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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 hæmorrhoidal affections, by inducing general relaxation, and of the venous system in particular ; they also favour 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 hæmorrhoids. 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 inflammatory 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 hæmorrhoidal 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 hæmorrhoids. 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 hæmorrhoids. 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 tumours developed in the pelvis or abdomen, which, by pressure won 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.

Hæmorrhoids 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 hæmorrhoids 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 veins, interfere more or less with the return of the blood. In this habit of body the hæmorrhoidal vessels become greatly engorged during the act of defecation, from the violent efforts of the expulsatory muscles, and the congestion, arising during the temporary suspended respiration that always attends violent muscular action.

Those persons whose habits of life are sedentary

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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 hæmorrhoidal vessels. From these circumstances it is very common to meet with hæmorrhoidal 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 hæmorrhoidal 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 hæmorrhoidal flux will appear as a translation of hæmorrhagic discharge from some other

organ; thus arresting and keeping in abeyance morbid action that has given rise to bæmoptysis, hæmatemesis, 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 hæmorrhoids, 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 laboured 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 hæmorrhoidal flux continuing, he had no return of the epistaxis, or any of the unpleasant circumstances attending its suppression.

Mental emotions and passions, both exciting and depressing, are causes of hæmorrhoids : thus anger, fear, sorrow, ennui, &c., excite a remarkable and vital action of the ganglionic nerves of the abdomen, mani.

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