rectum which commenced ten years previously. At that period he experienced itching and a fulness about the fundament, and occasionally lost a small quantity of blood: the accession of these symptoms was soon attended with protrusion of tumors from the bowel each time he visited the closet, and he was seldom free from pain in the rectum and sacral region. He gradually grew worse, and for the last four years he daily lost a considerable quantity of blood, and any slight exertion was attended with violent palpitation of the heart, and a feeling of faintness; he also suffered from cramps in the legs, and great irritability of the bladder, inducing a frequent desire to micturate. He had tried various medicines. that had been prescribed, and had been for twelve months in Germany, drinking mineral waters, but experienced no benefit.

When I first saw him, his countenance was pale, his lips and gums colorless, and the tongue much furred; the eyes were dull; his pulse was weak and irritable. By straining slightly, an indurated hemorrhoidal tumor the size of a chestnut was made to protrude the finger being introduced into the bowel, it was found to be connected with the upper margin of the internal sphincter. At the posterior part of the rectum, an ulcer three-eighths of an inch in diameter was felt: the tissues around were so dense as to raise a suspicion of cancer in the mind of a medical friend who examined him also, but in this opinion I did not coincide. Blue pill and ipecacuanha were directed to be taken at bedtime, and a tonic and aperient draught every morning. After using these remedies for six days, his general health being much improved, with the assistance of Mr. H. Thompson, I passed a double ligature through the base of the hemorrhoidal tumor, and tied it in two portions. I afterwards, with a probe-pointed knife, carried up on the index finger of the left hand, incised the ulcer on each side of the median line. On the third day, the bowels were moved by castor oil; on the sixth day, the ligatures came away: he suffered so little after the operation, that he was now able to leave the house. directed to take the following draught twice a day for three or four weeks:

R Syrupi Ferri Iodidi, 3j; Tinctura Ferri Sesquichlor., mxx ; Aquæ, 3xj. Ft. haustus.

And he very shortly returned to Ireland. Three months after

wards, passing through London on his way to Brussels, he called on me; his countenance was florid, and he informed me he had been perfectly free from all symptoms of his former complaint; that he could walk many miles without fatigue, had been free from palpitation, and had gained a stone and a half in weight. I examined the rectum; all induration had disappeared, and no evidence of former disease remained. I saw this gentleman again a few months since, and he remains quite well.

CHAPTER X.

ENLARGEMENT OF THE HEMORRHOIDAL VEINS.

THE hemorrhoidal veins are liable to dilatation quite distinct from, and not to be confounded with, the morbid condition of the several tissues constituting piles. They assume precisely an analogous condition to the veins of the testicle forming varicocele, and to the branches of the saphena vein constituting the troublesome affection generally known as varicose veins of the leg.

There are certain physiological causes that predispose to the enlargement of the hemorrhoidal veins, and others that are pathological. It will be remembered that the portal system, which commences in the veins of the rectum, is destitute of valves, consequently the radical branches are subject to the pressure of the entire column of blood. Impediments to the venous circulation are very liable to occur from congestion of the liver, from pressure on the venous trunks by overloaded and distended intestine, by the pregnant womb, by ovarian and other abnormal abdominal

tumors.

Generally there appears to exist a predisposition to venous dilatation in those who have the hemorrhoidal veins enlarged, it being not unusual to observe it associated with varicocele and a varicose condition of the branches of the saphena veins.

The symptoms are a sensation of weight and distension about the rectum, uneasiness in the loins, a feeling of sinking and general lassitude, and the same mental depression which is observed to attend dilatation of the veins of the leg and testicle. The dilated veins may be felt on either side of the rectum like a bundle of earth-worms, the same as in varicocele. They sometimes form tumors, projecting internally or externally to the sphincter, but their appearance is very different from those caused by hemorrhoids.

Since the publication of the first edition of this work, through the kindness of my colleague, Mr. Hulme, I had an opportunity of examining a very aggravated case of this disease occurring in a female, a patient of his, at the Blenheim Dispensary. The veins formed large tumors around the anus, and as far as the finger could reach were felt extending up the rectum; the veins of both labia were also greatly dilated, and conveyed to the touch the feeling that has been described. In other cases which have come under my notice, the veins have not formed tumors external to the sphincter ani muscle, but could be distinctly felt within its margin, and were attended by the symptoms above mentioned.

Surgery will be of no avail, either in the cure or in the relief of this affection; but by judicious medical treatment the symptoms and distress arising therefrom may be much mitigated. It is most essential that attention be paid to the proper performance of the chylopoietic organs, that constipation be not permitted to exist, and that the skin and kidneys should duly perform their functions. Moderate exercise will be beneficial, as the venous circulation is thereby facilitated: the patient should avoid standing for any long period, as the erect posture favors gravitation of the blood. The subjects of venous dilatation being generally of lax fibre, they will be much benefited by the use of tonics, more especially the mineral acids. Six or eight ounces of cold water may be injected into the rectum twice or thrice a day with advantage: the cold bath, and ablution in cold water night and morning, will afford great relief, as also will a jet of cold water directed against the anus.

CHAPTER XI.

PROLAPSUS OF THE RECTUM.

INDEPENDENTLY of the eversion of the mucous membrane that frequently attends internal hemorrhoids, and which has been considered in the Chapter on Hemorrhoidal Affections, the rectum is subject to protrusion from other causes.

Prolapsus or procidentia ani, are the terms by which this form of disease is familiarly known; an error in nomenclature very evident from the fact that the anus is merely the terminal aperture of the alimentary canal, and cannot therefore itself be protruded. Prolapsus recti is now very properly used by several recent writers, and conveys a correct idea of the affection.

Two forms of prolapsus recti occur: in the one the whole of the tunics of the rectum descend, in the other the mucous membrane alone is prolapsed. By many former writers it was maintained that the muscular coat of the intestine was never extruded; but preparations which are to be seen in King's College and other museums, incontestably show the opinion to be erroneous: in the large majority of instances, particularly where the eversion does not take place to a great extent, it is the mucous and submucous areolar tissue only that descends: the firmer attachment of the muscular coat to the surrounding parts and its function render it less liable to be prolapsed than the mucous membrane, which is more voluminous, and but very loosely connected. Mr. Copeland' doubted the protrusion of the muscular coat: he says, "In almost every case of prolapsus ani, it is the internal membrane only of the intestine which descends through the sphincter muscle. The connection of the external surface of the rectum is so firm with

1 Observations on the Principal Diseases of the Rectum and Anus," by Thomas Copeland, third edition, 1824, p. 73.