like, to prevent the circulation becoming overloaded, and the occurrence of hemorrhage in more important organs.

SECTION II.-OF PILES.

PILES are soft tumours, generally round, sometimes flattened, sometimes with a broad base, sometimes attached by a neck, varying from the size of a pea to that of a French walnut, which form within the lower intestine, and at or about its orifice.

Sometimes they are situated entirely without the bowel, and are covered by the common integument; these are called outward piles, or skin piles.

When they form within the bowel above the sphincter muscle, they are of course entirely covered by mucous membrane; these are called inward, or intestinal piles. They are liable to be forced down when the bowels are relieved, so as to protrude externally; but their appearance is so different from that of outward piles, and their place of attachment and origin is so easily determinable by examination, that it is hardly possible to mistake the one for the other. They are soft, with more or less firmness, and red, blue, or brown in colour, under different circumstances.

Sometimes piles are situated exactly at the margin of the intestine, and are wholly without

the sphincter, or nearly so, forming swellings with this peculiarity, that they are half covered with mucous membrane, half with skin. These are marginal or anal piles; they are sometimes confounded with inward piles.

These swellings, whatever situation they occupy, consist of the following elements; first, of a growth or production of skin or mucous membrane, which forms their covering; secondly, of a growth of the minute vessels, which goes with the growth of the flap of mucous membrane or integument; thirdly, of dilated veins, which are partly produced, like varicose veins of the legs, by the pressure of the column of venous blood in the intestines, partly by the local increase of vascularity; fourthly, of inflammatory products, lymph or serum, which infiltrate the tissue of the flap of skin or mucous membrane, giving to it more or less firmness. Piles in different cases present one or other of these elements more prominently than the rest. Some are merely little pendulous flaps, others have the highest vascularity in addition, others with some thickness are soft, and are blue with dilated veins, others again are of a firm consistence, whitish if external, brown if internal, from effused lymph or serum.

Piles generally occur in persons who are liable to the attacks of vascular fulness already described, which are thence often miscalled attacks of piles.

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But the piles are generally there before the attack, although they swell and become larger during the attack; they continue for a time swollen after the increased heat and pain have subsided; they then gradually become less full and tense, and remain not more sensible than the surrounding parts.

Piles have been divided into bleeding piles, and such as do not bleed; the bleeding, however, has little to do specifically with the piles. If they are external, they do not bleed, (for blood most rarely transudes through the skin;) if they are internal, they bleed only in connexion with the disposition to bleed common to the adjacent mucous surface.

Or the tumours called piles bear the following relation to the congestion described in the preceding section. They sometimes arise from it; when they already exist they participate in it, and are the principal seat of the pain; and they probably render the attacks of congestion more frequent than they otherwise would be.

The progress of this complaint presents several varieties. Or this is common to each sort; the lump which forms the pile may come either suddenly or gradually; its condition is always fluctuating, sometimes more uneasiness being present than at other times; but the alternatións with the attacks of pain are often remissions only, and there is constantly present greater or less uneasiness. In other cases, and these by far the most frequent,

there are intervals of entire absence of pain, in which the lump, now less than before, has not more sensibility than the neighbouring parts; finally, the lump may continue for a lifetime; or may disappear by suppuration, forming a small abscess; or, what is more common, may waste, losing its firmness and interior hardness by absorption, and becoming only a thin flap of skin or mucous membrane, with no disposition to pain or action of any kind.

I shall describe the three varieties of piles separately.

External piles are little lumps, generally oblong, and more elevated than thick (resembling, for instance, in shape, the seed of a lupin adhering by its concave edge), and from that size, to the magnitude of an inch in length, half an inch or more in height, and the same in breadth. They are laid generally laterally to the orifice of the bowel. Sometimes there is one only, more commonly there are two or three. Sometimes they are flatter. They are covered by the common integument, of which they have the colour. In their quietest state they are soft flaps of skin and membrane, having common sensibility; when angry, they are firm, hard, and exquisitely painful.

There are several modes of treating external piles. When they are unattended with pain, the best way is to leave them alone, only scrupulously

using soap and water after each action of the bowels, as the irregularity of the surface makes it otherwise probable that some impurity would remain, and it is certain that nothing contributes to the growth of these tumours more than this cause. It is unnecessary to repeat that the greatest attention should be paid to the action of the bowels. When the swellings are painful by fits only, and this often happens for two or three days together, unfitting the patient for his customary avocations, the best way by far is to remove them by an operation, which is painful indeed, but is over in a moment. They should not be removed by the ligature, which is slow as well as painful, having to act upon a fold of skin; but they should be taken off with scissors, or with the knife. The part has then to be poulticed for two or three days, during which the patient should remain in the recumbent posture. If the patient has not nerve enough to submit to the momentary but severe pain, the next best thing is to apply pressure. This may be made by means of a metal cylinder, like a ruler, an inch and a half in diameter, on which the patient is to habituate himself to sit. At first the pressure is painful; but use renders it less so, and the tumours often waste under it. When the pain arising from outward piles is constant and severe,—and it sometimes will continue incessantly for months,-the same plan, with cooling lotions, or cold water fre