following points should be attended to. If a large tumour is to be tied, it is better to pass a double ligature through its base with a needle, and to tie each half separately. And again, it is important before tying the ligature, to cut into the tumour. These precautions are necessary to allow the ligature to be drawn so tight as completely to strangulate the tumour, and to cause it at once to mortify. If the tumour is only half strangulated, the pain instead of subsiding continues till the fact is discovered, and the ligature tightened.

In this form of the complaint, if the ligature is resorted to, it is unnecessary, when there are several, to tie more than one or two of the tumours; the rest will be sure to waste. To tie more would give more pain, and lead to what sometimes follows this operation, constriction of the gut.

This operation is attended with as little danger as any operation. Still it must be borne in mind that there is some. Once in a hundred times, fatal inflammation of the membrane of the belly follows it. Nor is it possible out of many patients with the appearance of good general health, to conjecture on whom the unfortunate lot would fall; yet out of many, one or more there would be whose health is wavering, so uncertainly fixed, that this weight thrown in the adverse scale is mortal.

Removal by ligature must be considered as the best treatment for the third and fourth kinds of

inward piles which I have described. I conclude that there is less risk from the operation in those cases. The tumours have in both a character further altered from the natural structure. The operation again is so far necessary that it is the only mode of getting rid of the complaint; inasmuch, at least as far as my experience has gone, tumours of this kind do not waste, but remain permanently troublesome. All these circumstances being explained to the patient, it rests with him to decide whether he will bear the habitual inconvenience, or incur the very trifling risk attending the operation for its removal.

Looking at the varieties of inward piles in reference to their occasional changes, whether towards aggravation or otherwise, the following features present themselves.

1. They are, of course, liable to be involved in the general congestive state already described, to relieve which the recumbent posture, fomentation and poulticing, abstinence, and laxative medicine, are appropriate.

2. When in this state, they are liable to slough, which is the best thing that can happen. This change has a formidable appearance, but the sloughing does not go beyond the tumour, which it removes and cures.

3. The congestive state of piles occasionally leads to suppuration in them, when they form

little abscesses, which being opened, or bursting spontaneously, the tumour afterwards shrinks and disappears.

4. After a severe congestive attack, piles are more likely to shrink and waste, than when they are in a chronic state of uneasiness.

5. Inward piles, when of large size, and casually swollen, sometimes cannot be returned by the patient when they have protruded. In this state they cause extreme pain, and excite inflammation and fever. By gentle pressure, the surface being smeared with cold cream, a surgeon should have no difficulty in returning such a tumour. This is a case in which, the irritation of the temporary strangulation having subsided, removal by the ligature should be strongly recommended.

SECTION III.-OF PROLAPSUS.

THE lower intestine is liable to protrude inverted like the finger of a glove. This may result from two causes, either from habitual straining, that forces the bowel out of the anus, or from relaxation of the sphincter, which deprives it of the natural support.

The cases of protrusion from unusual straining are again of two kinds,-in one there is adventititious local disease: in the other, none. The principal of the adventitious local diseases referred

to, are piles, stone in the bladder, and worms. The first is not an uncommon cause of prolapsus in adults: the two last, in children. In general the prolapsus ceases when the adventitious disease is removed. If it should persist, either from the natural adhesion of the bowel to neighbouring parts being relaxed and elongated, or from dilatation of the sphincter, or from both causes united, it has to be treated by one of the methods presently to be mentioned.

The common cause of prolapsus, where there is no antecedent local disease, is costive bowels: it is then a complaint of very slow growth. At first the protrusion is hardly perceptible, and returns spontaneously, immediately after the bowels have acted; but it goes on increasing; and after some months or years, a length of four, five or six inches is extruded at every motion, to return which, some time, and the recumbent posture, and pressure, are necessary: add to which, there is a constant flow of mucus, and the bowel is liable to prolapse in walking or riding, or even on standing any length of time and the constant exposure of the mucous membrane causes it to become sore and excoriated, and, at times, the prolapsed part will swell to a volume which it is beyond the patient's power replace, and he lies in considerable pain till the tumour can be returned by a surgeon. Even when the quantity of intestine protruded is not great,

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nor attended with much soreness or swelling, sometimes hours will pass before the patient can return the part himself. So I have known a patient, as a protection against the inconvenience of prolapsus, habituate himself to relieve the bowels once in forty-eight hours only, and that before retiring to rest, in order that, during the night, the bowel might gradually become replaced.

For different cases of this complaint the treatment must be different.

When it occurs in children (in whom it is very frequent) from costive bowels, it is generally only necessary to obviate the constipation by laxative medicine, and the disorder ceases. For this purpose, the lenitive electuary, or præcipitated sulphur, or rhubarb with magnesia, are appropriate medicines. When, the bowels having been thus regulated, the complaint persists, the daily use of an astringent injection is to be recommended. Three or four ounces of lime-water, or of infusion of catechu, or of the same, with a few grains of alum, or of sulphate of zinc, will give tone enough to the part to prevent its reprotrusion. These injections should be administered before the child gets up.

In grown-up persons, when this complaint depends on costiveness, both the cause and the effect may often be together remedied by the daily use of an injection of cold water. When this is not