Notes on the Injection Treatment of Internal Haemorrhoids.

condition of her tongue also supported this impression. The abdomen felt very resistant but not rigid. At operation there was a large quantity of blood-stained fluid. The last two feet of the ileum were a brilliant scarlet colour, and showed numerous small black areas of haemorrhage. The gut wall was markedly thickened, owing to the blood in the tissues, and this explained the mass felt per rectum. The haemorrhage stopped abruptly at the ileo-caecal valve, leaving the caecum almost normal. The appendix, apparently normal, was removed, and was found to contain masses of threadworms. The rest of the ileum was mottled, the mottling gradually decreasing towards the jejunum. The other abdominal viscera failed to reveal any further relevant pathology. Recovery was complete and convalescence normal, except for the following incidents. For three to four days after operation the motions were mixed with dark blood, and on the third day the urine was similarly discoloured. The post-anaesthetic vomitus contained blood. On about the tenth day she had a severe attack of epistaxis, and about the same time a marked purpuric rash appeared, involving both feet and the outer sides of the ankles. This was so severe that the feet were almost blue. There was also considerable swelling of the ankles. Blood examination after operation was as follows. Blood filmn: marked preponderance of mononuclear cells. Differential count: mononuclears 35 per cent., large lymphocytes 22 per cent., small lymphocytes 8 per cent., polymorphonuclear leucocytes 35 per cent.; coagulation time 5 minutes; blood platelets, 114,000 per c.mm. ; red blood cells, 5,500,000 white blood cells, 16,500. It is interesting to note that, although the case was a definite example of purpura, the internal signs appeared long before the surface rash, and although the girl was operated upon when the disease was at its height haemorrhage at this time was not greater than usual. The scar showed some keloid formation. There are many examples such as this in the literature, but usually some petechial spots are present to help. If Pulex irritans can be excluded-difficult in the hospital patient-such a rash should raise suspicions.