The diagnosis and treatment of hæmorrhoids, with general rules as to the examination of rectal diseases

jnosis and Treatment
of Haemorrhoids.

By Chas. B. Kelsey, M. D

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THE

Diagnosis a^d Treatmen/ of H/Emorrhoids,

WITH GENERAL RULES AS TO THE

EXAMINATION OF RECTAL DISEASES.

CHAS. B. KELSEY, M. D.,

Surgeofi to St. Paurs Injirma)-y for Diseases of the Rectwn; Con-
sulting Surgeo7i for Diseases of t lie Rectum to the Harlejn
Hospital and Dispensary for Women and Children .

NEW YORK.

1887.
GEORGE S. DAVIS,

OSTROIT, MICH

Copyrighted by
GEORGE S. DAVIS.

TABLE OF CONTENTS.

Page.

Chapter I. General Rules for Examination and Diag-
nosis ^

II. Varieties of Hemorrhoids 20

III. Treatment 3°

IV. Ligature 4i

V. Injections 45

VI. Clamp 65

ILLUSTRATIONS.

Page.

Fig. I. Electric Illuminator 9

2. Internal Hemorrhoids with Eversion ii

3. Author's Rectal Retractor 17

4. External Venous Hemorrhoids 21

5. External Cutaneous Hemorrhoids 23

7. Syringe for Carbolic Acid 48

8. Pile Forceps 65

9. Author's Clamp 66

10. Smith's Clamp 66

11. Paquelin Cautery 68

PIlJ]rACE.

Concerning this little book it is only necessary t© say
that it contains the results of my own experience with the
various methods of curing hemorrhoids up to the present
time. It is written solely for my fellow practitioners, and
with the wish that they may find it a safe guide in practice.
In it many of the questions which are constantly asked as
to the value of different operations will be answered as far as
I am able to do so.

CHAS. B. KELSEY.
No. 25 Madison Ave., New York.

CHAPTER I.

EXAMINATION AND DIAGNOSIS.

Generally, to one unaccustomed to the ex-
amination of patients suffering with disease of
the lower bowel, the diagnosis is surrounded by many
purely imaginary difficulties. This is shown by the
fact that the first inquiry of almost all such practition-
ers is " What speculum do you use ? " as though there
must be some mechanical contrivance by which the
senses of touch and vision can be so improved upon
as to render the discovery of obscure troubles much
simpler than it otherwise would be.

The same idea is well fixed in the minds of
patients who, under the false idea that an examination
and diagnosis necessarily mean a painful use of instru-
ments, will defer treatment until disease has made
irreparable progress. The surprise of such patients
when a diagnosis is made by mere sight, or at most
by a painless digital examination, is only equalled by
that of the young practitioner when he is told that
only in exceptional cases is it necessary to use any
instrument whatever.

The secret of successful diagnosis of these dis-
eases consists in taking nothing for granted. Every
affection of the lower four inches of the bowel can be
both seen and felt if the practitioner will only take the
necessary trouble to go about it in the proper way;

and a disease which can be felt and looked at is gen-
erally eas)- of diagnosis. The man who fails to detect
the nature of a rectal trouble is generally the one who
has refused to employ the necessary and yet simple
methods bv which alone a diagnosis can be reached ;
and the man who acquires a reputation as a diagnos-
tician in this department is the one who simply uses
his eyes and his fingers, and refuses to deceive him-
>elf by jumping at conclusions in the dark.

To one in the daily practice of any department
of surgery a routine practice soon recommends itself
as most likely to eliminate errors and lead to a correct
conclusion ; and the following is the one which has
been adopted by myself, and one to which every
patient great or small, male or female, submits.

The patient's name, age, condition in life, etc.,
are first entered in a case book. Next he or she is
urged to tell the story of the disease in all its details,
and this story is never interrupted or cut short ; for in
the nervousness of a first visit, often made at great
expense of time and trouble, and with the fear of a
painful examination before their minds, a nervous
patient will often begin the history of his sufferings
backward, and if allowed to recover himself by a few
sympathetic words will not infrequently give the gist
of the whole matter at the very end. This takes time,
but time is never of any moment until the diagnosis
has been made. It is often necessary to devote an
hour or more to the first examination of a patient, but

— 3 —

no patient should be allowed to end his first visit un-
til a diagnosis has been made or the surgeon acknow-
ledges to himself his inability to make such diagnosis.

By the time the patient has told the story the sur-
geon should be in the possession of certain informa-
tion, and if not he must proceed by a few direct ques-
tions to try and obtain it. What he must know is this.
How long has the patient been sick ? Is there any
pain, if so of what character, and is it in any way
dependent upon the evacuation of the bowels ? Is
there any protrusion of the bowels at stool, and if so
what is its character, and does it return spontaneously
or is it necessary to replace it ? Are the bowels regu-
lar or is there diarrhoea, and of what character ? Is
there any bleeding ? In addition it must be discovered
whether there has been emaciation, febrile action, and
discharge of any sort.

From such a verbal examination much may be
gained. In fact the positive diagnosis can sometimes
be made. But, on the other hand, it is astonishing
how often the most intelligent patient will utterly
mislead the examiner ; and though I have great confi-
dence in this indispensable history as a prelude to
actual examination, considerable experience has
taught me never to trust to it alone, for the simple
reason that although it may convey all the informa-
tion necessary, the surgeon is never sure that he is not
being unwittingly led upon a false track by the most
intelligent answers his patient is able to give.

For example : A gentleman whose medical fame
has extended wherever medical literature is read,
came to me some time since for " piles which had
troubled him ever since he could remember." He
was sure he had them when seven or eight years old,
and an examination showed three very large fibroid
polypi. Another told me he suffered only from
severe pain at defecation, but asserted that "there
never was any tumor to speak of." Of course I ex-
amined him for fissure, but none existed. Then after
an enema, he again placed himself on the table and
showed a cluster of well-developed internal hemor-
rhoids, tightly constricted by the sphincter.

A patient with the strongest motive for conveying
all the information in her power, is often unable to do
so except in language which though perfectly true, will
convey an entirely different idea to the physician from
the correct one. I have just returned from the bed-
side of a lady upon whom I operated a few days ago
for a laceration of the neck of the womb and large
hemorrhoids. Her nurse informed me yesterday with
an air of great wisdom that the whole bowel came
down for an inch or more, all around, whenever she
had a passage, and the patient had already told her
lady friends that she was quite sure the operation was
a failure. The most careful questioning of both
patient and nurse brought out the facts that every
time the bowels had moved since the operation there
had been a protrusion ; that this tumor was fully an

— 5 —
inch in length ; that it completely surrounded the anus
and went back spotaneously with more or less pain.
Failing to weaken this testimony by any cross-ques-
tioning, I had about made up my mind that the patient
was suffering from an invagination and asked for an
examination. She was placed on the commode, the
protrusion was pressed down, she moved gently back
into bed and I was called from the next room, but the
tumor had disappeared. It had, however, been "fully
. an inch long," as usual. Another attempt was made
and the tumor was again brought down in the same
way, and this time I saw it in its enormity. It con-
sisted of a slight eversion of the muco-cutaneous junc-
tion of the anus — the pedicles of the very large hemor-
rhoidal tumors I had removed. In this case the anus
was very patulous, the patient of very slight muscular
power and of relaxed fibre, and at the operation it had
been a question as to how much of the muco-cutane-
ous tissue to remove. Enough was taken off to cure
the patient but not enough to cause a subsequent
stricture, and when the swelling subsides she will be
perfectly satisfied, and there will be no eversion.

This is but an example of how little positive infor-
mation many patients are able to give their physicians
as to their own condition. A prolapse two or three
inches long and a simple pruritus will both be de-
scribed as piles.

After this line of investigation has been exhausted
the inevitable examination by touch and vision follows.

General practitioners tell me they have difficulty
in obtaining the consent of patients to an examination.
I never have had, save once. That case was a for-
eigner who told me when I proposed it that he '^ had
entirely too great a respect for me to allow me to do
such a thing." My only answer was that 1 had too
great a respect for myself to treat him without know-
ing what was the matter, and we parted amicably.

And yet an examination to a lady is not a pleasant
thing. It is in fact a thing which will cause her to
suffer silently for many years rather than submit to it.
It is only when suffering has forced her to it that she
will submit, but that point has always been reached
when she consents to consult a sugeon or a specialist
for treatment. Then she expects to be examined (in
fact has very little respect for the surgeon if he does
not examine), and it remains for him to make the un-
avoidable examination in the way least offensive to his
patient.

For this purpose a trained female attendant should
always be in waiting. After the history has been taken
and the physician has in a measure gained the confi-
dence of his patient, she is handed over to the nurse
in waiting, who gives the enema, arranges the patient
on the chair, covers her with a sheet, and when all is
ready, signs to the doctor. His work may be done at
a single glance, or may require careful investigation
and examination with finger or instruments; but when
it is done the patient is again given over to the nurse,

— 7 —

and when she is once more herself, the diagnosis is
made and the question of treatment may for the first
time be entered upon.

I do not know that it is necessary to dilate upon
this point any further, except to say that I have found
it best in my own practice to have two entirely separ-
ate waiting-rooms, one for ladies and the other for
gentlemen. It is pretty well known that all patients
who come to me have rectal disease, and ladies do not
care to take their turn in the presence of several gen-
tlemen, I have also a special apparatus for the ad-
ministration of enemata, and in immediate connection
with the examining-room there should always be a re-
tiring-room and water-closet. This is absolutely in-
dispensable, both for decent privacy of the patient and
for thorough examination.

The enema may be given in any way most con-
venient, but often requires great gentleness on the
part of the giver. For my own use I have rather an
elaborate apparatus, consisting of a glass jar holding-
one gallon, which stands upon a shelf seven feet above
the floor, and is filled by a rubber tube connecting
with what is popularly known as a barber's faucet, by
which either hot or cold water can be drawn from the
same tube at pleasure. This, how^ever, is useful for
several other purposes besides the administration of
an ordinary enema.

A small, smooth, glass tube may often be intro-
duced with less pain than the usual metal tip of tht-

— 8 —

Davidson's syringe; and a small, soft rubber catheter
answers an equally good purpose, but whatever in-
strument is used, should be either in the hands of the
surgeon or of an intelligent nurse.

The examination may be made on any ordinary
operating table, or on a more elaborate gynaecological
chair, as the operator prefers. Since, however, there
is a good deal of gynaecological work to be done in
connection with this specialty, the patient should be
enabled to assume Sims's position with ease. For
a rectal examination alone, in male or female, the
left lateral position is the best, and the correct Sims's
position is not necessary. Either natural or artifical
light may be used. For many cases there is little
choice between the two, but for illumination within the
rectal pouch artifical light has the advantage. For
this reason I have long been in the habit of using a
large and powerful lamp and lens, such as is used for
laryngological examinations, and is figured in my work
on Diseases of the Rectum.*

The small incandescent electric lights to be intro-
duced into the bowel are of little use for ordinary ex-
aminations, because without ether and stretching of
the sphincter, the lamp and speculum fill up the entire
space and nothing can be .seen, but under favorable
conditions with a widely-dilated anus they may be of
^reat practical advantage.

* Diseases of the Rectum, N. Y., Wm. Wood & Co., 1884,
p. 63.

A better form of electric light is that manufactured
by the " U. S. Electrical Co.," and shown in the cut.
It can only, be used with a storage battery, but it
has this advantage, that it is portable, and is never
obstructed by the head of the operator in his motions
to obtain a good view.

Fig. t.

Suppose now that an enema has been given, the
patient has strained down the protrusion which ordi-
narily takes place, and while it is down has taken the
place upon the examining table in a good light.

If any protrusion at all be visible it will be one of
the following things:

1. External hemorrhoids.

2. Internal hemorrhoids which have been brought
to light.

3. Prolapsus.

lO

4. Polypus.

5. Cancer.

As the patient is never able by a verbal descrip-
tion to enable the surgeon to decide which of these he
is to treat, the necessity of this examination and the
folly of dispensing with it become self-evident.

I'he various forms of external hemorrhoids will
be described in the next chapter.

Where internal hemorrhoids are to be distinguished
from other protruding tumors, I hardly know how to
convey in words what is so perfectly evident to the
eyes when one has seen, if only for a single time, the
different varieties of tumors. The diagnosis is gen-
erally between hemorrhoids and prolapse, and where
the two conditions are typical they are easily distin-
guished. An hemorrhoid is a distinct, varicose new
growth. It springs from a part of the circumference
of the rectum or anus, and when it protrudes it gen-
erally drags down the margin of the anus to which it is
attached. When several hemorrhoids protrude several
different points of the anal circumference are involved,
and the tumors all meet in the centre, some larger and
some smaller, like a bunch of large and small grapes,
but all trying to get out of the anus at the same point
and filling up the outlet. With prolapsus the condition
is different. The bowel is telescoped into itself from
above, and what protrudes is normal gut and not
a new formation. The protrusion is attached evenly
all around; it is composed of comparatively healthy

1 1

mucous membrane, and it does not spring from the
muco-cutaneous verge of the anus, but is a part of the
rectum proper, and is therefore covered by mucous

Fig. 2.

membrane, and not by skin and mucous membrane.
It is one tumor and not several; and yet there is
a form of disease in which the protrusion is made up
entirely of the muco-cutaneous verge of the anus —
swollen, enlarged, prolapsing it is true, but without

I 2

distinct hemorrhoidal tumors. The patient strains
down and the margin of the anus turns out with skin
on one side and mucous membrane on the other.
The tumors thus formed are not properly hemorrhoids,
nor do they constitute a prolapse, though they will be
found described under both heads. If the sphincter
be stretched the patient will be found to have large in-
ternal hemorrhoids which, by their mechanical effects,
have loosened the cellular tissue at the verge of the
anus. The condition to which I refer is well shown in
Fig. 2, in which the part marked i, is covered by
mucous membrane, and the others by skin. And
this condition may sometimes lead the t)perator to
wonder in his own mind whether he is operating for
hemorrhoids or prolapse ; but since the operation is
the same in both cases, and invariably cures the
patient, there is not much in the name.

Internal hemorrhoids are distinguished from polypi
both by the appearance of the tumors themselves and
by their attachment. In the former the base is the
largest part of the tumor. In the latter the tumor
is attached to the wall of the rectum by a distinct
pedicle often very long and delicate. To the practised
eye the appearance of the presenting tumor is suffi-
cient for a diagnosis, but the difference between the
two though easily appreciated by sight is difficult to
express in words. The polypus is generally harder,
firmer, and contains more connective tissue. It is also
apt to be mamellated like a mulberry, while the mucous

_ 13 —

membrane covering a hemorrhoid is tightly stretched
and even. The pedicle, of larger or smaller size, is.
however, the diagnostic point. A tumor the size of
an egg, attached by a stalk the size of a lead pencil
has little resemblance to a hemorrhoid.

Between polypus and prolapse the diagnosis is easy
with care, and yet within a short time physicians of
skill have sent me cases in which there had been pal-
palable error. The first was a polypus, said to be a
prolapse, in which no examination had ever been
made. The second was a prolapse, said to be a poly-
pus and which really looked very much like one, but
in reality was a protrusion of a small lateral section of
the bowel, involving only a small part of its circum-
ference.

Between a cancer and hemorrhoids a mistake can
hardly be made when once the tumors are seen, though
the history and symptoms may be exactly identical.
A lady visited me from Albany some time since giving
the ordinary history of painful and bloody passages
with a tumor that protruded at stool but went back
spontaneously or with slight pressure. On examining
this tumor, which I supposed to be hemorrhoidal, I
found an epithelioma protruding from the anus, which
involved the entire circumference of the bowel, but
began two inches above the external sphincter and ex-
tended from this point for a couple of inches upward.
It was this tumor which acted like a foreign body and
was expressed in each act of defecation.

— 14 —

Again, I have seen old cases of protruding and
irreducible hemorrhoids which have been out of the
body for years, so ulcerated, eroded, and granulated
that they strongly resembled epithelioma of the anus,
but such cases are very rare and the distinction can
certainly be made by careful observation.

Suppose now that the patient has described a
distinct protrusion at stool, but when the enema has
been given, and the surgeon comes to examine, no
such protrusion is visible, or can not be brought into
view by any effort of the patient. It has simply " gone
back." Under these circumstances I cannot too
highly recommend an examination with the finger
while the patient is straining in the ordinary position of
defecation. Under these circumstances the expulsive
effort has the greatest possible effect, -and a. slight pro-
trusion often becomes perceptible to the touch which
cannot be seen with the patient in the lateral position
on a table.

Suppose, again, that the enema has been given,
the patient is in position, and there is no protrusion.
A careful inspection reveals no opening of a fistula,
no fissure just within the anus, and no capillary hemor-
rhoid (to be described in the next chapter). In fact
no disease is manifest.

The next step is a digital examination of the rec-
tum. The right index finger is oiled and gently intro-
duced through the sphincter. No force should be
used. The muscle at first is inclined to spasmodic

— 15 —
contraction, but this, except in abnormal states, is
easily overcome by gentle pressure, and the finger may
be introduced its whole length. In this way the last
three inches and a half of the bowel are brought with-
in the sense of touch, and many of the common affec-
tions may be diagnosticated — cancer, stricture, ulcer-
ation, abscess, fistula, misplaced uterus pressing upon
the bowel, and internal hemorrhoids which are not
sufficiently developed to protrude. For hemorrhoids
of the usual form may exist with all of the accustomed
symptoms except protrusion — hemorrhoids of the in-
ternal variety which are attached high up, cause pain,
bleeding, and other symptoms, and yet never come
down below the sphincter.

These are to be diagnosticated by digital exami-
nation. It may take a long time to educate the finger
up to the point of distinguishing these soft tumors
from the folds of mucous membrane in the healthy
bowel, but the facility must be acquired, and it can
only be done by constant practice.

Let us suppose now, once again, that all this has
been done, and yet the examiner has discovered no
disease. At this point he must take a decided respon-
sibility, for if from the patient's history he believes that
rectal trouble exists, he must still go on and find it,
but if he have no reason to believe this, he may abandon
the search at this point and commit himself to the
opinion that there is no rectal trouble.

If he decide to go still further, there is but one

— i6 —

line of investigation to be followed, and this consists
in the administration of ether, the dilatation of the
sphincter, and the use of the speculum.

It will be noticed that up to this time the question,
"What speculum do you use?" has not been answered,
and for the reason that up to this point in the exami-
nation I use no speculum; and as the vast majority of
examinations will lead to a diagnosis before this point
is reached, it follows that in about ninety per cent, of
all my rectal cases I use no speculum at all.

An entirely too exalted idea of the value of the
speculum exists. For ordinary examinations it is un-
necessary, and the diseases which cannot be detected
by the routine practice already described will not very
often be detected by the simple use of any variety of
this instrument. So strongly has this experience been
impressed upon me that I have abandoned the use of
every form of speculum for ordinary diagnostic purposes,
unless at the same time its auxiliary means can be em-
ployed— the administration of ether. With ether, a
light, and a speculum, a diagnosis may often be made
which would otherwise be impossible; but to use a
speculum, without ether, for the purpose of exploring
the rectal pouch, is merely in the vast majority of cases
to inflict useless suffering.

This does not apply to the question of treatment,
but simply to diagnosis. For there exists a certain
class of diseases, notably circumscribed ulcers, which,
when their situation is accurately known, can be

~ 17 -

brought into the field of vision by a speculum and thus
treated by direct applications, but this is a very differ-
ent matter from taking a patient who complains, per-
haps, of but the single symptom of rectal pain, intro-
ducing some variety of speculum by which only the
most imperfect view can be obtained, and because
nothing is discovered (as in the vast majority of cases
nothing will be), pronouncing the patient free from
disease.

Fig 3. — Author's Rectal Retractor.

I cannot make this ponit any stronger perhaps
than by adding that whatever success I may have
gained as a diagnostician in doubtful cases of rectal
disease has come from the simple rule of etherizing
my patient, dilating the sphincter, and then looking at
what at once becomes plainly visible, viz. the whole
lower five or six inches of the bowel. Under such cir-
cumstances, the simpler the instrument the better. A
medium-sized blade of Sims's vaginal speculum answers

3 A

— i8 —

■every purpose: or my own fenestrated rectal retractor
which exposes more surface and takes up less room.

It requires some courage and self-confidence on
the part of the examiner after making the usual visual
iind digital examination to say to his patient, "All this
has led to nothing. I have no idea what is the matter
with you. Vou must take ether, if you wish me to
find out.' But this is the only proper course, and
should be a routine practice in every case where the
svmptoms of rectal disease are sufficiently marked to
justify it.

From what has been said it must be evident to
every reader that the successful examination of any
doubtful case of rectal disease consists merely in mak-
mg use of the ordinary senses, with which we are all
provided. There is no occult faculty in all this, no
<kep power of knowing w^hat is concealed from the
majority of mankind. If the beginner will be honest
with himself, and will insist upon seeing what is to be
seen, and feeling what is to be felt, he will — except for
the experience which only practice can give — make as
good a diagnosis in his first case as the specialist who
has practiced for a lifetime.

I can add nothing more to what has already been
said on this point, except that the man who has fool-
ishly allowed himself to be beguiled into prescribing
some salve for a cancer, when he thinks he is treating
hemorrhoids, because his patient objects to an examin-
iition, need not feel hurt when he finds himself placed

— 19 —

in a ridiculous light by some better man than himself,
who has made his diagnosis before beginning treat-
ment. All his tender regards for the foolish suscepti-
bilities of his nervous lady patient will bring him no
mercy in her judgment. She is willing to admit that
she may have been foolish, but she will make no al-
lowance for the foolishness of her physician, and in
fact he deserves none.

There are but three ways of making a diagnosis —
by question, by sight, by touch. The man who has ex-
hausted these will seldom fail in his diagnosis, and
should he do so, need not be ashamed. The man who
neglects any one of them will, sooner or later, make
some error which he might easily have avoided.

CHAPTER II.

THE DIFFERENT VARIETIES OF. HEMORRHOIDS

There are several perfectly distinct varieties of
hemorrhoids, each requiring a different mode of treat-
ment, and a treatment which is applicable to one may
be entirely out of place in another.

Before discussing various modes of treatment,
therefore, we must understand exactly with what we
are dealing.

A patient presents himself complaining of hemor-
hoids with the usual symptoms, and an examination
shows a slight swelling, perhaps the size of the end of
the little finger, at the verge of the anus. This small
lound tumor may have any one of three distinct his-
tories:

First. — It may have formed suddenly in the course
of a few hours; may have been attended by consider-
able pain, and may have immediately driven the patient
to seek relief. The patient has been unusually consti-
pated in the morning, and may have strained a good
deal at stool; or, he may have been up late on the pre-
vious night, have drank heavily, smoked a good deal^
and lost more money at cards than he could well
afford; or, without any of these palpable causes, he
finds during the day that there is a sense of uneasiness
at the anus, and by examining himself finds a small,
round, sensitive tumor. At first he thinks nothing of

21

it, but as the pain increases he endeavors to push the
offending swelHng within the bowel, feeHng sure that
if it would only sta}^ there he would find relief. The

pressure gives temporary relief and as long as it is
continued the tumor disappears, but the moment after
it is removed the swelling is as large and painful as
before. This usually goes on all day, but at night
when the sufferer has gone to bed the pain is much

— 22

less, and in the morning he is quite sure that the
trouble is past. After a few hours however, it is
worse than ever, and then if he be at all inclined to
take care of his own health he seeks medical advice.
If, on the other hand, the patient be a sensitive woman,
it is at about this stage of the disease that she takes a
fine cambric needle and tortures herself by sticking it
into the tumor. A drop of blood and increased suffer-
ing are the only results.

This form of external hemorrhoid is well shown
in Fig. 4, and the pathology is well known. One of
the small branches of the external hemorrhoidal veins
has ruptured, and an extravasation has occurred in the
surrounding cellular tissue just at the verge of the
anus. The pain and swelling are due simply to the
pressure of a small clot of blood, which by a simple
incision through the skin may i)e turned out of its bed
entire.

Second. — Another patient comes with a some-
what different history. He or she also has a small
tumor at the verge of the anus, but it has been there
for many months. It is only painful at times, but it is
always present, never disappears within the bowel, and
sometimes causes a great deal of suffering.

Here the tumor is evidently a tag of skin and is
hard and solid, containing no clot of blood which
shows by its dark color through the stretched skin.
It may be red, swollen and painful, but the tumor it-
self is more apt to be comparatively insensitive, while

— ^z —

just at its base a distinct fissure of the anus is seea
which is the cause of the pain. This form of external
hemorrhoid can generally be traced to that which has
just been described. The clot has become organized,

Fi.

the cellular tissue around it has become hypertrophied,
the skin over it has been stretched till a permanent
growth remains. This tumor is often passive for long
periods of time, but at any moment from a slight cause
which often escapes the knowledge of the patient it
is liable to take on a subacute form ni inflammation.

— 24 —

l)ecome red, swollen and painful, and cause great
suffering.

Third. — The patient presents a circle of cutaneous
tumors as shown in Fig. 5.

These also are cutaneous hemorrhoids or condyl-
omatous tags as they are often called. They are
merely hypertrophies of the skin and subjacent con-
nective tissue, but there are several of them and they
are of large size, almost completely surrounding the
margin of the anus. The adjacent surfaces of these
growths where they rub against each other, and the
fissures at their bases between their points of attach-
ment, are apt to be ulcerated. These are also external
hemorrhoids, but they have been endowed with a
peculiar significance by various writers, in that they
are supposed to be proof of syphilitic disease of the
rectum. 1'here is I believe nothing in this idea, but
there can be no mistake in the fact that they are in-
dicative of serious disease within the bowel. This
disease may be either syphilitic ulceration, stricture,
or cancer.

Beyond this point I have never been able to trace
the pathological significance of these tumors. They
certainly, when largely developed as in the figure, indi-
cate grave disease above the sphincters, and are due
generally to the irritation of the discharge from such
disease, but they are not diagnostic of the character
of that disease.

Here, then, we have three distinct varieties of e.\-

ternal hemorrhoids, and it must be perfect!}' evident
that they are not all amenable to the same form of
treatment, nor are any of them to be treated as would
be one of the bleeding growths just within the anus,
which will be referred to; or as a large, prolapsing
varicose tumor arising above the sphincters, and only
appearing outside the body as a result of straining at
stool.

There is still anotlier form of external hemorrhoid
which differs from any yet described. In it there is
little or no hypertrophy of the skin and subcutaneous
connective tissue, as in the last, nor is there any blood-
clot as in the first, but when the patient strains down
there is a tumor formed just at the verge of the anus,
and rather on the cutaneous than mucous aspect. The
tumor is nothing more or less than a varicosity of an
external hemorrhoidal vein, and the vessel may often
be distinctly seen through the normal and delicate
skin. Such a tumor is not painful, and causes no
symptoms except in persons of extreme sensitiveness,
who are sometimes very much worried lest it should
result in something more serious.

All the forms of hemorrhoids thus far described
are covered by skin rather than mucous membrane,
and all of them spring from the margin of the anus.
None of them arise from within the sphincter and
come outside, and none of them can be forced within
the bowel and made to remain there. They are all
varieties of what are known as external hemorrhoids,

— 26 -

from their situation, to distinguish them from the in-
ternal or those which develop within the rectum proper.
This distinction between external and internal is gen-
erally very well drawn, and the two forms are easily
distinguishable; but in some cases the growths so in-
volve the margin of the anus on both its mucous and
cutaneous surfaces that it is impossible to say to which
class they properly belong. They are partly covered
by skin and partly by mucous membrane; they may in
great measure be replaced within the bowel, but not
entirely; and they turn out again on the least straining
or exertion; and they are liable to bleed, which none
of the other forms, described as purelv external, ever
do.

Again, there is the large internal hemorrhoid,
shown in Fig. 2. This arises from the rectum proper,
and may go on developing for years before it ever ap-
pears outside of the sphincter. While still c(M'npara-
tively small, and before the patient has ever had any
protrusion at stool, it may give rise to all of the symp-
toms of hemorrhoids, except those due to the forcing
of the tumors outside the body. In other words, the
patient may have pain, bleeding, discomfort in defeca-
tion, pain in the loins, thighs and legs, slight mucous
discharge with or between the passages, itching to an
annoying extent, and often a train of reflex nervous
.symptoms, and yet never have any protrusion; and the
physician must use care in his diagnosis and learn to
detect these tumors by digital examination alone; for

— 27 —

the condition is one for which patients in the higher
walks of life not "infrequently seek relief, and much
good may be done by treatment.

Finally, there is the nevoid condition, often spoken
of as the capillary hemorrhoid. In this form the
tumor is never large; never, I think, large enough to
protrude from the anus even with straining. The dis-
ease is rather a group of enlarged capillary blood-
vessels than a connective tissue growth. This is
usually situated just within the verge of the anus, and
when seen looks like the surface of a strawberry. The
mucous membrane covering it is generally eroded,
and the slightest touch with a probe is often sufficient
to set up a free arterial hemorrhage. This is the
bleeding hemorrhoid par fxcellencf, but it often causes
hardly any other symptoms.

Suppose, now, that an enema has been given and
there is no protrusion, and yet the patient complains
of bloody passages and some pain. By gently draw-
ing apart the margins of the anus a bright red, straw-
berry-looking surface appears just within the margin
when the patient strains down. There is little tumor;
nothing comes outside when the patient has a passage,
and yet he or she is nearly bloodless from the daily
hemorrhage in the closet. The finger is passed up
the bowel, and no changes are found. A slight
touch on the strawberry-like surface occasions a
free flow of blood, sometimes arterial and in jets, at
others bright red. but not per saJfeni. The diagnosis

— 2$ —

is made, and the patient is suffering from what is
known as a capillary hemorrhoid.

Some time since I was asked by Dr. Watson, of
Jersey City, to see with him a case with the following
history.

The lady had been suffering for a considerable
time from occasional severe hemorrhages from the
bowel. These occurred at considerable intervals, and
never while at stool, but always some time after the
natural evacuation. Half an hour or so after relieving
the bowels she would feel the desire for a second
movement, and this would be composed in great
measure of bright arterial blood, sometimes reaching
half a pint in quantity. The history being given, a
digital e.xamination was made, and nothing found.
By careful examination of the anus a strawberry
growth was seen, which bled freely on the merest
touch. I could see, when we reached the next room
and I gave my diagnosis, that it was looked upon by
the other medical gentlemen present with considerable
doubt, and I therefore strengthened it with the offer
that if, after one or two applications of strong nitric
acid to this spot, the bleeding did not cease, I would
come again to the city where this patient lived and
make another examination under ether, without fee.
The application was made and the patient was cured.

'J'here is apparently no limit to the amount of
blood a patient may lose from this form of disease.
Onlv recentlv I saw in consultation a case of bleeding

— 29 —

ti) the point of absolute exsaiiguination from these
tumors. The patient was a poor man in the tenement-
house district, who had bled at each passage till his
pulse was 120, his complexion waxy, and till he fainted
three or four times a day. He attempted a passage
at my request while making the examination, and
when lifted from the commode he had evacuated fully
half a pint, if not more, of bright red blood. He had
no disease except these bright red arterial hemor-
rhoids, and they caused no protusion at stool. It
hardly seemed possible that such a grave general state
could result from so slight a local disease, but the cure
of the local condition cured the patient.

CHAPTER III.

TREATMENT.

Before undertaking the treatment of a case of
hemorrhoids both patient and surgeon should
come to a distinct understanding. The latter can
assure the sufferer that he may be cured at once and
forever if he desires, and this applies to all forms of
the disease. The only cases in which this cannot be
said are those in which the patient is in such bad gen-
eral condition that no interference is justifiable. If
he be suffering from advanced disease of heart or kid-
neys, for example, and at the same time be troubled
with old hemorrhoids, it may be safer to do what can
be done by palliative measures and avoid anything
like radical treatment. This is the only thing that
should prevent the surgeon from attempting a positive
cure. Ordinary disease of the lungs has never pre-
vented me from operating and getting a good result.

Just at this point the surgeon will have many
questions to answer, and one of the most common is
whether nature did not intend that a great many
people should have a painful affection of the rectum
which should make a part of their lives miserable and
cause them to lose two or three ounces of blood every
time they go to the closet ; and whether it is safe for
the sufferer to have this beautiful condition interfered
with ? This question will come from very intelligent

people, who will back it up with the authority of some
physician, that by suffering in Uiis way they are es-
caping something worse. Should the same physician
who advises that this daily bleeding be allowed to
continue, make a practice of opening a vein in his
patient's arm once a day for years, and withdrawing
the same amount of blood, what would be thought of
his practice ? And yet one would be as good practice
as the other.

The iiext question will be whether the patient can
be cured without an operation, and at exactly this
point many a patient will disappear. The answer will
depend, as will be shown presently, upon the form of
trouble present. Many cases can be cured without
an operation, and many more by procedures so trivial
that they carry no terror in the thought, but some can
not. In the latter class of cases the young practitioner
must not, for his own sake, allow himself to be placed
at a disadvantage which is pretty sure to end dis-
astrously.

Unfortunately for the public they almost all con-
sider themselves pretty well educated on the subject
of piles. Cures "without knife, ligature, or caustic"
have caught their eyes in the daily press for years,
and they come to their doctor not to be guided by his
judgment, but to have him relieve them if he can do
so, subject to the restrictions they may impose. The
conditions are these. " If you can cure me without
an operation I am willing to be cured, otherwise I

_ 32 —

prefer to be let alone." There is no blame to the
patient in this, for he has a perfect right to make his
own bed and lie in it ; and it may be possible for the
physician to do as he desires and cure him without
ether, without confining him to his bed, and without
any "operation," as he considers an operation. But
the young surgeon must not be too anxious for the
case. He may be forced to say " what you desire is
impossible," and let his patient go; but he never must
be led into a line of practice which is not safe, for
when trouble comes no mercy will be shown him.
The patient is practically doctoring himself, with a
physician to assist him, and in his heart he knows it.
The case goes badly and the doctor has all the blame
and deserves it. The rule in my own practice is, 1
believe, the only one to be followed; after my examina-
tion I recommend the method of cure which seems to
me the best, and from that 1 never allow myself to be
shaken. If it seems to the physician that the clamp
should be used he must in honesty use it, and not
allow himself to be placed by his patient in the false
and untenable position of recommending one treat-
ment as best and then employing another. To be
.sure he will occasionally see his patient go elsewhere,
but less often than he fears; and on the other hand
he will avoid bad surgery with its unpleasant con-
sequences. He must make up his mind at first that a
great many patients had rather suffer all their lives
than be cured by any operation even as safe and pain-

— 33 —

less as this; and he may strive to find some method
of curing, or at least relieving this class which is free
from the terror of a cutting operation ; but he will
probably discover in his search that hemorrhoids are
bad things to experiment upon, and his first accident
will greatly dampen his ardor, in the light of the fact
that he already has at his hand a means of cure which
surgically leaves little to be desired. On this point
let me say that the profession in general, the great
body of practitioners scattered over the country, are
being unduly worried about a particular scheme of'
curing hemorrhoids by injections. The secret remedy
is known, it has been faithfully tried in hospital and
private practice by representative men both in Europe
and America ; it will be fully described in the course
of this little book, and its advantages and disadvan-
tages copmpared with other recognized means of treat-
ment. I also venture to predict that as a popular
quack remedy it has seen its best days ; for the re-
action in the public mind has already begun, and
where a year or so ago every patient was determined
to have nothing but carbolic acid, they now not in-
frequently are just as anxious to have nothing to do
with it.

If the surgeon wishes to try this method of treat-
ment, at the demand of the patient, he is justified in
doing so; but it is not equally adapted to all cases, and
in some respects its action is very uncertain, as will be
shown later.

4 A

— 34 —

Some patients will deliberately choose a course
of palliative treatment, even knowing that it is not
curative, rather than to be cured by surgical means.
For such, the practitioner must be prepared to furnish
what relief he can, and this is often very great, though
we cannot now enter into the details of treatment.

Though it is difficult to conceive of a case of
hemorrhoids that cannot and ought not to be cured,
where the patient is in any condition to bear treatment,
there are some which can only be cured after prolonged
preparatory treatment, and these are generally in
women. The doctor who does much rectal practice
becomes of necessity very familiar with many of the
diseases of women. He will not be long in practice
before he encounters the following combination. A
lady comes to him with hemorrhoids, upon which he
operates with, perhaps, the usual good result, though
possibly only obtained after rather a slow and painful
recovery. In the course of a few months the disease
has returned, or it may be that she has never been en-
tirely well since the operation. Another examination
is made, and the patient is found to have, in addition
to the hemorrhoids, an enlarged uterus with a lacerated
cervix, a ruptured or greatly relaxed perineum, and a
proctocele, all of which should have been cured before
the operation for hemorrhoids was attempted.

Many patients dread the taking of ether more
than the operation itself, and will refuse radical treat-
ment on this account. When cocaine was first intro-

— 35 —
duced I had great hope that this objection might i^v
the future be overcome, but the drug has not fully
reaHzed the expectations held concerning it. Never-
theless it answers in a great many cases, and should
always be at hand. By it small tumors tnay be removed
with absolute painlessness, and I have operated bot[?
with ligature and clamp under its influence, with great
satisfaction in some cases of large tumors, but have
been disappointed in others, before I found out by
frequent trials the limits of its applicability.

Where the tumor or tumors to be removed are
small, or where a single large one can be separated
from others and cocaine be injected with the hypoder-
mic syringe into the exact part where the ligature o:
clamp is to be applied, the drug will give satisfactory
results. In this way several large tumors may be
operated upon at one sitting, or at intervals of tei\
days or more, and the patient cured. But where the
whole margin of the anus is involved and turns out
with the hemorrhoids, and where it is necessary to
bring the entire circumference of the rectum for y
considerable distance upwards under its influence, the
drug is apt to be unsatisfactory; for the reason that tv
bring all parts of the wall under, its influence at one
time, as is necessary in stretching the sphincter, dan-
gerous symptoms may be produced before a sufficient
quantity of cocaine has been injected to permit of
painless operation.

In the New \'ork Medical Journal, Auiiust 7. iS.SO,

- 3^ -
1 reported a case of this sort. It was necessary to
♦)ilate the sphincters, and with a large speciUum care-
fully examine an exceedingly sensitive ulcer for a blind
fistulous track emptying into it. One hundred and
twenty minims of 4 per cent, solution of cocaine were
mjected into eight different points around the circum-
ference of the anus without giving sufficient anaesthesia
li) operate with any comfort; and on account of symp-
toms of general cocaine poisoning which developed, the
operation was finished with ether.

The recent suicide of Dr. Kolomnin was caused
by a somewhat simjlar case of ulceration of the rectum,
which he endeavored to scrape under cocaine. After
three injections of six grains each the rectum was still
^^ensitive; after another six grains, he was enabled to
operate with tolerable anaesthesia, but the patient died
of the drug, and Kolomnin took his own life.

The only explanation I have of the difficulty in
•^•etting anaesthesia of the whole of the lower end of
the bowel without sometimes using doses of the drug
which are dangerous, is the actual very large extent of
surface to be affected, and the great number of sensi-
tive nerves to be brought into local contact with the
*solution. On the whole, my experience has been, that
in minor operations the drug, when used hypodermi-
cally, is perfectly satisfactory; but in larger ones it is
r.ot to be relied upon absolutely, and may have to be
supplemented with ether.

I.et us now consider in detail the treatment of

~ 37 —

each of the varieties of tumor described in the last
chapter, and I shall hope to do so in a manner whicU
will enable the practitioner to answer his patients' o?>
repeated question, '* how do you treat piles ?" with the
simple statement, '' In a great many ways, depending
on the case."

The treatment of the first variety, that in which j
vein has ruptured and there is a small, exquisitely;
painful tumor at the margin of the anus, is very simple
The suffering is due entirely to the tension and press-
ure caused by the clot, and this should be turned ou:
of its bed by transfixing the tumor and laying it opei;
The knife for this purpose should be a very sharp -
pointed, curved bistoury with small and delicate blade.
The point is entered on the anal aspect, carried di-
rectly through the tumor in the direction of the radiat-
ing folds, and then made to cut its way out, the whole
procedure hardly occupying an instant of time. Co-
caine need not be used, for to inject it into the tumc.
is as painful as the incision, and to rub it on the sur-
face is almost useless. The clot may easily be ex-
pressed, if it does not follow the knife, and the incis-
ion should be filled with styptic cotton. There will
generally be some oozing of blood, and this shouhi
always be stopped completely before the patient leave:-i
the office. A good way is to cover the wound with
ordinary lint, place over this a large, hard pad made
of a couple of towels, and let the patient sit for a fev/
minutes on a hard chair with the pad in place for pres-

- 3S -

stirc. When, after a second examinatit)n, the l)leed-
'.ng has been found to have ceased, directions must be
.civen to repeat the pressure in the same way at the
patient's own home, should it return.

This is an operation which I occasionally take the
liberty of performing without consulting the patient's
wishes; but if it be explained to him and he refuses
the instant relief which it is sure to give, then he
should be directed to buy an ice-bag, fill it with finely
broken ice, go home and go to bed, have his bowels
freely moved with a saline purge, put on the ice and
i}ear his pain till nature relieves him, which may be in
one of two ways, and may take from three days to ten.
'I'he tumor may gradually subside as the clot shrinks
i p and thus relieves the pain, or it may go on to sup-
puration and end either in spontaneous cure or in a
vmall subcutaneous fistula.

The second form of external hemorrhoid, the
vwollen and painful tag of skin which often has a fis-
sure at its base, contains no clot to be released, and
therefore instead of being incised should be cut off,
wfter a few drops of cocaine have been injected into its
substance. 'I'his may also be done in the office, and
I he same method used to stop the oozing of blood as
iii the other case. When the tumor has become pain-
It^ss to the t(nich with cocaine, it is seized with a
small j)air of hooked forceps, gently drawn upon, and
•. ut off at its ba.se with a single closure of a pair of
•■;out and sharp scissors. There will be a little pain in

— 39 —

the cut for a day or two, and that is all. The wound
generally heals very kindly, but should any application
be necessary a ten-grain solution of nitrate of silver on
a brush, or a dressing with a few shreds of very fine
lint will cause rapid cicatrization.

There may be more than one of these tags to be
removed, and they may be cut off at one time or at
different visits, as the patient prefers.

In the third variety (Fig. 5) the cutaneous tumors
are larger and more difficult to manage. Inasmuch as
they are seldom seen to any such extent as is figured
except in connection with more serious disease within
the bowel, their treatment is secondary to the disease
above. I seldom should operate on the tags for
example unless at the same time I were operating for
the stricture or the ulceration. If the patient be under
ether and the stricture is divided, the external growths
may be snipped off with the scissors; but otherwise
there will be plenty to occupy the mind of the surgeon
within the bowel without stopping for this secondary
trouble, the importance of which is very slio^ht in con-
nection with that of the primary disease.

The fourth form — the varicose dilatation of the
veins of the anus without hypertrophy of the skin —
had better in most cases be left undisturbed, unless
there be some special indication for interference. Ex-
cept where the patient is very nervous and over-sensi-
tive, such a condition will cause no real trouble; and
in all the cases I have ever seen the suft'erinof was

— 40 —

more mental than physical. However, 1 have been
forced to relieve patients of this source of annoyance
more than once, and I have done it in various
ways. When he strains down it is at once apparent
that we have to deal with a small tumor composed of
one or more enlarged veins, often appearing through
the delicate skin to be the size of a lead pencil, and
perfectly distinguishable by their dark color. The
question is, what to do. Ablation alone I have never
tried, fearing hemorrhage. Once only have I injected
such a vein with a 15-per-cent. solution of carbolic
acid, seen it in a few seconds solidify and turn whitish,
and subsequently slough — an experiment w^hich for
obvious reasons I do not care to repeat. I have used
electrolysis with better results, but although the tumor
has coagulated and decreased in size, there has been
considerable pain and soreness for some days. Now,
when compelled to operate, I prefer the clamp, know-
ing that though the operation may seem formidable
for so slight an affection, it is at least safe and not at
all liable to be attended by untoward accident.

There remains but one other of these minor affec-
tions— the capillary bleeding tumor within the sphinc-
ter. For this I use fuming nitric acid on the end of a
stick; and it is the only form of tumor in which I be-
lieve nitric acid to be indicated. Here the slough
which follows a thorough application of this kind will
completely cure the disease, and by a single applica-
tion a hemorrhage may be stopped that has kept tlie
patient exsanguinated for years.

CHAPTER IV.

THE LIGATURE.

Of all the time-honored operative procedures
known to the profession for the cure of hemorrhoids it
is but a waste of time to discuss at the present day
more than two — the ligature and the clamp. The first
of these owes its present prominence to Allingham, and
is often described as his operation. In the way now
generally performed the name is correct, though the
treatment by ligature is very old.

The principle of his method is to dissect the
hemorrhoidal tumor away from its attachments for a
certain extent, and then to surround the remainder of
the base with a tight silk ligature. His belief is
that the chief arterial supply to the tumor comes from
above, and that all of the lower part may be dissected
away from the muscular coat without causing any
serious bleeding; while the ligature thrown around
what remains is an effectual barrier against hemor-
rhage. The advantage of this method is that the
ligature is not placed around the skin at the margin of
the anus, for this is divided with the scissors before it
is applied, and the ligature lies in the groove thus
made, and by this means much pain is avoided, and
much time is saved in the treatment.

Regarding the details of the operation but little
need be said, so simple is it in its performance. The

— 4-^ —

tumor to be tied is seized with strong forceps and
drawn down, the patient having been etherized and
the sphincter previously dilated.

With strong scissors the lower attachments of the
tumor all around, and especially the point of junction
of the mucous membrane with the skin, are divided;
the ligature encircles what remains, is tied as tightly as
possible; both ends are cut off short, and the greater
part of the tumor below the ligature is also cut off,
only sufficient being left to form a good and safe
stump for the ligature to hold. The patient is pre-
pared for the operation by the previous administration
of a purgative, and the bowels are confined for a week
or so after its performance, and then relieved by a
cathartic.

This, in brief, is the operation practiced by AUing-
ham, and it is an exceedingly good one. I began my
own practice by always performing it, and did I not be-
lieve that something else was better, should perform it
still. It is as safe as any operation can well be, and
when properly done, it cannot fail to cure; and per-
fect safety and surety are two great points to be gained
in any operation.

But a considerable experience with this opera-
tion led me after a time to begin the search for some-
thing just as safe and ju.st as sure without some of the
objections which any large number of cases will be
sure to show pertain to this method.

The first objection which developed itself in my

— 43 —
own practice was the great pain which the patient
often suffered for the first week or ten days. AlHng-
ham distinctly claims that after the patient has re-
covered from the ether there is often no pain. I can
only say that though this is sometimes the case, it is
by no means the rule in my own practice, or that of
other American surgeons. My explanation of the pain
I have often seen is that a nerve is compressed by the
ligature as well as an artery; but no matter what the
explanation, the fact remains that, having followed
Allingham's method in every particular, 1 have more
than once been forced to keep the patient constantly
under the influence of morphine till the ligature came
away; and I know that many others have had a simi-
lar experience.

A second objection was the frequent necessity for
the passage of the catheter for several days after the
operation.

A third was the amount of blood lost during the
operation, and the frequent necessity for leaving a
considerable wad of lint in the rectum on account of
the oozing, which caused great subsequent suft'ering
and was only removable after three or four days, and
then with considerable pain.

A fourth was the length of time required by my
patients before they were able to resume active busi-
ness.

It will be seen that none of these objections were
of* vital importance. The patients still recovered and

— 44 —

were radically cured, and in the end were satisfied in
spite of these difficulties; but still there seemed to me
an opportunity for a more satisfactory operation.

For these reasons I wais finally, by the advice of
Henr}' Smith, led to adopt another operative procedure,
which on the whole has served me better. I still oc-
casionally use the ligature, but I never apply it where
any of the sensitive tissue at the margin of the anus is
included in the loop. If a tumor be well circumscribed
and pedunculated, and a ligature can be thrown
around its base and still be well above the external
sphincter, it may be applied without causing any great
amount of reflex irritation, and hence of pain. In this
way I have not infrequently seized a prolapsing tumor
of considerable size, injected it with cocaine, and after
a few minutes tied a string around its base and cut it
off without having much subsequent pain. But when
it comes to a case of large, prolapsing, internal hem-
orrhoids, involving the margin of the anus and attended
by a good deal of the eversion of the skin, which is
shown in Fig. 2, 1 prefer another operation, because I
believe, though no safer and no more certain to cure,
it will cause less subsequent pain, and less confinement
to the house and bed, than the ligature.

CHAPTER V.

TREATMENT BY INJECTIONS.

As far as my own influence has gone 1 have done
what I could to take this method of treatment from
the hands of the quacks and place it upon a recognized
basis. In the July number of the "American Journal
of the Medical Sciences," 1885, I reported about two
hundred cases treated by this plan with very satisfac-
tory results, and in "The New York Medical Journal,"
Nov. 14, 1885, in answer t(^ numerous questions, 1
ofave full and definite directions as to its methods of
application.

The fact that since then 1 have had a succession
of bad and troublesome cases treated by this means,
and that these cases have led me in a measure to be
less hopeful of the results of the method, in no way
invalidates the reports of my own carefully-observed
cases up to that time. In writing now I shall use less
glowing terms than I did then, but I have by no means
abandoned the practice. It is still, to my mind, a very
good way of treating a great many cases: having in
certain points^ exceptional advantages over all others;
and in the fact that it does not apply equally well to all,
and that it will occasionally be followed by disagree-
able consequences, it in no way differs from other
operations. I say this so plainly in the beginning be-
cause I have so frequently been accused of having

— 46 -

first advocated the practice and subsequently aban-
doned it; while all that I have really done has been to
state fully and freely the objections to it, as at other
times I have with equal plainness stated the advantages
f)f it. It is now at a point where every practitioner
may try it for himself, and come to his own conclusions
regarding its value. All that can be said of my own prac-
tice is, that while for a year or more 1 used it almost
exclusively and was much pleased with its results, a
succession of bad cases have led me to modify my
views of its value and universal applicability, and that,
though I now use it constantly, it is only in selected
cases.

For years back a great number of irregular and
often very ignorant practitioners have been travelling
around the country injecting and ciiriui; hemorrhoids
with solutions of carbolic acid. The in.strument was
an ordinary hypodermic syringe, the solution was for
a long time a secret, but was finally discovered to be
pure carbolic acid mixed with oil, or glycerin and
water, in certain proportions. About the success of
their treatment there could be no question in a great
many well authenticated cases upon ordinarily intelli-
gent patients, who said that they simply felt the pricks
of a needle and were cured. By this simple process
large hemorrhoids which had been bleeding and pro-
truding for years disappeared after a single visit, and
this often without any subsequent pain or symptoms
of any sort. So often was this delightful story told

— 47 —

)iie by patients upon whom 1 had recommended other
and to them more formidable procedures, that I was
at last driven in pure self-defense to try and discover
what there was in this practice, and I therefore armed
myself with several preparations of carbolic acid —
a 15 per-cent. — 3.3 per-cent. — 50 per-cent. and the
pure acid — and proceeeded to inject them into a large
proportion of my cases.

The results in many cases were surprisingly good.
Some were cured without being confined to the house
at all, and without any pain which interfered with
their daily occupations. Others did not do quite as
well. They complained of severe pain coming on an
hour or so after the injection and lasting several hours,
but it was rare to have them give up their work and
go to bed, or to use the opium suppositories with
which they were provided in case of necessity. Once
in a while the injection would cause a slough and this
would put an end to the treatment for a couple of
weeks till it had healed, but the pain of this condition
was generally bearable and the patients expressed
themselves as perfectly satisfied and greatly preferring
even this amount of suffering to any "operation".
The cures also seemed to be permanent, none of my
patients returned with a fresh protrusion of the tumors
which had once been operated upon, even after an in-
terval of four years. At this time it was rare for mt
to have the tumors slough after an injection. Gener-
ally there was a hardening and shrinking of the hem-

— 4« —

orrhoid sufficient to prevent either hemorrhage or
protrusion, and this was produced by solutions of ;^;^
per-cent. and 15 per-cent.

At this time I published my cases and also the

Fig. 7.

rules which were to be followed in this method oi
treatment.

The solutions of carbolic acid were made in pure
water with sufficient glycerine added to make a per-
fectly clear and colorless mixture, and of these I kept
constantly ready one of 15 per-cent. one of 33 per-
cent., and another of 50 per-cent.

— 49 —

The glycerin and carbolic acid should both be
perfectly pure, and as soon as the solution began tc»
turn yellowish it was discarded.

The needles should be fine and sharp, and the .
syringe in perfect working order — one with side hand-
les is preferable — and after each time the syringe is
used it should be thoroughly washed out and left
standing in fresh water.

Before making an application give an enema of
hot water, and let the patient strain the tumors as
much into view as possible. Then select the larger
and deposit five drops of the solution as near the-
centre of the tumor as possible, taking care not to go-
too deep so as to perforate the wall of the rectum and'
inject the surrounding cellular tissue. The needle-
should be entered at the most prominent point of the •
tumor. If the hemorrhoid does not protrude from
the anus, a tenaculum may be used to draw it inter
view. After the injection has been made the parts-
should be replaced, and the patient kept under obser-
vation for a few minutes to see that there is no unusual
pain. The injection will cause some immediate smart-
ing if it is made near the verge of the anus; if made
above the external sphincter, the patient may not feel
the puncture or the injection for several minutes.,
when a sense of pressure and smarting will be appre-
ciated. In some cases no pain will be felt for half an
hour, but then there will be considerable soreness,
subsiding after a few hours. If it increases, instead of

s A

disappearing, and on the following day there is con-
^i-derable suffering, which may not perhaps be suffi-
* ient to keep the patient on his back, but is still
enough to make him decidedly uncomfortable; it is a
pretty good indication that a slough is about to form.
For the reason that it is impossible to tell absolutely
what the effect of an injection is to be until at least
twenty-four hours have passed, it is better to make but
one at a visit and to wait till the full effect of each
one is seen before making another. If on the second
day there is no pain or soreness, another tumor may
be attacked; and this will often be the case.

By following these rules all went well for a time,
but soon I began to be troubled with a constant
succession of sloughs with their attendant pain, and
the worst of the trouble was that I never knew
beforehand when a slough was likely to be caused.
My old solutions were all discarded and new ones
made to replace them; the syringes were all sent
away and renewed; and yet the sloughs continued
and I began to expect to encounter this objec-
tion whenever an injection was made, for the
strength of the solution or the character of the hemor-
rhoid seemed to make no difference. A solution of
15 per cent, would cause sloughing where one of 50
per cent, or even of the pure acid would produce only
a circumscribed induration, and 2>ice 7)ersa; so that
after a time I was forced to confess that I had no
means of determining beforehand whether the patient

_ 51 —

was to undergo the pain of an inflamed and sloughing;
hemorrhoid, though the injection made should be of
lo per cent or of pure acid.

The next complication was the occasional occur-
rence of small marginal abscesses after injections, and
as these always caused a great deal of pain this was a
serious objection. They usually appeared three or
four days after the injection, were situated just at the
verge of the anus, causing a tumor about the size of
the end of the thumb, covered partly by skin and partly
by mucous membrane. They showed a decided ten-
dency to break on both the mucous and cutaneous
surfaces and leave a short, subcutaneous track con-
necting the two openings.

These marginal abscesses were never at the point
of the injection, though always on the same side of the
gut; sometimes, in fact, they were fully two inches
below the injection.

Still, these complications were not of sufficient
gravity to cause an abandonment of this plan of treat-
ment. The small abscesses caused a good deal of
pain but were not serious in their ultimate conse-
quences; and the sloughs healed kindly with the aid of
local applications, though they greatly prolonged the
time of treatment, as I always thought it best to dis-
continue the injections after once a slough had formed
until it was entirely healed.

There are, however, still other objections to this
method of treatment. In my own practice I have had

— 52 —

one case of diffuse inflammation and suppuration,
lymphangitis, ischio-rectal abscess, and deep fistula,
following a single injection of strong acid into a small
tumor; and I have heard of other cases in the practice
of other surgeons. I believe that this serious acci-
dent was due to landing the strong acid entirely be-
low the tumor and under the muscular coat, but I
cannot be sure.

Again, within the past year 1 have twice been
called upon to treat a rare form of fistula arising
directly from injections. These fistulae were of the
blind, internal variety, having an opening near the
anus within the sphincters, and a track running up-
wards from this, under the mucous membrane, for a
considerable distance, and ending in a cul-de-sac.
One of these cases was in my own practice, and three
different tracks of this kind existed, each of which I have
no doubt was caused by an injection of carbolic acid,
made by myself. As I have no objection to reporting
my own bad cases, that others may derive the same
benefit from them that I do, I will give this in full.

The patient was a professional man of middle
age, who had long been a sufferer from hemorrhoids
of large size, and was in a very weak condition, hav-
ing lost much blood, become dyspeptic and nervous,
and having slight pulmonary trouble. The tumors
were quite large, the sphincter much relaxed, and the
margin of the anus very much like what is shown in
Fig. 2. Injections were made several times, the so-

— 53 —

lutions used being the weaker ones and never exceed-
ing 33 per cent. On the day following the first one
the following entry was made in the case-book:
" Considerable pain following first injection. Patient
has been in bed most of the time." Two days later
the following entry was made: "The single injection
of five drops of a solution of carbolic acid (one to
twelve) has caused great pain up to the present time.
The patient has been able to be about more or less,
but has suffered constantly and taken considerable
quantities of opium. Examination shows the mass of
tumors on one side black, inflamed, and angry-look-
ing; and though the injection was placed in a small
nodule, springing from the centre and most prominent
portion of this mass, the whole group has become in-
volved in the inflammation it has caused." Three
months later the following note appears: "The pa-
tient has had considerable sloughing of the tumors,
following the injections of a ^$ per cent, solution, and
has had one marginal abscess, leaving a subcutaneous
fistula which has been cut. He is now in great meas-
ure relieved." In exactly four months from the be-
ginning of the treatment the patient was discharged
cured — that is, he considered himself cured, there
being no more protrusion, except as the margin of the
anus tended to roll outwards, and no bleeding. Nine
months after the first injection he visited me and still
reported himself as having no symptoms. Eighteen
months from the time treatment began the patient

— 54 —

again reported with several hemorrhoids, which were
attached high up the bowel, and had only recently
begun to appear at the anus, and a few days later the
following note was made: ''Two injections (33 per
cent.) without trouble. Yesterday, third injection of
^^ per cent, into a distinct tumor. To-day, slough,
size of a silver quarter, irregular in shape, and in ad-
dition, a marginal swelling, size of a walnut." The
slough separated, cicatrization progressed slowly, and
at the end of a month the patient went away, having
no more hemorrhoids, but in their place an unhealed
ulcer, which seemed to be doing well and bid fair to
be entirely healed in a few days.

One year later he reappeared and reported that
this ulcer had never entirely healed, but had gone on
discharging and causing pain ever since. After sev-
eral examinations, I discovered three of the blind
internal fistulae already described, and in addition, two
more large internal hemorrhoids. The patient having
now been under treatment two years and a half, he
was etherized and operated upon. The fistulae were
laid open, and the hemorrhoids removed with the
clamp, and the patient finally discharged cured.

I have noticed that each of these fistulae were of
the submucous variety, running in the connective
tissue between the mucous and muscular layers, as it
might be inferred that they would be; for the acid
is deposited by the needle between these two layers,

- 56 -

and the amount of sloughing it causes is not Hmited
to the point at which it is introduced.

It may perhaps be instructive to record one {>r
two more cases.

In June, 1885, I was called upon to treat an old
gentleman, the mayor of a small town in Ohio, living
in a high, cool, country region, but much depressed
with business losses and worry. He came to Nev/
York in the middle of the hot season and submitted
to treatment. The hemorrhoids were the worst which,
up to that time, I had ever treated by this method.
The sphincter was much relaxed; the tumors had bte^\
down for twenty-five years without being replaced,
and were very large and vascular. There were three
distinct masses, each about the size of a hen's egg.
The case was not an attractive one, considering th<?
age and condition of the patient and the hot weather,
but I undertook it. Into the largest of the three
tumors I injected five drops of a fifty-per-cent. solu-
tion. It was followed by a good deal of pain and loss
of sleep for two nights, with some con.stitutional dis-
turbance. On the third day, the pain of the first in-
jection having somewhat subsided, I injected five
drops of pure acid into the second tumor, and had
much less trouble than with the fifty-per-cent. solution
in the former case. After three days more I agaiit
injected the same amount of pure acid into the third
tumor. Both of these last applications caused a dis-
tinct slough with resulting ulcerated surface and free

- 56 -

discharge of bloody matter. After a few days more I
returned to the first tumor, which had not sloughed,
t>ut simply become indurated, and injected five drops
-»:>f pure acid into that. The applications were all
Blade within the space of two weeks. During this
period the patient allowed his bowels to become con-
-stipated, and I had to clean them out with repeated
i:opious enemata. There was at one time some vesical
irritation and decrease in the amount of urine, whether
from direct absorption of carbolic acid or from
reflex irritation I do not know, and at the end of the
treatment the patient was considerably reduced in
-strength — so much so that I put him upon the most
nourishing regimen with bark and whisky. Just as he
■seemed on the point of rallying I discovered a small
abscess in the perinaeum, which was opened, and
Siealed kindly, having no connection with the rectum.
After recovering from this and gaining a considerable
flegree of health he went home to Ohio, and was im-
mediately brought to bed with a second, larger abscess
-on the buttock. From this he also made a good re-
lovery, and for one year he had no rectal symptoms
whatever, but at the end of that time, he informed me,
i)leeding had returned, and though I have not seen
him, I have little doubt that he is suffering again from
4he same tumors.*

This patient had his own way. He was not

* Previously reported in part. N Y. Medical Journal,
3Jov. 14. 1S35.

— 57 —

''operated upon" — but he would have had less suffer-
ing and less confinement if he had been. Moreover,
he would have been radically cured.

Let us now take another. *A man of about sixty
has had hsemorrhoids for twenty years. He is of
sedentary habits and nervous, but with no other dis-
ease than the tumors. An examination shows a very
advanced case of long-standing trouble. The tumors
can be divided into four chief ones — one posterior,
one anterior, and one on each side; but two of these
are as large as hen's eggs, and the others only a trifle
smaller They spring from above the sphincter, and
are entirely covered by mucous membrane ; the
sphincter is so relaxed that they protrude with the
slightest exertion, and the patient has worn a rectal
supporter for years.

It is a beautiful case for the clamp, and fit for
that only ; but at the outset I am met fairly by the
not infrequent obstacle — ''no operation." Argument
is useless ; he has heard of carbolic acid ; in fact, his
physician has sent him to me for that treatment, and
it is that or nothing. Unwillingly I consent.

An injection of thirty-three per-cent. is made
posteriorly, and with the usual caution and instruction
the patient goes home. Two days later he returns.
He has had pain — yes considerable ; but he does not
mind the pain as long as he can avoid an operation.

♦Previously reported, N. Y. Med. Record, Aug. 7, 1S86.

- 58 -

Another injection of the same strength on the left
side.

It is four days before he again appears, and they
have been passed mostly in bed, and he has used
several suppositories, but he is now better, and " if it
is no worse than this he can stand it." The tumor
injected last time is much smaller, but the posterior
one, which was first attacked, is not much benefited,
and five drops of pure acid are placed in its centre.

Three days later he reports that he is beginning
to be better, that there is less protrusion at stool, and
he has left off his supporter. The last injection ha«
not caused a slough, but a hard inflammatory indura-
tion in the centre of the tumor. Another five drops
of pure acid are injected into the same mass at a little
distance from the hard spot, and he then tells me that
ever since his last visit he has had considerable diffi-
culty in passing water, which is high-colored and
diminished in amount.

Four days later, says he had no very severe pain
after the last application, and straining at stool fails
to bring down either of the tumors which have been
operated upon. Another injection of pure acid into
the anterior tumor, the largest of them all. Three
days later he reminds me that he is in a great hurry
to go away on business, and is anxious to have treat-
ment crowded more rapidly. He had no pain at all
after last injection, and fears I did not get it in. The
injection has again caused a hard lump of inflamma-

— 59 —
tory induration, but no slough, and a decrease of
about one-third in the size of the mass. There is still
more work to be done on the first one, and another
five drops of pure acid are injected into it, causing no
pain at the time, or after, as he tells me two days
later.

Thus far all had gone well, and three of the
tumors had been treated without accident. An in-
jection of pure acid v/as made into the last one, that
on the right side. Three days later I am sent for to
come to him. Before this he has come to me, but he
has. been in bed ever since the last injection; the
urine has been very scanty and passed with difficulty ;
there is an enlarged and painful gland in the right
groin ; and a painful swelling at the verge of the anus
on the right side, circumscribed, the size of an
almond. Eleven days later, the patient being still
confined in bed, the abscess at the margin of the anus
was opened and a drachm or so of pus evacuated. A
couple of days later it was found to have also opened
spontaneously on the mucous side of the swelling, just
within the sphincter. Ten days later this was healed.
The patient had then been under treatment just forty
days. He was much better ; the tumors were all con-
siderably reduced in size, they still protruded at stool,
but went back spontaneously, and he promised to
report again in a few days. He never did.

In this case, also, the patient would have been
much better off, both during the treatment and in the

— 6o —

end, had he been operated upon in my way instead of
his own. In fact, it is a few such cases as this that
have led me to lay down the invariable rule of practice
to which I have referred — to select the mode of treat-
ment which seems to me most appropriate, and never
allow myself to be led into another which I do not
think as good, simply because the patient wishes it.
These cases are the bad ones, and I would not
convey the idea that all are like them. They illustrate
exceedingly well all of the objections to this plan of
treatment which I have ever encountered, except the
single one of deep inflammation and suppuration.
They may be enumerated in the following order:

1. Pain.

2. Ulceration.

3. Marginal abscess.

4. Fistula.

5. The impossibility of giving any definite prog-
nosis as to the length of time necessary to effect a
cure, or the amount of suffering the treatment will
entail.

6. The fact that the treatment may not result in
a radical cure, but that the tumors may reappear.

There is still one other complication which may
arise, and this is decided vesical symptoms, whether
from carbolic acid poisoning or merely from reflex
irritation, I have never been able to decide. I have
seen the urine decidedly diminished, and great pain
in passing it, after injections of the stronger prepara-

— 6i —

tions, but I have never seen the typical train of symp-
toms following carbolic acid poisoning.

It will be seen that none of these objections are
vital. Any of the well-recognized methods of opera-
tion are attended by some pain, and occasionally by
untoward accidents. I do not consider the operation
by injection as dangerous to life, and 1 have never yet
heard of a fatal case; and in all of my experience with
the method I have never had but one serious compli-
cation— a single case of deep suppuration, and even
this I think can be avoided by the use of weaker so-
lutions placed more superficially.

There is still one point about which there should
be no misunderstanding. From all the information
attainable, I believe that my experience with this
method is about that of the irregular practitioners
who thrive by it, and that the proportion of cures,
without any pain or bad symptoms, obtained by them
is practically the same as my own. I have certainly
tried all of the solutions ordinarily used by them, and
some besides. The tincture of iron and the fluid ex-
tract of ergot are two from which I hoped for better
results, but neither seemed to possess any advantages.
From cases which have from time to time come to my
knowledge, I know that abscesses, ulceration and
great pain are by no means unusual sequelae in the
practice of these gentlemen. It is not long singe one
of this fraternity was forced by his patient to return
the fee which had been paid in advance, after the pa-

— 62 —

tient had been confined to his house for several weeks
with a deep abscess; and only a few days ago I
operated with the clamp upon a gentleman who had
previously had a single injection made by one of these
men, had been confined to his bed with it for a month,
and had then abandoned the treatment. He had been
particularly unfortunate, as he had subsequently had
a ligature applied by another practitioner, which, as
he described it, "slipped on the fourth day," and he
had then abandoned that treatment also.

I believe I have now fairly stated the advantages
and disadvantages of this plan of operating upon
hemorrhoids, and have put, as far as my own experi-
ence enables me, each reader in position to choose for
himself whether he will use it or not.

The question in fact narrows itself down to this.
On the one hand we have a method of treatment which
is safe, certain and practically painless; but which in-
volves the administration of ether, the performance of
what the patient dreads, a surgical operation, and a
certain confinement to the house for a few days. On
the other hand we have a method which avoids the
ether, the surgical operation, and perhaps the con-
finement to the house; but which, in fact, involves
fully as much of an operation as the other, only more
quickly performed, and without ether, and which is
neither radical nor certain in its results. It is in fact
this uncertainty as to the course of a case after an in-
jection, and the fact that the operation may not result

- 63 -

in a radical cure even though it may be followed by
serious complications, which keeps me from employ-
ing this method oftener than the complications them-
selves, or the possible dangers. I have never aban-
doned the idea that the patient should submit to the
judgment of his physician as to his treatment, and I
am not convinced that the surgeon should yield his
preference for a method of treatment which long ex-
perience has proved to be as safe and certain as any
operation in surgery, to the foolish prejudices of a
timid patient.

As regards the comparative suffering caused by
the two operations, the clamp and the injections, it
may be taken for a fact that any considerable number
of cases will show greater pain spread over a longer
time with the latter than with the former: and all the
patient actually gains in the most favorable case is the
avoidance of a safe operation which he fears, while he
submits to an uncertain one which he does not fear be-
cause of his ignorance; together with a few days of
liberty during which he would be better off in his
room.

Should the surgeon decide to employ this method
the following points may not be useless:

Use the weaker solutions in preference to the
stronger.

Never use it in any of the forms of external
tumors already described.

- 64 —

In cases of large, prolapsing, and long-standing
disease expect pain and perhaps marginal abscesses.

Be very cautious in prognosis as to the time the
treatment will require, and the amount of pain it will
cause. In fact it will generally be safer to acknowl-
edge the uncertainty as to these two important points
of the operation.

The form of disease best adapted for this treat-
ment is the tumor of moderate size, having a well-
defined pedicle, and springing from the wall of the
bowel entirely above the sphincter. Such may be re-
placed within the bowel after the injection, and are
very likely never again to be heard from; and in them,
should sloughing occur it will be attended by the
minimum amount of suffering.

The injection of hemorrhoids with carbolic acid,
though apparently a simple and trivial affair, is to be
regarded in the light of a surgical operation, and
should not be undertaken by the practitioner until he
has surrounded himself and the patients with all the
safeguards at his command.

CHAPTER VI.

THE CLAMP AND CAUTERY.

After what has been said, the reader may be
tempted to ask whether we possess any means of
curing hemorrhoids which is safe, certain, and free
from comphcations, and in this chapter I shall answer
that question in the affirmative.

The operation with the clamp is generally known
as that of Mr, Henry Smith of London, and to him it
owes its general introduction and acceptance by the
profession, as does the ligature to Mr. Allingham,
though he claims no originality in the method itself
but only in some of its details.

The essential idea of this operation is to seize the

Fig. 8.— Pile Forceps:

part to be removed, apply the clamp to its base, cut it
off with scissors, and cauterize the stump. The clamp
acts merely as a temporary ligature to prevent bleed-
ing during the operation ; and the cautery is to pre-
vent bleeding after the clamp has* been removed.
The instruments which are indispensable are therefore

6 A

— 66 —

four in number — a hook forceps to seize the pile,
shown in Fig. 8; the clamp shown in Fig. 9; scissors;
and the cautery.

Fig. 9. — Author's Clamp.

The clamp is a modification of Mr, Smith's which
I have had made for my own convenience, and the
difference can be seen at a glance. Mr. Smith's in-
strument. Fig. 10, is armed with ivory shields to pre-

FiG. 10.— Smith's Clamp.
vent the possible effects of radiated heat; it has
scissor handles; and the edges of the blades are
smooth. In my own there are no shields, the handles
are much larger, and the blades are serrated. I was
led to abandon the ivory shields because I found
them practically unnecessary and because they made

-67-

the instrument more cumbersome. The handles were-
modified to give increased power and to avoid the
general use of the screw for closing the blades. The^
edges were serrated to add to the crushing force, but
experience has convinced me that even with thi.-.
amount of power the clamp is incapable of crushing;
the tissues to any extent. I have placed it on a tumor,
screwed it up to its greatest possible power, and left
it in this condition for fifteen minutes. While it was-
in position the hemorrhoid became cold and livid, but
when the pressure was removed the vessels immedia-
tely filled up and the circulation was restored. It is
for this reason that I say the clamp acts merely as a
provisional ligature during the operation. In fact no
force capable of crushing the tissues to the point of
causing the occlusion of the vessels and the death of
the parts can be exercised without much greater
mechanical power than this clamp possesses. There
can be no bleeding while the clamp is in position, if
the handles are firmly closed with one hand ; but un-
less the cut surface has been thoroughly cauterized,
there will be immediate bleeding on its removal. The
advantage of the form of handle shown in my instru-
ment over that of Mr. Smith's is that an adequate
pressure can be kept up for any length of time with-
out the intervention of the screw, and by this fact the
length of time consumed in operating is much dimin-
ished.

The cautery is the most important of all the in-^

— 68 —

-struments, being the most delicate. The latest modi-
fications of Paquelin's instrument leave little to be
-desired. If the operator prefer, he may use the gal-

vano-cautery, and with a storage-battery this is a very
convenient form of instrument, but I have not yet in
any own practice abandoned my old favorite for the
-newer invention. The Paquelin cautery is shown in

Fig. II, and maybe obtained from Tiemann & Co.. of
;Kew York, at a cost of about thirty dollars.

Fig. II. — Paquelin Cautery.

Its beauty lies in its reliability and portability,
^nd for these rea.sons I always carry it with me for

-69 -

operating at long distances from home. Filled before-
starting, it can always be used on the following day».
and generally after two days; and should the opera
tion be very extensive, as in cases of cancer, it is only-
necessary to be provided with an additional ounce or
two of benzine. The instrument merely requires to
be properly understood and managed to secure per-
fect reliability, though I always carry an extra pla
tinum blade, to be secure against the temporary dis-
abling of one which generally is due to the lack of
experience of an assistant.

The scissors need only to be strong and moder
ately long, though a slight curve in the blades wiU
sometimes be found an advantage.

Very little preparation for this operation will be
found necessary in a healthy patient. When one in
good health tells me his bowels are acting regularly, Y
have about abandoned the time-honored custom of
deranging their action with a purgative just previous
to this operation, and if they have moved on the
morning of the operation, all that is necessary is a
simple enema of soap-suds an hour before the opera
tion begins. If given an hour before, it will generally
all be passed before the arrival of the surgeon. Ir
given after the arrival of the operator, he stands a-
good chance of receiving a large portion of it in his-
lap and on his towels the moment he dilates the-
sphincter.

The operation is performed in the following man-
ner:

As a rule the patient is etherized, though unless
there is a good deal of tissue to be removed at the
verge of the anus, the operation may be done with
cocaine. Ether should be advised in almost every
case, and cocaine only used as a substitute; for al-
though a tumor which is visible may be removed with
the latter, it is difficult to thoroughly stretch the
sphincter under its influence, and by omitting this two
great advantages of ether are lost — the chance to
thoroughly search the rectum, and the avoidance of
the pain following the operation which is secured in
part by a complete paralysis of the sphincters. Many
hemorrhoids which are not visible at an ordinary ex-
amination will become visible after a patient has been
etherized and his sphincter dilated, and it is an awk-
ward thing to assure a patient that he is radically
cured because three or four perfectly visible tumors
have been removed, and have him return in a few
weeks with one or two more, which were overlooked
at the operation simply because they did not crowd
themselves into view.

The tumors are next seized and removed one by
one. No speculum is necessary for this, but if one be
used, a medium-sized blade of Sim's vaginal speculum,
or the retractor shown in Fig. 3, will be found most
convenient. The tumor is seized with the forceps and
held by the left hand till the clamp is applied with the

— 71 —

right. The forceps are next detached, the tumor cut
off with the scissors (but not so short but that a good
firm stump remains) and the cautery is then taken
from the assistant, whose sole duty should be to have
it always ready, and applied thoroughly to the stump
of the hemorrhoid. No haste should be used in this
step of the operation. The pedicle should be thorough-
ly charred with the platinum at a dull red heat. When
this has been done, the clamp may be loosened with-
out being removed, to see if any vessel in its grasp is
still inclined to bleed, and if a bleeding point appear
it is again tightened, and the cautery is again applied.
Thirty seconds is an abundance of time for each
tumor, and I have often done four to the minute— the
greater part of this being devoted to the thorough ap-
plication of the cautery.

When all have been removed, the stumps will
naturally retract within the sphincter, and no dressing
will be necessary.

The thing most difficult for the unpracticed
operator to understand is at just what point to apply
the clamp, and this can best be learned by experience,
as it really constitutes the delicate point in the opera-
tion. There is no difficulty when the tumor is an in-
ternal one arising fairly from the mucous membrane
above the sphincter, and not involving the skin of the
anus. In such a case the clamp does not implicate the
the muco-cutaneous junction at the anus, and remov-
ing too little tissue will not leave unsightly and annoy-

— 72 —

ing tags of skin, nor will removing more than is neces-
sary result in cicatricial contraction to a serious ex-
tent. But where the margin of the anus tends to roll
over, as is shown in Fig. 2, considerable experience is
necessary to learn just how much tissue to include in
the clamp.

In such a case a groove should be made with the
scissors in the cutaneous border for the application of
the clamp so that no skin may be included in its grasp.
If this groove is made at the line of junction of muc-
ous membrane and skin marked in the figure, painful
tags of skin will certainly be left, which will cause
subsequent annoyance, and considerably detract from
the success of the operation. If, on the other
hand, all the protruding mass be cut off, and the
clamp be applied in the groove where the protrusion
joins the anus, too great contraction is apt to result
except in cases where, on account of a very lax
sphincter, it is deemed advisable actually to reduce
the size of the orifice. The endeavor must be to so
draw the lines between these two extremes in an ordi-
nary case as to leave no tags after cicatrization, for
these are always unsightly, generally annoying, and
sometimes subject to a subacute inflammation which
renders it desirable to remove them by a subsequent
operation with cocaine.

When it is necessary to divide the skin of the
anus with the scissors before applying the clamp, there
will be a little bleeding, but when the clamp is used

— 73 —

without any preparatory cutting the operation is al-
most bloodless, and under any circumstances it is un-
necessary to soil more than a single towel. This is a
great desideratum in cases of enfeebled patients, be-
sides enabling the operator to have his wounds per-
fectly dry without the use of any lint or other dressing.

The operation with the ligature, as done by
Allingham, by previously cutting away a part of the
attachment of the tumor, is by no means bloodless,
and unless the operator takes the risk of being called
back after a few hours to stop the oozing of blood, he
is apt to use considerable lint, and having pressed it
into the wounds to leave it. This is a constant source
of pain, and often it is practically impossible to re-
move it before the end of the third or fourth day,
when it has become thoroughly loosened by the dis-
charges.

A rectum partly stuffed with lint, and containing
three, four, or more ligatures around sensitive parts, is
in a very different condition from one which contains
no foreign substances, and the wounds of which have
have been dressed in the most thoroughly antiseptic
way possible with the cautery in the act of making
them. One condition may be no safer than the other,
but it is certainly much more comfortable.

No dressing of any sort is necessary after the
clamp operation. If the patient seems to be doing
well and complains of no untoward symptons, the

— 74 —

parts need not be examined for ten days, and all that
is required is cleanliness to the external parts.

I usually introduce an opium and belladonna sup-
pository at the time of the operation, and it is seldom
necessary to use any further anodyne. This will con-
fine the bowels for forty-eight hours, and about thirty-
six hours after the operation — in other words, at night
of the following day — the bowels should be encour-
aged to act by a slight laxative, either a pill or a
saline. A single dose will generally be sufficient, and
when the time comes for the bowels to move, an
enema of oil should be thrown up the retum to facili-
tate the passage. In this way an almost complete clear-
ing out of the rectum is secured on the second day.
The patient dreads this first motion, but is agreeably
disappointed, often being surprised that he has much
less pain than his hemorrhoids caused him in each
passage before they were removed.

The bowels may be treated in this way after
Allingham's operation with great advantage, though
his rule is to have them confined for a week or more.
By the one method a comparatively, and sometimes
positively, painless evacuation is gained before the
rectum has become loaded with solid matter. By the
other, the pain which is sometimes and generally
caused needs to be seen and felt to be appreciated. I
have left my bed at night, roused my assistants, driven
to an adjacent city, given ether, and unloaded a rec-
tum, on the seventh day after an operation, in a deli-

— 75 —

cate, nervous lady, after the rectal tenesums had re-
duced her to a condition of unmanageable hysteria, in
spite of trained nurse, repeated saline cathartics, and
enemata of all sorts; and one experience of this sort
of unnecessary suffering will convert almost anybody
to the other plan.

An additional advantage of thus moving the
bowels on the second day is that the rectum is thus
cleansed of all blood and discharges, and that no
special restrictions need be placed upon the patient's
diet, while much headache and general malaise which
follow the constipation, produced by the daily use of
opium, are avoided.

I have recently been tending a case where much
trouble resulted from an unintentional departure from
this rule. The usual operation was done with a
simultaneous closure of a lacerated cervix uteri, and
at the end of forty-eight hours the usual laxative was
given.

I was told on the following day that it had acted
nicely, and it was ordered to be repeated every night
for the following week. Each day the patient was re-
ported as doing well in this regard, though once or
twice it was necessary to give two pills simultaneously
when the bowels seem.ed to be acting irregularly. On
the tenth day the patient was up and about, preparing
to leave the city for her home. On the eleventh she
had an attack of intestinal and rectal pain, and after a
great deal of straining and suffering, passed a very

- 76 -

voluminous and hard passage, with considerable blood.
It was evident that the bowels had not been effectively
moved since the operation, and the result of her efforts
was a tearing open of the wounds, and a further con-
finement to the house for nearly three weeks, each
movement of the bowels being attended with some
pain and bleeding.

I do not wish to convey the idea that no pain fol-
lows this operation, but I can honestly say that many
patients have less pain on the day following it than
they have suffered daily from their hemorrhoids for
years before. I usually expect some of that annoy-
ing spasm of the levator which no stretching of the
sphincter can prevent; and when this is present it will
begin a few hours after the ether, and may last for
the following day or two; but it is not generally suf-
ficient to prevent a good night's sleep, and it is often
so slight as to cause no comment by the patient. It is
very exceptional for any anodyne to be necessary even
on the first night after operating. Even this spas-
modic contraction of the muscle is not always present.

The length of time the patient is confined to the
house of course varies. They are generally sitting up
on the second day, or at most the third day, and walk-
ing around the room tending to their own wants, the
men smoking and reading, the women receiving visits
or sewing: and one of the details about which the phy-
sician needs to be most strict is to keep the patient
quiet in the house until the healing has so far advanced

— 77 —

as to make active exercise safe. Many of my own
cases come from a considerable distance and are anxi-
ous to return to their own homes as soon as possible.
I usually aim to secure at least ten days, but I find
they are very apt to depart at the end of a week, and
occasionally five days sees them on their journey. I
do not mean that this should be encouraged or recom-
mended, for it is very much better that the patient
should remain quiescent until the wounds are well ad-
vanced toward cicatrization; but it shows better than
anything else the general condition of the patient
when there is no suffering which induces him to wish
to stay in his room.

There remains very little to be said. Within the
past two or three years several plastic operations have
been advised and practiced — operations consisting in an
elaborate dissection and removal of the hemorrhoidal
tumors and subsequent careful suturing of the wounds.
These have seemed to me such very long ways around
to reach a given point that I have never been tempted
to try them. My own practice, after much searching
after improvements, has reduced itself to about this:
If the patient wishes to be relieved but is unwilling to
be cured, I try to relieve him by medical or perhaps
the minor surgical methods described. If he desire to
be cured, and I deem the case fit for cocaine, carbolic
acid, etc., I employ them. If he have extensive dis-
ease, in which nothing blit radical operation is indi-
cated, and he refuses to submit to this, I have found

- 73 -

it better to abandon the case than to do what I do not
myself believe to be to his or her best advantage.
If, under the same circumstances, the patient will be
wholly guided by me, I prefer the clamp to all other
radical measures, as being less painful, and giving a
quicker recovery.

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