cumstances, the assistance of a surgeon will be required to effect the replacement of the extruded parts. If the patient delays seeking the necessary aid, mortification takes place, endangering his life should the constitution be impaired by any cause, or the vital powers be naturally feeble: if the contrary condition exists, and the general health be good, the tumors will slough off, and a cure will thus be effected, but at the expense of much suffering.

The converse condition of the anus to the preceding will cause serious distress to some, as a consequence of the sphincter having lost its tone, and becoming greatly dilated by the frequent protrusion of the piles, by their size, and by the long persistence of the disease, the patient will not only be subject to the annoyance of prolapsus of the bowel with its attendant miseries, but will be unable to retain his fæces.

In addition to the complications and consecutive effects which have already been considered, others will arise: thus, in the female, by the contiguity of parts, the vagina and uterus are liable to be affected; whence arises leucorrhoeal discharge more or less profuse in quantity, accompanied by pain and distressing bearingdown sensations. In the male, from the same cause, and the free anastomosis which exists between the prostatic plexus of vessels and those of the rectum, the prostate gland may be affected, inflammatory action excited, inducing enlargement and other evils; the neck of the bladder will not unfrequently be sympathetically involved, and strangury or retention of urine result. By the long continuance of chronic inflammation from hemorrhoidal disease, stricture of the rectum sometimes occurs.

Numerous causes tend to excite hemorrhoidal disease. In some cases we shall be able to trace it to hereditary predisposition: age has its influence; sex, climate, and period of the year, also have effect. Plethora, particularly when combined with sedentary occupations and indulgence in the pleasures of the table, strongly predisposes to the disease; mechanical and pathological obstruction to the venous circulation of the intestine is another cause; irritation within the bowels, as from ascarides; diarrhoea, dysentery, irritating enemata, the injudicious use of mercury, certain stimulating purgatives, highly-seasoned dishes, and certain alimentary substances; diseases existing in contiguous parts, as of the prostate gland, stricture of the urethra, stone in the bladder, &c., will give

rise to hemorrhoids; and, lastly, may be mentioned, excessive venery and masturbation.

It will be desirable to trace how far, and in what manner, the several causes that have been mentioned operate in inducing the disease.

Hereditary predisposition sometimes promotes the establishment of the disease, not so much by any local tendency to the formation of piles, as by a similarity of constitution and general organization. Thus we shall find both parents and children to be of a bilious temperament, of lax muscular fibre, the venous system of an augmented state of development, and the nervous sensibility exalted, whereby the depressing passions have a greater influence. This hereditary aptitude to hemorrhoidal affections has been traced by many authors: Bushe1 has observed it in several families in connection with similarity of organization, and also where that did not exist. A French author2 mentions an instance of a family of nine people who were thus afflicted.

From several circumstances we do not often meet with hemorrhoids till after the age of puberty; diseases from sanguineous engorgement more frequently in early life attacking the head and chest than the abdominal organs: however, at the Blenheim Dispensary, I had a child of two years of age under my care suffering from external piles. One author mentions two cases occurring in his practice, in which one patient was between six and seven years of age, and the other five; the latter also had stone in the bladder. Other practitioners have met with the disease at an early period, but this is very far from being commonly the case. In the middle period of life we find all diseases of the abdominal organs more frequent, owing to the peculiar susceptibility then existing to vascular repletion and engorgement of this region; the circulation is less rapid in the adult, and that portion of the vascular system returning the blood to the heart is more fully developed in mature life. It is after the age of puberty that the various affairs and occupations of life engage the attention; then the habits become sedentary: depressing passions and the influence of temperament appertain also to the middle period of existence.

1 Op. cit. p. 170.

2 M. J. B. de Larroque sur "Les Hæmorrhoïdes," Paris, 1819.

Females who have enjoyed immunity from hemorrhoidal affections during that portion of their lives when the menstrual functions were regularly performed, not unfrequently become the subjects of them at the climacteric period, especially those who are plethoric; and, in such cases, the hemorrhoidal flux may be regarded as salutary, by diverting those congestive affections from the several important organs, that so often succeed the cessation of the catamenia.

Great diversity of opinion prevails as to the relative frequency of hemorrhoidal affections in males and females. Much will depend on the circumstances in which both are placed. Montègre thinks them more common in females in an occasional or accidental form; and to occur in males in a more regular and constitutional form. The experience of Mr. Syme and Dr. Bushe tends to confirm their greater frequency among men: the latter writer supposes the menstrual function should sufficiently relieve the system of sanguineous repletion; certainly, in the majority of cases of hemorrhoids occurring in females that have come under my observation, the catamenia have either been suppressed, or the functions more or less deranged, but in some cases this will be rather an effect than a cause. Females who are plethoric are very liable to be the subjects of hemorrhoids at the turn of life, when the menstrual flow ceases; and, in some instances, these discharges alternate with each other for some time before the uterine functions entirely subside.

Warm, moist, and miasmatous climates dispose to hemorrhoidal affections, by inducing general relaxation, and of the venous system in particular; they also favor congestion of the abdominal viscera, and develop the bilious, sanguineo-bilious, and melancholic temperaments. Those who have resided for some time in the East or West Indies are very prone to suffer from hemorrhoids. In the Southern States of America, in South America, in Egypt, and Turkey, these affections are very common. In the two latter countries, the morals and manners of life of the people exert a great influence in producing these diseases. In dry climates, whether cold or temperate, these affections are less frequent, as is also the case with regard to many other diseases. In our climate, the variableness of the temperature often produces congestion of the internal organs, giving rise to various inflamma

tory and morbid actions: these are more liable to occur if the functions of the skin have been excited from any cause, and then checked by its being suddenly cooled down by a rapid fall in the atmospheric temperature.

The periods of the year in which the vicissitudes of temperature are greatest predispose more to the development of these affections. than when the weather is either warm or cold, but equable. Some writers think these diseases occur more frequently in spring, from the phenomena of life being more active at that season, the blood being more readily formed, and in greater quantity; also that the increased temperature expands the volume of the circulating fluid. It is also asserted that northerly and northeasterly winds bring on the hemorrhoidal discharge; but I presume they have no specific influence further than by checking the cutaneous exhalation, and thus determining the blood internally.

Plethoric individuals are more liable than others to be affected with hemorrhoids. In them the state of repletion of the vascular system is often induced by partaking of a larger amount of aliment than nature requires, combined with a deficiency of exercise, which also excites several of the other causes co-operating in producing disease of the rectum.

Any impediment offered to the return of the blood from the lower bowel will cause hemorrhoids. It will arise from two causes, the one being mechanical in its immediate effect, the other pathological, and depending on disease and alteration of structure in some of the internal organs. Those causes which act mechanically are the pregnant uterus, ovarian and other tumors developed in the pelvis or abdomen, which, by pressure on the large venous trunks, impede the ascent of the blood; tight lacing and cinctures also have the same effect. The pathological causes are congestion and structural diseases of the liver, pancreas, and spleen; diseases of the lungs, heart, and large blood vessels, interfering with the free circulation of the blood.

Hemorrhoids are frequently a concomitant of pregnancy, and in this state are of the accidental or occasional form, being induced by the gravid uterus pressing on the venous trunks, and by the general plethora which exists during this period.

Constipation is one of the most frequent and common causes of hemorrhoids which we meet with: it tends to induce the disease

There can be no doubt that the quantity of blood lost in many of the cases recorded must have been greatly exaggerated; and patients are always prone to imagine it larger than it really is, from the alarm created by the sight of blood, by the show it makes on their linen and clothes, as well as from the liability of its admixture with other fluids imposing on their inexperience.

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Mr. Du Pasquier informed me a patient of his lost one night, while in bed, eight or nine pounds of blood. Mr. Calvert1 adduces the two following cases, which came under his own observation. "A middle-aged woman, a patient of the Manchester Infirmary, in whom the hemorrhoidal discharge had been long suppressed, was seized with colic pains, with a sensation of weight about the loins and sacrum; an enema was exhibited, which brought away some liquid fæces, and soon after a discharge of bloody fluids, amounting to more than three chamber-pots full in less than two hours. She was dreadfully reduced in consequence, but the pains subsided, and after some time she regained her former strength." "A young woman, an out-district patient of the same hospital, was affected with pain in the head and loins, symptoms of general fever, with tenesmus and sympathetic irritation of the bladder. In this state she continued for some days, when the hemorrhoidal discharge to which she had been subject returned, and more than a pint of blood was voided for near a fortnight. The pains in the head and loins, with the other symptoms, disappeared with the recurrence of the discharge, and were succeeded by a small, feeble pulse, œdema of the face and extremities, oppression at the region of the stomach, and great prostration of strength. The discharge was eventually stopped by the vigorous use of spirituous and astringent injections, with such other means as are generally employed when affections of this nature are continued from debility."

The following are some of the cases quoted by Montègre,2 to which, however, credence cannot be given without hesitation. "Montanus, according to the report of Schwevcher, saw a patient who had passed two pounds of blood for forty-five successive days,

3

1" A Practical Treatise on Diseases of the Rectum and Anus," by G. Calvert, pp. 16, 17, London, 1824.

2 Op. cit. pp. 27-30.

3" Apend. Consilior Montani," p. 59, Basil, 1588.