an error is made, and the oedematous integument removed, the serious evil of contraction of the anus will ensue on the cicatrization of the wounds. Whether excision, ligature, or the application of nitric acid be had recourse to, a dose of opium should be administered after the operation, and in this there is a double intention to be answered, the one to tranquillize the system and allay pain; the other, and the chief one, is to lock up the bowels for a day or two, to prevent the irritation that would be produced by their action. On the third day, if the bowels are not moved of their own accord, an emollient lavement must be administered: this should be repeated on the fourth or fifth day; afterwards the bowels must be kept open by castor oil, lenitive electuary, infusion of senna with decoction of cinchona, or similar remedies. : For the first two days the patient must be confined to his bed on the third day, according to circumstances, he may be allowed to leave his room, and lie on a sofa about the fifth day he may begin to move about, and, if the weather permit, he may take a gentle walk, or a drive in a carriage. : The diet for three or four days must consist of sago, arrowroot, barley-water, beef-tea, mutton, veal, or chicken broth when the patient begins to walk about, some solid food may be allowed, but great moderation must be observed. : When the ligatures have come away, or the eschar produced by the action of the acid separates, leaving an ulcerated surface, the injection of four or six ounces of water, with two grains of sulphate of zinc to the ounce, will expedite its healing. Occasionally it happens on the second or third day following the operation, that the patient experiences some difficulty in micturating: a dose of hyoscyamus, with nitric ether, in camphor mixture, and a hot hipbath, will generally remove these symptoms. Should these means, however, not succeed, and retention of urine supervene, it will be necessary to introduce the catheter; but we shall seldom be called upon to do so: nevertheless, the bladder must not be allowed at any time to become over-distended. In the treatment of ulceration of piles, it will generally be advisable to remove them: if they are external, they must be excised; if internal, the ligature or nitric acid must be employed. When fissure of the anus exists as a complication, it will usually be found accompanying the external form of hæmorrhoids. The tumours must be excised, and a mild astringent ointment, with or without the extract of belladonna, applied, according as there is spasm of the sphincter muscle or not. If this be insufficient to heal it, it will be necessary to have recourse to the operation described in Chapter V. If abscess take place in connection with piles, an early and free incision must be made, otherwise fistula in ano may result. The protrusion of large internal piles from the anus causes the patient great annoyance, and at times is alone sufficient to induce him to seek surgical aid. At first the protrusion only takes place at stool, but in the progress of the disease, the sphincter becomes relaxed and the anus dilated, so that they fall down when the patient makes the slightest exertion, or even on his assuming the erect posture. If no contraindication exists, the removal of the tumour or tumours is the best treatment; but if this is not admissible, six or eight ounces of cold water must be thrown up the bowel twice or thrice a day: various astringents may be added to the fluid, such as sulphate of zinc, alum, acetate of lead, tannic acid, &c. Surgical mechanicians have invented various instruments for the prevention or cure of piles, but they succeed in accomplishing neither; however, their contrivances are useful in assisting to prevent the protrusion, and the discomfort arising therefrom, when it is unadvisable to remove them by operation. It has been recommended to make temporary pressure on internal piles, by the introduction of a bougie into the rectum, and retaining it there for an hour or longer every day; but whenever success has appeared to follow the proceeding, it has been due to the constitutional treatment that has been adopted at the same time, and not to the use of the instrument. Those who advocate this plan, entertain the idea that internal piles are dilated veins, and that as pressure is beneficial in dilatation of the veins of the leg, it must also be beneficial in these cases; forgetting that the rectum is surrounded by yielding parts, and the impossibility therefore of making firm and equable pressure they also overlook the fact that in the varicose condition of the veins of the leg, pressure is only useful so long as it is continuously applied; that the bandages require great nicety of adjustment to afford the desired relief, and, even after their use has been unremittingly persevered in for years, the veins remain in the same dilated condition, and all the miseries attending them return if the bandages are left off only for a few hours. When the patient begins to regain health and strength, he must avoid all the causes that induce the disease from which he suffered. He must live sparingly, and be careful to keep the bowels regular: he must take as much exercise, short of fatigue, as he can, so that the skin and other excretory organs may fully perform their functions and prevent plethora. If these means are insufficient, or, if by neglect of the advice given him, and returning to former habits of indulgence, he is threatened with congestion of any of the organs in the head, chest, or abdomen, the feet should be immersed every night in hot water and mustard, and the bowels should be freely acted on: a dose of calomel and jalap will be the best to commence with, afterwards a few grains of blue pill, or gray powder, with a grain of ipecacuanha, may be taken at bedtime, and a purgative draught in the morning, as the compound infusion of senna, with decoction of cinchona, or potassio-tartrate of soda in infusion of calumba. Blood may be taken by cupping from the region of the organ threatened, or from the sacrum and perineum. With regard to the use of chloroform in operations on hæmorrhoidal tumours, much must depend on the patient's own wishes on the subject: I should never recommend it except in removing external piles that have become permanent, the pain attending their excision being very sharp for the time. Applying the ligature or the nitric acid to internal hæmorrhoids does not usually cause more pain than the patient can very readily bear, unless the nervous system be very excitable, or he is peculiarly obnoxious to pain. Besides, the surgeon requires his co-operation to prolapse the tumours, and to prevent their retraction while he is performing the operation. However, if the wish to inhale it is expressed, I should never |