926. In both cases it is supposed that the flow of blood is from tumours previously formed, which are named Hæmorrhoids, or Piles; and it frequently happens, that the tumours exist without any discharge of blood; in which case, however, they are supposed to be a part of the same disease, and are named Hæmorrhoides Cæcæ, or Blind Piles.

927. These tumours, as they appear without the anus, are sometimes separate, round and prominent, on the verge of the anus; but frequently the tumour is only one tumid ring, forming, as it were, the anus pushed without the body.

928. These tumours, and the discharge of blood from them, sometimes come on as an affection purely topical, and without any previous disorder in other parts of the body; but it frequently happens, even before the tumours are formed, and more especially before the blood flows, that various disorders are felt in different parts of the body, as headach, vertigo, stupor, difficulty of breathing, sickness, colic-pains, pain of the back and loins; and often, together with more or fewer of these symptoms, there occurs a considerable degree of pyrexia.

The coming on of the disease with these symp toms, is usually attended with a sense of fulness, heat, itching, and pain in and about the anus.

Sometimes the disease is preceded by a discharge of serous matter from the anus: and sometimes this serous discharge, accompanied with some swelling, seems to be in place of the discharge of blood, and to relieve those disorders of the system which we have mentioned. This serous discharge, therefore, has been named the Hæmorrhois Alba.

929. In the hæmorrhois, the quantity of blood discharged is different upon different occasions. Sometimes the blood flows only upon the person's going to stool, and commonly, in larger or less quantity, follows the discharge of the fæces. In other cases, the blood flows without any discharge of fæces; and then, generally, it is after having been preceded by the disorders above mentioned, when it is also commonly in larger quantity. This discharge of blood is often very considerable; and, by the repetition, it is often so great, as we could hardly suppose the body to bear but with the hazard of life. Indeed, though rarely, it has been so great as to prove suddenly fatal. These considerable discharges occur especially to persons who have been frequently liable to the disease. They often induce great debility: and frequently a leucophlegmatia, or dropsy, which proves fatal.

The tumours and discharges of blood in this disease, often recur at exactly stated périods.

930. It often happens, in the decline of life, that the hæmorrhoidal flux, formerly frequent, ceases to flow; and, upon that event, it generally happens, that the persons are affected with apoplexy or palsy.

931. Sometimes hæmorrhoidal tumours are af fected with considerable inflammation; which, ending in suppuration, gives occasion to the formation of fistulous ulcers in those parts.

932. The hæmorrhoidal tumours have been ofen considered as varicous tumours or dilatations of veins; and it is true, that in some cases varicous dilatations have appeared upon dissection. These, however, do not always appear; and I presume it is not the ordinary case, but that the tumours are formed by an effusion of blood into the cellular texture of the intestine near to its extremity. These tumours, especially when recently formed, frequently contain fluid blood; but, after they have remained for some time, they are commonly of a firmer substance.

933. From a consideration of their causes, to be hereafter mentioned, it is sufficiently probable, that hæmorrhoidal tumours are produced by some interruption of the free return of blood from the veins of the lower extremity of the rectum; and it is possible, that a considerable accumulation of

blood in these veins may occasion a rupture of their extremities, and thus produce the hæmorrhagy or tumours I have mentioned. But considering that the hæmorrhagy occurring here is of ten preceded by pain, inflammation, and a febrile state, as well as by many other symptoms which shew a connection between the topical affection and the state of the whole system, it seems probable, that the interruption of the venous blood, which we have supposed to take place, operates in the manner explained in 769; and therefore, that the discharge of blood here is commonly from arteries.

934. Some physicians have been of opinion, that a difference in the nature of the hæmorrhois, and of its effects upon the system, might arise from the difference of the hæmorrhodial vessels from which the blood issued. But it appears to me, that hardly in any case we can distinguish the vessels from which the blood flows; and that the frequent inosculations of both the arteries and veins which belong to the lower extremity of the rectum, will render the effects of the hæmorrhagy nearly the same, from whichsoever of these vessels the blood proceed.

935. In 769, I have endeavoured to explain the manner in which a certain state of the sanguiferous system might give occasion to an hæmorrhodial

flux; and I have no doubt, that this flux may be produced in that manner. I cannot, however, by any means admit, that the disease is so often produced in that manner, or that, on its first appearance, it is so frequently a systematic affection, as the Stahlians have imagined, and would have us to believe. It occurs in many persons before the period of life at which the venous plethora takes place it happens to females in whom a venous plethora, determined to the hæmorrhodial vessels, cannot be supposed; and it happens to both sexes, and to persons of all ages, from causes which do not affect the system, and are manifestly suited to produce a topical affection only.

936. These causes of a topical affection are, in the first place, the frequent voiding of hard and bulky fæces, which, not only by their long stagnation in the rectum, but especially when voided, must press upon the veins of the anus, and interrupt the course of the blood in them. It is for this reason that the disease happens so often to persons of a slow and bound belly.

937. From the causes just now mentioned, the disease happens especially to persons liable to some degree of a prolapsus ani. Almost every person, in voiding fæces, has the internal coat of the rectum more or less protruded without the body; and this will be to a greater or less degree, according