these small, vascular, granular piles, strong carbolic acid is
a very good application, as also is the subsulphate of iron in
the form of an ointment ( 3 ss to 3 j of Unguentum Cetacei
is the strength I employ) or as a suppository (gr. ij c. gr. v
Cacao butter). It acts as a most powerful astringent; it is
not cauterant; it causes no pain; in fact, in inflamed hemor-
rhoids it seems to act as a sedative; it arrests haemorrhage
with absolute certainty. I have with this remedy effected
many cures, and materially relieved numbers of cases when
an operation has not been desirable, or when the patient
was too nervous to submit to one. I am confident now,
from a large experience, that it is a most valuable agent in
the treatment of many rectal affections. Rouse & Co., the
chemists in Wigmore Street, prepared for me an excellent
Liquor Ferri Subsulphatis, and I found it answer admirably
as a styptic and astringent in small ulcerations as well as
capillary haemorrhoids.

I may as well remark here that the capillary haemorrhoid,
or the pile with a capillary surface, is the only form likely
to be benefited by the application of nitric acid or acid
nitrate of mercury. Ten years ago, when this treatment
was in vogue, it was frequently used in the most reckless
and unscientific manner, quite regardless of how much it
really could do. I used to see at the hospital patients with
large, fully developed rectal tumors, to which acid had been
applied half a dozen or more times, causing great pain,
and with the result of no real curative impression being
made upon the disease. I am sorry to say this method is
not yet quite obsolete, for not very long ago I saw, with Dr.
Playfair, an elderly lady with large piles, who had suffered
very severely from several applications of strong acid, made
a short time before by a hospital surgeon of considerable
repute.

In the second variety, or arterial internal haemorrhoid, the
suffering occasioned is more directly associated with the con-
dition of the haemorrhoid itself as to the inflammation and
ulceration, and with the state of the sphincter ani muscles.
These piles protrude at stool, or on making some particular
movements, as stooping, etc., and in that way alone they
cause much discomfort; they also discharge a gummy, acrid
mucus, which keeps the part constantly damp, leads to excori-
ations around the anus, and favors the growth of cutaneous
excrescences; moreover, it stains the linen, and on this



78 INTERNAL HAEMORRHOIDS.

account is a source of great annoyance to sensitive, delicate-
minded persons. Generally, after visiting the water-closet,
the patient is some time before he can get at all comforta-
ble, often having to lie down, and when he walks about he
is almost always aware of the fact that he has a rectum. In
health, no person feels that he possesses one organ more
than another, unless he has to use that organ; after the first
intimation of impairment of health is the recognition of the
fact that there is a preponderance of sensitiveness or some
abnormal sensation in one member of the body. So, in rec-
tal diseases the fact is always present to the mind of the
sufferer that he has an anus. He scarcely ever feels that
his bowel has been properly relieved, and this feeling often
leads to frequent visits to the closet, and attempts to procure
satisfaction by straining, which ultimately aggravates the
malady. The condition of the sphincter ani plays an
important part in causing distress; if it be strong and tight,
when the piles come down, they get nipped, and their return
is rendered difficult and painful; on the other hand, if the
sphincter be lax, the bowel is constantly coming outside on
the slightest exertion, as in coughing, stooping, or even walk-
ing; and in these cases, when the bowel is down, the patient
can seldem retain liquid motions. I frequently meet with
patients who say they have to retire to a urinal and push up
the protrusion when it descends, or they cannot walk at all.
The employment, of course, has much to do with the dis-
comfort of the patient; again, constipation adds greatly to
the severity of the symptoms, and so also does habitual
relaxation, which, by causing frequent protrusion, induces
inflammation and ulceration of the part. These advanced
haemorrhoids are almost always associated with cutaneous
hypertrophies around the anus, and these, being irritated by
the discharges, become inflamed and very tender. Some-
times I have seen a number of polypoid growths studded
over the mucous membrane at the entrance to the anus; in
a patient of mine, at St. Mark's Hospital, I counted twelve
of these, and recently I have had a private patient on whom
I counted twenty-two excrescences.

When called to a patient who has forced his piles down
and cannot return them, proceed in this way: Place him flat
on his face, with three or four pillows under his pelvis, to
raise the hips well up and allow the intestines to gravitate
toward the chest; then smear the piles over with some oint-
ment, pass one finger into the bowel, and with the other hand



INTERNAL HAEMORRHOIDS. 79

gently apply pressure, trying to empty the piles of their
superfluous quantity of blood; this should be done very
gently, as you would apply taxis to a hernia. Should this
not succeed, place a bladder of ice over the part, and leave
the patient in the position I have recommended for an hour;
then try taxis again, and you will in all probability return
the mass. I have found, on several occasions, that freezing
with the ether spray has been an effective and more rapid
method of inducing contraction temporarily, and removing
the sensitiveness, so that you can apply more direct pressure,
but I am bound to say this manoeuvre is usually followed by
severe burning pain in the rectum. If your attempts at
replacing the piles have not been successful, try to persuade
the patient to have them operated upon without delay; if
he will not accede to this proposal, you may order some
leeches, or apply moderate cold. If there be much stran-
gulation, ice should not be kept on very long, or you may
produce more sphacelus than you desire. In some instances
warm applications, with sedatives, are more comforting, and
relieve pain sooner than cold. •

For my own part I never hesitate to operate at once if I
can get my patient's consent; a speedy and radical cure of
the disease is thus obtained. I never saw a case of this kind
do badly, although some surgeons have said that inflamed
haemorrhoids should not be operated upon. I will make an
exception in cases of protruded piles, where mortification
has set in to any extent; here, although it may be necessary
to operate, care must be taken, as the tissues are so broken
down that the ligatures will not hold, and haemorrhage may
result. In a case I had, in the practice of Dr. Tanner, of
Newington, the parts were so friable that the ligatures cut
through the piles, and there was considerable difficulty in
arresting the bleeding; I accomplished it by passing a tena-
culum deeply below the vessels, and applying a ligature
around it. I then cut the tenaculum away from the handle,
and left it ;n for three days. This patient did exceedingly
well, and was about in less than a fortnight.

In old-standing prolapsed haemorrhoids there is frequently
a difficulty in retaining wind or loose motion; this is caused,
in part, by the relaxed,* weak state of the sphincter, but more
particularly, I believe, by the loss of the acute sensitiveness
of the mucous membrane at the lower part of the rectum.
This sensibility in the healthy subject gives timely warning
to the sphincter ani to contract when necessary.



8o INTERNAL HAEMORRHOIDS.

Very rarely, in advanced states of haemorrhoidal disease,
is a cure effected without having recourse to an operation,
but I have seen such cases; one particularly recurs to my
mind, from the fact that 1 had given a most positive opinion
that no permanent benefit could be obtained without oper-
ating. This was a gentleman, past middle age, who had suf-
fered for years; his piles were full sized, they used to bleed
much, and always protruded more or less at stool; they were
of the venous passive form, and no doubt were dependent in
some degree on the condition of the liver. In this case,
great attention to the state of the bowels, the patient always
lying down to have an action, and remaining recumbent for
an hour or two afterwards; care as to diet, which was of the
most unstimulating character, and almost devoid of alcohol;
smearing the piles over with the subsulphate of iron and
other astringent ointments; the occasional use of a full-sized
bougie; injection of a quarter of a pint of cold water daily,
and the internal administration of Ward's paste, tincture of
the muriate of iron, and other remedies, in about four years
effected a cure. At least, he told me lately that he had no
trouble now with his piles; nothing came down at stool, he
had no bleeding, and suffered no other inconvenience. This
gentleman was, I must say, able to command every comfort,
and was never in anyway compelled to exert himself; he had
an insuperable objection to anything like an operation, but was
most determined, persevering, painstaking, and intelligent in
carrying out all the devices I have mentioned. Such condi-
tions are rarely met with in ordinary life; and therefore, for
all practical purposes, it may be said an operation is indis-
pensable. I have, since this case, met with others of a simi-
lar character, and some have yielded to general treatment
and the internal use of the chloride of ammonium.

It is in this, the third or venous kind of pile, that I think
constitutional treatment most likely to be successful, not,
perhaps, in always curing the disease, but in materially alle-
viating it, as the malady often depends upon uterine or liver
affections,and a generally overloaded,congested condition of
the system found in those who habitually eat and drink too
much, and who take but little exercise; these causes may,
to a great extent, if not altogether, be removed, and if they
are so, the haemorrhoidal disorder will be found to be bene-
fited to an equal degree. A prolonged course of the Fried-
richshall and Carlsbad waters will be found useful. I have
also seen benefit derived from the oil of sandal wool taken



INTERNAL HEMORRHOIDS. 8l

in conjunction with such remedies as relieve congestion of
the portal system, and depurate the blood generally.

Professor Richet, of Paris, at Hotel Dieu, delivered a lec-
ture on what he termed " white piles " {Jiemorrhoide blanche)
as they did not discharge blood, like ordinary internal
hemorrhoids, but a sero-mucous fluid. The professor stated
that the white piles are merely ordinary piles in a more
advanced stage, and consisted principally of hypertrophy of
the papillary bodies of the mucous membrane. The inces-
sant discharge acted as perniciously as frequent bleeding,
being nothing more or less than transformed blood; and he
advised them to be operated on in the usual way, preferring
himself the cautery to any other method; he objected to Chas-
saignac's "ecraseur," or Maisonneuve's wire "constricteur,"
which, he says, often produce permanent contraction of the
anus. For my part, while agreeing with M. Richet, I do
not see any sufficient reason for introducing a new name in
addition to those generally in use.

In women suffering from a retroverted or anteverted
uterus an operation upon piles is very undesirable, and will
most certainly end in disappointment unless the uterine
complication he attended to at the same time, or what is bet-
ter, prior, to the operation. My experience warrants me in
saying that the rectal affection will soon become a compara-
tively small matter. In my early operation upon women I
did not take into sufficient consideration the condition of the
uterus, and I could relate many cases in which I was most
griew)usly annoyed to find that the patient did not recover,
as I anticipated she would have done. I have found that
if the wounds heal there is but little relief afforded ; the
same bearing down and distressing sensation exists in the
bowel as it did before the removal of the piles. More com-
monly the wounds do not heal, and very painful, unhealthy
ulceration follows; this will never get well as long as the
abnormal condition of the uterus remains, I will briefly
related a case or two bearing upon this point.

Mary C — , set. 34, came under my care, in the early part
of the year 1842, at the Farringdon Dispensary. She was a
single woman, and had suffered for years from haemorrhoids;
they came down at stool; she lost blood and had much bear-
ing down; she was likewise troubled with her water, passed
it very frequently, and with difficulty, never feeling that she
had quite emptied the bladder. The urine was not turbid,
and she did not have actual pain — only discomfort. On
6



82 INTERNAL HEMORRHOIDS.

examination four full-sized haemorrhoids were found (their
character is not stated in my note book). Aided by my
friends, Dr. Frodsham and Mr. Charles Smith, I applied
ligatures to them. The operation was followed by retention
of urine, and a catheter had to be passed for the first few
days. While she was in bed she seemed better, but after a
fortnight, when she began to get about, she complained of
bearing down in the " back-passage," and much pain in defe-
cation. The bowels were very difficult to get to act. These
symptoms I had expected would pass away when the wounds
were quite healed; but, to my dismay, they did not, and two
months after the operation 1 found there was ulceration of
the bowel, and she suffered a great deal. I had for some
time suspected that the uterus was not right, so I obtained
the opinion of Dr. Edward Cock, who was at that time obs-
tetric physician to the Dispensary, and that gentleman pro-
nounced thas she had a fibroid tumor of the uterus (this
diagnosis was afterwards confirmed by many other authori-
ties). I need not prolong this history; suffice it so say that
she never got well ; for years I saw her occasionally; she
always had rectal symptoms and suffered a great deal of
pain. I do not think the ulceration of the bowel ever
entirely healed. I took her into St. Mark's Hospital in the
year 1867, and by rest and treatment she got better, but not
well ; for the last three years I have lost sight of her. I
believe she gained admittance into one of the hospitals for
incurables. I am quite certain of one thing, /. ^., she was
not benefited, and I am strongly of opinion that she was
damaged, by the operation I performed upon her.

Emma N — , was admitted into the Great Northern Hos-
pital, under my care, in February of 1864; she was a single
women, aet. 24. She complained of great pain in passing
her motions; the pain lasted for hours, and then gradually
subsided, and she was easy until she had again to go to stool.
Of course my diagnosis was fissure, and I was correct, but in
addition I found three large internal arterial haemorrhoids. I
incised the fissure and tied the piles. She went on very well
and left the hospital, feeling quite comfortable, and free
from pains in the bowels acting. In about a month she
came again to me, saying that her old symptoms had returned,
but on examination I could find no fissure or ulceration, or
anything the matter with the rectum; she complained of pain
and straining when the bowels acted, and a sensation of not
being relieved afterwards. The only thing I could find to



INTERNAL HEMORRHOIDS. 83

account for this was a tendency to intussusception of the up-
per part of the rectum on her bearing down. I treated her
with laxatives; sedative injections, suppositores, and other
remedies, but with very little benefit ; what seemed to do
her most good was rest in bed. Suspecting uterine disease,
I recommended her to see an obstetric physician, and she
came under the care of my friend Dr. Palfrey, and that
gentleman found that she had retroflexion of the uterus.
She was under his charge for a very long period, and under-
went some operative treatment at the London Hospital,
After this I took her into St. Mark's Hospital, but could
never find any organic mischief in the rectum, although she
still suffered pain and much discomfort in connection with
defecation, I have recently heard that this patient is much
better, but for years she was incapable of doing any work.
It was said that masturbation was the primary cause of these
women's sufferings; it might be so, but I cannot say that I
am prepared to endorse that opinion,

Mrs. R — , a patient of my friend, Mr. Charles Waller, of
Sydenham, was operated upon by me for severe haemorrhoids,
Mr. Waller assisting me. I knew this lady was suffering, at
the same time, from vaginismus, but I thought the removal
of the rectal disease might be generally beneficial to her
health, which was very much deteriorated by the losses of
blood she sustained. After the operation she was much bet-
ter for a few weeks, but the wounds in the bowel healed
with great difflculty, and after some time she had a good
deal of pain on defecation and the bowels were very con-
fined; I could not discover any disease of the rectum,
although her symptoms were directly referable to that organ.
A year or so she was operated upon by Dr. Barnes for the
cure of the vaginismus; but I know that she has never
recovered good health, and is an invalid to this day, her
sufferings being most prominently rectal.

Tripartite disease of the rectum, uterus, and bladder or
urethra, is very common. I attended a lady of middle age
who had haemorrhoids and fissure ; after the operation she
still suffered pains in the rectum and I suspected disease of
the womb, as she had difficult and painful menstruation.
She was seen by a distinguished gynaecologist, who found a
contracted os uteri, and she underwent an operation which
for a time did good; then she suffered from spasm of the
urethra and great pain on micturition. Dilatation of the
urethra was performeji also with temporary benefit, but her



84 INTERNAL HAEMORRHOIDS.

rectum, although perfectly sound, was every now and again
very painful, and always so at her menstrual period. I know
this lady consulted most of the eminent men in London, and"
had all kinds of treatment, and still she comes to
me from time to time — it is quite five years since I first saw
her — with all her old symptoms, not merely subjective, but
objective as inflammation of the rectum, uterus, bladder, and
urethra. One or all at the same time.

I have had a lady under my care, sent me by my friend
Dr. Leeson, who suffered from subinvolution of the uterus,
with ulceration of the os and painful profuse menstruation;
she had also haemorrhoids, which prolapsed and bled, and a
circular ulcer in the bowel. It was agreed that an opera-
tion should be performed, and I removed her haemorrhoids
with the clamp and cautery, and incised the ulcer. The
healing was most difficult and tedious; ulceration took
place, and such contraction as to cause stricture, which after
some months I was compelled to divide. She also acquired
inflammation of the bladder, after having a catheter passed
only a few times, so that great pain on micturition was added
to her other troubles; only after the most constant atten-
tion, and compelling her to occupy the recumbent position
for more than four months, did she recover. Parallel cases
are so common with me, that I could relate many more, but
I only want to show how complicated and difficult to treat
these cases are.

In cases of haemorrhoids in persons with congested livers,
or who habitually eat and drink too much, I make a rule of
administering every night, before the operation (for three or
four nights), a five-grain blue pill, and in the morning a
modification of the old-fashioned black draught. This may
seem to be rather rough treatment, but I see the most bene-
ficial results accrue from it; and I am confident that patients
thus served do better than many others; again and again I
have been perfectly astonished at the rapidity with which
they recover. My friend. Dr. David Young, of Florence,
has recommended glycerine to be taken internally as an
effective remedy in haemorrhoids, even of advanced growths.
Knowing what an accurate observer Dr. Young is, I have,
now in many hundreds of cases, prescribed his remedy, but
I am bound to say without any marked success, although I
have persevered with it for months continuously.



OPERATIONS UPON INTERNAL HAEMORRHOIDS. 85

CHAPTER IX.

OPERATIONS UPON INTERNAL HAEMORRHOIDS.

When you have determined that there is no constitutional
impediment, and that an operation is positively necessary to
effect the cure of your patient, yoy will then have to decide
what proceeding will be the best suited to the case you have
in hand. From this you will conclude that, in my opinion,
no particular method of operating can be always wisely
employed to the exclusion of all other modes.

There are several distinct operations and modifications of
them from which to choose, and most of them have been
advocated by surgeons of repute, well skilled in their art,
and worthy of consideration. I shall first name the opera-
tions and then proceed to describe them, and I trust fairly
to express my opinion as to their various merits or demerits.

1. Excision with knife or scissors.

2. The ecraseur of Chassaignac or the wire of Maison-
neuve.

3. The application of various acids and caustic pastes.

4. The injection of carbolic acid or other caustic or
astringent fluids into the body of the pile.

5. Cauterization," ponctuee " of Demarquay, Mr, Reeves,
and others.

6. Cauterization, " linear " of Woillemier.

7. Removal by the galvanic cautery wire.

8. Removal by the clamp and scissors, appplying the
actual cautery to arrest haemorrhage.

9. Dilatation of the sphincter muscles.

10. Removal by means of the screw-crusher.

11. Ligature.

I. EXCISION BY THE KNIFE OR SCISSORS.

In days gone by excision was performed by Dupuytren,
Sir Astley Cooper, and others, but they all acknowledged
the danger of the operation, and many fatal cases are
recorded as having occurred even in the hands of masters in
surgery. With our newly devised modes of operating, and
especially of arresting hemorrhage, we can now in many
cases perform the operation of excision without incurring
any extraordinary danger, and therefore it need not be sum-
marily dismissed from our consideration.



S6 OPERATIONS UPON INTERNAL HEMORRHOIDS.

For my own part, I think it is one of our best operations,
and I have now records of seventy cases in which I excised
internal piles with remarkably good results. Little pain has
been experienced, and the recovery has been so rapid that
nearly all my patients have been absolutely well by the sixth
day; by this I mean that the wounds were all soundly
healed. I consider this the only test of perfect recovery ; to
say that they were convalescent and could go about would
not express the whole truth; the word " convalescence " is
very elastic as regards its significance, and is often erron-
eously used as synonymous with "cured." I do not recom-
mend excision in cases where the haemorrhoids are very
large or unusually numerous. In my cases there existed one,
two, or at most, four piles. In performing excision I first
gently but /////>' dilate the sphinctei muscles, and employ a
retractor to keep the anus well oper I then seize the pile
deeply by its base, cut it off above the level of the volsel-
lum, and do not let it go until all bleeding is arrested by
torsion of the arteries; rarely more than two vessels spout
and require twisting. I wiait for a little while to see that all
bleeding has ceased, and then I treat the other piles in a
similar manner. After all the arteries have ceased to bleed,
I place a piece of cotton wadding, previously saturated in a
solution of tannin and water (strength, one ounce of tannin
to one ounce of water), within the anus, as higH as my scis-
sors have cut. In no case did any recurrent haemorrhage
take place. This operation must be done slowly and care-
fully, and therefore occupies more than the usual time,
which, however, is of no moment, as the patient is insensi-
ble. As far as my present experience can lead me to judge,
I am of opinion that numerous cases are amenable to this
treatment. The single perineal hasmorrhoid, so frequently
found in women, is peculiarly well suited to this operation.
I have used several times the ingenious toothed scissors of