depends on the strength of the constitution; the sanguineous hemorrhoidal tumor occurring in the strong, and the serous in those of low vital powers. He very justly dwells on the necessity of drawing a distinctiom between the two kinds, as our treatment will thereby be influenced. This serous hemorrhoidal tumor is pale, elastic, shining, semitransparent, and more frequently forming a ring round the verge of the anus than appearing as a distinct tumor. I have many times observed these swellings, but cannot agree in considering them as a separate variety of hemorrhoidal tumor, 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 hemorrhoids than from any other cause, though I have witnessed it occurring from fissure of the anus, acrid intestinal secretions, and similar conditions.

Internal hemorrhoids.-The tumors constituting internal piles, consist of a morbid alteration in some portion 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 hemorrhage, 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 color. But examinations on the living subject, and dissections on the dead, clearly demonstrate a different condition. A varicose state of the hemorrhoidal veins is not unfrequently met with; however, they form tumors very different in character, and in the symptoms they occasion, from those now under consideration.

By dissection, internal hemorrhoidal tumors 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 tumors have existed long, and been subject to repeated inflammatory attacks, it will also be condensed. The surface of these

tumors is frequently 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 color. 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 hemorrhoids vary much in size and number, but the accessory phenomena attending them, such as pain, hemorrhage, &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 tumors 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 tumors, 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 tumors whilst he is in the horizontal position, in which he also experiences more speedy relief from pain. In many cases, when the tumors 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 tumor 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.

The annexed wood-engraving is a typical illustration of the ordinary appearance of internal hemorrhoids that have existed some time: the sphincter has lost its tone, and the tumors protruded, even by the patient assuming the up

right position. The case occurred in one of the suite of the late Duke of

he had suffered intense pain and lost much blood: he also experienced great irritability of the urinary organs. In December, 1856, with the assistance of Dr. Sanderson, I removed the tumors by ligature chloroform was administered by Mr. Clover. In a fortnight he was quite well, and now enjoys perfect health.

As a consequence or complication, some of the following phenomena always attend hemorrhoidal tumors: inflammation, pain, hemorrhage, mucous discharge, ulceration, abscess, fistulæ, fissure, prolapsus, and irritation and spasm

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 tumors 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 hemorrhoidal flux, may induce various morbid actions in the tumors, as ulceration, suppuration, &c. ; it is also liable to extend to the contiguous organs in either sex.

The pain attending hemorrhoids will vary much in character and intensity in different cases, and will bear no proportion to the size or number of tumors which exist, being frequently most severe when only one small hemorrhoid is present; the complications attending this affection will also have great influence with regard to it. In the quiescent state of the tumors, 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 hemorrhoidal affection. He says,

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"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 labored also under internal piles, which protruded at the 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."

Hemorrhage 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 hemorrhagic discharge. The color of the blood evacuated is bright vermilion, and is exuded by the capillary vessels of the mucous membrane of the tumors 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 hemorrhage ceases.

The severity of the concomitant symptoms denoting a loaded state of the hemorrhoidal vessels is not always an index of the amount of hemorrhage 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 hemorrhoidal 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 hemorrhage 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 hemorrhoidal discharge interfering with or becoming vicarious with the catamenial functions, and in some instances these discharges will alter

nate.