Internal hemorrhoids; medical treatment not arresting the symptoms; the tumors removed by ligature.

The Rev., æt. forty-seven, of ordinary stature, of studious and sedentary habits; lived more freely than was compatible with the little exercise he was accustomed to take; had long suffered from constipation, flatulence, and giddiness. For several years previous to my seeing him he had been subject to hemorrhoids, attended with great loss of blood at times. When he consulted me in the spring of 1846, bleeding had occurred daily for three weeks, which had greatly reduced him. On examining the intestine, three internal piles were discovered, two being much larger than the other. His pulse was quick and weak, his tongue furred, and skin dry. Ordered five grains of gray powder, and six grains of Dover's powder, to be taken at bedtime, and one ounce of castor oil in the morning: an hour after taking the oil a pint of thin gruel was thrown up the bowel. The medicine and enema acted freely, bringing away a large quantity of indurated fæces, attended with pain and a considerable loss of blood. The bowels were kept easy by an aperient electuary, and eight ounces of cold water, containing a scruple of acetate of lead and twenty minims of tincture of opium, injected twice a day: the hemorrhage continuing, turpentine and other remedies were tried, but without any beneficial result. I proposed ligature of the tumors, to which he was unwilling to submit. Mr. Liston then saw him in consultation, and agreed upon the necessity of the operation. On the following day, double ligatures were applied to the tumors, in the manner directed in the text, and firmly tied: a dose of castor oil and an enema had been administered, and had acted freely before the operation was performed: thirty minims of the liquor opii sedativus, in camphor mixture, were given immediately afterwards. Pain was experienced during the afternoon of the first day. On the third day after the operation, the bowels were moved by castor oil the ligatures separated on the fifth and sixth days. The bowels were kept easy by emollient enemata, and half a pint of cold water, containing sixteen grains of sulphate of zinc, was injected twice a day. He was quite well in less than four weeks:

he had taken the following mixture for some days, and was ordered to continue it till the bowels got into a regular state:

R Decocti Cinchonæ, 3vss; Tincturæ Cinchonaæ comp., 3iv; Magnesiæ Sulphatis, 3vj; Acidi Sulphurici diluti, 3j. Misce fiat mist. sumat cochl. ij, magna bis in die.

He was enjoined to take exercise every day, and to attend to the condition of the digestive functions. I have not heard of this gentleman since the summer of 1852, but up to that time he had been quite free from any hemorrhoidal affection.

Internal hemorrhoids; great loss of blood; removal of the tumors by ligature.

K. M, æt. thirty-seven, single, a cook in the service of my colleague, Mr. Hulme, who requested me to see her. She stated she was first attacked with piles ten years ago, and has never been well since: for the last five years she has lost a considerable quantity of blood at intervals. Hemorrhage had been going on for three weeks previously to my seeing her (Feb. 1853): she had not informed Mr. Hulme of her indisposition till she was no longer able to keep about: he ordered her to bed, and directed cold and astringent applications. When I saw her she was perfectly blanched, and hardly able to turn in bed; her pulse was feeble and quick on making an examination, the anus was observed surrounded by a fold of integument greatly distended, and having a pale, semi-transparent appearance. Three internal hemorrhoidal tumors existed; they were pendulous, and about an inch in length, and three-eighths of an inch in diameter: the mucous membrane was granular, and bled freely on being slightly touched.

Taking into consideration the duration of the disease, the state of the patient, and the condition of the tumors, I deemed removal of them by ligature the most appropriate plan of treatment. Early in the morning she had taken a dose of castor oil, which had acted freely, it was therefore determined to perform the operation at once: an enema of warm water was administered, and on being ejected the tumors were prolapsed; double ligatures were then passed through each of them, and tied tightly, so as entirely

to interrupt all vascular and nervous connection. The ends of the ligatures being cut off, the piles were returned within the sphincter thirty minims of tincture of opium were given for the purpose of producing temporary constipation and of tranquillizing the system.

On the second day after the operation she had pain in the bowel, and slight difficulty in micturating. Directed to have a hip-bath, to take a dose of castor oil the following morning, and to have an emollient enema injected twice in the twenty-four hours.

The whole of the ligatures had separated by the eighth day: no bleeding had occurred since their application. Slight inflammation of the rectum supervened, which was due to the patient not attending strictly to the directions given her with regard to diet and medicines; it speedily yielded to simple treatment, and she made a favorable recovery. The external fold of oedematous integument collapsed, and the anal orifice resumed its natural size. She has had no pain, hemorrhage, or other symptoms of the disease, and continues perfectly well.

Internal piles; catamenial and hemorrhoidal flux alternating ; tumors removed by ligature.

M. C, æt. thirty-nine, married twelve years; has had five children; for several years has suffered from internal piles, which first appeared while she was pregnant with her second child; prior to that time she enjoyed good health. She placed herself under my care in 1845: she was then pale, nervous, and weak. During the preceding twelve months the hemorrhoidal affection had troubled her greatly her bowels were torpid, never acting without being excited by medicines: she experienced great pain in the bowel, up the sacrum, in the loins, and down the thighs. Sometimes at the catamenial period profuse hemorrhage occurred from the rectum, and superseded the uterine function; on other occasions the menstrual flow appeared in due course, and then there was little or no bleeding from the piles. In the intermediate time she lost blood whenever the bowels acted, and was much troubled with mucous discharge. Her pulse was quick and weak, her skin pale, dingy, and clammy; she complained of violent palpitation of the heart

from the slightest exertion; her feet were always cold, and swelled much during the after part of the day. I examined the bowel: the anus was somewhat relaxed, and two large internal hemorrhoids were partly prolapsed: they were highly congested and very painful. The first object was to improve her health generally for this purpose she took small doses of gray powder and Dover's powder at bedtime, and castor oil in the morning; also, for a few days, a mixture of citrate of potash and nitrate of potash in camphor julep; afterwards the ammonio-citrate of iron in infusion of calumba: several enemata were exhibited. In ten days her health was improved; the bleeding from the piles, though not so profuse, still continued; she had considerable pain at times, and experienced great annoyance from the mucous discharge and prolapsus of the tumors.

It being determined, after due consideration, to apply a ligature to the hemorrhoids, a large enema was thrown up the bowel by an elastic tube, and after it had come away a double ligature was passed through the base of each tumor and tied; the ends were then cut off, and the parts returned within the anus. My late and lamented friend, Mr. Morton, attended the case with me, and kindly lent me his assistance on the occasion. Some pain was experienced during the night, and in the morning she felt slight difficulty in passing her water: these symptoms were relieved by a hip-bath, and warm poultices to the anus; a draught of hyoscyamus and nitric ether in camphor mixture was prescribed. On the third day after the operation the bowels were moved by a dose of castor oil, which was repeated every second day for a fortnight. The first ligature separated on the sixth, and the last on the ninth day: six ounces of water, containing twelve grains of sulphate of zinc, were then injected up the bowel night and morning. In three weeks the local affection was quite cured; but as the bowels did not act freely, and she had not thoroughly regained her strength, the following medicines were prescribed :

R Infusi Sennæ Comp., Infusi Cinchonæ, āā Zvj; Potassæ Sulphatis, gr. xxx Liquoris Taraxaci, 3j. M. fiat haustus primo mane sumendus.

R Infusi Calumbæ, 3vss; Ferri Ammonio-citratis, 3ss; Spiritus Ammoniæ Aromatici, 3j; Syrupi Zingiberis, 3iij. Misce fiat mist; capiat cochl. ij, magna bis in die.

She continued the remedies for a few weeks, in which time her health was restored, and the catamenia became regular.

Internal hemorrhoids; existence for several years; operation by ligature.

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Mr. S, æt. forty-three, tall, muscular system of ordinary development; is of very regular habits, and moderate in regard to both eating and drinking. Being engaged in business, he is not able to take much exercise. He has always been of costive habit, the bowels not generally acting oftener than once in two or three days. For many years he has suffered from the several annoying and distressing symptoms usually attending internal hemorrhoids. About eight years previous to applying to me, the piles descended at stool for a time they were retracted after defecation, but for several years he has been obliged to replace them for two years they have protruded from the anus on his assuming the upright position. The discomfort and annoyance caused by their constant protrusion became so great as seriously to interfere with all the pleasures and enjoyments of life. He had not had advice for several years, but had treated himself, and possessed most of the books that had been published on the subject for a long time past. His countenance was clear; tongue but slightly furred, and not notched by the impressions of the teeth; his skin was cool, and the urine free from deposit. The sphincter ani was relaxed; and two hemorrhoidal tumors, the size of hazel-nuts, dense and but slightly compressible, were prolapsed. By passing the finger into the rectum they were found to be connected to the upper margin of the internal sphincter. It being evident that removal of the tumors was the only treatment that could relieve him, and the state of the constitution admitting the immediate performance of the operation, it was decided that ligatures should be applied. The following medicines were prescribed :

R Extracti Colocynthidis comp., gr. vj; Pilulæ Hydrargyri, gr. iv. Misce fiant pilulæ ij, hora somni sumendæ.

R Infusi Sennæ comp., 3vj; Infusi Cinchonæ, 3vj; Pulveris Rhei, gr. viij; Potassæ Tartratis, 3j; Tincturæ Cardamomi comp., 3j. Fiat haustus, primo mane sumendus.

R Decocti Hordei, 3xx. Fiat enema.