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substituted; and in the morning one of the following draughts should be taken:—
ty Infusi Sennas comp., 3vj! Infusi Gentianas comp., 3V;
Tincturas Cardamomi comp., 3j- Fiat haustus.
ty Decocti Cinchonae, Infusi Sennas comp., aa 3VJ- Pint
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.
ty Confectionis Sennae, Sulphuris Loti, aa Jj; Pulveris Jalapae, 3j; Pulveris Zingiberis, 3ss; Sodas Potassio-tartratis, 3iv; Syrupi Zingiberis, q. s.: ut flat eleetuarium.
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 formulae 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 haemorrhoids 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 haemorrhoids, 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 irritating matter, the other by the immediate impression of the cold upon the nerves and vessels of the intestine.
The several complications and phenomena attending haemorrhoids 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 haemorrhoidal 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 haemorrhage, 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 of leeches. If the piles are internal, and are prolapsed, they must be returned within the sphincter by gentle pressure, made by a fold of lint smeared with olive oil or spermaceti ointment; this must not be neglected, or, from vascular engorgement or constriction by the surrounding muscular fibres, mortification will probably result, occasioning severe constitutional disturbance and much suffering. Several instances of the disease being thus removed have come under my observation. In tins manner the celebrated Horne Tooke was cured of a disease he had long suffered from. Sir Benjamin Brodie,* in his lectures, narrates the circumstance :—" Many years ago I was dining with Dr. Pearson, and after dinner he gave an account of Home Tooke's illness. He said that he had long laboured under piles; that at last mortification had taken place; that there was no chance of his recovery; and he added, that he had that morning seen him for the last time. I remember that in the middle of this history there came a knock at the door, on which Dr. Pearson said, 'Here is a messenger with an account of my poor friend's death.' However, it was some other message; but by-and-by a messenger did arrive, saying that Home Tooke was much the same, or a little better. It turned out, as I have been informed, that the piles sloughed off, and from this time he never had any bad * 'Medical Gazette,' vol. xv., p. 746.
symptom. In fact, he was, if I have been rightly informed, cured of a disease which had been the misery of his life for many years preceding, and he lived for some years afterwards."
After the tumours have been replaced, hot poppyhead fomentations should be applied, to be succeeded by hot linseed-meal poultices. Some surgeons have advised punctures and scarifications of the inflamed and protruded piles: it is a practice that should not be adopted, being founded on erroneous principles, and will only cause the patient much annoyance without affording the desired relief. Mr. Calvert says he saw a case of fatal haemorrhage follow the practice. Montegre and Bushe alike condemn the proceeding. After the inflammation has somewhat abated, cooling and anodyne lotions will afford great relief; an aqueous solution of opium with acetate of lead and elderflower water or rose water will answer the purpose. Enemata of cold water are beneficial in the latter stage of inflammation: the instrument used should be provided with an elastic gum jet, as one of ivory or metal will be likely to injure the tender parts. The bowels must be kept gently open by means of an aperient electuary, castor oil, or other laxative.
If the tumours have fallen into a state of mortification from excess of inflammatory action, or from constriction by the sphincter muscle, meal poultices must