the patient's legs while standing; it may also be very acrid, and produce excoriation of the external parts, adding greatly to his other sufferings.

By sympathy and contiguity, the irritability and sensibility of the bladder and urethra will be increased, micturition will be more frequent, and in the aggravated form we shall observe the opposite effect, strangury, or even retention of urine.

All patients who are the subjects of hemorrhoids suffer more or less from constipation, with its concomitant symptoms, flatulence, pain, and constriction at the epigastrium, vomiting, &c. Where the disease is fully established, particularly if much blood has been lost, there will be pallor, and a peculiar dingy waxy appearance of the countenance; the respiration will be hurried and irregular, the heart's action readily increased by the slightest bodily exertion or mental emotion: this is often so distressing as to lead the patient to think he has disease of that organ, for which he may seek advice, and, by dwelling too exclusively on this one effect, may mislead his medical attendant from the real disease.

Giddiness, drowsiness, weight and pain in the head, are very common symptoms in these affections, and occasionally, spasm and rigidity of the extremities will be complained of. The attacks are not unfrequently ushered in by rigors; the tongue will be furred, large, and deeply notched by the impressions of the teeth; the skin will be harsh and dry; the functions of the kidneys deranged; the pulse, increased in velocity, will be hard and contracted, or rendered weak, irritable, and quick, from debility, suffering, and loss of blood.

Hemorrhoidal affections are liable to be overlooked from two causes the one being a delicacy on the part of the patients, leading them to conceal the origin of their sufferings; the other the severity of some of the symptoms, or derangement of other organs consequent upon them, diverting the attention away from the real seat of disease: however, a careful investigation into the origin and history of the case will not fail to elucidate its true

nature.

The diagnosis of hemorrhoids will not be attended with much difficulty, there being few diseases with which it is possible to confound them, and the error can occur by taking only into consideration some one or other of the prominent features of the affection.

Hemorrhoidal tumors may be mistaken for polypi of the rectum; but the converse is more usually the case, particularly by patients themselves. Polypi are more gradual in their growth, they are not preceded or accompanied by the constitutional or local inflammatory symptoms that attend piles: in the benign variety of polypi, hemorrhage does not occur, except to a very slight extent, and that only on the passage of a bulky and costive stool; their surface is smooth and somewhat glistening, and not villous or granular, like hemorrhoidal excrescences.

A very cursory examination will enable us to distinguish hemorrhoidal tumors from prolapsus of the rectum: in fact, the only form with which they can be confounded is, when a fold of mucous membrane on either side descends, and, in the course of time, becomes thickened and rugous: in this state, however, there is an absence of the ordinary symptoms of piles; the prolapsed portion of the intestine is free from hemorrhagic discharge, is not subject to alternations of turgescence and flaccidity; and, besides the extent of the base of attachment, we can roll the two surfaces of the membrane upon each other.

External hemorrhoids, when their surfaces are ulcerated, may be mistaken for venereal excrescences; but by tracing the origin. of the tumors, by the subsequent history of the case, and the absence of other symptoms of the latter affection, a correct diagnosis may be formed.

The most important distinction we have to consider, both in the prognosis and with regard to treatment, is the source of hemorrhage, which may be intestinal, and not the result of piles. But here a little consideration will prevent error: intestinal hemorrhage is generally a result of acute and dangerous visceral disease, and the constitutional disturbance attending it will be severe, and of marked character; it more frequently accompanies the advanced stages of malignant fevers and general cachexia. The state of the blood discharged will enable us to form a tolerably correct opinion whether it be from piles or not: when it occurs from any portion of the intestinal canal above that which is the seat of hemorrhoids it will be clotted, very dark, and mixed with the fæces and excretions, and will be passed at stool without any of the distress attending piles; nor shall we be able to detect by digital examination per anum any form of tumors or varicose state of vessels.

But, on the contrary, if the hemorrhage be from piles, the blood will either precede or follow defecation, will be florid in color, and fluid, with all the characters of being recently extravasated. There will also be the local symptoms attending these affections, as weight and fulness in the rectum, pain, and others which have been previously mentioned: these will be aggravated at stool; besides, examination will reveal the presence of one or more tumors, or other lesions.

Before commencing the treatment, it is most important that a careful and minute examination of the rectum and anus should be made when a patient complains of any of the symptoms of hemorrhoidal disease: firstly, that we may arrive at a correct knowledge of the peculiar kind of tumor, and the condition of the parts, also as to the existence or not of any complication; and, secondly, because the accounts given by patients themselves are frequently inaccurate, and they are too apt to dwell on any one or more of the symptoms that may be most distressing to them.

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In making an examination in the male, the patient should be directed either to lean over the back of a chair, or to lie sofa on his side, with the nates projecting over the edge, and the knees drawn up; the latter position is preferable, and should always be adopted with female patients. The parts when inflamed being acutely painful, all possible gentleness must be observed, particularly if fissure of the anus exist as a complication, as slight irritation will often induce excruciating agony. Previous to making a digital examination of the interior of the bowel, the cavity of the nail should be filled with soap, which will prevent its scratching the intestine, and the finger must be dipped in oil to facilitate its introduction; lard and unguents do not answer so well, as they interfere slightly with the delicacy of the sense of the touch.

Having become acquainted with the abnormal condition of the parts, the next consideration is, whether the hemorrhoidal affections are of a constitutional or accidental origin: it is on arriving at a just conclusion on this point that the principles of treatment must be based, and on it our success must depend. When piles have existed for a long period, have continued from youth, or the commencement of puberty, when they supervene upon or replace some serious organic or habitual affection, if they are preceded by

constitutional disturbance, and succeeded by an improvement in the state of the health, if well-marked indications of plethora exist, which is relieved by the accession of the hemorrhoidal flux, and if indications of congestion, or disease in any of the organs accompany or follow its suppression or interruption, or an hereditary predisposition exists, a constitutional nature may be inferred; and local treatment must be a secondary consideration, and not adopted till the constitutional cause has been removed or palliated: this is especially necessary if there is a predisposition, hereditary or otherwise, to apoplexy, gout, phthisis, hemoptysis, epistaxis, or other kinds of hemorrhage.

Various authors mention instances in which a neglect of the consideration of the constitutional origin, and the adoption of a local treatment of piles, has been followed by serious or fatal consequences. Dr. Copland mentions three cases having come under his observation, in one of which fever was induced, in another apoplexy, and in a third melancholia, by the improper arrest of hemorrhoidal discharge. Mr. Howship states the case of a gentleman subject to gout, who, in opposition to proper medical advice, was induced by a charlatan to have recourse to a strong vitriolic lotion, with the effect of arresting the hemorrhagic discharge, but the patient soon after died of gout in the stomach.

The general treatment of hemorrhoidal affections must consist in enforcing a strict observance of moderation in diet, due attention being paid both to the quality and nature of the aliment, as well as quantity; all stimulating food and beverages must be forbidden, and only that allowed which is unirritating and easy of digestion: this is a matter so important, not only in the diseases herein treated of, but in all others, that it would be well to give a patient written instructions on this point, in the same manner as when medicines are directed to be taken. The bowels must be regulated, and constipation combated, by deobstruent laxatives and stomachic aperients. If fæcal accumulations in the colon exist, these must be removed by emollient enemata in many cases the use of O'Beirne's tube will be highly serviceable in dislodging the excrementitious matter. When the secretions and excretions of the chylopoietic viscera are depraved or deficient, means must be adopted to restore them to a healthy state; for this purpose a few grains of the blue pill with one of powdered ipecacuanha should

the system, and by determining the blood to the organs in the pelvis, produce hemorrhoidal disease.

Certain purgatives and drastic medicines, as aloes, scammony, gamboge, black hellebore, rhubarb, the neutral salts, &c., particularly if prescribed in too frequent and too large doses, induce hemorrhoids they act directly by irritating the mucous membrane of the rectum, and by inordinately exciting that portion of the intestine, and the lower part of the colon. Of all medicines, calomel and the other preparations of mercury have been productive of most mischief in the affections we are now considering, as well as inducing other diseases of the digestive organs. It is not from the use of the mineral, but its general abuse, that the evil arises the practice is justly reprobated by Drs. Copland, Elliotson, and other writers on the practice of medicine. It may, however, be questioned whether all the medicines first mentioned, when properly administered, exert much influence in inducing the disease, and whether it is not rather to the state of the constitution rendering these medicines necessary that we should ascribe the local affections. They will severally readily reproduce the hemorrhoidal flux when once it has taken place, but it is not to be inferred from this that they will cause the disease, as morbid action having once occurred in a part is much more easily re-established even by slighter causes; therefore, before attributing the malady to medicines, it is essential to ascertain if there may not be other causes to which it may owe its origin.

As well as to living above par, conjoined with a deficiency of exercise, we shall be able to trace the disease in some people to eating various alimentary substances, particularly highly-seasoned dishes, spices, onions, shallots, &c.; to partaking of very hot or cold beverages, or too great a quantity of stimulating drinks: certain wines, such as claret, champagne, also cider and beer, will, in some individuals, readily induce the affection.

The local application of cold or heat, as sitting on stone seats, on the cold and damp ground, on damp cushions, the habit of standing with the back to the fire, riding rough horses, prolonged walks in hot weather, travelling a number of consecutive hours in a carriage, sitting on pierced seats whereby the blood gravitates to the anus, consequent upon its being unsupported, and on the obstruction to the circulation from the pressure on the surrounding