, and as a result of our vast
experience, and in consequence of our original and improved methods of
diagnosis, it is not generally necessary that we should see and examine
the patient in person. We can almost always determine the exact nature
of the patient's malady, and its stage of advancement, without seeing
the subject in person.

PILES. (HEMORRHOIDS.)

There are few maladies more common than this, and few which are more
annoying. Piles consist of tumors formed within the rectum and about the
anus, by dilatation of the hemorrhoidal veins and thickening of their
walls. Sometimes, when attended by considerable inflammation, or when
the attacks are very frequent, there is thickening of the adjacent
cellular and mucous tissues.

There are two general forms of this disease, the external or blind
piles, in which the tumors are outside the anus, and the internal or
bleeding piles, in which the tumors are formed within the sphincters,
although after their formation they may protrude. The external piles are
commonly made up of thick tissues; upon one side, the skin forms the
covering, while on the inner surface is the mucous membrane of the
bowel. It is this surface which is most tender and irritable and liable
to inflammation. The internal form of the disease is situated from a
half an inch to two and a half inches above the sphincter muscle of the
anus. The tumors are usually round, oval or cylindrical in form. They
may be scattered over the surface of the bowel, or clustered together.
The illustrations (Figs. 1 and 2) show the two forms of the disease. The
two protruding tumors in Fig. 2, illustrate the usual form of prolapsing
internal piles, whilst the one highest up in the bowel shows the form
most commonly met with. It is seldom that one pile tumor is found alone,
there usually being two or three, and sometimes as many as five or six,
in a cluster. Fig. 3 shows the manner of distribution of the veins in
the rectal region. The small venous loops, or bulb-like terminations of
the veins H. _i_., are the points at which the piles most frequently
occur.

[Illustration: Fig. 1.
Swollen External
Piles.]

CAUSES. Whatever tends to favor an undue accumulation of blood in the
hemorrhoidal veins predisposes to piles. For this reason the affection
is frequently a result of diseases of the heart and liver, which cause
an obstruction in the circulation of the blood through the portal vein.
Mechanical pressure from tumo