remained in bed, and his diet was restricted to broth and arrowroot. The constitutional symptoms subsided; the third day he had some castor oil, and the dressings came away, when the bowels acted; after which a lotion of nitrate of silver was used to the ulcer, and simple lint to the incisions. The plan was continued till the parts were quite healed, which occupied little more than a month.

CHAPTER IX.

HEMORRHOIDAL AFFECTIONS.

HEMORRHOIDS is a term generally applied to certain tumors occurring at the verge of the anus, or within the rectum. The term, like many others, is not the most appropriate that could be chosen, as it conveys no adequate idea of the nature of the disease; yet by use it has become familiar both to the profession and the public, and its import generally understood: piles is the popular name under which these affections are known, indeed, by many, and by the working and poorer classes especially, almost every other disease about the rectum and anus receives the same desig nation.

It is not surprising that the ancients, from a deficiency of knowledge of anatomy and pathology, were unacquainted with the true nature of the disease, that they should have had very erroneous opinions of the structure of the tumors forming hemorrhoids, and have entertained the notion that they performed the function of evacuating black bile and melancholic humors from the system. After the discovery of the circulation of the blood by the illustrious Harvey, a new but equally erroneous theory was generally received; it being conceived that bleeding from external piles depleted the system generally, and that hemorrhage from internal piles depleted the portal system only.

Montègre gives the following classification of hemorrhoidal complaints:

1 "Des Hémorrhoïdes, ou Traité Analytique de toutes les Affections Hémor hoïdales," par A. J. de Montègre, Deuxième Edition, Paris, 1830, p. 71.

Although this classification is very complete and comprehensive, and clearly shows the various characters and phases of hemorrhoidal tumors, the most practical and important to bear in mind, as influencing the treatment, is the division adopted by most English authors into internal and external hemorrhoids; the former being those which occur within the margin of the anus, and involve the mucous membrane of the intestine, and the latter those which are situated external to the sphincter ani, and are covered by the thin integument of the anus.

The nature and structure of hemorrhoidal tumors have not been clearly understood till within recent times. By the older writers they were considered to be dilatations of veins, the same

their brief period of existence, are constantly under the influence of spirituous liquors.

Syphilitic ulceration not unfrequently leads to perforation of the recto-vaginal septum in the female, and recto-vesical walls when occurring in the male: records of such cases are more numerous in the writings of foreign authors than in those of this country.

In

The treatment must be varied according to circumstances. phagedæna we must try to arrest the morbid action by the application of the concentrated nitric acid, taking care not to induce perforation of the bowel. The constitutional powers must be maintained by nutritious food, stimulants, quinine, &c.

Ulceration occurs in cases of stricture of the rectum above the constricted part, as a consequence of pressure of accumulated fæces; the whole thickness of the intestine may be perforated, giving rise to abscess, which may open externally by the side of the anus, or perforate the serous cavity of the abdomen, producing fatal peritonitis.

In the treatment of this last form of ulceration our attention must be directed to the cause, and if that cannot be remedied we shall be able to do but little to mitigate the effect.

Superficial ulceration treated with nitrate of silver.

Mrs. T, of middle age, delicate constitution, had been subject to mucous diarrhoea. Three weeks previous to consulting me, she experienced great pain at stool and afterwards, of a smarting, burning character; she had purulent discharge, and complained of a sense of weight in the rectum, pain up the sacrum and in the loins, and bearing down of the womb. By examination I discovered extensive superficial ulceration near the upper margin of the sphincter. I injected an enema of decoction of linseed, and afterwards passed the solid nitrate of silver over the ulcerated surface. I directed she should confine herself to the couch, and that her diet should consist of broths and farinaceous foods, and desired her to have a hot hip-bath each night before retiring to bed. Her bowels were kept easy, and enemata of four ounces

of mucilage with liquor plumbi diacetatis and tinctura opii, were injected into the bowels twice a day. Twelve days sufficed to effect

a cure.

Superficial ulceration treated with nitric-acid lotion.

Mr. Hsought my advice on account of purulent discharge from the anus, great pain in defecating, continuing for some hours afterwards; he also had irritability of the bladder. He was accustomed to high living, and attributed his indisposition to having swallowed a spicula of a bone of a partridge, which injured the bowel in its passage outwards. By examination I detected a superficial ulcer, somewhat less than a shilling in size: the edges were inflamed, and the surface covered with a tenacious mucopurulent matter. I applied the nitric-acid lotion on the occasion, put him on spare diet, enjoined the recumbent position, and directed the administration of an enema every day. He made a rapid recovery.

Ulceration of the mucous membrane; incision of the sphincter.

Mrs. L for several months had suffered pains in the rectum at and after defecating, accompanied by purulent discharge, which she attributed to internal piles: she took various empirical remedies recommended by her friends, being unwilling to seek medical assistance; but, her sufferings increasing, she ultimately placed herself under my care. Her bowels had always been constipated, seldom acting without medicine. Some years previously she had hemorrhoids, which were removed by operation. I examined the bowel, and discovered above the sphincter an ulcer on the right side of the intestine of the size of a shilling; the edges were indurated, the surface pulpy. Being unwilling to submit to an operation, a variety of applications were used, the nitrate of silver, nitric acid, and others of a less active character; the recumbent position was adhered to, and a light diet observed: the bowels