they early break and bleed. And 2ndly, where they present, outside the bowel, a small tumour, separable into lobes, altogether like a piece of sponge, coloured, and bleeding occasionally from the surface.

Of all the causes which operate in the production of piles, habitual constipation is the most frequent. The excrementitious matter is delayed in the bowel, becomes hard and knotty, and a source of great irritation; this irritation induces a determination of blood to the part, and the gradual dilation of its vessels. takes place as a consequence, which eventually forms the tumours known under the appellation of piles. Now as in pregnancy there is a greater disposition to costiveness than at any other time, and as piles may be a consequence of this disordered function, so this disease is much more prevalent during the pregnant state than at any other period-another argument, and a very powerful one, why costiveness should be diligently guarded against.

The symptoms of this complaint are well known. There will be weight, heat, and a sense of fulness about the lower bowel, a frequent desire both to relieve the bowels and bladder; all of which symptoms are removed for a time if a discharge of blood takes place.

If the piles be outside the bowel, they are constantly irritated by the friction of the parts in the ordinary motion and erect position of the body, and that to a painful degree during the period of the evacuation of the bowels. If exercise be taken in a carriage the pain is much aggravated; and if the irritation produce inflammation, the piles will become swollen, red, or purple, and excessively painful.

The treatment of this disease, when it occurs during pregnancy, is twofold-general and local. We must

remove the cause by such means as excite a brisker action of the bowels; and our choice of aperients must be directed to those which act efficiently but mildly, and without irritating the lower bowel itself. Next to small and repeated doses of castor-oil-say a tablespoonful-the most desirable form of aperient that can be employed is the confection of senna (i. e. lenitive electuary) combined with sulphur and magnesia. Of the following form, a dessert-spoonful or more should be taken, at first, twice daily :-Confection of senna, two ounces; flowers of sulphur, one ounce; carbonate of magnesia, two drachms and a half.

In conjunction with this medicine, much benefit may be derived by the injection of half a pint of warm or cold water (whichever soothes most) as a lavement; but it must be administered very cautiously, to avoid irritating the parts with the pipe of the instrument, which should be made of caoutchouc, and not of hard bone or ivory.

The best form of instrument is figured below. It consists of an elastic bottle with a flexible tube. To use it, unscrew the top, and fill the bottle with the fluid to be injected, replace the top, and having smeared the tube with a little sweet oil, introduce it gently into the rectum, and empty the bottle by firmly squeezing its sides together; be careful to keep up

FIG. 3.

MAW

the compression until the tube is withdrawn, or otherwise the fluid will be drawn back from the bowel into the bottle. Maw's instruments are the best and cheapest.

It is important that medicine, in frequent use, should be so taken as to act upon the bowels in the

evening only; for if the bowels are acted upon in the morning, the patient, being obliged to move about all day, will suffer considerable distress and local irritation, whereas, if the bowels are not evacuated till the evening, the horizontal position and the perfect rest of a long night will obviate all inconvenience. If the bowels, however, do act during the daytime, it will be desirable to lie down for an hour or so, and great comfort will be thus afforded.

Great assistance may be afforded in the cure, and also in alleviating pain, by external applications to the tumours themselves. If, however, the piles are swollen and inflamed, and the pain experienced great, half-adozen leeches, or from half-a-dozen to a dozen, should be at first applied in their immediate neighbourhood, the parts fomented, and then warm bread-and-water poultices renewed every three hours. These remedies will afford very considerable relief; and when the inflamed state is subdued, the following ointment must be applied to the tumours and around them night and morning :-Powdered galls, two drachms; camphor, half a drachm; lard, two ounces. Mix. Or, powdered black hellebore-root, one drachm; lard, one ounce. Mix.

The latter preparation will, for some time after its application, give pain, but proportionate relief will follow. The diet must be sparing in quantity, mild in quality, and such as to leave, after its digestion, as little to pass through the bowels as possible.

I may add, that the removal of piles by operation during the pregnant state is perhaps never justifiable. Let the patient, therefore, consult her medical attendant in time, and not, by a false delicacy, expose herself to an evil which it is her duty to endeavour to prevent,

ENLARGEMENT OF THE VEINS OF THE LEGS.

89

Sect. 8.-Enlargement of the Veins of the Legs.

This is a frequent, but not very troublesome, accompaniment of the latter months of pregnancy. It arises in some degree from the pressure of the womb upon the large venous trunks, impeding, to a certain extent, the free flow of blood through them. It is frequently remarked in pregnant women who have passed a certain age; but it is unusual in the young woman, even during a series of repeated pregnancies.

When first observed, if the veins have not become knotty-that is, having little lumps or swellings in their course up the legs - the only means which it is necessary to employ is the application of a calico bandage-six yards in length and as wide as three fingers-from the sole of the foot up to the knee, and sufficiently firm to give support to the venous trunks. This bandage well and equally applied to the limb, with a little aperient medicine twice a week, and the recumbent position for two or three hours in the middle of the day, will cure this form of the affection.

When, after a time, the veins, more and more distended, have become lengthened, tortuous, coiled up, or knotty, a sense of heaviness, numbness, and sometimes very acute wandering pain, will begin to be experienced through the whole of the affected limb. And in a more advanced stage, in proportion as the knotty tumours increase, the limb becomes generally swollen. This form of the disease calls for much care and patience on the part of the sufferer. The legs should be strapped, from ankle to knee, with strips of adhesive plaster; and over this a calico bandage must be applied with a moderate degree of tightness, and kept wet with Gou

lard-water. An elastic laced stocking, made for the purpose, may be worn, and will be found at once a sufficient support to the limb, and a source of great comfort to the wearer.

It will occasionally happen, and I have lately seen it even in young married women, that, connected with enlargement of the veins of one or other leg, there will also be a similar enlargement of the veins of the external parts of the corresponding side of the body. Appearing for the first time at an early period of the pregnancy, the enlargement increases as the months advance; so that just before confinement it will sometimes have acquired the size of a pear or orange. It becomes a source of great annoyance, as it almost incapacitates for walking, and is always much increased, for a time, by attempting to do so. It also causes great anxiety; for which, however, there is not the least occasion. When it increases much in size, the recumbent posture must be kept during the greater part of the day, halfa dozen leeches applied very near to the parts, and a gentle aperient taken occasionally, as great attention ought to be paid to the state of the bowels. The parts within being sometimes hot and irritable, they should be dressed night and morning with a piece of lint folded and spread on both sides with spermaceti ointment. These means will generally considerably diminish the swelling and remove uneasiness; but the swelling itself will continue during the remaining weeks of pregnancy. After delivery it will gradually subside, although perhaps it will never entirely disappear.