effused into their interior becomes absorbed, and if they have not been distended to any great extent the skin contracts, and the parts resume their natural condition; but if the tumours have attained the size of a cherry, or larger, the elasticity of the integument will have been destroyed by over distension, and upon absorption of their fluid contents pendulous flaps remain, prone to take on increased action, and form excrescences which may attain a considerable size

When several attacks of external piles have occurred, the cellular tissue of these tumours, by inflammatory action, become infiltrated with lymph, and condensed, and they do not then collapse on the subsidence of the inflammatory stage, but remain permanent, and give rise to other lesions, which occasion as much or more suffering than the primary disease.

Mr. Howship* describes another form of external pile, which he terms the serous hæmorrhoid; he thinks the difference in structure depends on the strength of the constitution; the sanguineous hæmorrhoidal tumour occurring in the strong, and the serous in those of low vital powers. He very justly dwells on the necessity of drawing a distinction between the two kinds, as our treatment will thereby be influenced.

This serous

*Practical Observations on the Symptoms, Discriminations, and Treatment of some of the most important Diseases of the Lower Intestine and Anus,' by John Howship, 1824, p. 208.

hæmorrhoidal tumour is pale, elastic, shining, semi-transparent, and more frequently forming a ring round the verge of the anus than appearing as a distinct tumour. I have many times observed these swellings, but cannot agree in considering them as a separate variety of hæmorrhoidal tumour, but as an oedematous distension of the loose cellular tissue and thin skin of the parts, depending on irritation in the immediate vicinity. This state is more frequently seen as an effect of inflamed internal hæmorrhoids than from any other cause, though I have witnessed it occurring from fissure of the anus, acrid intestinal secretions, and similar conditions.

Internal hæmorrhoids.-The tumours constituting internal piles, consist of a morbid alteration in some portions of the mucous membrane of the rectum, and submucous areolar tissue, with an augmented and abnormal development of the capillary vessels. Like the external variety, they were formerly considered to be a dilatation of the veins. It appears somewhat surprising that this opinion should have been retained by many of the later writers, for when speaking of the character of the hæmorrhage, they describe it as florid and bright, and more nearly resembling arterial than venous blood, which it would not if it were poured out from veins, particularly when they are in a dilated and debilitated condition; in them the circulation must necessarily be slow, and, consequently, the blood would

acquire a deeper colour. But examinations on the living subject, and dissections on the dead, clearly demonstrate a different condition. A varicose state of the hæmorrhoidal veins is not unfrequently met with; however, they form tumours very different in character, and in the symptoms they occasion, from those now under consideration.

By dissection, internal hæmorrhoidal tumours will be found to consist of both arteries and veins, the latter capacious, not in a diseased condition, but merely of abnormal development; the areolar tissue of the mucous membrane is hypertrophied, and if the tumours have existed long, and been subject to repeated inflammatory attacks, it will also be condensed. The surface of these tumours is villous, presenting to the unassisted eye a granular appearance; they generally bleed freely if rudely touched, or accidentally scratched by the nail during an examination, the blood being of a bright red colour. Dr. Bushe states, he has been able to rub off an exceedingly vascular and fragile adventitious membrane from their surface, and is of opinion, they may thus acquire an increase in magnitude. To the touch they have a spongy elastic feel, and by some authors are considered to resemble erectile tissue in structure; had they compared them to those abnormal developments of the vascular system termed aneurism by anastomosis, the analogy would have been more correct.

Internal hæmorrhoids vary much in size and number,

but the accessory phenomena attending them, such as pain, hæmorrhage, &c., are not increased in proportion to either, and cases are met with in which a greater loss of blood occurs, or a greater amount of pain and suffering is induced, from one or two small piles than when there are several large ones.

When one of these tumours is situated near the anus, though it may not have attained any great size, it

is

very liable to be prolapsed during defecation, particularly if the bowels are costive, giving rise to pain, spasm of the sphincter, and other distressing symptoms. Those that are situated higher in the bowel are not prolapsed so early in the disease; but, by repeated irritation and the dragging down they experience during the time the fæces are evacuated, they become elongated, and at length protrude externally; at first they return within the anus, by the action of the muscles of the part, but after a time the patient finds he is obliged to replace them with his fingers; in some cases this is done with facility, but others present where greater difficulty is experienced, owing either to the size of the tumours, or to their being constricted by the sphincter muscle under these circumstances the suffering is very great, and the individual is induced to postpone the calls of nature, or defer them till the night, finding it easier to return the tumours whilst he is in the horizontal position, in which he also experiences more speedy relief from pain.

In many cases, when the tumours are large and numerous, and have been subject to prolapse for a length of time, the sphincter and tissues of the anus lose their tone, are much relaxed, and the patient is subject to constant annoyance by their protrusion whenever he attempts to walk, and even by riding in a carriage; nor is the prolapsus in this stage confined to the tumour alone, for the bowel, having lost its support, the pouch of the rectum is easily dragged down by the morbid growths, and by the expulsive efforts at stool.

As a consequence or complication, some of the following phenomena always attend hæmorrhoidal tumours; inflammation, pain, hæmorrhage, mucous discharge, ulceration, abscess, fistulæ, fissure, prolapsus, and irritation propagated to other organs, as the urethra, bladder, prostate gland, and testicles in the male, and to the vagina and womb in the female.

Inflammation, of greater or less severity, always attends the formation of piles; it may not be severe at first, nor occasion much inconvenience, being marked only by itching of the anus, and a sense of fulness and slight aching; in other cases the inflammatory symptoms will be much more prominent. When it has recurred several times, and the tumours have become permanent, the pain will be very great. Inflammation, if not checked by treatment, or terminated by resolution or by the supervention of the hæmorrhoidal flux, may induce