cupping-glasses to the upper parts of the body, and sinapisms and ligatures to the upper extremities; others have recommended bleeding from the arm: but I think few surgeons will be inclined to adopt the latter recommendation in a patient already reduced by the hæmorrhoidal flux. Plugging the rectum, and in extreme cases the actual cautery, have been advised; but neither of these means is often practicable, unless the point from whence the blood flows can be brought into view, and then, by ligature or other means, we may be able to succeed in stopping the bleeding. When the hæmorrhage is of a passive character, occurring continuously, and weakening the patient by slow degrees, the administration of the preparations of cinchona, in combination with the mineral acids, will be of service sulphate of quinine and sulphuric acid, and the various chalybeate preparations, may also be

administered.

The discharge of mucus from the bowel, which so generally accompanies internal hæmorrhoids, and is a cause of extreme annoyance to the patient, is to be arrested by the injection of cold water into the rectum morning and evening. But if the disease has existed long, and the secretion is profuse, a few grains of sulphate of zinc, acetate of lead, or tannic acid, may be added to the water.

Tumours occurring at the verge of the anus, form

ing external hæmorrhoids, require different treatment from those which are internal to the sphincter. In the acute stage of external piles, when they are small, hot fomentations, poultices, and the medical treatment already advised, will generally succeed in relieving the symptoms; but if they be large and tense, much time and pain will be saved to the patient by making a free incision through them, and evacuating the contained blood. The incision should be made with a small curved bistoury in the direction from the circumference towards the centre of the anus; immediate relief will follow, and the very slight bleeding that takes place, which is rather beneficial than otherwise, is never sufficient to cause either the patient or surgeon any anxiety; the wound will heal by granulation, the skin contracts, and the parts are restored to their normal condition in a few days. But if this proceeding be neglected, permanent tumours will be formed in the manner previously described.

When these exist, they should be excised, and it is the only advisable plan of treatment; if the error be committed of applying ligatures to these as to internal piles, intense suffering will result, a striking example of which I witnessed in a case some time since. Care should be taken not to remove more of the integument than covers the tumour, or, upon cicatrization of the wounds, contraction of the anus will ensue, the serious

consequences of which have been referred to in Chapter IV. The usual mode of excision is by means of a pair of curved scissors; the pile, being seized with a vulsellum or pair of forceps, is to be cut off with the scissors, the incisions radiating from the circumference towards the centre of the anus. A less painful mode of removing these tumours is by a probe-pointed straight bistoury: when the tumours are large and much indurated, they slip before the edge of the scissors, rendering a second or third cut necessary; besides, a certain amount of bruising of the tissues occurs in this manner of operating, and occasions great pain unless the patient is under the influence of chloroform. In using the knife, the incisions can be made with a greater degree of exactness: each tumour is to be held with the forceps, and incised at its base, the lower half of the incision being made first, that the blood may not interfere with our view. If the hæmorrhoid be small it can be cut off with one stroke of the knife, but if large the preceding plan is the better, as the removal of more of the integument than is necessary can be thus avoided. Should fissure of the anus coexist, it will generally heal after the excision of the tumours : slightly stimulating lotions and ointments will sometimes be advisable till the cure is complete.

In the majority of cases it will not be necessary to

interfere surgically with internal piles, if the treatment already described be steadily pursued, and the patient strictly attends to the injunctions of his medical adviser with respect to diet and exercise. Even when the tumours are large, and have existed for some time, the use of soap and water externally, night and morning, the injection of cold water or lime water after each dejection, and keeping the bowels easy, will enable the subjects of them to pass their lives in tolerable comfort. But when, notwithstanding the adoption of these means, the tumours continue affected with pain, wearing out the strength of the patient, or bleeding occurs to such an extent as to affect the constitution, producing the various symptoms that have been described, or that the tumours are constantly protruded, and a profuse mucous discharge kept up, it will be advisable to remove them by surgical operation. I may be permitted to repeat that it is only when the constitution suffers from the local disease we are to remove it; and we must be careful not to do so when that disease appears beneficial in warding off those of the more important organs of the chest, head, and abdomen, which, if aggravated, might terminate fatally.

If after a minute and careful inquiry as to the existence of any hereditary predisposition in the patient to other disease, and as to his previous state

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of health, also to his freedom from disease of the head, of the thoracic and abdominal viscera, and after a mature consideration of the whole circumstances of the case, the propriety of an operation shall be determined on, the next question that will engage the attention is the best mode of proceeding. It is It is premised, that before having recourse to any surgical interference, the general health of the patient has been attended to, and the bowels thoroughly unloaded, measures that are highly important to a successful issue of the case, the neglect of which has often seriously aggravated a patient's sufferings, and led to a tardy recovery. Formerly great difference of opinion existed regarding the plan to be adopted, many eminent surgeons advocating excision, while others used the ligature. One reason for this want of agreement among those who have written on the subject depends much upon their not having drawn a distinction between internal and external piles, but applied a general rule to the treatment of both kinds. It is now, however, generally admitted, that excision. is applicable only to external tumours, while the ligature, and, in some cases, the use of nitric acid, are preferable in the removal of internal hæmorrhoids. That the operation of excision itself is more rapidly performed than the application of a ligature cannot be denied; but when we take into account the frequency