Observations of the diseases of the rectum

Preface

In the following pages, T have endeavoured to give a concise account of the changes that take place in the stracture of the rectum, and of the symptoms and treatment of its diseases. Although the subject has been inuch and ably written on, I have been assured that such a work, founded upon adequate observation, and including modern improvements in treatment, would be acceptable to the younger members of the profession. That there will be found many deficiencies, I am fully aware ; indeed, a complete treatise has not been attempted, but it has rather been my object to offer such views of pathology as may lead to judicious practice. Should I be so far successful, or have in any degree aided in the promotion of surgical knowledge, I shall be suiSciently rewarded for the pains bestowed in preparing these observations.

37, New Broad Street, City, AprU 1851.

Contents

CHAPTKR I.

INTRODUCTORY OBSERVATIONS ON DISEASES OF THE RECTUM.

PAGE

Chapter II. Irritable Ulcer Of The Rectum

Description of the Folds at the lower part of the Rectum. . 6

Seat and Characters of the Irritable Ulcer 7

Symptoms of the Disease 7

Mode of inspecting the Sore 9

Treatment of Imtable Ulcer g

Division of the Sphincter Ani 1q

Treatment after the operation II

Sores and Ulcers at the margin of the Anus 12 viii

CONTENTS.

PAGE

Chapter III. Spasm Of The Sphincter Muscle

Symptoms of Spasm 14

Chapter IV. Hemorrhoids

Arrangement of the Veins in the lower part of the Rectum. . 1 6

Different Forms of Haemorrhoids ] 6

Morbid Anatomy of Piles, and changes in structure consequent upon them 17

Causes of Hsemorrhoids 19

Symptoms 20

Disorders of the Urinary Organs in connection with this

Disease 22

Inflammation, Suppuration, and Sloughing of the Hsemor-

rhoidal Folds 24

Bleeding from Piles, and periodical discharges of blood from

the Rectum 25

The Sources of Haemorrhage 27

Treatment of External Hsemorrhoids 28

By Excision 29

Treatment of Internal Haemorrhoids 30

By Excision 33

By Escharotics 34

By Ligature 35

Mode of Arresting Haemorrhage 38

Use of Mechanical Aids 41

Chapter V. Prolapsus Of The Rectum

Pathology of Prolapsus 44

Symptoms '^^

CONTENTS. ix

PAGE

Cure by Operation •''O

Chapter VI. Polypus Of The Rectum

Description of Polypus in Children 54

Polypus in the Adult 57

Chapter VII. Fistula In Ano

Description 59

Causes of Fistula 60

Situation of the Inner Opening C3

Complicated Fistula 65

Treatment of Rectal Abscesses 66

Mode of examining a Fistula . . ; 67

Treatment of Complete Fistula by Operation 67

Treatment of Blind External Fistula 70

Treatment of Blind Internal Fistula 70

Cure of Fistula by Ligature ; 71

Treatment of Complicated Fistula 73

Treatment of Fistula communicating with the Vagina .... 74

Treatment of Lacerated Perineum in Child-birth. 75

Chapter VIII. Chronic Ulceration Of The Rectum

Description of the morbid changes in Chronic Ulceration . . 77

Causes yg

Syphilitic Ulceration

Symptoms of Chronic Ulceration qq

X

CONTENTS.

CHAPTKR IX.

STRICTURK OF THK RRCTUM.

PAGK

Description of the changes in the coats of the Rectum

occurring in Stricture S2

Causes of Stricture 84

Contraction produced by the heahng of ulcers and wounds

in the Rectum 85

The Seat of Stricture 86

Excrescences on the mucous surface occurring in Cases of

Stricture 87

Symptoms of Stricture 88

Obstruction from Tumors external to the Rectum 92

Treatment of Stricture 92

Dilatation by Bougies 93

Mode in which Bougies operate in curing Strictures 94

Difficulties in the examination, and treatment of Strictures

high up in the Rectum 97

Dangei's incurred in the use of bougies in such cases 97

Incision of Strictures 98

Treatment of the diseased mucous surface 100

Treatment of Obstruction from Stricture in the Rectum. ... 103

Operation for Artificial Anus 106

Advantages of Littre's and Caliisen's Operation compared. . 106 Operation of opening the colon in the left iliac region

described 108.

CHAPTi^R X.

CANCER OF THE RECTUM.

Morbid Changes in the Rectum produced by the different

forms of Carcinoma 109

Usual seat of the Disease Ill

Symptoms Ill

Excision of the Carcinomatous Rectum 115

CONTENTS.

XI

PAGE

Obstruction from Caucer, and propriety of operating for Artificial Anus 115

Epithelial Cancer of the Rectum 116

CHAPTER XI.

FiECES IMPACTED IN THE RECTUM.

Symptoms 119

Mode of affording relief 120

CHAPTER XII.

ANAL TUMORS AND EXCRESCENCES.

Fibrous Tumors ]22

Warts 123

ON

DISEASES OF THE RECTUM.

Chapter I. Introductory Observations

The terminal portion of the alimentary canal — the rectum — is subject to numerous and varied derangements, dependent upon its structure, its peculiar office in the economy, and its relation to the important parts in its vicinity. As a class of diseases, those of the rectum are as common as any to which the human body is liable ; and they give rise to sufferings, in many instances, not only severe, but also often accompanied with depression of spirits, and an anxiety of mind, out of all proportion to the gravity of the disorders. Many of these diseases spring from habits prejudicial to health, engendered by sedentary pursuits, or consequent on indulgence in the luxmies of civilized life. They are, therefore, found to be most prevalent in the middle and upper classes of

B

DISEASES OF THE RECTUM.

society. With a few exceptions, there are no diseases which yield more readily and effectually to careful management and surgical treatment, or which in their results afford greater satisfaction to the practitioner.

In the treatment of these diseases it is, in most cases, important that an early and careful examination should be made of the part affected. By neglect of this precaution, serious disorders, which, if detected in time, would yield easily to treatment, are allowed to make progress, and to become much more difficult of cure. In females, the dehcacy of the sex too frequently leads to concealment of these complaints, and raises obstacles to an inspection of the seat of them. The examination of the parts diseased, as well as the performance of certain operations, may be considerably aided by the use of a speculum. They are made of various kinds, some of them ill adapted for the object in view. Thus, many of the dilators are of little use in consequence of the bulgings of the mucous coat of the bowel between the narrow blades of the instrument. There is an old-fashioned but semceable instrument, consisting of a longitudinal section of a steel tube, with one extremity closed, which has long been employed at the London Hospital in examining these diseases, and which is well adapted for protecting the bowel, and finger of the surgeon, in operations for fistula. Mr. Hilton has recently contrived a plated speculum, with the end closed, and an aperture at the side into which a moveable piece sUdes. I have often used it, but

INTRODUCTORY OBSERVATIONS.

have found the side opening too narrow to afford a complete view of an ulcer or pile of any size ; and in consequence of the aperture not being carried to the extremity, faeces are Hable to lodge there and prove troublesome to remove in protracted examinations, as in searching for the inner orifice of a fistula. Ferguson, of Giltspur Street, has therefore made, by my direction, a plated speculum of a conical form, so as readily to penetrate the sphincter, with the side opening of sufficient width, and carried to the blind extremity of the instrument : and instead, also, of a moveable piece, I have substituted an ebony plug, fitted with a plate which fits close into the aperture. The plug admits of being more feadily removed and replaced than a slide. The subjoined engra\ing shows the speculum, reduced in size about one-half.

In the application of remedies to the interior of the rectum, the common glass reflecting speculum, coated with caoutchouc and an open end, will often be found useful. Leeches may be applied to the mucous mem-

DISKASES or THE RECTUM.

braiic of the bowel by means of a glass speculum with a small side opening near the closed extremity. Before using any of these instruments, the rectum should be well cleansed by an injection of warm water.

In the treatment of diseases of the rectum, chloroform is a valuable auxiliary. In making examinations, I have derived the greatest assistance and advantage from it. Under its influence the irritable sphincter relaxes, and a complete view can be had of the seat of disease in cases where pain and spasm would otherwise offer almost insuperable obstacles to a satisfactory exploration. And, in operations more painful than serious, the use of this remedy has not only facilitated their performance, but saved the patient considerable suffering and distress.

It may seem superfluous to remark, that no operation, even of a trivial character, should be performed on the anus or rectum without due inquiry into the state of the patient's general health. I have heard of diffuse inflammation of a fatal character arising after the removal of a small excrescence from the anus, and after the division of a fistula ; and of phlebitis occurring from the removal of haemorrhoids ; and although all operations are more or less liable to ill consequences, they very rarely happen except where the precaution alluded to is neglected. No prudent surgeon would undertake an operation on these parts in a person with a broken-down constitution, or with organic disease of the lungs or liver, or with albuminous urine ; but with ordinary caution in the selec-

INTRODUCTORY OBSERVATIONS.

tion of cases, and with common care in performing the operations necessary in diseases of the rectum, and conducting the after-treatment, they are as successful and satisfactory as any belonging to surgery.

Chapter II. Irritable Ulcer Of The Rectum

The mucous membrane of the lower part of the rectum is arranged in longitudinal folds, which disappear in the expanded state of the bowel. These folds terminate below at the external sphincter. Just within this structure, and between the folds, the mucous membrane is slightly dilated, variously in difiFerent subjects, but in many to such an extent as to form small sacs or pouches. Besides these folds, and in the spaces between them, there is a series of short projecting columnar processes, about three-eighths of an inch in length, separated by furrows or sinuses, more or less deep, which are arranged around the lowest part of the rectum. These various folds, though no doubt well developed in the living state, are not always obvious after death, unless the vessels are congested. They are rendered distinct by injections with coloured size, both in the adult and in the fcetus. Now in the evacuation of the rectum, foreign bodies or little masses of hardened faeces are hable to be caught or detained in the pouches just described. And it is in these little sinuses, thus exposed to irritation and abrasion, that a superficial circumscribed ulcer is occasionally formed.

IRRITABLE ULCER OF THE RECTUM.

On examining the ulcer, without distending the rectum, the lateral edges only being presented to view, the breach of surface has the appearance of a Jissure,— the term commonly given, but improperly, to this sore, which is obviously more than a mere cleft or rent in the mucous membrane of the bowel. Such an ulcer may occur in any part of the lower circumference of the rectum, but it is very generally found at the back part, towards the sacrum. It is quite superficial, and, though sometimes circular, is more usually of an oval shape ; its long axis being longitudinal, and its lower extremity extending within the circle of the internal sphincter. On tactile examination, the breach in the mucous surface and the extent of the ulcer can be easily distinguished by a practised finger, especially when the edges are, as is often the case, somewhat indurated. With the speculum, the longitudinal folds being stretched out, the ulcer can be fully exposed, and it is then clearly seen not to be a mere fissure, but a superficial sore, which may extend beyond the edges of the opening in a common-sized speculum. The surface is of a brighter red than the surrounding membrane, and has the usual indented appearance of an ulcer.

The amount of sufi'ering produced by this superficial ulcer varies a good deal, but the sore is generally extremely sensitive, and occasions severe distress. It is so situated that the faeces, in their passage outwards, rub over its surface, and the painful contact excites spasm of the sphincter muscle, causing a sharp burning pain, and often a forcing sensation, which lasts for two or three hours, the distress being usually greater after defecation than during the act. This is sometimes so acute that patients resist the desire to pass their, motions, and allow the bowels to become costive in dread of the sufferings brought on by evacuating them. The stools, when passed, are streaked with blood. The pain, though much increased during and for some time after defecation, is in many cases constant ; the patient never being free from a sharp lancinating pain, which disturbs rest, depresses the spirits, and renders the sufferer truly miserable. The least pressure at the anus gives uneasiness, so that the patient is obliged to avoid sitting, and either to rest on one hip or to lie down. The pains often assume a neuralgic character, and are described as shooting up the back, down the limbs, or along the urethra. The irritation may extend to the bladder, producing painful micturition.

This irritable ulcer occurs commonly in middle hfe, and is much more frequent in women than in men. It is met with as often in single as in mai-ried women, and in persons of an hysterical temperament there are occasionally pains of so anomalous a character as sometimes to mislead the practitioner. Indeed, it is surprising how often this sore is overlooked, even in common cases. In all instances of painful defecation for which the sui'geon is unable to account, the rectum should be carefully examined with the aid of the speculum. Ulceration of the lower part of the rectum sometimes occurs in connection with internal piles, and is attended with bleeding.

IRRITABTiE ULCER Of THE RECTUM.

On the attempt to separate the margins of the anus, or to dilate the sphincter to get a view of the ulcer, or even to introduce the finger, spasm, with an aggravation of pain, is, in most cases, immediately excited ; and the orifice becomes strongly contracted and forcibly drawn in. When this is the case, it is better to desist, and to get an assistant to administer chloroform. As soon as the system is under its influence, the sphincter yields completely, and the surgeon is able to make a satisfactory exploration of the part, and to ascertain the exact seat, character, and extent of the ulcer. In those cases in which there is little or no spasm of the sphincter, or when the muscle is relaxed under chloroform, the surgeon may dilate the anus Mdth his two fore-fingers, so as to get a tolerably good view of the sore. A better examination, however, may be made by the aid of the speculum.

This ulcer seldom heals under the influence of local applications. The treatment necessary is a longitudinal incision through its centre, including the sphincter muscle. The object of the operation is to place this muscle at rest for a time, and to enlarge the passage and displace the sore ; thus removing those sources of irritation which prevent its healing. An incision, it is true, is not invariably required ; but in all cases in which the pain is considerable, and in which there is much spasm of the sphincter, the attempt to procure the heahng of the sore by local applications so often protracts the patient's sufferings, and so constantly ends in failure, that it is not desirable to make it. In the

DISEASES OF THE RECTUM.

evening before the operation, an aperient sliould be given, in order that the bowels may remain at rest for a day or two after the incision. The patient shoukl be placed on the left side, with the nates projecting a little over the edge of the bed, and opposite a good light, and with the thighs bent. Chloroform can then be administered. The division of the ulcer may be performed in two ways ; by an incision from within, or from without the rectum. In the latter mode, a sharppointed bistoury is carried through the base of the ulcer at a sufficient depth to include the sphincter, and the parts are divided by an incision from without inwards through the centre of the ulcer. A speculum must be previously introduced, to protect the opposite walls of the bowels from the point and edge of the bistoury. I prefer the operation from within outwards, which may be easily, and, indeed, more conveniently performed without the speculum. The cutting edge of a straight blunt-pointed bistoury is to be applied to the centre of the ulcer, which is to be divided by an incision extending to the internal sphincter. The fibres of this muscle are easily felt with the left fore-finger, and the depth of the incision regulated accordingly. When the ulcer is situated in the front part of the rectum, it should be divided a little to one side, or tbe wound will not heal readily. Besides, in the female, the division towards the vagina may cause incontinency of faeces.

After the operation, a small portion of dry lint should be passed into the wound as a plug to prevent bleeding.

IRRITABLE ULCER OF THE RECTUM.

and to keep the edges apart.' I have never been troubled with haemorrhage after this operation, but if any vessel be seen pumping out blood, it can be seized with AssaUni's forceps and tied. In two days a mild aperient may be given, and repeated when necessary, to prevent costiveness, and keep the motions somewhat soft. In many cases no further local application is required than a pledget of lint dipped in sweet oil, which the nurse may carry to the bottom of the wound after each evacuation. The healing of the sore may often be promoted by first coating the lint with the following application: — Liquor Plumhi Diacetatis, 53. ; Confectio Roscc, 3j., M. ; and then dipping it in sweet oil. The effect of the operation is remarkable. It at once relieves the severe symptoms, the pain experienced afterwards being merely the sore of the wound, and rarely fails to secure the healing of the ulcer in the coiu-se of two or three weeks. The progress of the sore must, however, be watched until the s.urgeon is satisfied by an examination that the part is quite healed ; for I have known of disappointment ensuing, and the painful symptoms returning, after the case had been given up under the supposition that the patient was cured. If the healing of the ulcer proceed slowly, it may be touched with a camel's hair pencil dipped in a solution of the nitrate of silver (gr. x. to 51.), or occasionally smeared over with some mild stimulating ointment. No weakness of the muscle results from division of the sphincter, its function being perfectly performed afterwards.

DISEASES OP THE RECTUM.

Patients will not always submit to the division of the sphincter without a previous trial of other means ; and where there is not much spasm, and but little suffering, the cure of the sore may often be obtained without it. The patient should remain at rest in the recumbent posture, and should take some mild aperient medicine to ensure soft evacuations. The ulcer may be brushed over occasionally with a solution of the nitrate of silver, and a mild mercurial ointment smeared over its surface night and morning, — such as the Unguentumhydrargyri diluted with two parts of lard, or the Unguentum hydrargyri niiratis mitius. For sensitive ulcers, ointments containing the extract of belladonna are recommended ; and this drug is sometimes added to mercurial applications. It may be used in the proportion of from 5j. — 5ij. to 5j. of lard. I have found marked relief derived from an ointment containing chloroform. The following is a prescription for this ointment, which will be found useful in many painful affections of the rectum and other parts : —

The dehcate skin at the margin of the anus is subject to a linear abrasion or chap, and small sores occasionally form between the folds of integument at the outer edge of the sphincter, which probably origin at

IRRITABLE TILCER OF THE RECTUM.

in an affection of the follicles of the part. These chaps and sores cause some uneasiness in defecation, and often give rise to troublesome itching ; but they are never attended with spasm of the sphincter or vs^ith the severe pain which occurs in ulcer of the rectum, aud there is no difficulty in getting them to heal. A piece of lint soaked in black wash, or in a lotion of the oxide of zinc (^j. to ^vj.), or of common Goulard, and lodged in the part, generally answers the purpose. The small sores sometimes require to be touched with the point of the lunar caustic. A lotion of the nitrate of silver is objectionable, as it stains the linen. Primary syphilitic sores sometimes occur in the immediate vicinity of the anus. In females, a chap or excoriation at this part may be readily inoculated by the matter from a sore on the vulva. A description of the appearances and treatment of such ulcers would be beyond the scope of this work, and I call attention to them, only, that if they should be met with, their true character might not be overlooked.

Chapter III. Spasm Of The Sphincter Muscle

Persons occasionally suflFer from symptoms similar to those described in the last chapter, but more moderate in degree. There is pain in defecation, increased afterwards, and lasting for half an hour or an hour. It is described as a forcing sensation, or a feeling as if the bowel were unrelieved. The anus is strongly contracted and drawn in by the action of the sphincter. Any attempt to examine the part induces spasm ; and, the finger being passed through it, is tightly grasped by the muscle, as if girt by a cord. In cases of some standing, the muscle often becomes hypertrophied, and forms a mass, encircling the finger like a thick unyielding ring. The spasm is not always confined to the anus, for the fibres of the internal sphincter occasionally become enlarged, contracting the lower part of the gut, and closing strongly around the finger. The faeces, however, are not streaked with blood : there is not the racking and constant pain experienced in the case of ulcer, and there are intervals of ease and relief from pain, particularly when the patient's attention is engaged.

This affection occurs commonly in hysterical females.

SPASM or THE SPHINCTER MUSCLE.

I have not myself met with it in other persons independently of some local source of irritation, as an ulcer or an inflamed internal pile ; and I believe that in men simple spasm is a rare complaint. The investigation of such a case is not satisfactory without an examination of the rectum with the speculum ; and, in most instances of painful spasm, I am convinced that some direct cause of irritation will be discovered. I recently attended an Itahan who had severe spasm, consequent upon the irritation of an inflamed prostate from gonorrhoea. In women, the suffering attending this complaint is aggravated during the menstrual period.

The treatment required in simple spasm is mild laxatives, and the local application of an ointment containing chloroform, opium, or belladonna. In obstinate cases, especially when the sphincter is hypertrophied, it becomes necessary to divide the muscle, which should be done on one side, towards the ischium. This usually succeeds in relieving the complaint, but in hysterical cases the benefit is not always permanent. In an unmarried giii upon whom I performed the operation, relief was experienced for a time ; but some months afterwards she called on me again, complaining of her old symptoms. In these cases attention must be paid to the uterine functions Steel medicines, the shower-bath, and sea-bathing, will be found beneficial.

If)

Chapter IV. Hemorrhoids

The hsemoiThoidal veins distributed in the submucous tissue at the lower part of the rectum 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 hsemorrhoidal veins are very liable to become dilated and varicose, giving rise to the disease termed hcemori'hoids or piles. When the plexus beneath the mucous membrane within the external sphincter are thus afi'ected, the haemorrhoids are said to be internal : when the veins beneath the integuments outside the

HAEMORRHOIDS.

muscle are enlarged, the haemorrhoids 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 haemorrhoids vary a good deal. In internal piles the veins of the plexus are irregularly dilated, and are filled in spots with dark coagula, which are often compact and hard. A section shews 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 unfrequently there are two or even three transverse elevations of smaller size. The arteries likewise enlarge considerably. The mucous membrane involved

c

DISEASES or THE RECTUM.

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 is a softish elevation in the skin, near the margin of the anus, of a slight blue tinge, being nothing more than swelling from a varicose vein. At a later period, a projecting fold of skin, with a broad base, encloses a vein more or less dilated, 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 hsemorrhoidal 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 eflPused 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

HAEMORRHOIDS.

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

It appears that repeated distension of the hsemorrhoidal 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 and organized structure, though not of the character of erectile tissue or nsevus, 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.

Haemorrhoids is a disease of middle and advanced age. They rarely occur before puberty, and but few persons in after -Hfe 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 faeces occurring in constipation ; the strain on the coats of the veins takiug 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 by the gravid uterus or a greatly enlarged prostate gland ; abdominal tumors pressing on the inferior mesenteric vein ; disease of the liver interrupting the

DISEASES OF THE RECTUM.

portal circulation, may all be regarded as causes of hsemorrboids. There is, no doubt, in many persons a natural predisposition to the complaint, which is then produced by slight causes. 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 haemorrhoids 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. Haemorrhoids, though a very common disease in both sexes, occur more frequently in males than in females. Pew women, it is true, bear children Avithout 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.