If the piles be without 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 two-fold—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.[24] 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, that is, 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. 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. 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 a dozen leeches, or from half a dozen to a dozen, should be 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, an ointment must be applied to the tumours and around them night and morning, composed of two drachms of powdered galls, half a drachm of camphor, and two ounces of lard; or composed of one drachm of powdered black hellebore root, rubbed down in one ounce of lard. The latter preparation will, for some time after its application, give much 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.