A proper speculum is very essential to the successful treatment of sacculated mucosa, and I know of none equal to that devised some thirty years ago by Dr. A. W. Brinkerhoff. The speculum is easy to introduce, and by drawing a slide the tissue is properly exposed or shut out to a nicety, exhibiting just the amount you wish to treat. In some cases there is a rather lengthy sacculated mucosa on the side, or on the anterior wall of the anorectal tube, and it is advisable to treat only the upper third or half, and at a subsequent visit or visits to treat the remainder, thus avoiding annoyance to the patient. The paramount concern should be to avoid causing pain both during the treatment of a sacculated mucosa or its possible occurrence a few hours or days later. I have often remarked that when pain or soreness follows the treatment of a mucous sac the fault is in the application of the remedy, and not in the remedy itself. Now and then there may be conditions in which you will expect pain or soreness to follow the treatment, and you will prepare your patient with the necessary appliances and remedies to overcome it promptly. Where there are no possible means for avoiding the pain consequent upon a treatment, leave nothing undone to make it as slight as possible. All mucous sacs ought to be treated without any after-annoyance to the patient, and they can be if we only wait for the proper time to treat them. I have not thus far considered the muco-cutaneous sacs around the anus, which are neither useful nor ornamental, and which often indicate the volcanic action of inflammation and the amount of mucous lava thrown out around the vent. CHAPTER XXII. EXTERNAL AND THROMBOTIC PILES VERSUS MUCO-CUTANEOUS SACS AND THROMBUS. The vent of a crater indicates the convulsive and destructive changes that have taken place within; and, very often, the vent of the gastro-enteric sewer gives like evidence of long, great, and severe destructive changes. The fire of inflammation has burned fiercely for many, many years, and serous lava has, from time to time, poured forth, leaving a searing, inflammatory path. As it was forced from the recto-anal crater, the acrid, burning mucus, that had been imprisoned, made subcutaneous streams, cavities, channels, sacs, etc. Its course is marked around the anus by peaks, crags, muco-skinny tabs, small and large bulging muco-cutaneous sacs, dilated anal veins in which clots of blood often form; light gray, brittle, shiny skin with small and large red and sore oases, thickly studded over the itching area, which the sufferer has scratched in the vain hope of appeasing the torture of pruritus ani, scroti, vulvæ; while cold drops of perspiration stand over his or her face and body, serving to indicate the physical and mental anguish inexpressible in words.