VIRGINIA MEDICAL AND SURGICAL JOURNAL EXTEA. ON THE TREATMENT OF HEMORRHOIDAL TUMOURS. BY ALPHONSE AMUSSAT. Tflrflma Med & Surfl. Journal. H-1. T II E VIRGINIA/%^^ MEDICAL AND SURGICAL JOURNAL EXTRA ;onGen/', On Circular Cauterization of the Base of Internal Hemorrhoidal Tumours Complicated with Prolapse of the Mucous Membrane of the Rectum* By Dr. Alphonsk Amussat, Jun. The number of works which, both in ancient and modern times, has been published on the subject of hemorrhoids, the place which this affection occupies in pathological treatises, and the various remedies proposed against it, testify at once to its frequency and its importance. The question, so long debated, of * This monograph translated for the Dublin Quarterly Review from the Bulletin Thcrapeutique, is well worthy of the space assigned it, because of the ingenious and novel method of applying caustics to hemorrhoidal tumours without endangering the integrity of the surrounding tissues. The best and safest operation for the radical cure of these tumours is still not set- tled. The most common method of cure, the ligature, has its opponents, who attrib- ute to its use phlebitis, especially; and at a recent discussion before the Medical So- ciety of London, February 1854, Mr. Henry Smith reported a case of tetanus from the application of the ligature. The employment of the nitric acid in the treatment of hemorrhoids, first suggested by Mr. Houston of Dublin, ha? been received with approbation by the profession. Mr. Quain, in his work on the rectum, speaks of its use with some favor. The great danger, however, in the caustic treatment is the risk of involving the surrounding parts in its application. Mr. Ashton relates three instances in which a communica- tion has been formed between the rectum and vagina by the use of nitric acid in too large quantities. The instrument employed by Dr. Amussat, of which wo give a diagram, prevents effectually the occurrence of this accident; and deprives the caus- tic method of its greatest objection. [Ed. Va. Med. and Surg. Jove. 2 the expediency of surgical interference in affections of this nature, has not yet been decided in the minds of all practitioners, and I have no intention of enter- ing here on a discussion which would lead me beyond the limits I have laid down for myself. A survey of our periodical literature will at once show the efforts which the most distinguished physicians and surgeons of all countries have made, especially since the commencement of the nineteenth century, to facilitate and render more certain the cure of this disease, whether, in its simple form, it con- stitutes principally an annoyance and an inconvenience, or complicated with ul- ceration, severe hemorrhage, or prolapse of the neighbouring rectal mucous membrane, it threatens life, or slowly exhausts the patient's strength. The the- rapeutics of this affection are consequently more than ordinarily rich in medicines, and varied operative proceedings. For my part, whenever hemorrhoids are of long standing, voluminous, ulcer- ated, accompanied by prolapse of the mucous membrane of the rectum, or with copious hemorrhages ; when they affect the general health ; and when the more ordinary therapeutic means have failed, and no special contra-indication exists, I remove one or more according to their number and volume. During twenty-five years that my father has pursued this plan, the destruc- tion of the hemorrhoids, combined with the precautions he has recommended to the observance of his patients, has never given him other than satisfactory re- sults, both as respects the local condition of the parts, and the state of the gen- eral health. Prolapse of the mucous membrane of the rectum, being one of the most fre- quent complications of confirmed and long-standing internal hemorrhoids, has appeared to me worthy of fixing our attention, both as to its etiology and its treatment. Admitted by most authors, this prolapse is easily explained when we carefully study the course of the principal affection. In the beginning, hemor- rhoids appear as the effects of hereditary predisposition, of constipation, a se- dentary life, the abuse of stimulants, or of a too nutritious diet, and are at first formed only by a determination of blood to the vessels of the inferior extremity of the rectum; little tumours, invisible externally, are soon developed, and become the seat of itching and of tension, which increase under the influence of the producing causes, often disappear to return again, and are, in a great number of cases, accompanied by more or less abundant hemorrhages. The affection in this simple state belongs to internal pathology, and a return to suitable hygienic rules, or the adoption of a very simple antiphlogistic treat- ment is, most frequently, sufficient to overcome it. But when, continuing to be developed, the hemorrhoidal tumours have acquired a certain volume, they begin to appear at the anal orifice, which they more or less obstruct; and however little the patient may be constipated, as is most usually the case, the hardened faecal matters push down the tumours before them during the action of the bow- els. The consequence is, that the mucous membrane of the rectum, necessarily following their movements, becomes as much lengthened as possible ; but soon this extension ceases to be sufficient; united to the muscular membrane by a loose cellular tissue, it is gradually separated from it, and subsequently returns with progressively increasing difficulty, being retained externally by the hemor- 3 rhoidal masses, and the sphincter compressing them. If the patient, induced by deceptive inclinations to go to stool, by pain or any other cause, acquires a habit of making prolonged efforts at defecation, the hemorrhoids increase, and the prolapse of the mucous membrane augments to that point, that it soon becomes impossible to return it after each motion without the employment of a regular taxis. By degrees, the sphincter becoming relaxed, the hemorrhoids come down on the least movement; at last a period arrives when they remain constantly out, unless they are retained by a bandage specially adapted to the purpose, the pre- sence of which—always inconvenient—finally becomes insupportable. These facts I have verified in a sufficiently great number of patients, and I shall here- after quote cases which will establish them. In some very rare instances a protrusion of the rectum and internal hemor- rhoids coexist; we have, then, two distinct affections to treat. During ten years that I have attended my father's practice, I have only once had an opportunity of observing this coincidence,* while I have often seen long-standing voluminous hemorrhoidal tumours accompanied by a more or less extensive prolapse of the rectal mucous membrane. Since the month of April, 1844,f the date of the first employment of the cau- terization of the base of hemorrhoidal tumours with grooved forceps charged with Filhos' caustic,]: the idea of which originated with me, we had per- ceived that this new mode of operation enabled us to obtain the cure of he- morrhoids, and that the hemorrhages, ulcerations, &c, disappeared with the tu- mours ; but it remained to be shown whether, in cases in which these affections should be complicated with tolerably extensive prolapse of the rectal mucous membrane, cauterization by the same plan would remedy the principal affection and its complication. Experience has not been tardy in justifying the hope we had entertained in this respect. It is, moreover, easy to account for this result, which we verified in all our operations of this kind, in reading the description of our proceeding. The cases of the patients in whom this complication was sufficiently advanced, and the drawings taken from nature, which I have appen- ded to them, will, I trust, enable practitioners to understand it. When we are about to examine a patient whom we suppose to be affected with #Memoire sur la destruction des Hemorrho'ides Internes, par la Cauterisation circulaire de leur Pedicule. Par J. Z. Amussat. 1836. Page 23. f Ibid. p. 32. J Filhos' caustic is the potaasa c calce of the U. S. Pharmacopeia carefully pre- pared and moulded into sticks. The Joum. de Pharm. gives this description of its preparation. The potassais fused in an iron spoon, and one third of its weight of lime is added in divided portions; the whole being stirred with an iron rod. The fused mass is then run into lead tubes, closed at one end, about three inches long and from a quarter to half an inch in diameter. The sticks are kept in the lead tubes with the open end downwards, in glass tubes containing quick lime and closed with a cork. When required for use, as much of the lead is scraped off as may be necessary to uncover the caustic. [Ed. Va. Med. and Surg. Journal. 4 internal hemorrhoids, we cause him to place himself on a Vessel, and to make efforts at defecation ; the tumours then come down, and we easily demonstrate their presence; often they even permanently appear externally, or show them- selves on the exercise of the least effort. But as it is necessary to judge precisely of the extent of the prolapse of the mucous membrane of the rectum, we advise the patient to take a lavement, and to pass it again in our presence some moments after, using efforts, and continuing the latter when he gets up. With the assis- tance of this mode of investigation, we arrive at an exact appreciation of the extent of the affection, and the operator i3 enabled to judge beforehand at what height he ought to place the porte-caustique forceps, in order to cure at once the hemorrhoidal affection, and the rectal prolapse which complicates it. The introduction of the index finger into the rectum is a means of diagnosis on which we must not place too much reliance, for I have known several patients who, examined in this manner by the most distinguished practitioners, had been declared not to have hemorrhoids, and in whom I, nevertheless, found even vol- uminous ones. The surgeon accustomed to this mode of examination, indeed, experiences internally a peculiar sensation of softness in certain points, proves the existence of inequalities rather than of tumours disappearing under the fin- ger, and gives pain to the patient when the tumours are ulcerated ; but in gene- ral these signs are not sufficient to enable him to affirm whether a hemorrhoidal affection exists or not. The rectal toucher is especially useful in ascertaining whether any particular complication, such as a stricture, polypus, or cancer, coexists. At the same time we examine the number of tumours which ought to be cau- terized, as, for the following reasons, we never destroy them all:—In order not to suppress suddenly and completely a state to which the system has long been accustomed, and not to expose the patient to a disturbance which might not be free from inconvenience ; besides, experience has shewn that when we have destroyed the more voluminous tumour when there are two, or the most volu- minous ones when there are more, those which remain diminish and give much less inconvenience. The cauterization of the largest hemorrhoid, when well performed, often prevents the others coming out, and the ulcerations, if such exist, being no longer subjected to a continual friction against one another, ci- catrize, and the patients enjoy as good health as if they had been completely freed from them. Consequently, a different mode of proceeding would be at least useless, and might sometimes be dangerous. If, contrary to what usually occurs, the patient should subsequently suffer, recourse might be had to the op- eration, which would not then be more severe than before, and would remedy an inconvenience which we sometimes meet with, but which much more fre- quently does not present itself. In ordinary cases I employ my forceps in the form of a compass with protecting blades,—more convenient when it is necessary to carry the cauterization to an elevated point of the rectum,—but in the case of which I am now speaking, I prefer the T-forceps of my father, or those which I have had made on the same plan, with very slight modifications. In fact, when there are voluminous hem- •{Ma.Med 8 Sur Journal. iitigpUL.^agi)J»^ T.SHidau-'s.titli.Phil 5 orrhoids, with more or less extensive prolapse of the mucous membrane, the tumours expanding largely externally, it is very easy to cauterize their base. Since the month of June, 1844, the period of the construction of my first grooved forceps for the cauterization of internal hemorrhoids, we have subject- ed both the instruments and the operative manipulation to numerous modifica- tions, which have made the operation so simple that a perusal of the description of it will render its application easy ; and already distinguished surgeons, among whom I would mention MM. Maher, J. Roux, and Laurencin, Professors in the Schools of the Imperial Marine, MM. H. Larrey, Barthelemy, Martin Sainte-Ange, Thirion (of Namur), Mascarel, &c, have employed this proceed- ing with success, using instruments made on the model of ours, or having the greatest analogy to them. The T-shaped porte-caustique forceps of my father, a drawing of which is given above, was made on the model of a little forceps he used for rupturing the internal membranes of arteries, m order to facilitate torsion. This instrument is composed of two legs, united at one of their extremities by a spring ; at the other they are furnished with two grooved semicircles of steel, perpendicular in their direction, and so arranged as to oppose one another when the forceps is closed, or when it embraces the base of the tumour which it is wished to caute- rize. Two small sliding plates, having a movement of rotation around the grooves, which are cylindrical, have at one of their extremities a small handle intended to be used for moving them, and consequently to cover or uncover the caustic when it is thought advisable to do so. A screw is used for tightening the legs of the instrument. The two sliding plates, to which I have given the name of protectors, have partly replaced the preserving forceps which we origi- nally used for completely isolating the tumours from the surrounding parts pre" viously to cauterizing them. When the protectors are placed in front of the grooves, the caustic beinz entirely covered, we may seize the tumours, let them go again, take hold of them, or slide the grooved semicircles to a greater or less height without the patient experiencing the slightest painful sensation. To fill the grooves of the instrument, I employ Filhos' caustic in paste, or solid. The caustic paste is made by throwing a sufficient quantity of pulverized Filhos' caustic into a saucer, adding some drops of alcohol or eau de Cologne, and tri- turating the mixture with a spatula. When the paste has the consistence of or- dinary honey it is placed in the grooves, and covered with the protectors. To fill them with solid caustic, the latter is poured into them while in state of fu- sion. I have had forceps made on this model with but a very slight difference, as may be seen by the figure on the opposite page. This instrument, to which I have given the name of pince porte-caustique a etau (these instruments have been made in the manufactories of M. Charriere), constructed at once on the model of my father's forceps, and of a little hand-vice, differs from his instru- ment in this, that the grooves which are movable on their axis, being placed in other grooves, attached to the legs of the forceps, may be withdrawn, and have the fused Filhos' caustic easily poured into them ; besides the resistance of its legs admits of the tumour being compressed as with a vice, and of the produc. 6 tion of mortification by pressure. This forceps acts then at the same time by cauterization and pressure combined, and allows us to operate more rapidly, since each of these actions is separately sufficient, though it requires more time, to accomplish the mortification of the tumour. When about to use these forceps, the grooved pieces are withdrawn, and fused Filhos' caustic is poured in so as to be level with the edges without overflowing them; should it overflow, it mus' be rubbed off with a cloth, or a piece of pumice stone, until it is exactly level > the two little grooves are then enclosed in a ground glass stoppered bottle filled with powdered lime, in order to preserve the caustic from the contact of the air* and from moisture. At the time of operating they are well wiped and replaced in the forceps, and turned round, so as to cover the caustic until the moment when it is to act upon the tissues. To effect the cauterization in this particular case I prefer the T-forceps, because their grooved portions being parallel, they exercise upon the tissues a pressure in every sense equal; but this operation may be performed with the different forceps which have been invented for cau- terizing hemorrhoids ; we may, even more easily than in other cases, cauterize the tumours with a cone of Filhos' caustic, as I shall hereafter describe. Internal hemorrhoids are often complicated with corresponding external hemor- rhoids, or rather with swellings forming two rows of superposed tumours. Ex- perience has proved that it is not necessary to destroy the externaJ swellings— they die away when the internal hemorrhoids have been destroyed by caustic. The operation having been decided on, I generally prepare the patient for several days previously with depuratives, baths, and mild regimen, even venesec- tion, if it should appear necessary ; and the evening before the operation I pre- scribe a purgative of cold drawn castor oil, in order to unload the bowels, and to prevent the occurrence of alvine evacuations for two or three days at the least. The articles necessary for the operation are : one or two porte-caustique for- ceps ; pulverized Filhos' caustic ; alcohol or eau de Cologne ; a sheet folded square ; a piece of oilcloth ; a syphon for continuous irrigation ; a syringe, or a clyso-pump ; Iwo large vessels, one to contain cold water intended for the irri- gation to be carried on during the operation ; the other to receive the fluid when it shall have passed over the anus. Before the operation the bed on which it is to be performed should be ar- ranged. The folded sheet is placed across it, and is covered with an oilcloth reaching to the vessel placed under the edge of the bed, to receive the water projected during the operation ; and in order that the latter may flow off easily, the two inferior angles of the oilcloth should be pinned together, so as to form a channel to carry the water directly into the vessel intended to receive it. The patient, having taken a lavement during these preparations, passes it again, at the moment of operation, into a vessel left near the bed, and then lies down, still keeping up the efforts at expulsion, which are indispensably neces- sary to allow the surgeon to place the forceps properly. The position of the patient which I prefer is the same as that for the operation for fistula in ano. Doubtless, if the patient were on his knees, or placed as for the operation of lithotomy, he would be better circumstanced for keeping up the 7 efforts ; but notwithstanding the advantage the operator might have by employ- ing one or other of these positions, I have renounced them on account of the fatigue the patients experience—a degree of fatigue which once seemed to me to have occasioned syncope. I am not in the habit of submitting my patients to the action of anaesthetic agents unless they earnestly request it; knowing by experience that the opera- tion is not sufficiently painful to render their employment necessary, for under the influence of the very strong compression used, and of the douches of cold water, the pain is easily borne. During the operation the patient feels a pinch- ing which, in a great measure, masks the pain of cauterization, and consequently only complains of the latter at the moment of the withdrawal of the instrument. This smarting, besides, is diminished rapidly enough by the means I employ im- mediately after the operation. Two assistants placed at the sides are engaged in holding back the neighbouring parts; a third is occupied in directing a con- tinued stream of cold water on the anal region. Strictly speaking, one assis- tant, and that even a non-medical person, might be sufficient, as he would only have to work the piston of the instrument, for the operator could direct the cur- rent of liquid with the left hand, while he held the forceps in the right, but it is much more convenient to be assisted by several persons. The patient having been placed on the bed in the manner described, and con- tinuing the efforts at defecation made in passing the lavement, the assistants carefully keep back the surrounding parts. The operator, holding in his right hand the porte-caustique forceps with its troughs covered, so as to be able to touch the tissues without causing the least painful sensation, seizes the tumour gently, without compressing it, and desires the patient to make efforts, if possible, still more energetic, in order to allow him to pass the instrument to the height he judges advisable. This period of the operation, very important in all cases, is especially so in this. When the forceps is well placed, he tightens the screw sufficiently to prevent the tumour escaping, but so as to be able, with ease, to turn the grooved pieces or the protectors. When the caustic is in contact with the tissues, the instrument is tightened as much as possible, but gradually, in or- der to bring the compression to its maximum. By acting thus, the duration of the operation is shortened, and the pain is diminished, the patient most frequent- ly complaining only of the pressure. The douche of cold water is immediately commenced, and continued while the operation lasts, which varies from two to four minutes. With strong forceps and fused caustic two minutes are longer than is necessary for cauterization. The time, however, as may be supposed, varies according to the bulk of the tumours to be destroyed. The instrument is then gradually loosened and withdrawn, care being taken to re-cover the grooves to prevent the caustic touching the neighbouring tissues. The assistants should keep the parts separated, and the patient should be again de- sired to make efforts at expulsion, that the cauterized tissues, on which a little caustic, the action of which is not yet over, still remains, may not cauterize those which should be protected. The operation being over, the douches of cold water both on the anus and in- ternally should be continued so as to neutralize the last portions of caustic which s may not have acted. I have often, with advantage, applied olive oil or vinegar and water to the cauterized parts. Should a porte-caustique forceps not be at hand, the operation might be per- formed as follows :—The patient having been placed in the position I have de- scribed, and the same preparations having been made, the tumour it is wished to destroy should be seized, as high as possible, with an ordinary dressing or dissec- ting forceps, and cauterized directly, by placing in the centre a stick of Filhos' caustic cut into a conical shape, to which a rotatory motion should be given to make it penetrate the hemorrhoid, so as to destroy it centrally and laterally. It would be necessary, during the operation, to protect the surrounding parts with spatulas or paper-knives, and afterwards to wash the cauterized tumour with slightly acidulated water, so as to neutralise all the caustic which might not have combined with the tissues. The subsequent treatment should be precisely the same as in the ordinary proceeding. Immediately after the operation, the patient is placed in a large bath, and when the tumours have been bathed for some moments, they are returned. He remains in the bath for an hour, and sometimes longer, and always experiences great relief from it; for it is then he feels the action of the caustic, which had, during the operation, been masked by the pressure. On coming out of the bath, cataplasms of linseed meal enclosed in muslin bags are applied to the anal region, or irrigations of tepid water are directed to the part if smarting is still felt. The pain which patients experience after the operation is very variable ; I have seen some who felt very acute smarting for twenty-four hours; but with the majority the painful sensation is, after some hours, but slight, if the precautions already mentioned have been observed. Some of my patients do not go to bed even the day of th^ operation ; in general they remain sitting or lying on a sofa—for walking causes pain—and they are unable to go out for some days ; elderly patients generally keep their room for a fortnight. After the operation, I allow but little nourishment, and that of a nature ad- mitting of easy assimilation, in order to avoid action of the bowels, which always occasions acute pain. When the patients feel a desire to go to stool, I advise them to inject into the rectum two ounces of lard melted in a water-bath ; it is use- ful in facilitating the passage of the faecal matters, and in diminishing the smar- ting caused by the motion. A tepid sitz-bath should be taken immediately after the stool. Sometimes I give, during the treatment, a gentle purgative, in order to remove constipation when the eschar is not yet detached; while it is, on the other hand, advisable that the patient should not go to stool at the time when the cauterized tumour is separating, in order to avoid the flow of blood which might then take place. An examination of the parts enables us to get a glimpse of the cauterized hemorrhoid, and to ascertain whether elimination proceeds more or less quickly ; experience, however, has shown that, in general, the ol- der and weaker the patients are, the more slowly this process goes on. The fall- ing off of the eschars requires a very variable time, generally from five to eight days; I have seen some become detached at the end of seventy-two hours, while in other patients they were still adherent fourteen days after the operation. To 9 render the consequences of the operation as favourable as I have described, the patient ought to take every day several sitz-baths at a moderate temperature, rather cool than warm, to keep cataplasms or water-dressing constantly on the anal region,, and to use a very light diet. When the swelling has disappeared, the same treatment should be continued for some days, but the nourishment may be gradually increased ; we may then, with advantage, form our opinion of the re- sult of the operation, and decide whether it is necessary to cauterize other he- morrhoids. Such are the operative manipulation and the treatment I employ in the affec- tion under consideration ; the following cases will enable the reader to judge of their practical value. [The author then details a case of internal hemorrhoids, with prolapse of the mucous membrane of the rectum, treated with circular cauterization of the base of the most voluminous of the tumours, with a T-shaped porte-caustique forceps with projecting plates, and terminating in cure. The patient was a mer- chant, sixty-eight years of age, of temperate habits, but always subject to consti- pation. From the age of twenty-six he had suffered from hemorrhoids, accom- panied by losses of blood, and it appeared that every two months he experienced a sort of very painful hemorrhoidal crisis, followed by a flow of blood which brought relief. During the last ten years the tumours had come down while walking or making efforts at defecation, and as the inconvenience and pain at- tending them continued to increase, Dr. Nacquart, on the 11th December, 1846, called in the author and his father. The operation was performed on the 14th, and lasted two minutes and a half; the following day there was headache and slight fever, which, however, soon passed away. On the 21st, the shreds of the cauterized hemorrhoid had fallen off, the volume of the tumours becoming pro- gressively less. On the 25th, notwithstanding the efforts the patient was encou- raged to make, nothing was found in the situation of the cauterized hemorrhoid but a small, granulating, suppurating surface; the external tumours being, at the same time, very much flattened. On the 4th of January, the patient in- formed his attendants that his efforts at defecation had ceased to be attended with any protrusion ; he was able to sit and to walk for a long time without feeling pain, and the external swellings had almost disappeared. The author saw this patient again on the 8th of March, 1852 ; since the operation, he had enjoyed a degree of health to which he had previously been a stranger, and the result of the cauterization had continued as just now described.] [The second case described by the author, of which, as well as the remaining cases, we shall, as we have done in the preceding instance, give only an abstract, was likewise one of internal hemorrhoids, with prolapse of the mucous membrane of the rectum, and was cured by circular cauterization of the base of the tumours, with a porte-caustique forceps. It occurred in an attendant in a workhouse, aged forty-six, of strong constitution and good general health, except that he had always been subject to constipation, and had for the last fourteen years, suffered from piles, with frequent pains about the anus, and discharges of blood at stool. The hemorrhoids had latterly greatly increased in volume, and came down when ii 10 the bowels acted, bringing with them a portion of the mucous membrane of the rectum; so that the patient was careful to go to stool in the evening, because the tumours returned more easily during the night, while in the daytime he had much difficulty, and often failed in returning them; at such time the friction of the shirt caused great pain, and frequently the patient could scarcely sit down, His general health becoming impaired, he applied to the author's father, who, on the 1st of March, 1848, made a circular cauterization of the left half, cir cumscribing the base of the tumour with a T-shaped porte-caustique forceps with protecting plates, charged with Filhos' caustic, and placed as high as possible. The cauterization lasted about three minutes ; the patient suffered little, and the cauterized hemorrhoid separated on the fourth day. On the 15th of March, 1848, the patient was examined by MM. Lallemandde Montpellier, Beauvieux, Remondet, and Chaussat, who ascertained that but half of the hemorrhoidal swelling remained. This was removed by a second applica- tion of the T shaped forceps, charged with caustic, and allowed to remain on for three minutes. On the fourth of April, the mucous membrane of the rectum had ceased to come down, the linear cicatrix of the cauterized hemorrhoids was sit- uated about the fifth of an inch above the orifice of the anus. This patient was seen again on the 5th March, 1849. The cure was complete ; he no longer suffered at stool, there was no hemorrhage, and the constipation had ceased. No trace of the hemorrhoidal tumours or of the mucous membrane of the rectum was perceptible externally.] The foregoing case affords an illustration of the difficulty we sometimes expe- rience in forming an accurate diagnosis of the affection. In fact, on the first ex- amination I made of the anal region, I thought the patient suffered from a sim- ple prolapse of the mucous membrane of the rectum, and were it not for the abundant losses of blood he had, joined to his other antecedents, I should have thought this was his disease. But on a second investigation, made after the ad- ministration of a purgative, the vascular element became much more apparent • there was no longer any doubt that hemorrhoidal tumours existed with prolapse of the rectal mucous membrane. We see from this how useful it is to examine patients after the administration of a purgative, in order to be able to establish with precision the diagnosis of tbe affection. As to the surgical treatment it ought, I think, to be the same in both cases, as I shall show at the close of this essay. [The third case was one of— Internal Hemorrhoids with Prolapse of the neighbouring rectal mucous mem- brane ; Circular Cauterization of the base of the most voluminous; Cure.—The patient, aged fifty-four, of strong constitution, had enjoyed excellent health to the age of eighteen years, when he got syphilis, for which he underwent a full course of treatment. At the age of nineteen, being garrisoned on the frontiers of Spain, he was attacked with intermittent fever of a tertiary type, which lasted eighteen months; from that period he enjoyed good health until he attained the age of forty, when he quitted active military service to enter an office under the Minister of War. This change of life was not advantageous to him, f>r in 1843 he began to experience general malaise, headache, oppression of the chest; he 11 ■ lost his appetite, became dyspeptic ; suffered from severe attacks of pain at the anus, in the abdomen, and sometimes in the genital organs; he occasionally felt great smarting in the urethra while passing water. His motions became diffi- cult and painful, and to relieve his sufferings he had frequent recourse to baths and lavements. In 1848 the hemorrhoids, which had not hitherto appeared externally, began to come down ; he lost blood at distant intervals, which gave him some relief. In 1849 his digestion improved, but he lost blood every day, and was besides obliged to return the part every time he went to stool. In 1850, the affection becoming worse, he could not go out, or walk without the inconvenience of feeling the hemorrhoids come down, and experiencing se- vere smarting; besides, the friction of the tumours against one another pro- duced ulceration, and his linen was stained with mucopurulent matter. He was constantly obliged to return the hemorrhoids, which soon protruded again. In January, 1851, he came with Dr. Laurand to consult the author. A simple examination showed the existence of a large hemorrhoidal tumour, beside which was a smaller one; the epithelium was rubbed off for a certain extent at the point of contact of the tumours; there was, moreover, prolapse of the mucous membrane of the rectum, especially at the base of the more voluminous of the tumours. It was determined to cauterize the latter. The operation was per- formed on the 1st of February, and on the 10th the hemorrhoid, which was blackish and shrivelled, separated. On the 13th the patient was advised gradu- ally to increase his diet; on the 14th he had a motion for the first time, and from this period he returned to his usual mode of life, resuming the duties of his office on the 16th. The cicatrization progressing slowly, he applied rhatany ointment to the anus twice a day, and was soon completely cured. On the 13th of April, the author wishing to have a drawing made of the cic- atrix left by the separated hemorrhoid, requested the patient to make every effort to bring it into view ; but it was filiform and linear, and so difficult to see well on account of the mucous membrane at that side not coming down, that he had to renounce the design. The smaller hemorrhoid, which before was seen externally, scarcely appeared. The bowels acted every day without pain, and the patient was free from all inconvenience. The author saw this gentleman again about a month before the publication of this essay, and ascertained that the result of the cauterization continued such as has just now been described. The patient's general health was remarkably im- proved, but he occasionally experienced a feeling of tension towards the extrem- ity of the rectum, which he attributed to his sedentary life; the author advised him to take as much exercise as possible, and carefully to avoid constipation, which would very probably occasion the development of the small tumours which still existed.] [The fourth was one of— Very voluminous Hemorrhoids, with Prolapse of the mucous membrane of the Rectum ; Circular Cauterization of their base with caustic potash and lime ; Cure. The patient was a Wallachian prince, aged 52, who had been operated on with the ligature for internal hemorrhoids by the author's father in 1836, and returned 12 in May, 1848, labouring under the same affection. Since the former operation, new hemorrhoids had become developed, and produced great inconvenience. Efforts at expulsion showed the existence of two large hemorrhoidal tumours occupying the entire of the anal orifice, with decided prolapse of the mucous membrane of the rectum. One of the tumours was at the right, the other at the left of the anus; numerous hemorrhoidal vessels existed. On the 6th of May, 1848, an operation was performed by M. Amussat, sen., which consisted in seizing the right-hand tumour with his T-shaped porte-caus- tique forceps, so as to include not only the base of the tumour, but also the pro- lapsed portion of the mucous membrane; the instrument having been firmly placed, and the tissues sufficiently compressed, the round pieces were uncovered by giving a rotatory motion to the protecting plates, and the screw was again tightened, so as to compress the tumour strongly. The operation lasted three minutes. The eschar became detached, and the cicatrix formed so quickly that on the 23d it was difficult to see it, on account of the retraction which the tis- sues of the right side of the anus had undergone. The pathological state of the anal region appearing remarkable, the author obtained permission to have a drawing made of the remaining tumour. On the 26th, twenty days after the first operation, the circular cauterization of the pedicle of the left hemorrhoidal tumour was performed in the manner just described. The pain was slight, and the patient felt so well the next day that M. Amussat found him in his drawing room seated on a sofa. On the 29th an examination of the anus having been made after a motion, neither hemorrhoidal tumour nor prolapse of the mucous membrane could be discovered. The prince soon after left Paris for Wallachia, completely cured. In the month of August last the author received a most satisfactory account of his patient, his general health was much improved, and he was in the habit of walking about three leagues a day. This exercise, of which he was com- pletely deprived while he had the hemorrhoidal tumours, contributed much to the favourable state of his health, and the author was led to hope that new tu- mours would not become developed, although the affection under consideration is very common in the country the prince resides in.] The fifth case is headed Voluminous internal Hemorrhoids, with Prolapse of the rectal mucous menbrane; Circular Cauterization of the largest with my T- shaped porle-casiique forceps, with the grooves movable on their axes; Cure.— M. S., aged forty-eight, came to consult me in the end of January, 1851, for an affection which, because her linen was constantly stained with purulent matter, she supposed to be a fistula. On carefully examining the affected parts, I as- certained the existence of two internal ulcerated voluminous hemorrhoidal tu- mours, with prolapse of the rectal mucous membrane, and some small varicose tumours at the edge of the anus; there was no fistula. The purulent discharge, which had deceived the patient as to the nature of her malady, came from the surfaces of contact of the hemorrhoids, which were superficially ulcerated. On questioning Madame S. as to the history of her case, I learned that, although of a delicate constitution, she enjoyed tolerably good health up to the time when the hemorrhoids had acquired some degree of development. She was the mo- 13 ther of four children, after the birth of each of whom she had hemorrhoids for a time, but then the affection rapidly disappeared, and did not return until the next confinement. Each time that the hemorrhoids appeared under these circumstances they dis- charged much. In 1848, when she had been for several years free from them, they came on after much anxiety, and, in spite of the adoption of all ordinary means, they did not disappear ; gradually they even increased in size. In 1849 they began to come down after each motion, and were always accompanied with discharge of blood. In 1850 the affection advanced still further; the tumours became more pain- ful and much more difficult to return. During the latter six months of that year the patient could not succeed in reducing them, with much pain and trou- ble, until two or three hours after each evacuation. Her digestion became more disturbed; she had frequent attacks of colic ; her strength diminished so much that she was scarcely able to take any part in domestic matters ; and she soon became unable to use anything but a little cafe au lait or very light soup. She then decided on consulting me, and on submitting to the operation I proposed to her. On the 3rd of February, 1851, in presence of Dr. Cruveilhier, Surgeon-Ma- jor of the 62nd regiment of infantry, I performed the circular cauterization of the more voluminous of the tumours, situated at the right of the anus, with a T-sha- ped forceps, made after the model of my father's, but with the grooved pieces movable on their axes, admitting of the caustic being covered and prevented ac- ting until the moment it was thought advisable. The operation was performed as I have already described; the cauterized part was well washed with cold wa- ter, and smeared with olive oil. The patient took a bath, in which she remain- ed for an hour and a quarter ; on coming out of it warm poultices were kept continuously applied to the anal region. The smarting felt after the operation gradually subsided. The cauterized hemorrhoid had, on the 10th, completely disappeared ; on the 12th, with the aid of a lavement, the patient had a motion, and passed a little blood. An examination made on the 22nd showed that, in addition to the disappearance of the cauterized tumour, the mucous membrane no lonser protruded, and that the second tumour came down in a much less de- gree. From this period Madame S. ceased to lose blood, or to have any purulent discharge ; her digestion improved ; the attacks of colic did not return. She still occasionally felt pains about the anus, but which were nothing in compari- son to those she had before suffered. The following is the report of the 6th April, 1853 :—The hemorrhoid of the left side comes down less than before the operation, and is no longer ulcerated ; the small varicose tumours at the cir- cumference of the anus seem to have increased a little in size ; the right side appears as if there had never been either tumour or prolapse of the mucous membrane. In order to give a still more complete and exact idea of the affection to which I have endeavoured to call the attention of the profession, I have added the an- 14 nexed drawing,* taken from nature, of hemorrhoidal tumours, with prolapse of the mucous membrane of the rectum, on which I shall shortly operate by the process I have described. The patient is in the habit of supporting these tu- mours with a spring bandage, furnished with a ball of gum elastic. The con- stant pressure of the ball upon the anus has produced a dilatation of the sphinc- ter, which allows the tumours to come down when they are not supported.f I might easily have brought forward a greater number of facts, but those I have recounted will suffice, I think, to prove the simplicity and the safety of the op- * The drawing alluded to is omitted, not being necessary to the complete under standing of the text—[Ed. Va. Med. & Surg. Journal. f We have, however, seen many cases of hemorrhoidal tumours, and of prolapse of the mucous membrane of the rectum, in which the greatest benefit has been de- rived from the support given by an anal truss, manufactured by Mr. Duff, of Moles- worth-street, in this city. This instrument consists of a steel spring, well padded and covered with leather, passing round the hips, and furnished in the part which rests on the sacrum with a little cushion. To its centre posteriorly is screwed a steel plate, perforated with three or four holes over one another for the admission of the screw; attached to this plate, by a joint admitting of lateral flexion, is a rod of steel also covered with leather, descending vertically, and terminating in a rounded cone of ebony, and so curved that the latter shall rest against the anus. The length to which this rod descends can be increased or diminished by screwing the plate of steel above mentioned, at one or other of the holes, to the horizontal spring. As an illustration of the effect of this instrument we may mention the case of a medical man, then aged 38, who had/or five or six years suffered from a gradually increasing prolapse of the mucous membrane of the rectum, which had in the commencemeni of 1851 attained such a height that he was unable to walk more than a quarter of a mile without the membrane protruding and becoming painfully strangulated. This was attended with a copious discharge of mucus, which rendered his state uncom- fortable in the extreme. Almost every action of the bowels was accompanied by copious hemorrhage. A loss of both red, and what Sir Henry Marsh has so well termed white, blood was thus taking place, which must soon have undermined his health. An eminent surgeon gave his opinion that operation was indispensable. A truss was, however, procured, and, having been properly adjusted, was worn with the effect of wholly preventing the occurrence of the prolapse. Asa consequence, the discharge of mucous and the hemorrhages have altogether ceased, and all annoyance has been entirely removed. The tendency of the use of the instrument is, moreover, by preventing the descent of the parts, to promote their contraction, and thus, if the bowels can be duly regulated without the irritating effects of medicine, to lead to a real cure. It is better to use the instrument only at such times as the patient is likely to be actively engaged. Due attention should of course at the same time be paid to the avoidance of much standing, sitting on hard seats, straining at stools, or lengthened attempts at defecation. Wc have never seen the dilatation of the sphinc- ter above alluded to produced by the use of this instrument, and we think it will be found that there are few cases of hemorrhoidal tumours, or of prolapse of the rectum, in which the necessity for operation may not be indefinitely postponed by it, and where, under favorable circumstances, even a cure may not eventually be reasonably looked for.— Trans. Dublin Quarterly Review. 15 erationlhave described. I may add, that MM. Hippolyte Larrey, Martin, (Saint- Ange), of Paris; Dr. Mascarel, of Chatellerault; MM. Maher, J. Roux, Lau- rencin, Professors in the schools of the Imperial Marine, have kindly communi- cated cases of patients successfully operated on according to my plan. Lastly, MM. Barthelemy and Jobert,* who formerly gave an exclusive preference to the actual cautery, have now abandoned it, and employ instead the caustic pot- ash with lime. As the details I have given in describing my operation appear to me sufficient to enable the reader fully to understand its several stages, and with ease to put them in practice, I shall not return to that part of my subject; but I think it useful to dwell for a little on its sequelae, and the consequences which may result from it, for the rule of conduct I have adopted is the result of an experience based on the numerous facts I have observed during more than ten years. The two or three minutes which I judge necessary for the cauterization hav- ing elapsed, the forceps is removed, care being taken that the caustic it contains shall not touch the neighbouring parts, and the injection of cold water, which has not been interrupted during the operation, is continued. The jets of liquid should be directed chiefly to the linear depressions formed by the instrument. in which the caustic is situated, in order to remove particles which may not have chemically combined with the tissues. It is at this time especially that the patient feels the cauterization, which is no longer masked by the pressure of the forceps, and the cold fluid pouring on the tissues has, in addition to the effect just mentioned, that of acting as a local anaesthetic. When the parts have been washed sufficiently to have removed all the caustic, the tumours are carefully smeared with olive oil, and returned into the rectum. The oil both serves to facilitate the reduction, and, to a certain degree, protects the tissues by combin- ing chemically with the alkalies, should any still remain. Small quantities of cold water are also thrown into the rectum, and allay the pain, and afterwards the patient is placed in a cold sitz-bath, or, better, in a full sized bath at an agreeable temperature, which will, of course, vary according * M. Jobert de Lamballe has recently published a new mode of cauterizing he- morrhoidal tumours en masse by means of caustic potash with lime. This surgeon seizes the tumours with a double arch of silver, which forms a sort of capsule, any covers them with Vienna paste, which he leaves applied for some minutes. The only patient on whom this operation has been performed had hemorrhoids of ordinarp size, and two successive applications of the paste were necessary to destroy them. This mode of operation cannot be compared with the circular cauterization of the base of the hemorrhoids I have described. By my proceeding, in fact, the caustic is applied on a surface of but very limited extent, and the pressure of the forceps, combined with the continual irrigation with cold water, so moderates the pain of tho operation that it is only exceptionally I have recourse to anaesthetic agei.ts. More- over, the pain which follows the operation is much less than in M. Jobert's proceed- ing, the cauterized surface being less extensive. His plan can only be compared with the mode I formerly pursued with a stick of Filhos' caustic. The latter pro- ceeding possesses the advantage of not requiring a special instrument, and besides, the solid caustic acting more quickly than the paste, the operation lasts a shorter time, and I have never been obliged to repeat the application. 16 to the time of the year. In this he generally remains about an hour, being guided in this respect by his own sensations. Generally speaking, on coming out of the bath, the pain, which has gradually diminished, is very slight; occasionally, however, in very nervous persons, or when the caustic has not been completely removed from the tissues, it is still severe. In this case we advise the patients to return to bed, and to place them- selves in a position similar to that they observed during the operation, while a continued douche of water, which in winter should be tepid, in summer cold, is directed against the anal region. I have known some to find it more convenient to substitute for the douche, continued applications of lint dipped in cold, some- times even iced water, and very frequently renewed. This latter means, though undoubtedly efficacious, should be employed with care, so as to avoid the reac- tion which is apt to set in when it is suspended or left off. Other patients re- main all day in the sitz-bath, the temperature being kept up by the addition, from time to time, of warm water. I once attended, with my father and Dr. Pouget, a person who, after the cauterization of two tumours, remained in a sitz-bath almost constantly for a week; he said he was very well in it, and not the slightest bad effect resulted from this protracted use of it. Most frequently two or three sitz-baths during the day, small continued dou- ches, with poultices on the anal region in the intervals, constitute the local treatment. This plan should be persevered in until the wound is almost completely cica- trized, especially if the least sign of inflammation should be observed. The only nourishment I allow is strong beef tea, and I recommend the patient to keep his bed for two reasons : first, because by so doing, he bears the restricted diet better ; and secondly, because the bowels are then less liable to act. Those who will not submit to this plan are obliged at once to take a more substantial diet, the result of which is stools, which are more painful in proportion as they occur nearer the time of the separation of the eschar. Frequently a dysuria comes on which lasts some hours, and subsides spontane- ously, for I do not remember having had recourse to catheterism in a single in- stance. There is generally swelling, sometimes partial, sometimes genera], of the areolar tissue about the anus. The patients complain of it a little, and gen- erally think it is the hemorrhoids which have come down. I employ only the lo- cal means I have mentioned, and if the patients are very irritable, I have the poultices sprinkled with a little oil and laudanum. I sometimes give on the first night a composing draught with syrup of poppies. The state of the patients is generally so satisfactory on the following days, that they complain only of the diet and rest which are imposed upon them. At the end of three, four, six, eight, or twelve days, portions of sloughs will be seen on the poultices, indicating that the mortified tumours are thrown off, of which the characteristic odour they diffuse likewise gives notice. The broth diet is continued as long as the patient does not complain too much of it, and in this way the work of elimination and reparation goes on very well, as there is nothing to interfere with it. I endeavour to postpone the first motion as long as possible, without, however, annoying the patient too much. When he feels a 17 repeated desire to go to stool, which generally occurs at the end of six or eight days, I direct two or three ounces of lard melted in a water-bath, or a lavement of decoction of marsh-mallow, to be thrown into the rectum. The introduction of the tube should be managed with the greatest care, so as not to irritate or injure the wound. This duty should be entrusted to an assistant or an intelli- gent nurse. The first stool is always rather painful, and the patient passes a few drops of blood; in two of my patients two or three ounces were lost without any bad ef- fect except some increase of weakness, which I met by improving the diet. If the exclusive use of beef tea does not become too repugnant to the patient, which generally takes place. I induce him to continue it for some days, being guided by the time at which the eschars fall off and the probable state of the suppurating surface, the extremity of which can generally be seen at the anal orifice. It is unnecessary to observe, that I discontinue the baths as soon as the pain about the anus has ceased, as they would, along with the restricted diet, lower the patient too much. My object in continuing the exclusive use of the broth is to postpone the second motion, and to render it as small as possible. If, however, this diet does not sufficiently support the strength, or if disgust comes on, I substitute fresh eggs, gravy, and a little bread or pastry, gradually increasing their quantity. The second stool usually takes place from the twelfth to the fifteenth day, and ought to be preceded by the precautions I have detailed in reference to the first. The patient now begins to resume his ordinary mode of life, a great many go out, and some return to their occupations, taking care, however, to use an occasional sitz-bath, to foment the anus with tepid water several times a day, and particularly after having been at stool. Such are the phenomena I have observed, and the measures I advise, after the circular cauterization of the base of hemorrhoidal tumours, whether simple, or complicated with prolapse of the neighbouring rectal mucous membrane; and from what I have stated it will be easily inferred that not only have I never lost a patient in consequence of the operation, but I have never had reason to be un- easy about my patients. I may add, that in no case have I observed the slightest symptom of pyemia to arise. It would, perhaps, now be well to compare this new mode of treatment with those in ordinary use—the ligature and excision : but to draw this parallel would lead me beyond the limits of the present essay; it may suffice to remark, that I have never observed the nervous or phlebitic attacks to result from the new plan which have been attributed to the ligature, nor have I ever witnessed the hemorrhages and purulent absorptions to which excision occasionally gives rise. In a future essay I shall examine, comparatively, the other modes of cauteriza- tion employed in the treatment of hemorrhoidal affections. It will, no doubt, have been remarked, that the five cases I have^ quoted are those of patients advanced in life ; the remaining facts which have come under my observation confirm the opinion generally received in reference to this affec- tion, namely, that it is more common in those who have passed forty years than in younger persons. It may be fairly asked if it is advisable to cauterize hem- iii 18 orrhoidal tumours in old people, and especially when, being of long standing, they have become habitual and constitutional. As I have already said, I never take away all the tumours, confining the operation to those which give most an- noyance ; and although it has been objected that in acting thus we do not com- pletely remove the affection, and that the tumours which are left may subse- quently be developed, and oblige the patient to undergo the operation anew, still, as this reproduction has hitherto been very rare, and as my plan has always been attended with fortunate results, I think it right to persevere in the same line of conduct. In a word, I am of opinion that we ought only to remove the tumours which are really prejudicial to health. Among the advantages which result from the operation, I shall point out, first, the cessation of that constant and great irritation caused by the protrusion and perpetual friction of the tumours against one another. This friction quickly re- moves the epithelium from the surfaces which are in contact; the patients feel an incessant smarting, which enervates them; a weakening, muco-purulent dis- charge is set up at a period of life when losses suffered by the system are re- paired but slowly and with difficulty. Moreover, the sufferers are debarred from the little exercise their lower limbs would still allow them, by the fear of its producing an aggravation of their state. It is rarely, too, that the phenom- ena of digestion are not more or less disturbed; the advantages to be derived from terminating such a state of things will be at once apparent. Double care should, however, be taken after the operation to guard against metastatic engorgement of the organs of respiration or of the liver; of such the physician should be particularly watchful, especially at first. I may add, that spring should, if possible, be chosen for the performance of these opera- tions, so as to have the fine season for the period of transition. It was my original intention to have closed my essay here, having, I think, sufficiently demonstrated the proposition I had advanced; but on reviewing the various cases of voluminous and complicated hemorrhoidal tumours I had ob- served, and reflecting on the comparisons which might be established between the affection I have been speaking of and prolapse of the mucous membrane of the rectum, whether simple or complicated with hemorrhoidal tumours, that is to say, on the cases in which the complication becomes, by its development, the principal affection, as well as on the difficulties which sometimes exist in clearly diagnosing between these two pathological states ; I asked myself if an opera- tion which succeeds so completely in one case might not be applicable to the other. The study of the etiology and ordinary progress of prolapse of the mu- cous membrane of the rectum shows that, most frequently commencing as a complication of the hemorrhoidal affection, it may at length become the promi- nent ailment in consequence of its development and of the derangements it pro- duces ; and it is often true that while the vascular element little exceeds its ordinary limits, the prolapse alone attracts the entire attention of the surgeon. Is not, in both cases, cauterization with a porte-caustique forceps applicable to the mucous tumour protruding from the anus, and may it not be regarded as the logical corollary of the treatment we employ in the cure of hemorrhoids 1 Ligature, excision and cauterization have been already employed in the treat- 19 ment of prolapse of the mucous membrane of the rectum. As in hemorrhoids, ligature has given rise to fatal nervous symptoms, excision to severe hemo- rrhages ; accordingly, these two methods appear to have been abandoned in both cases. The actual cautery employed by the ancients, especially advocated by Marcus Aurelius Severinus, and described by Sabatier, who proposed to trace burnt lines upon the tumour, by means of an iron wire brought to a white heat, has been successfully practised by Dr. Kluiskens of Ghent, and by several French sur- geons. It appears to me, however, that this process, which I believe to be preferable to the former two, may with advantage be replaced by the use of caustics. We find in the records of science instances of complete gangrene of the pro- lapsed part, caused by strangulation produced by the sphincter, with cure. It would, therefore, at once occur to us to seize the base of the prolapse with a strong porte-caustique forceps, so as to induce immediate mortification, as in the case of hemorrhoids, in imitation of what is sometimes done by nature. By ac- ting thus we should probably do more than is necessary, and expose ourselves to the risk of causing a subsequent contraction of the anal orifice. I think it would be sufficient and preferable, in such a case, to follow the plan I adopt with voluminous hemorrhoidal tumours, namely, to destroy, by the same process of cauterization, the half or two-thirds of the mucous tumour, so as not to have a continuous linear cicatrix. Such were the deductions I thought might strictly be drawn from the facts I have quoted, when, on the 25th of last August, M. X., a physician in the envi- rons of Blois, who was acquainted with the former part of this essay, came to consult me about his wife, whose case I subjoin, and who was affected with a prolapse of the mucous membrane of the rectum. This very interesting case gives to the proposition I have announced the sanction of an experience recent indeed, but which I hope to establish in a positive manner when lime and facts shall have enabled me to make in it such modifications as may hereafter appear to be necessary. [The case alluded to was one of voluminous prolapse of the mucous membrane of the lower extremities of the rectum, treated by cauterizing the two lateral por- tions of the tumour with a T-shaped forceps armed with Filhos' caustic ; and resulting in cure. The patient, Madame X., aged 63, had always suffered from obstinate constipation; in her youth she was often, when she had not recourse to lavements, ten, twelve, and sometimes fifteen days without a motion. She had also long and alarming fainting fits at the times when the bowels felt as if about to act, and she made violent and prolonged efforts to expel the faecal mat- ters. At the age of 54 the patient perceived that the mucous membrane of the rec- tum protruded externally, but this was not constant, taking place only at inter- vals of two, three, or four months, and continuing for not more than three or four days at a time. It was preceded by a feeling of general uneasiness, headache, and a sensation of weight and heat in the rectum, and was followed by a tolera- bly abundant hemorrhage at stool, when all returned to its normal state. 20 Two years later, without the hemorrhage being more frequent, the prolapse from having been intermittent, became constant when the patient was up, and exhibited itself from the beginning under the form of four non-pediculated tu- mours, one superior, one inferior or perineal, and two lateral; the superior and inferior being smaller than the two lateral ones. This prolapse became in time more voluminous and more inconvenient, in consequence of the feeling of weight and dragging it occasioned in the uterus and its appendages. The pa- tient, being no longer able to walk a step without putting her hand behind to raise the tumour, except during some hours after rising, when she had the eve- ning before taken lavements, decided on submitting to a surgical operation.] A lavement having been administered, and efforts at defecation having been made, an examination was instituted. On exploring the vagina with the index finger, I ascertained that the cervix uteri was united posteriorly by a cicatrix such as my father obtains by cauterization in cases of retroversion and retroflex- ion. Bearing in mind the analogy existing between this affection and that which is the subject of this essay, I proposed to cauterize a portion of the mucous tu- mour, as if we had to do with voluminous hemorrhoidal swellings. To this M. X. agreed. On the 29th August, Madame X. having in succession taken and passed two lavements, using as violent efforts as possible, was placed on a bed furnished with a folded sheet and oilcloth, and in the position usually adopted for opera- ting for hemorrhoids. The prolapsed anus now presented itself, divided by sulci into four parts. Its two lateral portions being the larger, I seized each at its base with a strong T-shaped porte-caustique forceps with protecting plates, and when I had placed the instruments as high as possible, I uncovered the caustic, and strongly tight- ened the two screws. But as the fissures between the four portions of the tu- mour were very shallow, I was obliged to add to one of the extremities of each forceps a forceps with porte-caustique rods, charged with paste of potash with lime, so as to make artificially furrows which did not already exist. Everything having been thus arranged, I caused a current of iced water to be thrown on the anal region with two large Eguisier's irrigators, during the ten minutes that the instruments remained applied. Under the influence of the very strong pressure exercised by the forceps, and of the current of iced water, the patient, a very nervous person, bore the operation so well, that she did not re- quire the use of chloroform, which we had before agreed to exhibit. The operation being over, I removed successively the small forceps, then the T-shaped forceps, and continued the douches of iced water for about a quarter of an hour, taking care to direct the jet on the points where the caustic had touched. Having smeared the entire mucous surface with olive oil, I returned it by means of a regular taxis, and the patient was placed in a cool sitz bath, a compress of linen having been fixed on the anal region so as to prevent the protrusion of the mucous tumour. The pain she had experienced after the operation was allayed soon became very tolerable. In the evening there was a little fever and com- plete retention of urine, which rendered the catheterism necessary. The reten- 21 tion continued until the 2nd of September, when it ceased. On the 1st of Sep- tember the patient voided per anum a blackish liquid ; this kind of discharge continued for some days. On the 6th, a long portion of mortified areolar tissue was passed. On the 30th, a month after the operation, an examination was made ; nothing was visible externally, and it is stated that no protrusion took place at stool. On the following day the patient returned to the country- Since that time Madame X. has often had motions with scarcely any suffering ; but being always constipated, she has frequently passed hard matters covered at first with a little blood, then with purulent matter ; moreover, she takes walking exercise without the occurrence of the slightest prolapse. It will be observed, in perusing the foregoing statement, that I followed in this case, both in the operation and in the subsequent treatment, precisely the method that I have laid down for the cure of hemorrhoidal tumours, namely, the cauterization of a portion of the mucous mass with forceps furnished with grooves filled with a caustic paste, and afterwards a strict diet, with the view of avoid- ing motions, particularly after the operation; accordingly, [the consequences have been as simple and as favourable as in the affection I have just mentioned. Prolapse might, no doubt, be treated with direct cauterization by means of a stick of Filhos' caustic ; but this proceeding, though more simple, and not re- quiring a special instrument, would be more painful for want of the compression, and the continued injection of cold water. Hitherto the result of the operation has been as satisfactory as could be wish- ed, and it will continue so, if I may judge by the results we have obtained in the treatment of the largest hemorrhoidal tumours. To recapitulate from the foregoing, I think we may conclude :— 1. That the circular cauterization, such as I have described, enables us to cure hemorrhoidal tumours, and the prolapse of the rectal mucous membrane which accompanies them. 2. That this operation has always been, in my hands, perfectly harmless in its immediate consequences. 3. That the health of hemorrhoidal patients operated on after my mode has eventually improved, contrary to the generally received opinion. 4. That by circular cauterization we may also obtain the cure of prolapse of the mucous membrane of the rectum.—Bulletin de Therapeuiique, vols. 44 and 45. RICHMOND: COLIN & NOWLAN, PRINTERS. • o c. The Virginia Medical and Surgical Journal, the largest Med- g ical Monthly in this country, will issue the first number of its fourth § volume on the 1st of January 1855. The terms of this work axe fee dollars a year, for which the subscri- ber receives two volumes of eleven hundred pages, containing a large n 8 amount of valuable and practical information on every branch of medi- 8 ■ - 8 cal science. Unconnected with any medical association, collegiate | § institution, or publishing house, it is designed to be the independent g advocate of the rights and interests of the entire medical public. o EDITORS. J. B. McCAW, M. D., Richmomd. J. F. PEEBLES, M. D., Petersburg. GEO. A. OTIS, M. D., Corresponding Editor. 3 All remittances and letters on the business of the Journal should be | addressed to " Editors of the Virginia Medical and Surgical Journal," g Richmond, Va. |6^IOOAOOA02&9ig9ig9Jg9lg9lg9ig9ig9ig9ig9ig