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 hæmorrhoids 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 acrue 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 hæmorrhage. 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 hæmorrhoids subsided. There being a disposition in the stricture of the urethra to contract, a bougie is passed once or twice, at intervals of a few weeks.

Internal hæmorrhoid; loss of blood inducing suppression of the menses; leucorrhea; nitric acid applied to the pile; health restored.

M. J——, æt. twenty-seven, married four years, has no Jfamily. Tall, and of ordinary conformation. Her habits are sedentary previous to her marriage she followed the occupation of a dressmaker: 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 hæmorrhage 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 bowels 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 hæmorrhage. 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 hæmorrhage 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 hæmorrhoids; 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 hæmorrhoidal tumours prolapsed their surfaces were florid and granular, and one tumour 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 contracting. The prostate gland was indurated and slightly enlarged; his urine was alkaline and thick. I first directed attention to unloading the bowels, which was effected by aperients and enemata; and afterwards restoring tone to it, by the administration of small doses of strychnia, and the use of astringent injections. These objects were accomplished, but the bowel continuing to descend, and my patient being much troubled by the sense of fulness in the rectum, I applied the concentrated nitric acid to the hæmorrhoidal excrescences; the pain it occasioned was so slight that no confinement was necessary. On the third day after the operation, the bowels

were moved by medicines, and their action was attended with considerable smarting: each succeeding day this was less, and in ten days all inconvenience from the hæmorrhoidal disease was removed, and he has had no return of it since. On several occasions the irritability of the bladder has tormented him much, the urine at these times depositing a large quantity of phosphate of ammonia, forming a tenacious mass adhering to the bottom of the chamber utensil. This condition was relieved by the administration of small doses of morphia and nitric acid, and washing out the bladder with water slightly acidulated with the same acid. This gentleman continued under my care till his death, in Nov. 1857. By washing out the bladder more or less frequently as the condition of the urine necessitated, by the use of aperients and tonics as occasion required, he was able to pass the time very comfortably, and to take exercise when the weather permitted.

Internal hæmorrhoids; excessive pain; treated with nitric acid.

Mrs., æt. thirty-three, married; the mother of four children, the youngest three years old, of delicate constitution, has always suffered during her pregnancies from enlargement of the veins, and oedema of the legs; the bowels at those periods were particularly obstinate. She has always been of costive habit, and has had constant recourse to purgatives, chiefly salines: during the period of gestation she has also suffered from external piles. In 1848 she began to experience aching, weight, and fulness in the rectum; hæmorrhage occurred at intervals, increasing in quantity as time rolled on. Pain in the bowel become very distressing.