When I was consulted (1850), she had not been able to leave the house for some weeks, and had been confined to the couch, feeling easier in the prone position. She was pale, nervous, and debilitated; the menstrual secretion had been scanty, and occurred at lengthened intervals: she complained of acute pain in the rectum, increased to a violent degree at stool, followed by hæmorrhage of an arterial character. Her skin was dry, tongue flabby and furred, pulse small, urine scanty and high coloured; appetite bad, it had previously been capricious, sometimes voracious; she had pain at the epigastrium, and flatulence: the abdomen was hard, and dulness on percussion in the course of the colon existed. Examining the rectum, it was found loaded with indurated fæces on the right side, about three-quarters of an inch from the margin of the anus, were two excrescences, each about the size of a fourpenny-piece; their surfaces were florid and granular in appearance, and bled freely on the slightest touch. I proposed applying the concentrated nitric acid to the morbid tissues; but, it being necessary to unload the bowels and get the constitution into a better state, the following remedies were prescribed, and the patient ordered to remain in bed.

R Pilula Hydrargyri, gr. iij; Pulveris Ipecacuanha comp., gr. v; Extracti Glycyrrhizæ, q. s.; ut fiant pil. ij. hora somni sumendæ.

R Pulveris Rhei, gr. xviij; Soda Potassio-Tart., 3iss; Confectionis Aromatici, gr. x; Essentia Cinnamomi, mvj; Aquæ Cinnamomi, 3iss. M. fiat haustus, primo mane sumendus.

R Decoct. Hordei, 3xix; Olei Ricini, 3j. M. fiat enema.

The remedies acted freely in the morning, attended with pain in the rectum and a considerable discharge of florid blood.

R Potassæ Citratis, 3j; Potassæ Nitratis, gr. xxx; Tincturæ Serpentariæ, 3iv; Aquæ, 3vss. M. fiat mist.; sumat cochl. ij, ampla ter die.

The pills, draught, and enema were administered four times, the abdomen became soft, and the general health somewhat better; but the pain in the bowel continued, and hæmorrhage occurred at each action of the bowels, which the injection of cold water failed to check.

On the seventh day after I first saw her I introduced a speculum ani, and touched the raised and granulated mucous membrane with the strong nitric acid, using a piece of lint on the end of a probe: smarting was experienced at the time, but this soon subsided; an enema of four ounces of starch and thirty minims of liquor opii sedativus having been injected into the bowel. Ten grains of Dover's powder were administered at bedtime. She passed a tranquil night; on the third day the bowels were moved by a dose of castor oil, smarting was experienced at the time: she was directed to inject twice a day four ounces of water and eight grains of sulphate of zinc. In ten days the sloughs had separated, and the ulcerated surfaces nearly healed. The bowels were kept open by castor oil. In a few days more she was quite free from the local malady, but was still pale and weak.

The following draught was prescribed :

R Ferri Ammonio Citratis, gr. v; Potassæ Bicarb., gr. xij;

Magnesia Sulph., 9j; Aquæ, 3xj; Syrupi, 3j. M. fiat

haustus in actu effervescentiæ cum succi limonis cochl. amplo bis in die sumendus.

This medicine was continued for several weeks, and she went out every day for a walk, or in her carriage if the weather was unfavourable. Her health became better than it had ever been; the menstrual function was performed regularly, and was natural in quantity.

Internal hæmorrhoids preceded by dysentery; great loss of blood; stricture of urethra. Hæmorrhoids treated with nitric acid.

Major J——, a tall, fine man, of a naturally good constitution, but impaired by a long residence in India and active military service; had suffered several times from dysentery; for seven years had had piles, frequently lost considerable quantities of blood, the bleeding at times continuing for half an hour: defecation was always attended with pain and much straining, the pain being aggravated when the fæces were bulky and indurated; the bowel slightly descended at stool, but returned by muscular contraction. He had had various remedies prescribed, as lenitive electuary and sulphur, copaiba, Ward's paste, &c., but without benefit. No examination of the bowel had been made by the several surgeons he had consulted. His countenance and conjunctivæ were slightly yellow; tongue covered with a creamy fur; skin dry; appetite moderate; had flatulence, and frequently felt fulness and pain at the epigastrium after eating; urine high

coloured, and voided in a small stream, with some straining; slight tenderness over the liver on pressure; no enlargement of it indicated by percussion; pulse feeble and irritable. By examination after the action of the bowels, the mucous membrane being prolapsed, a florid granular surface, from which blood freely oozed, was observed; it was about the size of a shilling, and slightly raised from the surrounding tissue; it was very painful when touched: the finger introduced into the rectum did not detect any tumour. The treatment adopted was at first small doses of mercury with chalk, and extract of taraxacum; aperients every second morning; subsequently tonics, with nitric acid, and various preparations of iron: enemata of cold water were used; afterwards astringent fluids. Examination of the urethra detected a stricture, through which a No. 3 catheter was passed with some difficulty; the introduction of instruments twice a week was had recourse to, the size being gradually increased, till the natural calibre of the urethra was restored. By perseverance in the remedies, his general health was much improved, the countenance became clear, the pain in the region of the liver subsided; but though feeling much better, the bleeding from the rectum continued. Having given medical treatment a fair trial without much benefit to the local disease, I deemed the application of nitric acid advisable. The bowels having been freely moved by extract of colocynth and blue pill taken at night, and an enema administered the following morning, the florid granular surface of the pile was exposed by a speculum, and freely touched with strong nitric acid, chalk and water being subsequently used to neutralize the excess of acid, and prevent injury to the surrounding tissue. After the operation, a dose

of laudanum was administered. On the third day, the bowels were moved by castor oil; for some days subsequently he experienced smarting when at stool, but the pain gradually lessened. He was directed always to use enemata of cold water after defecating. It is now four years since I attended this patient, and he has not had the slightest return of any of the symptoms from which he previously suffered.

Internal hæmorrhoids; medical treatment not arresting the symptoms; the tumours 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 hæmorrhoids, 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