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Internal hæmorrhoids; existence for several years; operation by ligature.

Mr. S――, æt. forty-three, tall, muscular system of ordinary development; is of very regular habits, and moderate in regard to both eating and drinking. Being engaged in business, he is not able to take much exercise. He has always been of costive habit, the bowels not generally acting oftener than once in two or three days. For many years he has suffered from the several annoying and distressing symptoms usually attending internal hæmorrhoids. About eight years previous to applying to me, the piles descended at stool; for a time they were retracted after defecation, but for several years he has been obliged to replace them; for two years they have protruded from the anus on his assuming the upright position. The discomfort and annoyance caused by their "constant protrusion became so great as seriously to interfere with all the pleasures and enjoyments of life. He had not had advice for several years, but had treated himself, and possessed most of the books that had been published on the subject for a long time past. His countenance was clear; tongue but slightly furred, and not notched by the impressions of the teeth; his skin was cool, and the urine free from deposit. The sphincter ani was relaxed; and two hæmorrhoidal tumours, the size of hazel-nuts, dense, and but slightly compressible, were prolapsed. By passing the finger into the rectum they were found to be connected to the upper margin of the internal sphincter. It being evident that removal of the tumours was the only treatment that could relieve him,

and the state of the constitution admitting the immediate performance of the operation, it was decided that ligatures should be applied.

The following medicines were prescribed :

B Extracti Colocynthidis comp., gr. vj; Pilulæ Hydrargyri, gr. iv. Misce fiant pilulæ ij, hora somni sumendæ.

B Infusi Sennæ comp., 3vj; Infusi Cinchonæ, 3vj; Pulveris Rhei, gr. viij; Potassa Tartratis, 3j; Tincturæ Carda

momi comp., 3j. Fiat haustus, primo mane sumendus.

R Decocti Hordei, 3xx. Fiat enema.

The bowels by these remedies having been very freely acted on, in the afternoon I passed a double ligature through the base of each tumour. They were seized separately by a pair of forceps, and drawn down by Mr. Henry Thompson, who kindly assisted me, while I transfixed them with a needle. The ligatures having been drawn thoroughly tight, the ends were cut off within half an inch of the piles, which were then returned within the rectum. Half a drachm of tincture of opium in camphor mixture was administered immediately. On the second day after the operation, my patient, feeling no pain, had left his bedroom. His skin was cool, tongue moist, and pulse quiet. A laxative was prescribed to be taken if the bowels did not act the next day. In ten days this gentleman called on me; the ligatures had come away, and the parts had quite healed. I advised him to take an aperient and tonic mixture to get the bowels into a regular state, and to inject half a pint of cold water after defecating. This plan of treatment had the desired effect, and he has not since experienced the slightest inconvenience.

Aggravated case of internal hæmorrhoids; disease existed twenty years; ten ligatures required; successful operation.

Mr. H, æt. forty-seven, in business at the west end of London, requested my aid, as he was suffering severely from hæmorrhoids. When I saw him he was in bed, and so weak that he was scarcely able to speak; his countenance, the whole surface of the body, his lips and gums, were perfectly blanched, and he looked more like a corpse than a living being. I learned he had suffered from hæmorrhoidal disease for twenty years, and for many months had lost considerable quantities of blood, not only at stool but even while in bed: for several years he had been subject to frequent attacks of gout. Examining the local disease, the worst case presented I have ever seen; the sphincter ani had entirely lost all power, and a mass of internal hæmorrhoidal tumours extruded, exceeding in bulk the size of two fists. The tumours were ulcerated, and from their surface there was a copious exudation of discoloured serum, for it could not be called blood. Suffering intense pain when the bowels were moved, he had almost abstained from food, with the exception of tea, for several weeks, in order to render defecation less frequent. I returned the tumours, and retained them by a pad of lint and a bandage, and ordered him light, nutritious food, and stimulants at short intervals. The case gave me the greatest anxiety: his vital powers were so low that he could not exist as he was more than one or two weeks, and the shock of an operation on a constitution so reduced might be attended with fatal consequences; but it being certain that if the local

disease was not removed he could not survive, I determined to act. Having ascertained that the lungs, liver, kidneys, and other organs were free from disease, and the bowels having on several occasions been relieved by enemata, on 16th July, 1857, I applied ten ligatures, completely strangulating the whole of the tumours. Dr. Snow administered chloroform, from the effects of which he recovered soon after the operation, and then took a draught containing ammonia and opium, with the effect of tranquillizing the system and procuring a refreshing night's rest. The following morning he was easy, and decidedly better than previous to the operation. I directed small quantities of arrowroot with brandy, beef-tea, &c., should be administered at short intervals: for several days I watched him very closely and anxiously, and had the satisfaction of witnessing a gradual improvement; his pulse, which from the time I first saw him, was tremulous, now became distinct, and much slower; his countenance assumed some degree of animation, and he expressed a confident belief in his recovery. Fearing the effects of purgative medicines, the bowels were moved by enemata for the first week. By the twelfth day the whole of the ligatures had separated, and the parts were rapidly healing: on the fourteenth day he was able to be removed into the country, previous to which he had commenced to take the ammoniocitrate of iron, and aromatic spirit of ammonia in infusion of calumba he continued to take this for some time, and had recourse to cold enemata daily, and the occasional use of mild aperients, and I had the gratification to see him completely restored to health, gain flesh, and entirely free from the local disease which had so nearly produced fatal consequences.

The engraving is from the foregoing case, and conveys a good idea of the large size of the tumours and their ulcerated

[graphic]

condition: the smaller convolutions of mucous membrane were of a livid purple colour, and the larger tumours of pale vermilion.

Internal hæmorrhoid; constant descent of tumour; removal by ligature.

Mr., æt. thirty-seven, residing in Porchester Terrace, of ordinary stature and conformation; nervous, anxious disposition, has always experienced difficulty in regulating his

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