sphincter, which enabled him to command a view of the parts, in the event of any vessel requiring to be tied. This mode of securing the parts affords some advantage to the operator; but it often happens in this operation, that, although the bleeding may be comparatively slight at the time the piles are cut off, a large quantity of blood escapes in the course of a few hours afterwards, and gradually accumulates in the rectum. Dieffenbach's plan is preferable to the preceding. He first passed a ligature through the base, and grasping the pile with the forceps, excised it between the forceps and the ligature, which was then tied. The pressure produced by bringing the edges together assists in preventing hæmorrhage. Small elongated piles can be removed in this way without risk.

Internal piles admit of removal by cauterization. Dr. Houston, of Dublin, in a paper published in 1843*, strongly recommended the use of nitric acid for the cure of the florid vascular pile; and I have since employed this escharotic in cases of the kind. It has the advantage of being a safe and mild remedy, and is certainly well adapted for destroying the bright fungouslooking pile which is so often the source of hæmorrhage, and the cause of much local uneasiness. Means having been taken to bring the pile well into view, the patient should lean over a table, and his nates should be separated by the hands of an assistant. The surgeon may then take a glass brush, or a flat bit of wood, and, having dipped it in concentrated nitric acid, apply the escharotic to the entire surface of the hæmorrhoid, until its florid hue becomes quite changed to an ash colour. No speck of red should be allowed to remain. Care must be taken that none

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of the acid touches the skin at the margin of the anus. For the purpose of protecting the parts around the pile whilst applying the acid, I use a pair of steel forceps with electro-gilt blades, which are well adapted to grasp the base of the pile, and to shield the structures around. The moisture on the surface having been absorbed with lint, and the part smeared with sweet oil, the protrube placed within the sphincter. The pain consequent on the application is not severe, and the separation of the superficial slough and healing of the sore occasioned by the acid are attended with scarcely any uneasiness. If the pile be not large, this plan answers very well, but it is not adapted for the removal of hæmorrhoidal flaps and tumours of any great size. The escharotic treatment of piles has recently been a good deal resorted to, and several cases in which the attempt has been made to

remove well-developed growths by this method without success have come under my notice, and required other means of cure. In some instances, too, in which the nitric acid has been extensively applied, I have been informed that on the separation of the eschars there has been troublesome hæmorrhage; and, also, that the large sores which ensued have healed with considerable difficulty. The actual cautery, Vienna paste, and other caustics, are also used, chiefly by French surgeons, and some ingenious instruments have been contrived for their application.

For the cure of internal hæmorrhoids of any considerable size the ligature is the safest and most effectual

remedy. In order to apply the ligatures properly, it is necessary to promote the protrusion of the piles. For this purpose a dose of castor oil should be given about six or eight hours before the time fixed for the operation; and a pint of warm water should be thrown into the rectum shortly before the surgeon's arrival When the fluid is discharged the piles will descend, in which position they may be retained by the patient keeping up a slight expulsive effort. It is better to operate without chloroform, as the relaxation which occurs under its influence is very liable to occasion the ascent of the piles, and generally prevents their full extrusion. I now never employ chloroform unless the patient is very sensitive and much desires it. The operation should then be performed, the patient lying on the side with the thighs raised: otherwise the most convenient position is with the body leaning over a table,

and the nates separated by an assistant. The growth to be tied should be seized and drawn out either with the volsellum, or what is better, because it ensures a firm hold without tearing the pile or causing bleeding, with a broadbladed forceps grooved inside, having a rack catch at the bows to fix the grasp of the instrument. If the pile be an elongated one, a ligature may be tied tightly round its base. In other cases a curved needle set in a handle, with the eye near the point, and armed with a fine strong twine ligature, should be passed through the base of the pile from without inwards. The needle is then to be withdrawn, the ligature being left double. The loop

being divided, the pile is to be strangulated by drawing the ligatures close round the base, and knotting them as tightly as possible on each side. The other piles are afterwards to be treated in the same way. When the hæmorrhoids are large in size, a notch made with scissors on each side at the part to be girt with the ligature, just before it is tightened, will facilitate the separation without any risk of bleeding. The ends of the ligatures having been cut short, the strangulated piles should be gently pushed up into the

rectum.

I generally order a mixture of chalk with a full dose of laudanum to be given immediately after the operation, in order to relieve pain and bind the bowels. The sufferings of the patient afterwards vary a good deal, according to the extent of the parts strangulated and the irritability of the constitution, but they are generally slight and soon subside, a ligature on a mucous membrane not being productive of as much pain as when constricting skin. In some instances, however, they are severe and prolonged, and accompanied with restlessness and want of sleep. When this is the case, there is nothing capable of giving such complete relief as ice. A small india-rubber bag or bladder containing ice may be applied to the part, and refilled as occasion requires. Both immediately after the operation, and later when inflammation has been set up, the greatest ease and comfort are derived from this application. If the heat and swelling should be only slight, poultices and fomentations will give sufficient relief. No aperient should be taken for several days. I generally order a dose of castor oil on the third or fourth day after, and direct the patient to sit in a warm hip

bath as soon as it has acted. The tighter the ligatures are tied, the sooner they ulcerate through and come away. By notching the part in the way described, a voluminous pile has sloughed away in two days. The separation usually occurs in about four or five days, during which period the patient should remain in bed or on a couch. The detachment of the sloughs leaves, of course, at the lower part of the rectum a sore surface, which bleeds slightly when the bowels are relieved, and some attention will be required until this heals. The motions must be kept soft by mild aperient medicine, as the linitive electuary, or castor oil. If the sore be slow in healing, it may be smeared night and morning with a liniment consisting of a drachm of the liquor plumbi diacetatis and an ounce of the confection of roses; or it may be brushed over with a weak solution of the nitrate of silver. Should bleeding prove troublesome after the separation of the sloughs, a somewhat stronger solution (gr. x.—3iv.) will effectually check it.

The local irritation produced by the ligatures sometimes occasions retention of urine, and the passage of a catheter may be required in the evening after the operation. A hip-bath in addition to an opiate injection will generally relieve the urinary symptoms.

In operating on internal piles it is not necessary to be particular to include in the ligature every portion of the morbid growth, or of the hypertrophied mucous membrane extruded with it. The removal of large piles leaves a sore surface of such an extent that the contraction which ensues in healing is sufficient to reduce any part that may have escaped the ligature, and to correct the lax condition of the adjoining mucous