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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 Senna e comp., Jiv; Infusi Gentiana e comp., Jiij; Potass* Tartratis, 3iv; Tinct. Aurantii comp., Syrupi Aurant., aft 3iv. Fiat mistura; capiat cochl. iij, ampla primo mane.

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

The Rev. C. C , aet. 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 quautity 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 haemorrhoidal 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 haemorrhoidal 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:—

I}. Syrupi Ferri Iodidi, 3j; Tinctura Ferri Sesquichlor., mix; Aquae, 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.

CHAPTER X.

ENLARGEMENT OF THE HEMORRHOIDAL VEINS.

The haemorrhoidal veins are liable to dilatation quite distinct from, and not to be confounded with, the morbid condition of the several tissues constituting piles. They assume precisely an analogous condition to the veins of the testicle forming varicocele, and to the branches of the saphena vein constituting the troublesome affection generally known as varicose veins of the leg.

There are certain physiological causes that predispose to the enlargement of the haemorrhoidal veins, and others that are pathological. It will be remembered that the portal system, which commences in the veins of the rectum, is destitute of valves, consequently the radical branches are subject to the pressure of the entire column of blood. Impediments to the venous circulation are very liable to occur from congestion of the liver, from pressure on the venous trunks by overloaded and distended intestine, by the pregnant womb, by ovarian and other abnormal abdominal tumours.

ENLARGEMENT OF THE HEMORRHOIDAL VEINS. 213

Generally there appears to exist a predisposition to venous dilatation in those who have the haemorrhoidal veins enlarged, it being not unusual to observe it associated with varicocele and a varicose condition of the branches of the saphena veins.

The symptoms are a sensation of weight and distension about the rectum, uneasiness in the loins, a feeling of sinking and general lassitude, and the same mental depression which is observed to attend dilatation of the veins of the leg and testicle. The dilated veins may be felt on either side of the rectum like a bundle of earth-worms, the same as in varicocele. They sometimes form tumours, projecting internally or externally to the sphincter, but their appearance is very different from those caused by haemorrhoids.

Since the publication of the first edition of this work, through the kindness of my colleague, Mr. Hulme, I had an opportunity of examining a very aggravated case of this disease occurring in a female, a patient of his, at the Blenheim Dispensary. The veins formed large tumours around the anus, and as far as the finger could reach were felt extending up the rectum; the veins of both labia were also greatly dilated, and conveyed to the touch the feeling that has been described. In other cases which have come under my notice, the veins have not formed tumours external to the sphincter ani muscle, but

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