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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 anaemic condition of the patient thus induced, oedematous swelling of the feet and legs occur.
Mucous discharge from the anus is a very frequent and annoying accompaniment of haemorrhoidal 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 cellular tissue of 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 superadded 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 faeces, 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 faecal 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 fieces thrusting the tumours before them; when situated higher up in the intestine, they do not descend at so early a period, but, by the pressure and elongation they are subject to from the passage of the fieces, they at length protrude externally. At first the piles are retracted within the anus by muscular action alone after the bowels have been 'relieved; but in process of time this no longer occurs, and it becomes necessary to return them. Another source of distress from the prolapsus of piles, is their liability to strangulation, either by the spasmodic contraction of the sphincter, or by sanguineous engorgement: under these circumstances the assistance of a surgeon will be required to effect the replacement of the extruded parts. If the patient delays seeking the necessary aid, mortification takes place, endangering his life should the constitution be impaired by any cause, or the vital powers be naturally feeble: if the contrary condition exists, and the general health be good, the tumours will slough off, and a cure will thus be effected, but at the expense of much suffering.
The converse condition of the anus to the preceding will cause serious distress to some, as a consequence of the sphincter having lost its tone, and becoming greatly dilated by the frequent protrusion of the piles, by their size, and by the long persistence of the disease, the patient will not only be subject to the annoyance of prolapsus of the bowel with its attendant miseries, but will be unable to retain his faeces.
In addition to the complications and consecutive effects which have already been considered, others will arise: thus, in the female, by the contiguity of parts, the vagina and uterus are liable to be affected; whence arises leucorrhoeal discharge more or less profuse in quantity, accompanied by pain and distressing bearing-down sensations. In the male, from the same cause, and the free anastomosis which exists between the prostatic plexus of vessels and those of the rectum, the prostate gland may be affected, inflammatory action excited, inducing enlargement and other evils; the neck of the bladder will not unfrequently be sympathetically involved, and strangury or retention of urine result. By the long continuance of chronic inflammation from haemorrhoidal disease, stricture of the rectum sometimes occurs.
Numerous causes tend to excite haemorrhoidal disease. In some cases we shall be able to trace it to hereditary predisposition: age has its influence; sex, climate, and period of the year, also have effect. Plethora, particularly when combined with sedentary occupations and indulgence in the pleasures of the table, strongly predisposes to the disease; mechanical and pathological obstruction to the venous circulation