External hemorrhoid treated without operation.

Mr. tall and stout, generally takes moderate exercise, and lives temperately. Some years since suffered from fistula in ano, and was operated on by Mr. Copeland: an external pile was removed at the same time. He consulted me on the 5th of May, 1853, fearing his former malady was returning: for several weeks he had not taken his usual exercise, and had lived rather more highly. The last few days of April he had experienced itching and fulness of the rectum, and ultimately a lump formed: he then sought my advice. On making an examination, I perceived an external pile on the left side; it was tense, of purple color, and but very slightly painful: no internal hemorrhoids existed., His tongue was slightly furred and large, face somewhat flushed, conjunctivæ congested, pulse full.

R Hydrargyri cum Cretâ, gr. iij; Extracti Taraxaci, gr. vij. Fiant pil. ij, omne nocti sumendæ.

R Infusi Gentianæ comp., ziv: Infusi Sennæ comp., 3j; Potassæ Sulphatis, Diss. Fiat haust. secunda quaque mane sumendus.

The anus to be washed with water and yellow soap night and morning.

All inconvenience subsided on the second day after I first saw him, the tumor was flaccid, and was contracting. The pills and draught were continued for a few days longer; he still uses ablutions twice a day, and has had not the slightest symptom of any affection of the rectum since.

External hemorrhoid; incision of the tumor; rapid recovery.

W. C, æt. thirty-seven, a saddler; an out-patient at University College Hospital, in the summer, 1845; of ordinary stature and conformation, bilious temperament; works hard at his business, sitting ten hours a day; lives well, and is in the habit of drinking freely of beer and spirits, but is seldom tipsy. Several days before applying at the hospital, he experienced slight itching and fulness of the anus: on the evening previously the symptoms increased;

he then had throbbing and acute pain, became thirsty and feverish, and had not been able to sleep during the night. In the morning he was sensible of a tumor having formed at the margin of the anus. When he applied for advice his tongue was furred, skin hot, and his countenance indicated pain and want of rest. His bowels had been irregular, sometimes not acting for two or three days. ¦ On examination, an external pile presented; it was purple, tense, and very painful. Ordered to take four grains of blue pill, and one grain of ipecacuanha immediately, and the following draught two hours afterwards:

R Pulveris Rhei, gr. xv; Pulveris Jalapæ, gr. viij; Potassæ Sulphatis, 3ss; • Tincturæ Cardamomi comp., 3j; Aquæ Cinnamomi, 3xj. Misce fiat haustus.

To foment the parts with hot water, and to go to bed. The medicine having acted freely, on the following morning I divided the pile with a bistoury, and evacuated the contained blood: the fomentations to be continued. On the second day he resumed his business the incision healed, and the skin contracted to its normal condition. He afterwards took for two or three weeks a tonic and aperient mixture, and by my advice abstained from spirits, and drank but a moderate quantity of beer daily. The brother of this patient had previously been under my care for fissure of the anus.

External hemorrhoid; tumor incised.

Mr. æt. thirty; tall; of great muscular development, plethoric habit, not accustomed to take much exercise except occasionally during the sporting season, and is capable of great exertion and endurance without fatigue. He lives freely, his general health is good; occasionally feels a fulness of the head and drowsiness; he then has recourse to a brisk purgative, which relieves him.

He sent for me in May, 1852: he was in bed, complaining of great pain at the anus; his countenance was flushed, skin hot, tongue furred, pulse accelerated, and he had headache. He informed me he had been to a succession of dinner parties, and had

eaten and drunk freely, and had not felt quite well for several days: the morning before my seeing him he experienced an itching at the anus and a fulness about that region; towards evening his discomfort increased, and he began to experience throbbing and acute pain; he went to bed somewhat earlier, hoping a night's rest would relieve him. On making an examination I perceived an external pile, half an inch in diameter, spheroidal, tense, of a deep purple color, and very painful when touched. To use hot fomentations and to continue in bed; five grains of calomel and five grains of Dover's powder to be taken immediately, and the following draught two hours afterwards :

R Infusi Sennæ comp. 3xj; Pulveris Jalapæ, gr. viij; Soda Potassio-Tart., 3j; Spiritus Myristicæ, 3j. Misce fiat haustus.

The medicines acted on the bowels freely several times. On visiting him in the evening, finding the pile still tense, I divided it by transfixing the base with a small curved bistoury, and cutting outward. The next day he was able to be about; the wound healed without any trouble in a day or two after. I advised him to observe moderation in living, and prescribed the following draught to be taken every morning for two or three weeks :—

R Infusi Gentianæ comp., 3xj; Magnesia Sulph., 3j; Acidi Sulphurici dil., mxij; Tincturæ Aurantii, 3j. Misce fiat haustus.

External hemorrhoid and fissure of the anus.

Mr. æt. twenty-eight, residing in Westbourne Terrace, Hyde Park, was advised to consult me by my friend Dr. Quain. He is of ordinary stature and conformation, living moderately, not taking much exercise; has always been dyspeptic and of costive habits: the last few years he has suffered more or less from smarting during defecation, attended with slight hemorrhage, followed by aching pain.

The attack for which I was consulted commenced the day previously, with severe throbbing pain, and great tenderness at the anus; on making an examination, an external pile, the size of a filbert, on the margin of the anus of the left side, presented: it

was tense, exquisitely painful to the touch, and of a deep purple color. At the posterior part, and immediately within the margin of the anus, was a fissure about half an inch in length, appearing of recent origin, the margins being sharp and florid; the sphincter ani was slightly affected with spasm; general constitutional disturbance was indicated by thirst, loss of appetite, furred tongue, acceleration of the pulse, and by the preternatural heat and dryness of the skin. He was directed to observe the recumbent position, to foment the anus with a hot decoction of poppy-heads, to apply a piece of lint smeared with extract of conium and spermaceti ointment to the fissure, and to take at bedtime a teaspoonful of an electuary consisting of confection of senna, sulphur, jalap, bitartrate of potash, copaiba, and syrup of tolu.

On the following morning the bowels were freely moved, attended with smarting at the time. The tumor was still tense and painful, I therefore divided it, and turned out a clot of blood; bleeding to the amount of one or two drachms followed. Directed to use a sponge and water when visiting the closet instead of paper.

The electuary and ointment were continued for a short time, and in ten days all disease had subsided; the loose skin resulting from the distended hemorrhoid contracted entirely, the part resumed its natural condition, and the fissure of the anus quite healed.

Dr. Quain informs me he has seen this patient (Dec. 1853), and that he has continued free from all symptoms of fissure or piles.

External piles after bilious fever; prolonged suffering from not permitting incision of the tumor.

2

Mr. C. C æt. twenty-three, convalescent, after several weeks' severe illness from bilious fever. On one of my visits he complained of great pain and throbbing at the anus, and fulness of the perineum. An examination revealed a large external pile of the size of a cherry, on the left margin of the anus; it was of a deep purple hue, tense, and very painful. Under the idea of regaining his strength more rapidly, he had for several days eaten very heartily, and taken several glasses of wine, notwithstanding

he had been admonished to observe moderation in living. Ordered to confine himself to the recumbent position; to have no solid food; to use hot fomentations of decoction of poppy-heads to the anal region, and to take a teaspoonful of the following electuary at bedtime::

R Confectionis Sennæ, Sulphuris Loti, Extracti Taraxaci, āā 3j; Potassæ Bitart., 3iv; Syrupi Zingiberis, q. s. Misce fiat electuarium.

The next day he was no better; he had not been able to take the electuary, as his stomach turned against it: he was desired to form it into boluses of convenient size with wafer-paper. I proposed dividing the pile with a bistoury, but he would not listen to anything like an operation.

By the means suggested he managed to take the electuary, and it acted freely on the following morning. The pile was still tense, but not so painful; three others, of small size, had formed on the opposite side. He was directed to continue the electuary and fomentations, and to live sparingly. Under the treatment he continued to improve, but a fortnight elapsed before he was free from pain; the pile had then collapsed, leaving a large fold of loose skin. At this time he became very nervous about himself, was restless at night, and perspired profusely. Ordered to take twice a day the following:

R Infusi Cinchonæ, 3iss; Acidi Nitrici diluti, mx; Syrupi Aurantii, 3j. Fiat haustus.

In another week he was much better, and gaining strength; he left town for Brighton, where he remained for some time.

I have seen this gentleman lately; he is now stout and in good health the loose fold of skin around the anus still exists, and may probably become the seat of disease on the occurrence of a slight exciting cause. Had he consented to the small incision requisite, I have no hesitation in saying his sufferings would have been materially less, and of shorter duration.

External piles, with ulceration of their surfaces and fissure of the anus: operation: cure.

T. R, æt. twenty-eight, by occupation a copying-clerk in a