* Observ. Med.,' 26. f . Traités des Maladies Vaporeuses.' I • Consult. Med.,' 97 ; . Oper.,' t. ii. p. 203. $ • Hist. Med.,' 16, p. 40.
The amount of hæmorrhage in different cases varies much ; in some it is but trifling, perhaps not more than a few drops, or at most a teaspoonful, whilst in others it may be from one to several ounces, or even as much as a pint, depending on the general condition of the patient, and the presence or absence of irritation or vascular excitement in the pelvic viscera. At first, the discharge of blood may be salutary in effect, by relieving the congested condition of the vessels or liver giving rise to the local affection. Frequently the patient will experience a relief of the feeling of weight and fulness in the perineum and rectum, and the other unpleasant symptoms that existed, by the loss of a small quantity of blood. The occurrence of the hæmorrhagic flux may serve for a time to ward off fatal effects, by preventing vascular determination to organs important to life when they are affected by disease. But when the bleeding is great, or becomes habitual, the constitution suffers, and a train of unpleasant symptoms arise: the patient becomes pale, the florid colour of the lips in health fades, the gums and tongue are blanched, the complexion is sallow and dingy, and has a peculiar waxy appearance ; deficiency of physical and mental energy supervenes, he is listless, his sleep is disturbed, the temper becomes irritable and peevish, frequent headache occurs, which is increased by the upright position, and relieved by the horizontal posture; the heart's action is easily excited, and the organ will palpitate violently on slight bodily exertion or mental agitation ; there is difficulty of breathing, particularly in going up stairs, or ascending an incline, and, finally, as a consequence of the anæmic condition of the patient thus induced, cedematous swelling of the feet and legs occur.
Mucous discharge from the anus is a very frequent and annoying accompaniment of hæmorrhoidal affections. It varies much both as to quantity and appearance : in a female patient I attended at the commencement of 1853, it was most profuse; it ran down her legs while walking, and constituted the chief source of annoyance to her. When active irritation of the mucous membrane exists, the discharge is watery, resembling a thin solution of gum, and frequently acrid, producing excoriation of the surrounding parts. When the secretion is the effect of chronic irritation, it is gelatinous in appearance, and resembles
frogs' spawn, or the white of an unboiled egg. If the secretion is watery, it exudes from the anus, and soils the patient's linen, and renders him otherwise uncomfortable : when tenacious and moderate in quantity, it is discharged at stool only ; but if profuse, any exertion, such as running, walking, riding, either on horseback or in a carriage, and even laughing and sneezing, will cause its ejection.
Ulceration of the surface of the mucous membrane of piles is the result of severe inflammatory action, or is produced by friction and irritation of the patient's clothes, when the tumours are subject to prolapsus ; if arising from the former cause, it attacks the follicles, and penetrates deeply; whilst from the latter, the ulcerated surface will be more extensive, but superficial. External piles are more often affected by ulceration than internal ones, especially when they have become. permanent and indurated, in consequence of repeated inflammatory attacks. We not unfrequently meet with small abscesses and sinuses in this last class of tumours. Occasionally abscess will occur in the
the rectum, by its implication in the inflammatory action, or by perforation of the mucous tissue by ulceration, and thus lead to the formation of fistula in ano. Should abscess form in the male anterior to the anus, and press upon the urethra or neck of the bladder, retention of urine may be super
added to the patient's other symptoms. In females, the abscess will extend to one of the labia, or open into the vagina, forming recto-vaginal fistula, or, by bursting externally by the side of the bowel, establish fistula in ano.
Fissures of the anus, as a complication, more frequently take place when the piles are external, and have existed for some time, and the tissues, by chronic inflammation, are indurated and rendered less yielding to distension. They commence as slight cracks or tears, resulting from the passage of bulky and hardened fæces, and increase by the ulcerative process, from the constant irritation they are afterwards subject to by the action of the bowels and the lodgment of fæcal and acrid matters. The pain accruing from this complication is very distressing ; it is induced each time the bowels act, and will continue for several hours afterwards, attended with spasmodic contraction of the sphincter ani.
The sufferings and inconvenience to a patient affected with internal piles are often greatly increased by their protruding external to the anus. When the tumours are situated immediately within the rectum, they are subject to prolapsus in an earlier stage of the disease, owing to the eversion of the lower part of the mucous membrane, which occurs at the time of emptying the bowels, and to the fæces thrusting the