in the morning. To continue the fomentations, and to return the piles should they be prolapsed at stool.

By observing the treatment directed, the acute symptoms soon subsided. I proposed removing the tumours by ligature; but, being free from pain, he preferred waiting the chance of another attack. Ordered him to use soap and water externally night and morning, and to inject half a pint of cold water after each dejection.

Dec.-By following the injunctions given him he has been free from pain, but the tumours are occasionally protruded, and he has lost from time to time a small quantity of blood.

Nov. 1853.-At the present time I have a patient under my care with a very close stricture of the urethra, who was acquainted with D. B: he informs me that he died a few months since of some acute disease of the chest, following a drunken bout and exposure for several nights. He was very clever at his business, but seldom worked more than three days in the week: the remainder he spent in debauchery.

Internal hæmorrhoids; much loss of blood, attended with giddiness and drowsiness; oxaluria; relief by medical treatment.

R

R. R——, æt. thirty-eight, was advised to consult me by my friend, Mr. William Bennet, surgeon to the Bloomsbury Infirmary. About fourteen years since he first suffered from external piles, which have continued to trouble him more or less up to the present time: eight years ago he experienced pain within the anus, and a sensation of the presence

of a foreign body; defecation was difficult, attended with increase of pain and hæmorrhage, and from that period he has continued to lose a considerable quantity of blood at intervals: he has also been annoyed by a constant discharge of mucus from the bowel. He has always been subject to constipation, and suffered from flatulence, pain in the abdomen, giddiness of the head, and depression of spirits. His habits of life are temperate.

He came to me on the 10th of Nov., 1852: his countenance was sallow, eyes dull, lips and gums pale, tongue furred, pulse frequent and irritable, bowels acting scantily and irregularly; has little power of retaining his fæces during any violent exertion; the bladder is irritable; and he has some difficulty in micturating. The anal orifice is surrounded by a margin of loose skin, evidently collapsed external piles: the sphincter ani is relaxed. Introducing the finger within the intestine: two large internal hæmorrhoids were felt; these were extruded by a very slight effort at straining, and the mucous membrane was then seen in a granular state. He informed me that the hæmorrhoidal tumours descended by walking or riding in any vehicle that shook him much. To take six grains of extract of taraxacum and three grains of blue pill every night, and in the morning a teaspoonful of an electuary compounded of confection of senna, sulphur, bitartrate of potash, jalap, copaiba, ginger, and a sufficient quantity of syrup. To use ablutions of soap and water night and

morning

Nov. 14-He has taken the medicines ordered, and the bowels have acted every day, but not freely: he passed some

clots of blood yesterday, and this morning a tablespoonful of bright blood. To continue the remedies.

Nov. 17.-He has had very little pain, and passed but a small quantity of blood: still complains of drowsiness and giddiness. Examination of the urine demonstrated an excess of urea, and under the microscope numerous crystals of oxalate of lime were seen.

R Infusi Gentianæ comp., 3x; Magnesia Sulphatis, 3j; Acidi Sulphurici diluti, 3iss. M. fiat mist.; sumat cochl. ij magna bis in die.

To inject half a pint of water, containing sixteen grains of sulphate of zinc, after each evacuation of the bowels.

Dec. 1.-He has taken the medicines regularly, and used the enemata as directed feeling so much better, he did not think it necessary to see me at an earlier period. He has had no sanguineous discharge the last twelve days: a slight mucous discharge continues. He can now retain his fæces during exertion: he was drowsy on one occasion since his previous visit to me, but is not so now. His eyes are bright, countenance clear, pulse 76: the irritability of the uninary organs has ceased.

Dec. 15.-Has continued the medicines, and expresses himself as feeling better than he has for many years: his countenance is clear and healthy, pulse regular, appetite good. He does not suffer from flatulence: has gained strength, and does not feel fatigue after an ordinary amount of exercise. To inject cold water only after each stool.

This patient visited me in May, 1853: he had continued to take the medicines occasionally, and had not omitted the

injection of the cold water: the only annoyance he experiences is a mucous 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 hæmorrhoids; 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 hæmorrhoidal tumours. Medicines and enemata were prescribed to unload the bowels, afterwards an astringent injection was used after each evacu ation, for which cold water was substituted in about a fort night. Chalybeates and laxatives were then 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 hæmorrhoids induced by stricture of the urethra; excision of internal piles; subsidence of internal piles by cure of stricture.

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