uterine functions. Steel medicines, the shower-bath, and sea-bathing, will be found beneficial. The complaint is somewhat capricious, so that what gives relief in one case or at one time, fails in another case or at another time, and after resisting our best remedies it sometimes subsides spontaneously.

CHAPTER IV.

HÆMORRHOIDS.

THE hæmorrhoidal veins distributed in the submucous tissue at the lower part of the rectum communicate in loups, and form a plexus which surrounds the bowel just within the internal sphincter. The veins are best seen when somewhat congested, their deep purple hue being very apparent through the thin mucous membrane with which they are in close contact. The plexus is then seen to be about three-quarters of an inch in length, and composed of veins of various sizes, arranged for the most part lengthwise and in clusters, being especially collected in the longitudinal folds of the rectum. The plexus does not extend lower than the external sphincter, but branches from it, passing between the fibres of the internal sphincter, descend along the outer edge of the former muscle, close to the integuments surrounding the anus.

These hæmorrhoidal veins are very liable to become dilated and varicose, giving rise to the disease termed hæmorrhoids or piles. When the plexus beneath the

mucous membrane within the external sphincter are thus affected, the hæmorrhoids are said to be internal: when the veins beneath the integuments outside the muscle are enlarged, the hæmorrhoids are called external. Both external and internal piles very frequently co-exist. Where this is the case, on laying open the anus and rectum the distinction between the two is very marked, the external sphincter forming a narrow band separating the internal from the external piles, which appear arranged in rows one above the other. The changes in structure consequent upon hæmorrhoids vary a good deal. vary a good deal. In internal piles the lower veins of the plexus are dilated irregularly, or into pouches, which are filled with dark coagula. These coagula are often compact and hard. A section shows a number of veins of different sizes, mostly plugged with clots. A bunch of varicose veins, crowded in the lower ends of the longitudinal folds, produce prominent projections of the mucous membrane, and deepen the pouches between the folds. In addition to these elevations, a number of small dilated veins sometimes form in the short columnar projections described at page 6. Two or three of the larger prominences of the longitudinal folds meeting below coalesce, so as to form a transverse fold just within the sphincter. In old cases the mucous membrane and submucous areolar tissue become greatly hypertrophied. Thus are developed elongated processes of a polypus form, which grow as much as one inch in length, and projecting transverse folds, which I have known to measure one inch and a half in width. Not seldom there are two or even three transverse elevations of smaller size. The arteries which are abundantly supplied to the lower part of the rectum,

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taking, as shown by Mr. Quain, a longitudinal course towards the orifice where they freely communicate, likewise enlarge considerably. The mucous membrane involved in internal piles is not only thickened, but extremely vascular. The disease is not always confined to the smaller veins at the extremity of the rectum, but, as it makes progress, the larger veins higher up the rectum also become varicose.

The dilated veins of external piles are better covered than those within the sphincter. In the early stage, before the integuments have become thickened, there are softish elevations in the skin, near the margin of the anus, of a slight blue tinge, being nothing more than swellings from varicose veins. At a later period, a projecting fold of skin, with a broad base, encloses a vein dilated into a pouch, and filled with a dark coagulum. A thick fold of this kind, when cut, sometimes exhibits a congeries of small varicose veins, many of them distended with clots. A number of such hæmorrhoidal excrescences frequently form a ring around the anus. Inflammation spreading from the coats of the veins causes the skin and areolar tissue covering them to become thickened and hypertrophied. Lymph is sometimes effused into varicose veins, and leads to their obliteration, after which the folds shrivel up, and become reduced to small flaps, which give the patient no further trouble. In some instances, elongated flattish folds may be observed springing from the margin of the anus at the point of junction of the mucous membrane and skin, the outer surface of the fold being covered with a membrane resembling the delicate skin at this part, and the inner surface lined with an extension of the mucous membrane, small veins being visible through it.

These growths hold an intermediate place between internal and external piles.

It appears that repeated distension of the hæmorrhoidal veins from causes about to be described, renders their coats weak, and that, under a repetition of congestions, the vessels yield, and become permanently varicose. They also grow larger, being not only dilated, but elongated and tortuous. Their coats, and the areolar tissue around them, become thickened, as in varix of the legs. The arteries supplying the part also acquire a greater development, the lower part of the rectum becoming in every respect a more vascular structure, though not an erectile tissue, which piles have been erroneously supposed to resemble. At the same time the textures covering the veins, the skin and mucous membrane, are hypertrophied in folds.

Hæmorrhoids is a disease of middle and advanced age. They rarely occur before puberty, and but few persons in after-life altogether escape them. All those circumstances which determine blood to the rectum, or impede its return from the pelvis, tend to produce this disease. Drastic purgatives; the accumulation of fæces occurring in constipation; the strain on the coats of the veins taking place in protracted and forcible defecation, and in efforts to void the urine when the passage for it is obstructed; the impediments to the circulation caused in women by the gravid uterus and tumours of this organ, and in men by a greatly enlarged prostate gland; abdominal tumours pressing on the inferior mesenteric vein; disease of the liver interrupting the portal circulation, may all be regarded as causes of hæmorrhoids. There is, no doubt, in many persons a natural predisposition to the complaint, which is then produced by slight causes. This disposition is sometimes shown

in a weak condition of the venous system generally. Thus, I have several times met with varicose veins of the lower extremities and also varicocele combined with hæmorrhoids. The disposition may be hereditary. The complaint, indeed, often occurs in members of the same family who inherit the local weakness of their parents. But a predisposition is more frequently acquired by sedentary habits, indulgences at table, and excitement of the sexual organs, which explains the well-known circumstance that hæmorrhoids are more prevalent in the higher classes of society than amongst the labouring population. The latter take plenty of exercise, live a good deal in the open air, and are little liable to constipated bowels. Hæmorrhoids, though a very common disease in both sexes, occur more frequently in males than in females. Few women, it is true, bear children without becoming in some degree affected by them; but the urinary and genital disorders of the other sex, combined with freer habits of living, are still more fertile sources of piles.

The symptoms produced both by external and internal piles vary a good deal in different subjects, and in different stages of the complaint. External piles cause a feeling of heat and tingling at the anus. A costive motion is followed by a burning sensation, and the excrescence becomes slightly swollen and tender on pressure, so as to render sitting uneasy. This congested state of the pile may pass off or lead to inflammation, accompanied with considerable enlargement of the hæmorrhoid, forming an oval tumour, red, tense, and extremely tender. The inflammation may subside, or go on to suppuration. When the matter is discharged, a clot of blood escapes with it, the abscess closes, and the dilated vein is usually