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

in several ways; thus, when the fæces are retained, they become indurated and impacted, and produce irritation of the mucous membrane, and consequent afflux of blood to the rectum; by accumulation they distend the intestine, and, pressing on the i veins, interfere more or less with the return of the blood. In this habit of body the hemorrhoidal vessels become greatly engorged during the act of defecation, from the violent efforts of the expulsatory muscles, and the congestion, arising during the tem- ! porary suspended respiration that always attends violent muscular

action.

Those persons whose habits of life are sedentary are very generally the subjects of piles, more especially if they indulge freely at table. By inactivity of body, the functions of the several emunctory organs are diminished, and, not the least important, that of the skin, which, when properly performed, frees the system of the products of the effete tissues, which, if retained, have a most pernicious effect on the animal economy generally. From deficiency of exercise the function of the liver is lessened, and congestion is very liable to occur. Constipation, and its effects, as a result of this mode of life, is nearly always present. The sitting position maintained by persons of the habits under consideration determines the blood to the hemorrhoidal vessels. From these circumstances, it is very common to meet with hemorrhoidal diseases among clergymen, barristers, lawyers, those confined to the counting-house, and among the working-classes, the nature of whose occupations compels them to sit many hours, as dressmakers, tailors, shoemakers, and others. It is very common for individuals thus circumstanced to have the hemorrhoidal discharge occurring in a regular manner, and, when moderate in quantity, having rather a beneficial effect than otherwise, and possibly saving them from some more serious malady.

Sometimes the hemorrhoidal flux will appear as a translation of hemorrhagic discharge from some other organ; thus arresting and keeping in abeyance morbid action that has given rise to hemoptysis, hematemesis, epistaxis, &c. Bushe mentions having observed several instances in which this occurred, and records two cases: the one of a gentleman from Ireland, who had hæmoptysis, which ceased on his being attacked with hemorrhoids, and he enjoyed good health resorting to Paris, and being annoyed by the piles, he had them removed by Baron Dupuytren; after that

he returned to America, and labored under a determination of blood to the head, of this he was relieved by leeches to the anus, and by the administration of aloes and blue pill. The other case is that of a gentleman subject to epistaxis, and who suffered from a series of cerebral symptoms, consequent on its suppression. Dr. Bushe, being consulted, prescribed stimulating pediluvia and brisk purgatives. On the patient feeling a desire to defecate, he discharged about a pint of blood per anum, to the immediate relief of the head symptoms; a regular hemorrhoidal flux continuing, he had no return of the epistaxis, or of any of the unpleasant circumstances attending its suppression.

Mental emotions and passions, both exciting and depressing, are causes of hemorrhoids: thus anger, fear, sorrow, ennui, &c., excite a remarkable and vital action of the ganglionic nerves of the abdomen, manifested by a sense of sinking, weight, constriction, and pain at the epigastrium. The result of this impression is extended to the surface of the body; the cutaneous vessels contract, inducing pallor, and the blood, driven from the surface, accumulates in the internal organs, producing various functional disorders of the stomach, derangement of the liver, jaundice, diarrhoea, or hemorrhagic discharge from the rectum.

Internal irritation from a variety of sources will produce these affections. Ascarides, which infest the lower portion of the alimentary canal, are not an infrequent cause; irritation arising from diarrhoea and dysentery will excite the hemorrhoidal discharge, and we shall observe it not unfrequently as a crisis in other diseases thus it occurs in fevers, particularly bilious and gastric fevers; also when inflammation has attacked the brain or any of the organs lodged in the thoracic and abdominal cavities; and in other conditions of the system, as hypochondriasis, &c.

Diseases of contiguous organs, by inducing an afflux of blood to the pelvic viscera, and by extension of inflammation and irritation, are common causes of hemorrhoids: we observe them accompanying disease of the prostate gland; occurring as a consequence of stone in the bladder; the effect of stricture of the urethra, consequent on the vascular turgescence and violent straining in micturition, attendant on the aggravated forms of the latter affection.

Excessive venery and masturbation, by producing relaxation of

the system, and by determining the blood to the organs in the pelvis, produce hemorrhoidal disease.

Certain purgatives and drastic medicines, as aloes, scammony, gamboge, black hellebore, rhubarb, the neutral salts, &c., particularly if prescribed in too frequent and too large doses, induce hemorrhoids they act directly by irritating the mucous membrane of the rectum, and by inordinately exciting that portion of the intestine, and the lower part of the colon. Of all medicines, calomel and the other preparations of mercury have been productive of most mischief in the affections we are now considering, as well as inducing other diseases of the digestive organs. It is not from the use of the mineral, but its general abuse, that the evil arises: the practice is justly reprobated by Drs. Copland, Elliotson, and other writers on the practice of medicine. It may, however, be questioned whether all the medicines first mentioned, when properly administered, exert much influence in inducing the disease, and whether it is not rather to the state of the constitution rendering these medicines necessary that we should ascribe the local affections. They will severally readily reproduce the hemorrhoidal flux when once it has taken place, but it is not to be inferred from this that they will cause the disease, as morbid action having once occurred in a part is much more easily re-established even by slighter causes; therefore, before attributing the malady to medicines, it is essential to ascertain if there may not be other causes to which it may owe its origin.

As well as to living above par, conjoined with a deficiency of exercise, we shall be able to trace the disease in some people to eating various alimentary substances, particularly highly-seasoned dishes, spices, onions, shallots, &c.; to partaking of very hot or cold beverages, or too great a quantity of stimulating drinks: certain wines, such as claret, champagne, also cider and beer, will, in some individuals, readily induce the affection.

The local application of cold or heat, as sitting on stone seats, on the cold and damp ground, on damp cushions, the habit of standing with the back to the fire, riding rough horses, prolonged walks in hot weather, travelling a number of consecutive hours in a carriage, sitting on pierced seats whereby the blood gravitates to the anus, consequent upon its being unsupported, and on the obstruction to the circulation from the pressure on the surrounding

parts; stimulating pediluvia, irritating and large enemata, are other causes of hemorrhoidal affections.

The symptoms attending hemorrhoidal diseases vary much, and are greatly influenced by the state of the general health of the patient, the exciting cause whether accidental or constitutional, and the complications with which they are associated, and also by the piles being internal or external.

In the first attack, the patient will probably experience but slight inconvenience. If the disease is only of the congestive form there will be itching and a sense of weight and fulness in the rectum, with uneasiness in the perineum: in a few days bleeding may occur, but does not always take place in the early attacks, and when it does it is usually critical, all the symptoms and discomfort disappearing for the time. If the disease does not thus subside, but is permitted to increase, or when several attacks have been experienced, the symptoms will be augmented in number and severity; and, in addition to the weight and fulness at first felt, there will be heat and throbbing, the pain at stool will be greater, and will continue for some time afterwards: pain will also be felt up the sacrum, in the loins, and down the thighs; after a short time a flow of bright blood will be observed either preceding or after defecation; usually increasing in quantity with the duration of the disease, and often becoming the most prominent symptom, and causing great derangement of the general health. As the disease progresses, a feeling of the presence of a foreign body in the rectum will be experienced, and at stool one or more tumors will be protruded; at first they are retracted spontaneously after the action of the bowels, but, in process of time, from increase in size and loss of tone in the parts, it becomes necessary for the patient to replace them with his hand. Should the piles become constricted by the sphincter, many of the symptoms of intussusception or strangulated hernia may be induced. In weak and debilitated persons the sphincter loses its tone, and the anal orifice becomes dilated, and the hemorrhoidal tumors will then descend upon the slightest exertion, or even when he is in the erect position, causing great annoyance and discomfort: in this condition they will be liable to ulceration from the friction to which they are exposed by contact with the clothes. A mucous discharge soiling the linen is a frequent symptom; it is sometimes so profuse as to run down