discharge from the anus. I examined the bowel: the internal piles are still large, but not turgid; the mucous membrane is in a much healthier condition. Removal of the piles was advised in the first instance, but his occupations prevented him laying up fo: a few days; and as he now suffers but little comparative incorvenience, he is content to remain as he is.

Internal hemorrhoids; loss of blood; cessation of the catamenia: health restored without operation.

Miss, æt. twenty-two, of ordinary stature and conformstion: her health had declined three years previously to her coming under my care. The menses appeared when she was sixteen. and continued regularly till she was nineteen; they then became scanty, and twelve months afterwards ceased altogether. She became pale, lost flesh, suffered from dyspepsia, had frequent headaches, and was extremely nervous. Change of air had been tried. and she had been under medical treatment at various places.

On questioning her as to her symptoms and the state of the bowels, I learned she had always been costive, and at the com mencement of her indisposition she had pain and a feeling of fulness in the lower bowel, which increased in severity: after a time she lost blood per anum when the bowels were moved, the quantity increasing with the persistence of the disease, and the last two years she never visited the closet without losing more or less. She had not mentioned the circumstance to her mother, or to any of the medical men under whose care she had been; the reason she assigned for not having done so was that she had never been ques tioned on the subject. She was perfectly anæmic; her pulse was feeble and irritable; she had frequent headache, which was increased by walking, or even by sitting upright: her extremities were cold, the eyes dull, tongue furred, the countenance had a waxy unhealthy appearance; the abdomen was hard, and the bowel slightly descended at stool. I made an examination, and found two hemorrhoidal tumors. Medicines and enemata were prescribed to unload the bowels; afterwards an astringent injection was used after each evacuation, for which cold water was substituted in about a fortnight. Chalybeates and laxatives were then

3

ordered, and under this plan of treatment she perfectly regained her health and strength, and was able to resume the equestrian exercise she had previously been accustomed to.

Internal and external hemorrhoids induced by stricture of the urethra; excision of internal piles; subsidence of internal piles by cure of stricture.

B

G. B—, æt. forty-three, married, of robust constitution; for a long period had observed the stream of urine decrease in size, and for some months before applying to me it had not been larger than a small crowquill, and if the weather was wet or cold he passed it in drops only; he had frequent desire to urinate, and was obliged to get out of bed several times each night: during micturition he strained violently. For nine months he had suffered from internal and external piles, attended with frequent paroxysms of pain and bleeding. Although suffering much, he had neglected the stricture of the urethra; he sought my advice for the affection of the rectum. Tracing the progress of his maladies, I conceived the hemorrhoids to have been induced by irritation and determination of blood, excited by the disease of the urethra, and the straining that attended micturition; therefore it was necessary to relieve that affection before benefit could accrue from treatment of the piles. With some difficulty a No. 2 catheter was passed through the stricture: by the introduction of others, gradually increasing the size, the canal was ultimately restored to its proper calibre; during this treatment the bowels were kept open by laxatives; ablutions of soap and water were used night and morning. When the urethra was sufficiently dilated to permit the urine to pass without any straining, and the irritability of the bladder had subsided, half a pint of cold water was injected into the rectum night and morning, after defecation, with the effect of arresting the hemorrhage. The two external piles that existed were hard, and occasionally painful, and if he walked much were liable to get slightly excoriated; they were therefore excised; the wounds healed readily: by attending to keep the bowels easy, and continuing the injection of the cold water, the symptoms of the internal hemorrhoids subsided. There being a disposition in the

stricture of the urethra to contract, a bougie is passed once a twice, at intervals of a few weeks.

Internal hemorrhoid; loss of blood inducing suppression of th menses; leucorrhoea; nitric acid applied to the pile; heal

restored.

M. J, æt. twenty-seven, married four years, has no family. Tall, and of ordinary conformation. Her habits are sedentary: previous to her marriage she followed the occupation of a dress. maker; she had suffered much from dyspepsia and constipation. About the end of 1849, she began to experience discomfort in the rectum, having a sense of fulness and aching in the part; these disagreeable sensations increased, and in a few months resolved themselves into acute pain, which was aggravated after a motion: the bowels acted very irregularly, sometimes not for several days. at other times diarrhoea supervened. In a short period after the accession of acute pain, she began to lose blood per anum; the quantity increased, and varied from a tablespoonful to half a pint: at times it was florid, at others dark and clotted. The menses

became irregular, and at length ceased, and she was troubled with leucorrhoea. She had had advice, and taken various medicines, such as confection of senna, blue pill, saline purgatives, but without benefit.

When I saw her-autumn, 1850-she was pale, weak, and nervous, suffering from frequent headache, which was increased in intensity in the upright position: her feet were always cold, and she complained of flatulent distension of the stomach and abdomen, and great pain in the rectum, attended with mucous discharge and hemorrhage at stool. Ordered a dose of castor oil to be taken in the morning, and a pint of thin gruel as an enema two hours afterwards. The bowel acted several times; and when I visited her, the intestine was slightly prolapsed, rendering visible the margin of a florid, granular excrescence of the mucous membrane: by pressing the intestine down, the whole diseased surface was brought into view: it was about five-eighths of an inch in diameter, and of an oval form: the rest of the intestine was healthy. Laxatives and tonics were prescribed to regulate the bowels, and

restore her general health; and to restrain the bleeding, cold water, containing lead, zinc, and other astringents, was injected twice a day she was also confined to the sofa. The treatment was persevered in for a month, with the effect of improving her health, but not relieving the pain in the bowel, or diminishing, in any sensible degree, the hemorrhage. It was, therefore, determined to apply nitric acid to the morbid tissue. The bowels having been thoroughly freed, and the mucous membrane made to descend by the administration of an enema, concentrated nitric acid was applied to the diseased part, which was afterwards smeared with oil, and the intestine replaced. An opiate was administered; the patient experienced but slight pain after the operation, and slept well at night. On the third day she had some castor oil; when the bowels acted she felt some smarting, but no hemorrhage occurred. She was directed to inject four ounces of cold water, containing eight grains of sulphate of zinc, night and morning. In rather more than a fortnight all local disease had disappeared by the use of tonics, attention to the bowels, and taking exercise, she regained her health, the leucorrhoea ceased, and the catamenia reappeared at proper intervals.

.

Internal hemorrhoids; the patient upwards of eighty years of age; successful treatment by nitric acid; irritability of the bladder; phosphatic urine.

A gentleman, upwards of eighty years of age, applied to me, in 1854, complaining of a sense of fulness in the rectum, and a constant desire to defecate: he stated that whenever he visited the closet he lost a small quantity of blood, and that a protrusion of the bowel took place; he experienced no difficulty in returning it, but it often descended when he walked. He had tried several forms of mechanical appliances to retain the bowel in its position, but they failed in the intention, and only occasioned him uneasiness and annoyance. Making an examination, I found two hemorrhoidal tumors prolapsed: their surfaces were florid and granular, and one tumor was slightly ulcerated; the lower part of the intestinal canal was loaded with scybala; the pouch of the rectum was much dilated, and appeared to have little power of

discharge from the anus. I examined the bowel: the internal piles are still large, but not turgid; the mucous membrane is in a much healthier condition. Removal of the piles was advised in the first instance, but his occupations prevented him laying up for a few days; and as he now suffers but little comparative inconvenience, he is content to remain as he is.

Internal hemorrhoids; loss of blood; cessation of the catamenia; health restored without operation.

Miss æt. twenty-two, of ordinary stature and conformation: her health had declined three years previously to her coming under my care. The menses appeared when she was sixteen. and continued regularly till she was nineteen; they then became scanty, and twelve months afterwards ceased altogether. She became pale, lost flesh, suffered from dyspepsia, had frequent headaches, and was extremely nervous. Change of air had been tried, and she had been under medical treatment at various places.

On questioning her as to her symptoms and the state of the bowels, I learned she had always been costive, and at the commencement of her indisposition she had pain and a feeling of fulness in the lower bowel, which increased in severity: after a time she lost blood per anum when the bowels were moved, the quantity increasing with the persistence of the disease, and the last two years she never visited the closet without losing more or less. She had not mentioned the circumstance to her mother, or to any of the medical men under whose care she had been; the reason she assigned for not having done so was that she had never been questioned on the subject. She was perfectly anæmic; her pulse was feeble and irritable; she had frequent headache, which was increased by walking, or even by sitting upright: her extremities were cold, the eyes dull, tongue furred, the countenance had a waxy unhealthy appearance; the abdomen was hard, and the bowel slightly descended at stool. I made an examination, and found two hemorrhoidal tumors. Medicines and enemata were prescribed to unload the bowels; afterwards an astringent injection was used after each evacuation, for which cold water was substituted in about a fortnight. Chalybeates and laxatives were then