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duce the haemorrhoidal flux when once it has taken place, but it is not to be inferred from this that they will cause the disease, as morbid action having once occurred in a part is much more easily re-established even by slighter causes; therefore, before attributing the malady to medicines, it is essential to ascertain if there may not be other causes to which it may owe its origin.

As well as to living above par, conjoined with a deficiency of exercise, we shall be able to trace the disease in some people to eating various alimentary substances, particularly highly-seasoned dishes, spices, onions, shallots, &c.; to partaking of very hot or cold beverages, or too great a quantity of stimulating drinks: certain wines, such as claret, champagne, also cider and beer, will, in some individuals, readily induce the affection.

The local application of cold or heat, as sitting on stone seats, on the cold and damp ground, on damp cushions, the habit of standing with the back to the fire, riding rough horses, prolonged walks in hot weather, travelling a number of consecutive hours in a carriage, sitting on pierced seats whereby the blood gravitates to the anus, consequent upon its being unsupported, and on the obstruction to the circulation from the pressure on the surrounding parts; stimulating pediluvia, irritating and large enemata, are other causes of haemorrhoidal affections.

The symptoms attending haemorrhoidal diseases vary much, and are greatly influenced by the state of the general health of the patient, the exciting cause whether accidental or constitutional, and the complications with which they are associated, and also by the piles being internal or external.

In the first attack, the patient will probably experience but slight inconvenience. If the disease is only of the congestive form there will be itching and a sense of weight and fulness in the rectum, with uneasiness in the perineum: in a few days bleeding may occur, but does not always take place in the early attacks, and when it does it is usually critical, all the symptoms and discomfort disappearing for the time. If the disease does not thus subside, but is permitted to increase, or when several attacks have been experienced, the symptoms will be augmented in number and severity; and, in addition to the weight and fulness at first felt, there will be heat and throbbing, the pain at stool will be greater, and will continue for some time afterwards: pain will also be felt up the sacrum, in the loins, and down the thighs; after a short time a flow of bright blood will be observed either preceding or after defecation; usually increasing in quantity with the duration of the disease, and often becoming the most prominent symptom, and causing great derangement of the general health. As the disease progresses, a feeling of the presence of a foreign body in the rectum will be experienced, and at stool one or more tumours will be protruded; at first they are retracted spontaneously after the action of the bowels, but, in process of time, from increase in size and loss of tone in the parts, it becomes necessary for the patient to replace them with his hand. Should the piles become constricted by the sphincter, many of the symptoms of intussusception or strangulated hernia may be induced. In weak and debilitated persons the sphincter loses its tone, the anal orifice becomes dilated, and the haamorrhoidal tumours will then descend upon the slightest exertion, or even when he is in the erect position, causing great annoyance and discomfort: in this condition they will be liable to ulceration from the friction to which they are exposed by contact of the clothes. A mucous discharge soiling the linen is a frequent symptom; it is sometimes so profuse as to run down the patient's legs whilst standing; it may also be very acrid, and produce excoriation of the external parts, adding greatly to his other sufferings.

By sympathy and contiguity, the irritability and sensibility of the bladder and urethra will be increased, micturition will be more frequent, and in the aggravated form we shall observe the opposite effect, strangury, or even retention of urine.

All patients who are the subjects of haemorrhoids suffer more or less from constipation, with its concomitant symptoms, flatulence, pain, and constriction at the epigastrium, vomiting, &c. Where the disease is fully established, particularly if much blood has been lost, there will be pallor, and a peculiar dingy waxy appearance of the countenance; the respiration will be hurried and irregular, the heart's action readily increased by the slightest bodily exertion or mental emotion: this is often so distressing as to lead the patient to think he has disease of that organ, for which he may seek advice, and, by dwelling too exclusively on this one effect, may mislead his medical attendant from the real disease.

Giddiness, drowsiness, weight and pain in the head, are very common symptoms in these affections, and occasionally, spasm and rigidity of the extremities will be complained of. The attacks are not unfrequently ushered in by rigours; the tongue will be furred, large, and deeply notched by the impressions of the teeth; the skin will be harsh and dry; the functions of the kidneys deranged; the pulse, increased in velocity, will be hard, and contracted, or rendered weak, irritable, and quick, from debility, suffering, and loss of blood.

Haemorrhoidal affections are liable to be overlooked from two causes : the one being a delicacy on the part of the patients, leading them to conceal the origin of their sufferings; the other the severity of some of the symptoms, or derangement of other organs consequent upon them, diverting the attention away from the real seat of disease: however, a careful investigation into the origin and history of the case will not fail to elucidate its true nature.

The diagnosis of haemorrhoids will not be attended with much difficulty, there being few diseases with which it is possible to confound them, and the error can occur by taking only into consideration some one or other of the prominent features of the affection.

Haemorrhoidal tumours may be mistaken for polypi of the rectum; but the converse is more usually the case, particularly by patients themselves. Polypi are more gradual in their growth, they are not preceded or accompanied by the constitutional or local inflammatory symptoms that attend piles: in the benign variety of polypi, haemorrhage does not occur, except to a very slight extent, and that only on the passage of a bulky and costive stool; their surface is smooth and somewhat glistening, and not villous or granular, like haemorrhoidal excrescences.

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