piles have existed for a long period, have continued from youth, or the commencement of puberty, when they supervene upon or replace some serious organic or habitual affection, if they are preceded by constitutional disturbance, and succeeded by an improvement in the state of the health, if well-marked indications of plethora exist, which is relieved by the accession of the hæmorrhoidal flux, and if indications of congestion, or disease in any of the organs accompany or follow its suppression or interruption, or an hereditary predisposition exists, a constitutional nature may be inferred; and local treatment must be a secondary consideration, and not adopted till the constitutional cause has been removed or palliated: this is especially necessary if there is a predisposition, hereditary or otherwise, to apoplexy, gout, phthisis, hæmoptysis, epistaxis, or other kinds of hæmorrhage.

Various authors mention instances in which a neglect of the consideration of the constitutional origin, and the adoption of a local treatment of piles, has been followed by serious or fatal consequences. Dr. Copland mentions three cases having come under his observation, in one of which fever was induced, in another apoplexy, and in a third melancholia, by the improper arrest of hæmorrhoidal discharge. Mr. Howship states the case of a gentleman subject to gout, who, in opposition to proper medical advice,

was induced by a charlatan to have recourse to a strong vitriolic lotion, with the effect of arresting the hæmorrhagic discharge, but the patient soon after died of gout in the stomach.

The general treatment of hæmorrhoidal affections must consist in enforcing a strict observance of moderation in diet, due attention being paid both to the quality and nature of the aliment, as well as quantity; all stimulating food and beverages must be forbidden, and only that allowed which is unirritating and easy of digestion: this is a matter so important, not only in the diseases herein treated of, but in all others, that it would be well to give a patient written instructions on this point, in the same manner as when medicines are directed to be taken. The bowels must be regulated, and constipation combated, by deobstruent laxatives and stomachic aperients. If fæcal accumulations in the colon exist, these must be removed by emollient enemata in many cases the use of O'Beirne's tube will be highly serviceable in dislodging the excrementitious matter. When the secretions and excretions of the chylopoietic viscera are depraved or deficient, means must be adopted to restore them to a healthy state; for this purpose a few grains of the blue pill with one of powdered ipecacuanha should be directed to be taken at bed-time, or mercury with chalk and extract of taraxacum may be

substituted; and in the morning one of the following draughts should be taken :

R Infusi Sennæ comp., 3vj; Infusi
Tincturæ Cardamomi comp., 3j.

R Decocti Cinchona, Infusi Sennæ
haustus.

Gentianæ comp., 3v;
Fiat haustus.

comp., āā 3vj. Fiat

If these are not sufficiently active, sulphate of magnesia, potassio-tartrate of soda, or sulphate of potash may be added: castor oil is a most useful laxative in these diseases: a teaspoonful of the following electuary, taken either at bed-time or early in the morning, answers very well in moving the bowels once or twice.

R Confectionis Sennæ, Sulphuris Loti, aa 3j; Pulveris Jalapæ, 3j; Pulveris Zingiberis, 3ss; Soda Potassio-tartratis, 3iv; Syrupi Zingiberis, q. s.: ut fiat electuarium.

The addition of two or three drachms of copaiba to the above will be very beneficial in many cases, but it renders the electuary so nauseous that some patients cannot take it; if, however, it is made into boluses and wrapped in wafer-paper, it may be swallowed without being tasted. The functions of the skin and kidneys must receive most earnest attention: various diuretic and diaphoretic medicines must be prescribed, as the citrate of potash and nitrate of potash in camphor mixture; a solution of the acetate or citrate of

ammonia, camphor mixture, sweet spirits of nitre, and the inspissated juice of the elder; other formulæ will readily suggest themselves to the practitioner.

The importance of regular and moderate exercise must be enforced on the attention of the patient; by it the whole of the vital functions are stimulated to a healthy action thus the circulation is increased, particularly in the extremities, nutrition is more rapid, and the depurating and excretory organs are excited in eliminating matters that have served their purpose in the economy, which, if retained, are productive of much of the apparent derangement of the system.

The vicissitudes of temperature must be guarded against by proper clothing, and benefit will follow the occasional use of the warm bath, particularly when the action of the liver or skin is torpid. Both in external and internal hæmorrhoids ablution with soap and water night and morning will be attended with great benefit and comfort. It is not merely by washing away irritating secretions and excrementitious matter that this results, but by a direct and specific effect of the soap on the parts themselves. In internal hæmorrhoids, or in congestion of the vessels of the rectum, the injection of half a pint of cold water after each dejection will be of essential service; the advantage resulting therefrom arises from a twofold. effect, the one by removing any feculent and irri

tating matter, the other by the immediate impression of the cold upon the nerves and vessels of the intestine.

The several complications and phenomena attending hæmorrhoids require special consideration with regard to treatment, bearing in mind, at the same time, the cause and origin of the disease. When symptoms denoting congestion and repletion of the hæmorrhoidal vessels are present, the bowels must be moved by castor oil, or the electuary before mentioned, or some other gentle purgative. It may be necessary to have recourse to the local abstraction of blood; cupping over the sacrum or on the perineum is preferable to the application of leeches around the anus; it occupies less time, is less annoying to the patient, and does not produce the local determination of blood that leeches do. When the patient has previously suffered from hæmorrhage, leeches applied to the anal region will frequently reproduce it, or it may appear for the first time by the determination of blood induced by their application. After the bowels have been moved and blood abstracted, the warm hip-bath will afford ease, or flannels wrung out of hot water applied to the perineum and sacrum may be substituted.

When the tumours are inflamed, local depletion will generally be necessary; for the reason just urged, cupping will be more advisable than the application