bowels, which have been habitually constipated; not accustomed to active exercise. For several years he has lost blood at stool, and at times had severe pain in the rectum, which rendered him incapable of bodily or mental exertion. Two years previously to his coming under my observation, a tumour descended from the bowel when at the closet, and since its first descent, it has always been necessary to replace it by the finger. He mentioned these facts to Dr. Quain, his physician, who desired him to consult me. His pulse was weak; countenance pale; eyes dull; tongue furred; abdomen hard; skin dry; urine cloudy, which, under the microscope, presented numerous octahedral and dumb-bell crystals of oxalate of lime. The sphincter ani was contracted; the mucous membrane of the rectum was observed to be congested. By digital examination, a tumour, the size of a cherry, was detected, attached to the upper and interior margin of the internal sphincter by a fold of mucous membrane; it was firm, and but slightly elastic. From the nature of the tumour it was decided to remove it by ligature. He remained under the care of Dr. Quain for three weeks, during which time his general health was greatly improved. The bowels having been thoroughly freed by the administration of four grains of blue pill, and six grains of compound colocynth pill at bedtime the previous night, and castor oil and an enema in the morning, with the assistance of Mr. H. Thompson, I applied a doubled ligature to the tumour, transfixing its base with a needle fixed in a handle. He remained in bed three days, and experienced but little pain. On the fourth morning he took a dose of castor oil: the bowels acted freely, attended with some uneasiness in the part. He was directed

to get up, but desired not to stand or sit too much. The following draught was prescribed, to be taken every morning: Compound infusion of gentian, one ounce and a half; sulphate of magnesia, one drachm; carbonate of magnesia, ten grains. One ligature came away on the fifth day, and the other on the ninth; for some days afterwards he had smarting at stool, but it gradually subsided. He took the medicine for three. weeks, after which the bowels acted freely each day without it: he had greatly improved in appearance, was quite cheerful, and expressed himself as being better than he had been for many years.

Internal hæmorrhoid, attended with great pain, bleeding, and constant descent of the tumour; ligature applied.

The following case was also sent to me by Dr. Quain :— Mr. a publican, tall and stout, his eyes dull, and sclerotic conjunctivæ yellow, his tongue large and flabby, covered with a thick fur, and the edges deeply notched by the impressions of the teeth. He informed me that he took little or no exercise, sometimes not leaving the house for upwards of a week: he lives freely, but is not often intoxicated; has always suffered from constipation, and had long been annoyed by dyspeptic symptoms, as well as various uncomfortable sensations in the rectum. Four years previous to applying to me, he discovered that "a lump" descended at stool, attended with bleeding and severe pain; it had always been necessary to replace it with his fingers. Digital examination detected on the right side an indurated pile, attached to the bowel, about two inches above the anus. An

enema being administered, a pile the size of a large cherry was extruded. Considering the density of the tumour, its constant descent, and the strong desire of the patient to be relieved of his sufferings, it was decided an operation should be performed. Under the judicious treatment of the physician who referred him to me, in ten days the constitutional defects were remedied. At the expiration of this time, with the assistance of my colleague, Mr. Hulme, I carried a needle, armed with a double ligature, through the base of the tumour, and tied it firmly in two portions. The bowels had been freely relieved previous to the operation: after it had been performed, a dose of opium was administered. For four days, there was slight feverish excitement and oedema around the anus. These yielded to salines, low diet, and linseedmeal poultices. On the third morning, he took some castor oil, and repeated it every second morning for a few times. Enemata of flaxseed-tea were daily used. By the eleventh day, the ligatures had come away, and the ulcers resulting had quite healed. The necessity of taking exercise was strongly impressed on him, and he was directed to inject half a pint of cold water after defecating, to use soap and water externally morning and evening, to live moderately, and to keep the bowels regular by the following mixture :

:

R Infusi Sennæ comp., 3iv; Infusi Gentianæ comp., zij; Potassa Tartratis, 3iv; Tinct. Aurantii comp., Syrupi Aurant., āā ziv. Fiat mistura; capiat cochl. iij, ampla primo mane.

P

Internal hæmorrhoids; great loss of blood inducing debility and palpitation of the heart; an ulcer at the posterior part of the rectum, with considerable induration of the surrounding tissues.

The Rev. C. C, æt. fifty-three, residing in the North of Ireland, came to London to consult me for an affection of the rectum which commenced ten years previously. At that period he experienced itching and a fulness about the funda ment, and occasionally lost a small quantity of blood: the accession of these symptoms was soon attended with protrusion of tumours from the bowel each time he visited the closet, and he was seldom free from pain in the rectum and sacral region. He gradually grew worse, and for the last four years he daily lost a considerable quantity of blood, and any slight exertion was attended with violent palpitation of the heart, and a feeling of faintness; he also suffered from cramps in the legs, and great irritability of the bladder, inducing a frequent desire to micturate. He had tried various medicines that had been prescribed, and had been for twelve months in Germany, drinking mineral waters, but experienced no benefit.

Whan I first saw him, his countenance was pale, his lips and gums colourless, and the tongue much furred; the eyes were dull; his pulse was weak and irritable. By straining slightly, an indurated hæmorrhoidal tumour the size of a chestnut was made to protrude: the finger being introduced into the bowel, it was found to be connected with the upper margin of the internal sphincter. At the posterior part of

:

the rectum, an ulcer three-eighths of an inch in diameter was felt the tissues around were so dense as to raise a suspicion of cancer in the mind of a medical friend who examined him also, but in this opinion I did not coincide. Blue pill and ipecacuanha were directed to be taken at bedtime, and a tonic and aperient draught every morning. After using these remedies for six days, his general health being much improved, with the assistance of Mr. H. Thompson, I passed a double ligature through the base of the hæmorrhoidal tumour, and tied it in two portions. I afterwards, with a probe-pointed knife, carried up on the index finger of the left hand, incised the ulcer on each side of the median line. On the third day, the bowels were moved by castor oil; on the sixth day, the ligatures came away: he suffered so little after the operation, that he was now able to leave the house. He was directed to take the following draught twice a day for three or four weeks:

B Syrupi Ferri Iodidi, 3j; Tinctura Ferri Sesquichlor., mxx ; Aquæ, 3xj. Ft. haustus.

And he very shortly returned to Ireland. Three months afterwards, passing through London on his way to Brussels, he called on me; his countenance was florid, and he informed me he had been perfectly free from all symptoms of his former complaint; that he could walk many miles without fatigue, had been free from palpitation, and had gained a stone and a half in weight. I examined the rectum, all induration had disappeared, and no evidence of former disease remained. I saw this gentleman again a few months since, and he remains quite well.