Most of the symptoms produced by hemorrhoids are generally of a local character. They greatly vary in the different varieties of piles. In the early stage of external pile there occur off and on, especially after indiscretions in eating and drinking (principally effervescent wines or strong alcoholic beverages), attacks caused by an increased congestion of the hemorrhoids. These attacks may be described as follows: A sensation of fulness or clogging and slight pulsation in the anus are felt by the patient. Moderate constipation exists, compelling the patient to strain more than ordinarily. Itching of the anal region and the perineum frequently annoy the patient, especially soon after retiring, and may keep him awake for quite some time. On awaking in the morning the patient finds the anus tender and swollen, and after a movement a few stains of blood are discovered on the paper. Such an attack will, as a rule, pass off very quickly if the patient lives rationally and avoids the predisposing causes; if not, the attack will quickly recur with greater intensity and gradually assume a severer type.

External piles may become swollen and oedematous, and are then extremely painful to touch. Sometimes there may be ulceration, or suppuration may take place and small painful fistulae may form. The venous tumors now and then irritate the sphincter and levator ani muscles and produce spasm of the latter. The piles are then occasionally drawn up into the anus and pinched by the latter. This causes a great deal of pain and keeps the patient awake during the night. A feeling of throbbing and a sensation as of a foreign body in the anus exist. A frequent desire for defecation is thereby produced and the patient, as a rule, is inclined to attempt to expel the foreign body by forcible straining, which of course only aggravates the pain. Under these circumstances the patient can hardly sit down nor can he walk about comfortably, and on coughing and sneezing experiences great suffering on account of the constriction of the involved diseased parts. During a movement of the bowel and for some hours afterward the pains are greatly increased. The patient is unable to attend to his daily occupation.

General symptoms like fever, anorexia, dizziness, severe constipation, may accompany the local manifestations.

Of the internal hemorrhoids, the capillary variety, being small and only slightly elevated above the mucous surface, gives rise to scarcely any trouble. As a rule, there is no pain. Occasionally, however, ulceration takes place which may cause considerable suffering.

Arterial and venous hemorrhoids give rise to many more symptoms. In case the sphincter muscles are relaxed, the hemorrhoids often protrude on the slightest exertion. This also often occurs at stool. At first they spontaneously return within the sphincter after the bowels have moved or whenever the exertion has ceased. Later in the course of the disease, however, the patient is compelled to return them with the finger. In still more advanced cases they never remain long within the sphincter and protrude very often whenever the least exertion is made. In this manner the hemorrhoids cause much discomfort. They also discharge a gummy acrid mucus which keeps the parts constantly moist and leads to excoriations around the anus, and also favors the development of cutaneous excrescences. Patients with fully developed internal hemorrhoids experience a great deal of suffering during defecation. They also feel quite uncomfortable for some time afterward, occasionally to such a degree that they have to lie down.

When walking they are always conscious of the fact that they have an anus.

In other instances in which the sphincter ani is strong and tight, the piles in coming down become nipped and their return is rendered difficult and painful.

The symptom from which the hemorrhoids originally derived their name, namely, hemorrhage, is common to all varieties of piles, although it is by no means constant. In many instances it is absent, or it does not play any essential part, especially in external piles. In some patients a more or less considerable hemorrhage takes place at certain intervals, appearing periodically, occasionally with great regularity. A few premonitory signs, consisting in painful sensations in the back and around the anus, constipation, and other indefinite nervous symptoms usually precede for a few days the beginning hemorrhage. The blood as a rule then appears at first in small quantities gradually increases in amount, and the hemorrhage stops on the fifth or sixth day after its commencement. Physicians in olden times - and some of the laity even nowadays - looked upon the hemorrhage as an important event, freeing the system of vicious material. This is the reason why formerly the hemorrhoidal bleeding was termed the golden flow. Nowadays we do not attach any particular importance to these hemorrhages.

Their regularity or the periodicity of their appearance is simply attributable to the fact that the time necesary for the filling up of the nodules until they rupture is usually of the same length.

In some instances there are transient hemorrhages, lasting a shorter or longer period. Ordinarily the patients feel relieved after the bleeding; occasionally they remain quite well for a long time, sometimes for a year or two, until there is suddenly a new hemorrhage. In the latter case the hemorrhage is commonly caused by some unusual occurrence; thus, a very copious meal, a long ride on horseback, or an excess in venery may bring it on.

In another class of patients there may be continuous small hemorrhages. These occur more frequently in cases of capillary hemorrhoids. The quantity of blood lost at each action of the bowel is small, but being steady it becomes a serious strain upon the patient's constitution and may give rise to severe forms of anaemia and even pernicious anaemia.

The blood discharged from piles is either of a bright red or a dark brown color, depending upon its origin from arteries or veins. It is characteristic of hemorrhoidal hemorrhages that the blood usually appears in a liquid, non-coagulated state, covering the fecal matter, but not mixed with it. If the hemorrhage is very copious, unconsciousness may result combined with symptoms of profound collapse. This, however, happens very rarely. Accompanying the local manifestations, especially if the latter are of a high degree, there may be varied general symptoms. Thus dyspnoea, palpitations of the heart, angina 12 pectoris, irregular heart action, hiccough, headaches, giddiness, dizziness, buzzing in the ears, and cloudy vision may be present. Often a despondent feeling and a condition resembling hypochondria is met with. Anorexia, nausea, belching, and constipation also often occur. The general symptoms are especially marked if incarceration of internal piles within the sphincter has taken place. In case the swelling of the hemorrhoids is so extensive that a reposition cannot be quickly effected, there may be present besides the local pains high fever and signs of collapse.

If the incarceration lasts a long period, the hemorrhoids may become gangrenous and either fall off, accompanied by profuse hemorrhage, or, although rarely, give rise to septic and peritonitic conditions. In most instances after a falling off of the hemorrhoid a spontaneous cure takes place.

Some cases of hemorrhoids are complicated with catarrh of the rectum (proctitis). In such instances the stools reveal the presence of a considerable quantity of mucus, occasionally even of pus.. Sometimes the mucous or mucopurulent fluid admixed with the faeces may be tinged with blood. These cases are often accompanied by a paretic condition of the sphincters, which allow the secretion to dribble from the anus. This gives rise to excoriations and inflammation of the anus and the neighboring tissues. In the course of the proctitis prolonged tenesmus may appear at times. If the inflammation extends into the rectal cellular tissue, it may lead to the formation of abscesses which may empty into or outside the bowels. This is the most frequent way in which fistulae are produced.

Disturbances of the adjacent organs are also occasionally met with in cases of piles. Thus ischuria, stranguria, hemorrhages from the bladder, hemorrhages from the vagina, and catarrhal conditions of the latter are encountered.