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 THE 
 
 . SURGERY OF THE RECTUM : 
 
 BEING THE 
 
 LETTSOMIAN LECTUX .X 
 
 ON 
 
 »|; SUPiOEK Y, 
 
 DELIV .KE1) B>:ru). :C , . . 
 
 MELICAu SOCIETY OF LONDON, 1865. 
 
 HENRY SMITH, F.E.C.S., 
 
 ASM«TAMT*8l’RO£ON TO KING’S COUSGP HOSPTTAT. LATE PRESIDENT OF THE 
 w MEDICAL SOCIETY OP LONDON. 
 
 THIRD EDITION. 
 
THE UNIVERSITY 
 OF ILLINOIS 
 LIBRARY 
 
 From the collection of 
 Julius Doerner, Chicago 
 Purchased, 1918. 
 
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SURGERY OF THE RECTUM. 
 

 
 
THE 
 
 SURGERY OF THE RECTUM : 
 
 BEING THE 
 
 LETTSOMIAN LECTURES 
 
 ON 
 
 SURGERY, 
 
 DELIVERED BEEORE THE 
 
 MEDICAL SOCIETY OE LONDON, 1865. 
 
 BY 
 
 HENEY SMITH, F.E.C.S., 
 
 ASSISTANT-SURGEON TO KIN&’s COLLEGE HOSPITAL; LATE PRESIDENT OF THE 
 MEDICAL SOCIETY OF LONDON. 
 
 THIRD EDITION. 
 
 LONDON: 
 
 J. & A. CHURCHILL, NEW BURLINGTON STREET. 
 1871. 
 
PRINTED BY J. E. ADLARD, BARTHOLOMEW CLOSE. 
 
6 / 7.^3 
 
 5-y^j 5<? 3 
 
 CO 
 
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 TO 
 
 JOHN GAY, F.R.C.S., 
 
 SURGEON TO THE GREAT NORTHERN HOSPITAL, 
 
 THE FOLLOWING PAGES ARE INSCRIBED, 
 
 AS 
 
 §1 slight frilmft of |Ugarir for flint 
 
 A MAN AND A SURGEON, 
 
 BY HIS AFFECTIONATE FRIEND, 
 
 THE AUTHOR. 
 
 703422 
 
PEEEACE 
 
 TO THE 
 
 THIRD EDITION. 
 
 It was my intention in bringing out a Third 
 Edition of these Lectures to enlarge the work 
 considerably, and treat of some other important 
 disorders of the rectum ; but as the little work 
 in its present form has been so well received by 
 my professional brethren, and as I have very 
 recently written at great length on “ Diseases 
 of the Rectum,” in ‘ Holmeses System of Sur- 
 gery/ I have contented myself with making 
 a few additions to the observations made in 
 
 V 
 
 the previous issues. 
 
 82, Wimpole Street; 
 
 May, 1871. 
 
PREFACE 
 
 TO THE 
 
 FIRST EDITION. 
 
 The Three Lectures of which this work con- 
 sists were delivered before the Medical Society 
 of London, in my capacity of Lettsomian Pro- 
 fessor of Surgery for the year 1864-65. My 
 observations were on each occasion so favor- 
 ably received by a large and attentive audience, 
 that I hesitate not to publish them just as 
 they were delivered. The entire subject of the 
 Surgery of the Rectum could not, of course, 
 be discussed within the time allotted for Three 
 Lectures, and therefore my object has been 
 to draw attention to some of the more im- 
 portant points connected with this depart- 
 ment of Practical Surgery, especially to those 
 points upon which the information contained 
 
X 
 
 in books of special writers is somewhat scanty. 
 It will be perceived that the use of my im- 
 proved clamp in the treatment of haemor- 
 rhoids and prolapse of the rectum is fully 
 explained, and, together with the record of my 
 experience of the method recommended, forms 
 the subject of the whole of the last Lecture; 
 and I trust that these details will assist the 
 members of our profession in coming to some 
 conclusion regarding the value of a plan of 
 treatment safe and better, in my humble 
 opinion, than any other hitherto practised. 
 
 82, Wimpole Street, 
 
 Cavendish Square, W. 
 
CONTENTS 
 
 LECTURE I. 
 
 PAGE 
 
 On some points connected with Fistula in Ano 1 
 
 LECTURE II. 
 
 On Steictuee, Cancee, and Polypus op the 
 Rectum 39 
 
 LECTURE III. 
 
 On the Teeatment oe H^moeehoids and Peo- 
 
 LAPSUS 
 
 86 
 
ON THE 
 
 SURGERY OE THE RECTUM. 
 
 LECTURE T. 
 
 ON SOME POINTS CONNECTED WITH EISTULA 
 IN ANO. 
 
 Mr. President and Gentlemen, 
 
 I ought, perhaps, to make some apology for 
 bringing before you the subject I have chosen 
 for the three lectures which I have the honour 
 to deliver before you ; but I must beg your 
 indulgence on account of the great importance 
 which has been of late years attached to the 
 pathology and surgery of the rectum. I must 
 also request you to bear in mind what a vast 
 amount of suffering is produced by these diseases, 
 how readily the majority of cases are susceptible 
 of relief and cure in careful hands, and on 
 the other hand how easily and frequently they 
 are mismanaged when they are treated by the 
 ignorant and careless. 
 
 1 
 
2 
 
 It would be out of the question for me to 
 attempt anything like an inquiry into the 
 pathology and surgery of the rectum generally, 
 in a period of time extending over three hours, 
 even if it were desirable to do so ; and there- 
 fore I propose to bring before you some of the 
 more interesting points connected with the 
 surgery of these diseases, to discuss some ques- 
 tions about which surgeons are not yet in 
 accord, and to subject to your consideration 
 some methods of treatment which I have been 
 led to adopt in certain diseases of frequent 
 occurrence and great severity. I propose in 
 the first place to consider some points connected 
 with fistula in ano and stricture of the rectum ; 
 I shall then offer some observations on cancer ; 
 the subject of polypus of the rectum will receive 
 some attention at my hands ; and these lectures 
 will be brought to their conclusion by a re- 
 ference to my experience of the treatment of 
 haemorrhoids and prolapsus. 
 
 It is a fact somewhat curious, yet at the same 
 time one highly satisfactory as regards the 
 character of surgery, that many of the most 
 important facts connected with the pathology 
 and surgery of special diseases, if I may so term 
 
3 
 
 them, have been furnished or pointed out to us 
 by those most eminent as writers on general 
 surgery, and as regards the subject of fistula in 
 ano, we are mainly indebted for what we do 
 know to the writings of Pott, of Brodie, and 
 of Syme ; and one of the most important 
 points connected with the subject, viz., the 
 primary formation and cause of the disease, 
 has been very carefully considered and discussed 
 by the two latter eminent surgeons. Brodie, 
 after a large experience, and apparently very 
 careful consideration of the subject, promulgated 
 the view that in cases of fistula in ano an in- 
 ternal opening in the bowel always existed, and 
 that the first step in the production of the 
 disease was ulceration of the mucous mem- 
 brane and the formation of the aperture in 
 question. This doctrine was strongly main- 
 tained for some time, was thought to be correct, 
 and I doubt not, was productive of very con- 
 siderable errors in point of practice. Mr. 
 Syme, on the other hand, maintained with 
 equal determination that in cases of fistula in 
 ano “ the mucous membrane always remains 
 entire in the first instance, and is never per- 
 forated until after suppuration has taken place.” 
 
4 
 
 It is a somewhat strange circumstance to find 
 these two eminent and equally careful observers 
 totally at variance upon what must he simply 
 a matter of fact, not, perhaps, so easily recognised 
 as some writers would lead us to believe. It 
 is, however, pretty universally admitted and 
 taught in the present day that in the majority 
 of cases of fistula in ano the first pathological 
 change which takes place is an inflammation 
 and induration in the cellular tissue around the 
 rectum, and if this be not arrested suppuration 
 occurs, and the matter not finding a free vent 
 externally, discharges itself by a more or less 
 circuitous route into the cavity of the gut. An 
 exception must he made, of course, to those cases 
 where an aperture has been made in the mucous 
 membrane in consequence of the adhesion or 
 penetration of a foreign body, such as a nail, 
 a bristle, or a fish bone. Moreover, there are 
 cases to be met with where, from the history 
 during life, and from the morbid appearances 
 after death, there is every reason to believe 
 that the ulceration of the mucous membrane 
 has been the primary cause of the mischief ; 
 this is more noticeable in certain cases of 
 bad fistula occurring in the persons of those 
 
5 
 
 long resident in warm climates, and who have 
 suffered from dysenteric inflammation of the 
 colon and rectum — here several apertures in 
 the mucous membrane of the bowel will be 
 found to exist. 
 
 It might be supposed that it is not of much 
 consequence, in a practical point of view, to 
 define with exactness the first series of patho- 
 logical changes in the formation of fistula ; but 
 a careful consideration of the phenomena will 
 lead us to the conclusion that a correct appre- 
 ciation of the morbid changes must of necessity 
 lead here, as elsewhere, to a proper line of 
 practice ; and on the other hand that an unsatis- 
 factory and undecided plan of treatment will 
 result if the primary steps in the production of 
 a fistula be not clearly apprehended. I shall 
 have to say more upon this point by-and-by. 
 
 As there was at one time a considerable dif- 
 ference of opinion in reference to the precise 
 formation of fistula, so in like manner surgeons 
 and pathologists have been at issue with regard 
 to the locality and existence of the internal 
 opening ; for of course we cannot appreciate a 
 complete fistula in ano without an internal 
 opening being present as well as the external 
 
6 
 
 aperture. Brodie enunciated the doctrine that 
 an internal opening in the bowel always existed; 
 holding the views he did that ulceration of the 
 mucous membrane was the primary step in the 
 formation of the fistula, he could, of course, 
 come to no other conclusion ; and thus is shown 
 how one error in pathology, as in morals, leads 
 to the commission of another, for it is un- 
 doubtedly a fact that many cases of fistula in 
 ano are met with, wherein a sinus is left as the 
 result of an abscess, has lasted for some time, 
 and yet no internal opening can be found; to 
 this it may be objected that those who main- 
 tain this opinion do not look for the opening in 
 the right place ; but, on the other hand, it is 
 urged that a careful inspection of the parts 
 after death has given convincing proofs that 
 cases not unfrequently happen where, notwith- 
 standing the formation of a long and tortuous 
 sinus by the side of the rectum, the cavity of 
 the intestine has remained intact, and hence 
 the very proper distinction drawn by surgical 
 writers between what is termed complete and 
 incomplete fistula. Now, the question of the 
 universal presence of an inner opening is by 
 no means simply one of interest in a patho- 
 
logical point of view, but it is really of im- 
 portance, practically speaking. We are very 
 frequently asked by patients in private life as 
 to the absolute necessity of an operation for 
 fistula, and we are chiefly guided as to our 
 answers by our investigation of the inner por- 
 tion of the sinus ; if we detect an opening in 
 the bowel we may state with certainty that an 
 operation is necessary ; but, on the contrary, if 
 after a very careful examination we cannot 
 detect any internal opening, more especially if 
 the disease has not existed long, we may hold 
 out some reasonable hopes that the fistula may 
 heal up without resorting to the knife ; at all 
 events, that the major operation of dividing 
 the sphincter ani muscle may be dispensed 
 with. It is not very often, it is true, that our 
 hopes are verified, but every now and then we 
 meet with cases where a fistula not communi- 
 cating with the gut may heal up. Such a case 
 has recently occurred to me in the person of a 
 cavalry officer, a patient of Ur. Jephson, of the 
 5th Dragoon Guards, who came home invalided 
 from India for the express purpose of having an 
 operation for fistula performed. I performed the 
 operation upon him, and he got quite well; about 
 
8 
 
 six months after this he consulted me again, in 
 a very weak and depressed condition of health, 
 and on examination I found that he was suffer- 
 ing severely from a large abscess in the ischio- 
 rectal fossa. I promptly opened this, but as 
 some delay had occurred in the treatment of 
 this case whilst he was in the country, I found, 
 as expected, that a long sinus had formed, 
 running some distance up by the side of the 
 rectum, but I could not detect any aperture in 
 the bowel. He was, of course, most anxious to 
 avoid another operation, and, although I dared 
 not hold out much hopes, I commenced treat- 
 ment with the view of closing the sinus ; this 
 consisted in the administration of tonics and 
 liberal diet, and the occasional introduction 
 into the sinus of a probe dipped in a strong 
 solution of iodine ; the health began to improve 
 very rapidly, the sinus got less and less, and in 
 the course of a few weeks it had entirely 
 healed. 
 
 Before a very careful and correct investiga- 
 tion was instituted into the nature and pathology 
 of fistula, surgeons laboured under the impres- 
 sion that in most cases of complete fistula the 
 inner opening was situated either at the ex- 
 
9 
 
 tremity of the' sinus, or, at all events, would be 
 found some two or three inches up ; hut it is 
 now an admitted fact, and one capable of 
 demonstration, that in the majority of cases 
 where there is a fistulous communication with 
 the bowel the opening is situated within half 
 an inch or an inch of the verge of the anus. It 
 has indeed been stated that the opening is 
 always within one inch and a quarter, but 
 there are exceptions to this. I have recently 
 inspected the parts concerned in this disease 
 after death, where a fistula ran up by the side 
 of the bowel, and then opened into it at least 
 two inches from the anus. There is no reason, 
 anatomical or mechanical, why the internal 
 opening should not occasionally be situated 
 higher up than one or even two inches, and 
 experience tells us that every now and then 
 such cases are met with. I have lately had 
 under my care in King’s College Hospital, a 
 young man, who had a communication between 
 the rectum and ischio-rectal fossa on each side, 
 and the inner opening on either side w~as quite, 
 if not more than, two inches from the anal 
 orifice. I am somewhat under the impression 
 that too much has been made of the undoubted 
 
10 
 
 fact of the interna] opening being found in 
 many cases close upon the anus, and that an 
 erroneous practice is in some cases the result of 
 a too great reliance upon the supposed unvary- 
 ing seat of the inner opening ; for it is laid 
 down as an axiom in surgery that the incision 
 needful for the cure of this disease should be 
 confined to the limits of the external and 
 internal opening. When the inner opening 
 does exist, and in the situation referred to, I 
 believe we need not carry the point of the 
 bistoury further than this spot ; but it does 
 not follow that in those cases where an internal 
 opening does not exist, and where the sinus 
 runs some distance up the bowel, that we 
 should in all cases limit our incision to that 
 point where the internal opening is generally 
 expected to be found. 
 
 In connection with this part of my subject 
 I am led to consider the question of a very 
 annoying and serious result of an operation for 
 fistula in ano which is occasionally met with, 
 viz., a loss of power of the sphincter, and con- 
 sequent inability to retain the contents of the 
 rectum ; when it does occur it naturally causes 
 to the unfortunate sufferer a vast amount of 
 
11 
 
 annoyance and misery. It is found to occur 
 under different circumstances, sometimes when 
 only one operation has been performed, at 
 other times when one, two, or three operations 
 have been done. I have recently had occasion 
 to meet with several instances of the kind, and 
 consequently have been endeavouring to as- 
 certain how far any particular kind of opera- 
 tion may tend to this result, but I have not 
 been able to solve this problem in a manner 
 satisfactory to my own mind ; and I have not 
 been able to obtain any assistance in this 
 matter from the writings of those gentlemen 
 who have hitherto made the subject of disease 
 of the rectum a particular study. Thus, on 
 looking into the works of Syme, Bush, Curling, 
 and Ashton, there is either no allusion to this 
 very important point, or the circumstance of a 
 loss of power to retain the faeces is merely 
 mentioned as result of an operation, but no 
 attempt is made either to explain the occur- 
 rence or how to avoid it. 
 
 That this very unfortunate result does not 
 unfrequently take place I am satisfied from my 
 own experience, and it is one of the points 
 about which patients in private practice are 
 
12 
 
 very particular in their inquiries ; for they 
 very naturally consider that the want of power 
 to control the faeces is a greater misfortune 
 than the presence of a fistula. It is thought 
 by some, that this result is only likely to occur 
 when the operation for fistula has been per- 
 formed on both sides, or when repeated in- 
 cisions have been made through the sphincter. 
 It is true that it does occur in a more severe 
 form after the muscle has been cut through on 
 either side. I have recently discharged a man 
 from King’s College Hospital, where a deep 
 sinus into the rectum was divided on both 
 sides, and almost entire control over the rec- 
 tum was lost ; but I have also recently met 
 with a case where the same lamentable result 
 followed after a single division of the gut ; so 
 that the patient, a gentleman in active busi- 
 ness, considers himself in a much worse con- 
 dition than he was in before the operation. 
 Then, on the contrary, I have met with cases 
 where two, three, four, or five incisions have 
 been made through the sphincter, and yet the 
 power over the rectum has remained complete. 
 Under these circumstances, it is somewhat 
 difficult to come to any conclusion as to what 
 
13 
 
 this occasional loss of power results from. It 
 is supposed by some, that in many of these 
 cases of fistula and other rectal diseases, a 
 weak and dilated state of the external sphincter 
 obtains, and that even after it has been divided 
 only at one point, this weakness will be exagge- 
 rated and a loss of control over the evacuations 
 he the result ; this may be true, and perhaps 
 is so to a certain extent, but, as far as my own 
 observation goes, I have no reason to conclude 
 that there is often a great weakness of the 
 external sphincter in connection with fistula ; 
 the observation, however, undoubtedly applies 
 to instances of hsemorrhoidal affections and 
 old cases of prolapsus, but we are not dealing 
 with these diseases now. 
 
 It appears to me, after some reflection and 
 consideration of some cases where this unfor- 
 tunate result has occurred, that the loss of 
 power depends not so much upon the division 
 of the external sphincter at one or more points, 
 as upon a free incision carried through the 
 internal sphincter and circular muscular fibres 
 of the rectum. There can be no doubt that 
 these muscular fibres act not only as propellers 
 of the contents of the gut, but perform the 
 
14 
 
 office of a sphincter as well. This fact may 
 readily be ascertained by the introduction of 
 the finger high up into the rectum in healthy 
 individuals, when it is felt that not only the ex- 
 ternal sphincter, but that the circular muscular 
 fibres of the gut compress the part introduced 
 very powerfully ; and thus it is easy to under- 
 stand that when a free division of these fibres 
 as well as of those of the sphincter externus is 
 made, a corresponding loss of power w 7 ill he 
 the result. In the instance I have mentioned 
 where a complete loss of power was produced 
 by a single operation, the sinus ran up several 
 inches by the side of the rectum, and a very 
 high incision was necessary ; in the case I have 
 alluded to as occurring after an incision of the 
 bowel on either side at King’s College Hospital, 
 the knife was of necessity carried up at least 
 two inches from the anal orifice ; and in a 
 third case which occurred to me in private, 
 two previous operations had been performed 
 of an extensive character, unfortunately too, 
 not only producing loss of power, but resulting 
 in failing to cure the fistula. 
 
 If the explanation I have offered be the cor- 
 rect one, it is clear that in our operations we 
 
15 
 
 should confine our incisions as much as pos- 
 sible to the lower extremity of the bowel, and 
 fortunately it is found by experience that the 
 division alone of the external sphincter muscle 
 in the direction of the fistulous sinus, is sufficient 
 to produce a satisfactory cure ; but, as I have 
 before stated, there are exceptions to this rule, 
 and when a sinus runs up in the direction of 
 the cavity of the bowel, and perhaps opening 
 into it as high up as two inches, or as far up 
 as four inches, which occurred in a case of Sir 
 W. Fergusson, it becomes a question whether 
 we should submit the patient to a reasonable 
 chance of failure to cure the disease, or run the 
 hazard of producing a worse state of things 
 in the shape of a loss of power over the rectum, 
 more or less complete. 
 
 It is not, however, to be supposed that be- 
 cause a patient has lost power over the rectum 
 after an operation for fistula, he must, of neces- 
 sity, always suffer from this very grievous mis- 
 fortune. On the contrary, we may give a 
 reasonable assurance that as time goes on, and 
 a more thorough cicatrization of the wounds 
 takes place, a more or less complete control over 
 the part may be regained. I have had more 
 
16 
 
 than one instance of this occurrence in my 
 own practice, and I cannot do better than 
 mention the following as an apt illustration. 
 
 M. R., aged twenty-nine, was sent to me by 
 Dr. Hensley, in December, 1859 ; he was in 
 very good health, with the exception of the 
 local complaint. He informed me that early 
 in the spring he was operated upon for fistula 
 by a well-known and able surgeon; the wound, 
 however, was very sluggish, and never entirely 
 healed, so that in the course of the summer 
 he submitted to a second operation at the 
 hands of the same surgeon. Notwithstanding 
 all care this wound also refused to heal up 
 entirely, and on inspection I detected a fistu- 
 lous opening in the right side of the buttock, 
 which on careful examination I found led into 
 the bowel, one inch and a half from the anus ; 
 but just before the termination of the fistula 
 the finger came in contact with a narrow con- 
 striction of the bowel. In addition to the 
 discharge, the patient suffered from difficulty 
 in passing his motions, which only came away 
 in very small pieces ; moreover, he had the 
 misfortune of a loss of control over the rectum, 
 not complete, but worse at one time than at 
 
17 
 
 another. His health was in all other respects 
 very good, and although it was an ugly case 
 to operate upon, and it was impossible to 
 say whether a complete loss of control over the 
 sphincter would not result from a third division 
 of the muscle, I determined to undertake the 
 case, and previous to making an incision I 
 commenced the dilatation of the stricture by 
 the daily introduction of bougies. When a 
 fair-sized instrument could be passed I laid 
 open the sinus through its entire length, divid- 
 ing the stricture as well. Very great care and 
 trouble was taken in the after-treatment of the 
 case, and I watched with much anxiety the 
 result of this third operation. At first it looked 
 as though the patient’s troubles were added 
 to instead of being diminished, for the loss of 
 power over the sphincter was increased, but 
 not totally lost. By the careful introduction of 
 the bougie, however, at each daily dressing, the 
 stricture was prevented recurring, the wound 
 put on healthy action, and in the course of 
 a few weeks I was rewarded by seeing the 
 operation completely successful in its primary 
 object, viz., healing the fistula; the loss of 
 power, however, remained. With a double 
 
 o 
 
18 
 
 view, therefore, of obviating contraction and of 
 exciting the bowel to healthier action, I de- 
 sired the patient to pass a large bougie of black 
 wax for himself three times a week. By de- 
 grees he not only passed his motions much 
 more easily, but in the course of a few months 
 he began to regain the control over the sphinc- 
 ter ; in six months after, the wound had finally 
 healed. There was complete control, except 
 when he took aperient medicine. This power 
 gradually and surely returned, and when I last 
 saw this patient, which was about three months 
 since, and four years after the operation, he 
 was quite well, having discarded the use of the 
 bougie and regained the power over the rectum ; 
 at times, if he takes purgative medicine, he is 
 obliged to be careful, there being on such 
 occasions a tendency for the contents of the 
 gut to escape. I have detailed this case, not 
 only for the purpose of illustrating the point 
 I have been referring to, and which, curiously, 
 has not attracted the attention of previous 
 writers, but also of its bearing upon the con- 
 nection of fistula with stricture of the rectum, 
 a matter to which I shall draw your atten- 
 tion in a particular way by-and-by, when I 
 
19 
 
 shall have again to bring this case to your 
 recollection. 
 
 It will he perceived that in the treatment 
 of this case I laid particular stress upon the 
 employment of the rectum bougie, and I 
 strongly advocate its use after an operation 
 for fistula, and more especially if the incisions 
 have been of such a character or repeated so 
 often as to lead one to the supposition that a 
 weakness of the muscular tissues of the bowel 
 may result. I believe that the bougie is use- 
 ful in stimulating the bowel to a healthy and 
 more vigorous action, and that it assists mate- 
 rially in restoring control over the rectum. 
 I have mentioned this accident a little more 
 prominently, perhaps, than you may think it 
 necessary in this place, but the fact is, loss of 
 power of controlling the sphincter is a most 
 deplorable result of the operation, and one 
 much more common than it is thought to be ; 
 and if, by limiting our incisions during the 
 operation, or by a more careful treatment after- 
 wards we can prevent this occurrence, we shall 
 confer a great benefit upon our patient and 
 lessen our own anxieties and responsibilities. 
 
 I have at this moment under my care. No- 
 
20 
 
 vember, 1867, a gentleman who has undergone 
 two severe operations for fistula. He consulted 
 me first three years ago for loss of Control over 
 the sphincter, some months after the last of 
 these operations. I recommended the daily use 
 of a large rectum bougie and attention to his 
 general health ; he paid strict attention to these 
 matters, and he has completely regained the 
 power of the sphincter. I may mention that 
 in this case a very deep incision was made into 
 the rectum. This circumstance corroborates 
 my opinion that the loss of power after the 
 operation for fistula depends more upon cutting 
 through a large extent of the bowel than divid- 
 ing merely the external sphincter in several 
 places, and this is further shown by another 
 case recently under my care of a gentleman 
 aged sixty, who, within three years was obliged 
 to submit to three different operations for fis- 
 tula, but there is complete control over the 
 bowel — here I cut the external sphincter only 
 on each occasion. 
 
 I have now to bring before you some obser- 
 vations on a very important point connected 
 with the subject of fistula in ano, one also 
 which has not attracted so much attention as 
 
21 
 
 it deserves. We are all aware that occasion- 
 ally, and, indeed, I may say frequently, the 
 efforts and care of the surgeon are thwarted, 
 and the incision made in dividing the sphincter 
 does not heal up ; in fact, the fistula either 
 remains in the same condition as before, or 
 there exists even an opening of considerable 
 size, which steadily refuses to heal up. Now, 
 it is a very important matter to inquire 
 very carefully into the causes of failure after 
 this operation, and in many cases we shall 
 fortunately be able to ascertain what it is which 
 has rendered one or perhaps more operations 
 wholly unsuccessful. It has fallen to my lot, 
 as, doubtless, it has to many other surgeons, 
 to be consulted about several very interesting 
 cases of this description, and the result of my 
 observation is that in most instances the failure 
 of the operation has been only for a time. By 
 searching carefully, some cause, constitutional 
 or local, will be found out and, especially when 
 the latter exists, it can be remedied. I do not 
 mean in this place to say much about the con- 
 stitutional causes of failure, because it is well 
 known that there are certain conditions of the 
 system not unfrequently coexisting with fistula 
 
22 
 
 which, in reality, are a part and parcel of the 
 disease, and the latter is only one link in the 
 chain of morbid phenomena which are slowly 
 but surely taking the patient to his last 
 home. Thus, for instance, it is a well-known 
 fact that tubercular disease of the lungs is seen 
 very often in connection with fistula, although, 
 perhaps, not quite so often as it is supposed 
 to be. Then, again, it is equally well known 
 that those who have lived a long time in hot 
 climates, and have damaged their livers and 
 digestive canal by high living and want of 
 exercise, are particularly prone to suffer from 
 abscesses about the rectum and fistula of the 
 very worst kind. Now, except under peculiar 
 circumstances, which I have not time to con- 
 sider here, no scientific surgeon would think 
 of performing an operation, because he knows 
 that the incisions he makes will not heal up, 
 and that he may place the patient in a worse 
 condition than he was in before, by weakening 
 the power of the sphincter. But there are cer- 
 tain local circumstances in connection with 
 this malady which will prevent the success of 
 an operation, and here one surgeon shows his 
 superiority over another by finding out before- 
 
23 
 
 hand what these circumstances are, and how 
 they may he met. 
 
 It is a somewhat curious fact that the con- 
 nection between fistula in ano and organic 
 stricture of the rectum has not been much 
 insisted upon by surgical writers. When we 
 see a case of fistula in perineo the constant 
 association between that disorder and stricture 
 of the urethra is at once brought before us, but 
 it is so seldom that we hear of a fistula in ano 
 spoken of as occurring in connection with a 
 stricture of the bowel that we almost ignore, 
 practically, at least, the possibility and proba- 
 bility of such a condition ; but my own observa- 
 tion has led me to believe that in a considerable 
 proportion of cases a stricture will be found to 
 exist with fistula in ano, and that a failure to 
 cure the latter disease by operation has simply 
 been the result of overlooking the other morbid 
 condition of the bowel ; and it may be readily 
 overlooked if the finger is not passed well up 
 the cavity of the bowel, and if the contraction 
 be seated* as it is at times, beyond an inch and 
 a half or two inches. In some of the cases 
 where stricture does exist coincident with fistula 
 there can be no doubt that it has been the 
 
24 
 
 original disease and that the fistula is a 
 secondary phenomenon, but in others there is 
 every reason to believe that the contraction of 
 the gut ensued upon the fistula. In some cases 
 the situation of the internal orifice of the 
 fistula is above the stricture, in others the 
 orifice is either below or in the centre of the 
 contraction. There can he no doubt, however, 
 that, whether the stricture be primary or secon- 
 dary, it should be looked upon as the chief 
 disease when it is associated with fistula, and 
 that it will be of no use to attempt to cure the 
 latter by operation without first, or at the same 
 time, taking measures to get rid of the former. 
 
 In the case which I detailed above, in order 
 to illustrate another point, it will be perceived 
 that two operations had been done previous to 
 my seeing the patient, and in my endeavours to 
 ascertain the cause of failure I discovered a 
 stricture of the bowel; of course it is impos- 
 sible to say for certain whether this condition 
 existed previous to the first operation, but it is 
 most probable that it did, and that the failure 
 after each incision was due to the fact of the 
 stricture being overlooked, for the character of 
 the surgeon who operated was such as to en- 
 
25 
 
 sure perfect skill and knowledge in the proceed- 
 ing itself. Had I simply contented myself 
 with dividing the sphincter again in this case, 
 I doubt not there would have been a third 
 failure, but the use of the bougie on several 
 occasions previous to the operation, combined 
 with subsequent division of the stricture, was 
 sufficient to ensure a speedy and permanent cure. 
 
 As another illustration of somewhat the same 
 kind, I may mention a case of a naval officer, 
 w 7 hom I saw some time since, with very bad 
 fistula of some years’ standing ; the patient had 
 undergone a good deal of treatment, but he was 
 in a deplorable condition, and on examining 
 him carefully I discovered a very tight stric- 
 ture of the rectum, about two inches from the 
 orifice of the anus. I divided this with the 
 knife, and in a short time had well dilated the 
 gut with great comfort to the patient, but the 
 fistulous sinuses were so extensive that I did 
 not deem it prudent to lay them open into the 
 bowel, I thought it better to leave matters alone 
 and ascertain whether the openings might not 
 close as the contracted gut became more and 
 more dilated. 
 
 Mr. Tufnell, of Dublin, has drawn the atten- 
 
26 
 
 tion of the profession more prominently than 
 any other writer to this subject, and in his 
 little monograph has detailed a case somewhat 
 similar to the one just referred to, and in 
 which he contented himself with dilating the 
 stricture and leaving the sinuses alone ; and so 
 little annoyance was subsequently caused by 
 their presence that the patient did not care 
 to be operated upon. 
 
 From the many cases I have seen where 
 fistula in ano coexists with stricture of the 
 rectum, I am led to believe that the failure of 
 the operation is not unfrequently attributable 
 to the stricture being overlooked. It is easier 
 to overlook this condition than is imagined ; 
 we are too apt, when one symptom or morbid 
 phenomenon is presented to us readily, to pay 
 too much attention to that and overlook other 
 and less striking manifestations of disease. 
 How often do we see this in the case of 
 diseases of the bladder, for instance. A patient 
 presents himself with retention of urine as the 
 most prominent and distressing symptom ; to 
 this the surgeon pays the chief attention, 
 affords the necessary relief, and, perhaps, en- 
 tirely forgets to explore the bladder for the 
 
27 
 
 purpose of ascertaining the presence of a stone, 
 which may be at the bottom of all the suffer- 
 ing. So likewise in the case of the rectum. A 
 patient may come to us with a fistulous open- 
 ing as his only complaint ; seeing this, we may 
 content ourselves with the fact of its presence, 
 and entirely overlook the other condition. 
 Notwithstanding that I am impressed with the 
 necessity of examining very carefully for this 
 and other morbid conditions in connection with 
 fistula, I was temporarily led into error a short 
 time since in the case of a middle-aged woman, 
 who came amongst my patients into King's 
 College Hospital, saying she had stricture of 
 the rectum ; on examination I discovered at 
 once that she had a very tight contraction of 
 the gut, two inches from the anus, and I made 
 arrangements to divide it on some future day ; 
 but it was not until she was actually taken into 
 the theatre, and about to be operated upon, 
 that I discovered a fistula leading into the 
 bowel beyond the strictured portion, and was 
 thus prevented from making a very serious 
 oversight. 
 
 Cases are every now and then met with where 
 there is a fistula connected with and apparently 
 
28 
 
 dependent upon severe stricture, and yet where 
 it is undesirable to perform any cutting opera- 
 tion, either upon the stricture or the fistula. A 
 very interesting and severe case of this kind 
 has recently been under the care of Mr. 
 Partridge, in King’s College Hospital. A 
 young girl, only sixteen years of age, presented 
 herself at first amongst my out-patients with 
 two fistulous openings by the side of the rec- 
 tum ; finding such an unusual occurrence as 
 this condition in a girl so young, I examined 
 her very carefully, and then ascertained that 
 there was a very tight stricture about one inch 
 and a half from the anus, involving more than 
 an inch of the bowel, and into the centre of 
 this strictured portion the sinuses opened. She 
 was admitted into the hospital, and after a few 
 days Mr. Partridge placed her under chloroform 
 and, introducing his finger, dilated the stricture 
 by that means. In the course of another week 
 she was again placed under chloroform, and 
 the strictured portion of bowel was further 
 dilated by the fingers, so that a good-sized 
 bougie could be passed. From this time a great 
 improvement took place, the contents of the 
 bowel passed with ease, and she was shortly 
 
29 
 
 dismissed from the hospital, vastly improved, 
 although the sinuses had not healed up. Now, 
 in this case it would have been highly injudi- 
 cious to divide this stricture with a knife, as 
 such a large portion of the intestine was in- 
 volved. The indication evidently was to dilate 
 the stricture first ; and, should the sinuses not 
 then close up, they might be divided at some 
 future time. I may remark that this case was 
 peculiarly interesting, insomuch as it was an 
 instance of fistula and stricture occurring at a 
 period of life when these diseases are rarely 
 seen. I do not recollect ever having met with 
 either fistula or stricture in a person of so 
 youthful an age. 
 
 Whilst writing this Lecture a case has pre- 
 sented itself amongst my patients at the 
 hospital which illustrates, in a remarkable 
 manner, the points so strongly dwelt upon. 
 A man about thirty consulted me for fistula, 
 and I immediately recognised the patient as 
 one upon whom I performed a double operation 
 for fistula and stricture at the hospital two 
 years ago. At that time he had a bad fistula, 
 for which he had previously undergone two 
 operations, but without any good results. I 
 
30 
 
 therefore examined carefully into the case, and 
 on introducing the finger I ascertained that 
 there was a very tight annular stricture three 
 inches from the anus. Here was the cause of 
 the failure. A course of treatment was com- 
 menced with bougies, the stricture was con- 
 siderably dilated, and then the fistulous sinus 
 was laid open with complete success. The 
 patient was told to use the bougie from time to 
 time, but unfortunately he went to sea for a 
 year and entirely neglected himself ; the con- 
 sequence is that there is a return of the 
 
 stricture in as severe a form as before, and 
 
 there is an open sinus by the side of the anus, 
 which, in all probability, will require division ; 
 but previous to operating upon the fistula I 
 intend, either by the use of the bougie or by 
 incision, to dilate the stricture again tho- 
 roughly. I may also mention that I have 
 
 at the present moment a case under my care, 
 sent to me by our President, where there is 
 a fistula in connection with stricture. I 
 have been deferring an operation in order 
 that I may dilate the stricture fully, and the 
 amount of dilatation already effected has consi- 
 derably improved the appearance of the fistula. 
 
31 
 
 A failure in the operation of fistula results 
 sometimes from other local causes : thus, for 
 instance, a case may present itself where, to- 
 gether with a fistulous opening into the gut, 
 there may be sinuses branching out across the 
 buttock in various directions, and the disease 
 may have lasted so long a time that the sinuses 
 themselves have become lined by a distinct 
 membrane, and the tissues around greatly in- 
 durated. I have met with a case of this kind 
 where a previous operation had been performed 
 and had failed, and where in a second and more 
 successful operation it was necessary, in order 
 to divide the indurated parts freely, to use a 
 pair of powerful scissors, the ordinary fistula 
 knife entirely failing to effect the necessary 
 incisions. 
 
 Another cause of failure occasionally met 
 with is the coexistence of disease of the 
 bones of the sacrum. I attended a remarkable 
 and interesting case of this kind with Sir 
 W. Fergusson. The patient was an elderly 
 man, who had suffered for years from very bad 
 fistula. A severe operation had been per- 
 formed by a very eminent surgeon, but without 
 any favorable result. When Sir W. Fergusson 
 
32 
 
 saw him he inquired carefully into the cause of 
 failure, and on examination detected at the 
 bottom of the fistula a piece of necrosed bone. 
 Very free incisions were made both into the 
 bowel and in the direction of the sacrum, and 
 a portion of completely necrosed bone, as large 
 as a marble, was extracted, and in a few weeks 
 the patient was sent home with the fistulous 
 sinus completely closed. There is no doubt 
 that in this case the presence of the necrosed 
 bone had been entirely overlooked. 
 
 Failure may result from an operation being 
 imperfectly performed — in a case, for instance, 
 where the fistulous sinus is apparently quite 
 superficial, and hardly involving the external 
 sphincter muscle ; finding this to be the case, 
 the surgeon contents himself with merely 
 laying open the sinus without dividing the 
 sphincter. This operation, however, will gene- 
 rally be useless, for, even although the sinus 
 does not actually involve the fibres of the 
 sphincter, it is really within its sphere of action, 
 and in order to get it thoroughly healed it is 
 necessary to paralyse the action of the sphincter 
 for a time, by dividing it, as well as by 
 slitting up the sinus itself. A notable case has 
 
33 
 
 recently occurred in my own practice where this 
 took place, the first operation having entirely 
 failed in consequence of the surgeon not 
 dividing the sphincter, as the sinus was entirely 
 superficial. 
 
 Before finishing these observations I will 
 allude to a remarkable case which some little 
 time since occurred in my practice, and which 
 bears directly upon the causes of failure after 
 an operation for fistula. I am the more 
 anxious to detail this case as I never met with 
 another instance of the kind, and cannot find a 
 description of this kind of fistula in the writers 
 on the subject ; moreover I got a great deal of 
 credit by the success attending my treatment, 
 and it may prove useful in showing what we 
 may be possibly led to expect when a similar 
 set of symptoms occur. 
 
 In the month of September, 1862, a captain 
 in the navy, between sixty and seventy, and of 
 robust frame, consulted me for an affection of 
 the rectum with which he had been troubled 
 for several months. He resided in the country, 
 near a large town, where some very eminent 
 surgeons practised, and he placed himself under 
 the care of first one and then another, and he 
 
 3 
 
34 
 
 underwent a severe operation, the result of 
 which, however, was not at all successful. 
 When I saw him he was complaining of a 
 continual discharge of purulent matter from 
 the anus and pain in that situation. On the 
 first examination I could not detect anything 
 abnormal ; there was no opening in the integu- 
 ments outside the anus, there was no contrac- 
 tion of the bowel, and no appearance or 
 sensation of ulceration. There, however, was 
 the purulent discharge and pain, and there was 
 no reason to suppose any ulceration or other 
 disease of the bowel above. I was completely 
 puzzled about the case, and referred the symp- 
 toms at first to that very useful ally of ours — 
 gout. On his second visit, finding the symp- 
 toms still prominent, I undertook the most 
 careful examination with the speculum, and 
 after a long search discovered a small opening 
 in the mucous membrane of the gut, from 
 which issued purulent matter; this opening 
 was seated about one inch and a half from the 
 anus. On introducing a probe it coursed 
 upwards for a considerable extent, running 
 between the mucous and muscular tissues ; the 
 sinus also extended downwards as well, but 
 
there was no other opening whatever. On 
 very careful inspection there was a linear 
 mark or cicatrix in the mucous membrane of 
 some extent, the site of the operation which 
 he had previously submitted to. 
 
 The case was clear now, the affection being 
 a true internal fistula of the rectum, not in- 
 volving the tissues around it in any way, nor 
 implicating the external sphincter ; and it was 
 evident that the proper mode of treatment 
 consisted in laying the whole track of the sinus 
 open, both upwards and downwards. A simi- 
 lar kind of operation had been attempted, but 
 the incisions had not been sufficient. On the 
 following day I performed the operation, which 
 was one of extreme difficulty ; it was executed 
 by first introducing a bivalve speculum, getting 
 a clear view of the opening, introducing a 
 director upwards, and then slitting up the 
 sinus. Two days afterwards I treated the 
 lower part of the sinus in the same way, and 
 then dressed it carefully with lint. Consider- 
 able bleeding followed these operations, but 
 the wounds made began to heal rapidly, the 
 discharge diminished, and in a fortnight this 
 gentleman left for his home, from whence he 
 
wrote in a short time that he had perfectly 
 and quickly recovered. I had some corre- 
 spondence with the well-known and excellent 
 surgeon who had first operated upon Captain 
 C — , and who candidly admitted the difficulties 
 of the case, and his non-success, which was due, 
 as I wrote him, to the fact of his not having 
 laid open the sinus in its entire length. I may 
 mention that I saw the patient two years after 
 the operation, and that he remained perfectly 
 well. 
 
 Finally, I must say a few words regarding 
 another class of cases of fistula which occurs 
 to us, viz., those in which it is not prudent to 
 perform any operation ; not from any con- 
 stitutional cause, but simply from the reason 
 that the fistulous sinuses are of great extent, 
 involving a considerable portion of the adjacent 
 structures, and, besides, have existed for so 
 many years that, even if it were expedient to 
 open them up, it would be almost an impossi- 
 bility to get them to heal. I have recently 
 had two cases brought under my notice where I 
 was obliged to decline any operation, although 
 the patients were suffering great distress and 
 annoyance. 
 
37 
 
 In the one case the patient was a com- 
 paratively young man, but had seen a great 
 deal of service as a naval officer in foreign 
 climates. He had suffered from fistula for 
 some years before I was called to him, and 
 when examined it was found that the fistulous 
 sinus communicated at one extremity with the 
 rectum above a tight stricture, and that the 
 other end of the track actually extended half 
 way down the thigh ; here it would have been 
 absurd to attempt any operation on the fistula, 
 so I contented myself with dividing the stric- 
 ture, which gave great relief. 
 
 In the other case, a gentleman between fifty 
 and sixty had suffered from fistula for many 
 years, and had seen various surgeons. I was 
 requested to see him, and on examination both 
 the buttocks were found to be in a most 
 extraordinary state, riddled as it were with 
 sinuses leading into the rectum, and pouring 
 forth a profuse discharge ; any operation here 
 would of necessity be of great magnitude, and I 
 therefore strongly advised the patient to remain 
 as he was. These cases are fortunately rare, 
 but we see them sufficiently often to indicate 
 to us the necessity of not delaying the proper 
 
38 
 
 treatment of cases of fistula ; for when it is 
 undertaken in proper cases, no operation is, 
 as a rule, more successful or satisfactory than 
 this is. 
 
LECTURE II. 
 
 ON STRICTURE, CANCER, AND POLYPUS OF THE 
 RECTUM. 
 
 In the present Lecture I propose making 
 some observations on stricture, and on malig- 
 nant disease of the rectum, and concluding 
 with the details of some cases of polypus. I 
 have already referred at some length to the 
 subject of stricture of the lower bowel as a 
 complication of fistula in ano, and have endea- 
 voured to impress upon your minds the import- 
 ance of making a careful examination with the 
 view of ascertaining whether the presence of 
 a stricture be not the cause of failure after the 
 operation for fistula ; but I shall now consider 
 the affection by itself, make a few remarks 
 upon its pathology, and briefly discuss the 
 most efficient means of treating the disease. 
 
 You are probably aware that some years 
 since, stricture of the rectum was considered 
 to be a most common complaint, and a practi- 
 
40 
 
 tioner of large experience in rectum surgery 
 was said to have made large sums of money by 
 the successful treatment of the numerous cases 
 which came under his care. It was considered 
 by many that stricture of the rectum was not 
 quite so common as was stated to be by the 
 gentleman in question ; nevertheless, the public, 
 so easily led, or rather misled, in such matters, 
 were induced to believe that a vast number of 
 the ills which flesh is heir to were due to the 
 existence of a contracted rectum ; and possibly 
 you may have heard of the funny story regard- 
 ing the husband of a lady who had called upon 
 this well-known rectum doctor, and had been 
 operated upon by the bougie for the supposed 
 disease. Infuriated at the liberty which had 
 been taken with his wife, he called at the 
 house of the practitioner with a horsewhip in 
 his hand, intending to punish him for his 
 treatment of his wife ; but the story goes on to 
 say that the interview terminated, not by the 
 committal of the intended assault, but by the 
 peaceful submission of the husband himself to 
 the introduction of a rectum bougie on his own 
 person ; such was the influence of the surgeon 
 in question in persuading his patients to be- 
 
41 
 
 lieve that they suffered from stricture of the 
 rectum. 
 
 It is impossible, however, for any careful 
 surgeon to fail observing the not unfrequent 
 occurrence of stricture of the rectum amongst 
 the patients of our hospitals and dispensaries. 
 I believe that the disease is met with much 
 more frequently amongst the poor than amongst 
 the better classes ; I believe that this is partly 
 accounted for by the undoubted fact that stric- 
 ture of the lower portion of the gut is not 
 uncommonly associated with, if not directly 
 caused by, syphilitic ulceration of the parts in 
 the neighbourhood. It has so often occurred 
 to me to notice this affection in connection 
 with the later manifestations of constitutional 
 syphilis, that I am strongly impressed with the 
 view that stricture of the rectum is produced 
 either directly by the specific ulceration in the 
 part affected, or by contact of the discharge 
 from the surrounding parts. 
 
 Scarcely any writers on the subject have 
 alluded to this as a cause of stricture, with 
 the exception, perhaps, of Mr. Curling, who 
 refers to it, and alludes to a well-marked case 
 mentioned by that very accurate observer, the 
 
42 
 
 late Mr. Avery. This form of stricture is 
 usually seated very low down, and in con- 
 nection with it there are seen warty or condy- 
 loma tous growths around the anus, and indeed 
 these growths are so frequently associated with 
 syphilitic stricture, that I have more than once 
 formed my diagnosis accurately from this 
 feature alone, before I had made the necessary 
 examination with the finger. In my obser- 
 vations too, this form of stricture is much 
 more common in females than in males, and 
 this we can readily understand if we at once 
 admit as a cause the presence of venereal 
 ulcerations and discharges. 
 
 It is extremely important to recognise the 
 syphilitic poison as a cause of the disease ; 
 otherwise we shall be led into the error of 
 limiting our treatment to local measures alone, 
 whereas constitutional treatment for the specific 
 affection originally causing the stricture must 
 be employed at the same time. Fortunately in 
 these cases, as I have before stated, the stric- 
 ture is met with low down, generally within an 
 inch or less from the anus, and therefore there 
 is no objection to a pretty free use of the knife 
 prior to the employment of the bougies ; and 
 
43 
 
 if proper precautions be taken, these cases 
 generally terminate very satisfactorily. In em- 
 ploying the bougie here, after the necessary 
 incisions, I am in the habit of recommending 
 that it should be well smeared with the strong 
 mercurial ointment ; benefit is derived partly 
 from the local use of the mercury and from its 
 constitutional effect, as we know that it is pretty 
 readily absorbed into the system by the rectum. 
 The following is a good illustration of what I 
 may term syphilitic stricture of the rectum : 
 
 Mrs. R — , aged forty-two, a respectable mar- 
 ried woman, applied to me with the following 
 history : — Eight years previously she had con- 
 tracted from her husband a sore on the vulva 
 as large as a shilling, and which did not heal 
 for twelve months. Soon after this had healed 
 she noticed sores about the anus, and pain in 
 passing her motions; it was not, however, until 
 two years after this that she noticed any obstruc- 
 tion to the contents of the bowel. This diffi- 
 culty, however, gradually increased, and now 
 she passes nothing but very small portions of 
 faecal matter, and these with extreme pain and 
 difficulty. She is pretty comfortable so long as 
 she takes medicine, but if she neglects it she 
 
44 
 
 gets troublesome diarrhoea; there is always a 
 discharge of matter from the bowel before she 
 evacuates its contents. During the last five 
 years she has repeatedly suffered from synovitis 
 of the knee-joint* which has speedily yielded 
 to iodide of potassium* but no other secondary 
 symptoms of syphilis have presented. On 
 examination I found the anus surrounded by 
 several distinct ulcerations* such as we see 
 accompanying the other manifestations of con- 
 stitutional syphilis* and on introducing the 
 finger it is arrested at an inch from the anus by 
 a firm stricture* which just allows of its point 
 to be inserted. I contented myself in this case 
 with simply passing bougies from time to time 
 through the contracted rectum* as the stricture 
 pretty readily dilated without the previous use 
 of the knife ; and in a short time she was enabled 
 to evacuate her bowels easily. 
 
 Sometimes a case — and I generally find it is 
 in the person of a female — presents itself to our 
 notice* where the most prominent symptom is 
 severe pain* and on examination an ulcer of 
 considerable size is seen* involving the external 
 sphincter and lower portion of the gut ; and it 
 is very likely that we should overlook the real 
 
45 
 
 condition of things without a very careful ex- 
 amination. In connection with this peculiar 
 ulceration, which I believe generally to be of a 
 syphilitic nature, a stricture of the gut not 
 unfrequently exists, and prior to any treatment 
 of a specific nature being adopted, the stricture 
 should be dilated either by incision or by 
 bougie, and then the painful ulceration will 
 heal. Sometimes this ulceration is the only 
 manifestation of a syphilitic character, but in 
 other cases there are or have been very clear 
 symptoms of the constitutional disorder. In 
 another case where a respectable married woman 
 applied to me, the history of syphilis was very 
 clear, there being a sore, with much discharge 
 from the vagina, and not healing for six 
 months. A year afterwards the symptoms of 
 stricture gradually showed themselves, and 
 some time after this she suffered most severely 
 from a copious eruption on the skin, and from 
 syphilitic synovitis. 
 
 I need not say how important it is when 
 cases are so clearly revealed to us, and so 
 unmistakeably showing their origin, that we 
 should combine with the local treatment those 
 general remedies which we know exert a specific 
 
46 
 
 influence upon the system when contaminated 
 by the venereal poison. 
 
 Although, in the majority of cases, a stricture 
 of the rectum is met with very near the anus, 
 and in many of these I believe their origin to 
 be syphilitic, the disease is not unfrequently 
 met with higher up, and situated at a distance 
 of two to three inches from the anus ; more- 
 over, it is more rarely, but still occasionally, 
 found at the upper part of the rectum, close 
 upon the sigmoid flexure of the colon. In 
 some of the former class of cases the disease is 
 complicated by its involving a considerable 
 extent of the bowel — say from one to two 
 inches of its length — there may be also along 
 with this condition, enormous thickening of the 
 coats of the bowel at the site of the stricture, 
 and a dilatation and softening of the tissues 
 above it. It is in some of these cases that we 
 meet with great difficulty in the necessary 
 treatment ; for if the disease has been of long 
 standing, has involved a great extent of the 
 bowel, and there is much condensation of the 
 tissues at the site of the stricture, the use of the 
 bougie alone will be attended with little benefit, 
 and the employment of the knife is attended 
 
47 
 
 with danger. It will be necessary * in order to 
 produce any decidedly beneficial result* to in- 
 cise the whole length of the stricture* and the 
 mucous membrane above it may be in such an 
 unhealthy condition* that without the greatest 
 possible care the knife may easily be made to 
 penetrate the coats of the bowel and thus 
 produce fatal mischief. I have strong reasons 
 for believing that a mistake of this kind oc- 
 curred in one of my patients in King’s College 
 Hospital. The case was one of a woman who 
 had suffered a long time very severely from 
 stricture of the bowel* which was situated high 
 up but within reach of the finger : it was so 
 dense* and there was so much of the gut in- 
 volved* that I determined to divide it ; this I 
 did by very carefully nicking the sides of the 
 stricture on each side until I could introduce a 
 fair sized bougie. Two days afterwards this 
 patient became attacked with pain in the iliac 
 region and symptoms of low peritonitis* which 
 lasted for ten days and terminated in death. 
 On post-mortem examination we found that 
 there was evidence of extensive mischief in the 
 neighbourhood of the disease* suppuration and 
 infiltration of the cellular tissue* and on cleans- 
 
48 
 
 ing the parts there was found to be a large 
 opening above the strictured portion ; the mu- 
 cous membrane generally being much softened 
 and thinned. There was enormous thickening 
 and induration of the coats of the intestine 
 around the contracted portion, and to the naked 
 eye it looked as though the deposit was of a 
 malignant character, but on microscopical ex- 
 amination it was found to be simply fibrous 
 deposit. It was impossible to say whether I 
 had penetrated the coats of the bowel with the 
 knife or not ; but even if the opening was 
 merely the result of ulceration, the parts were 
 in such a condition as showed how readily the 
 bowel may be penetrated in similar cases on the 
 use of the least force. 
 
 I think it more prudent in a case of this 
 kind, especially if the stricture be within reach 
 of the finger, to place the patient under the 
 influence of chloroform, and dilate the con- 
 tracted portion by a somewhat forcible use of 
 the finger, or if that cannot be effected, we 
 must content ourselves with, nicking the lower 
 portion of the stricture, and then using the 
 bougie ; but, although there is a great temp- 
 tation to do so, it is more prudent not to 
 
49 
 
 carry the knife over the whole extent of the 
 contraction. 
 
 Of course these remarks do not apply to the 
 treatment of stricture of the rectum when it is 
 situated low down, and when the thickening 
 and contraction is limited ; in such cases the 
 knife may be used pretty freely without much 
 fear of producing mischief, and the bougie will 
 afterwards be employed with great benefit. 
 
 Since writing the above I have met with a 
 most striking instance of the good results of this 
 operation in a most difficult case. 
 
 I was called in May last by Dr. Vine, to see 
 a military officer, set. 40, who had returned 
 from India in the most miserable plight. He 
 had suffered for several years from chronic 
 diarrhoea, and had not got relief from any 
 measures ; and six months previously he had 
 been recommended by a medical board to go 
 by sea to England. On his arrival at South- 
 ampton, on his way to Edinburgh, his native 
 town, he was so ill that he determined to stop 
 in London, and when he arrived there he sent 
 for Dr. Yine, who, on hearing his history, at 
 once suspected something wrong with his 
 rectum, and making an examination, found an 
 
 4 
 
50 
 
 obstruction. I was requested to see him, and 
 I found the patient exactly in the condition of 
 one suffering from strangulated hernia ; he was 
 constantly vomiting, complaining of pain, and 
 the countenance was anxious, and he was much 
 emaciated ; the abdomen was immensely dis- 
 tended, and it was clear that if some relief 
 were not soon given, this gentleman would die. 
 
 In conjunction with Dr. Vine I made a most 
 careful examination, and I found on intro- 
 ducing the finger into the bowel as far as 
 possible, that it met with an obstruction, and 
 after some time I discovered what appeared to 
 be the opening of the stricture, more dike a 
 dimple than aught else. I was enabled to 
 introduce through this a No. 10 gum elastic 
 catheter, and through this instrument some 
 faecal matter and air came. I was thus made 
 to see that I had got beyond the stricture. 
 
 On the following day the patient was placed 
 under chloroform, and I guided a long straight 
 probe-pointed knife very carefully along the 
 side of my left index finger, and fortunately 
 got its point into the orifice of the stricture. I 
 nicked this on either side, and then got the 
 point of my finger into the obstruction, and 
 
51 
 
 dilated the orifice as much as I could, where- 
 upon an enormous quantity of faecal matter was 
 emitted, deluging the bed, and placing myself 
 and my assistants in a most unenviable position. 
 The abdomen became quite flat, and the patient 
 became at once immediately relieved. No bad 
 result followed this operation : in three days 
 we commenced dilatation by bougies, and I 
 was soon enabled to pass a full-sized rectum 
 bougie through the stricture. In a fortnight I 
 took my leave of the patient, recommending 
 Dr. Vine to pass the bougie daily. I heard a 
 few weeks afterwards that the patient had gone 
 to Edinburgh convalescent, and able to intro- 
 duce the bougie for himself. 
 
 This very interesting and successful case 
 illustrates the kind of treatment which should 
 be adopted, when the stricture, however tight, 
 is within reach of the knife. I was not quite 
 sure, before the patient was prepared for the 
 operation, whether I would be able to divide 
 the stricture with safety, so high up was it, and, 
 indeed, I had determined to perform Amussat’s 
 operation, if I could not have given relief per 
 anum, so severe and dangerous were the symp- 
 toms ; fortunately, this was not required. 
 
52 
 
 The case also shows the necessity of making 
 an examination of the rectum when diarrhoea has 
 persisted for many months or years, and has 
 resisted all remedial measures. It appears 
 that this step had never been adopted before 
 Dr. Vine, luckily for the patient, was called to 
 him. What a deal of misery and suffering this 
 precautionary and simple measure would have 
 prevented ! 
 
 I have recently met with three cases where 
 there was a tight stricture of the intestine at 
 the upper part of the rectum, close upon the 
 sigmoid flexure of the colon, and they were all 
 of considerable interest, insomuch as it was a 
 question whether some severe operative mea- 
 sure should not be adopted in each case. 
 
 The first case was a patient in King’s College 
 Hospital, a female, between thirty and forty ; 
 she had suffered for two or three years from 
 symptoms, more or less severe, of obstructed 
 action of the bowels, and had been in the 
 hospital previously for a severe attack. When 
 she came under my care the symptoms were 
 very severe ; there was an impossibility to pass 
 anything except by strong purgatives, or ene- 
 mata thrown very far up. On examination 
 
53 
 
 with the finger as far as it would reach, the 
 gut was in a normal condition, but on passing 
 a small elastic bougie, an obstruction was met 
 with at about eight inches; with great care this 
 was overcome, and it was found possible to 
 introduce a long flexible tube through the 
 obstruction, and thus evacuate the contents of 
 the large intestine ; by this means, and by 
 introducing a small bougie every other day, the 
 patient got great relief for a time, but the 
 symptoms of obstruction became aggravated, 
 there was great tension of the abdomen, sickness, 
 and loss of strength, and I prepared myself to 
 perform Amussat’s operation ; but on the day 
 I proposed to adopt this measure we were 
 enabled to throw up a large quantity of water 
 beyond the stricture, and the symptoms sub- 
 sided. After this we gradually increased the 
 size of the bougie, and the patient left the 
 hospital in a few weeks, able to evacuate the 
 bowels much more easily. I saw her some 
 months afterwards, when she continued in very 
 fair health ; doubtless, however, in course of 
 time, the contraction will return, and I think 
 it very likely that ultimately the operation I 
 contemplated will have to be adopted. 
 
54 
 
 The next case was a private patient, aged 
 forty-five, who had suffered from complete ob- 
 struction of the bowels for six days, and I was 
 called in to perform the operation of opening 
 the abdomen, it being thought by the physician 
 in attendance, that there was some band of 
 adhesion obstructing the intestine ; the symp- 
 toms certainly pointed to the neighbourhood of 
 the caecum as the seat of obstruction, and as 
 everything had been done which possibly could 
 be carried out but an operation, I consented to 
 explore the abdominal cavity. I may mention 
 that a long tube had been passed up the rectum, 
 and no obstruction was met with there ; and to 
 justify our proceeding, it may be stated that on 
 the right side, over the caecum and ascending 
 colon, the distension of the intestine was re- 
 markable — as though the obstruction lay just 
 above the latter part. I pointed out the serious 
 and uncertain nature of the operation, but the 
 patient, a remarkably cool and intelligent man, 
 eagerly caught at the least chance. I therefore 
 did the operation, exploring the abdomen care- 
 fully, and more especially examining the right 
 side, and taking out a considerable portion of 
 intestine. I could not, however, find any ob- 
 
55 
 
 struction, and it really appeared as though the 
 case would turn out as one merely of atony of 
 the intestines. Extraordinary to relate, the 
 patient seemed very much better after this 
 severe operation, was enabled to take nourish- 
 ment, and suffered less pain, but death occurred 
 somewhat rapidly on the fifth day. On post- 
 mortem examination, we found that the cause 
 of the obstruction was a close annular stricture 
 of the bowel at the junction of the colon and 
 the rectum, and just above the stricture a per- 
 foration of the intestine had taken place. 
 
 Now, had we been able to diagnose accu- 
 rately the seat of obstruction, we ought to have 
 performed Amussat’s operation, although pos- 
 sibly the pathological changes which led to 
 perforation may have been going on before I 
 was called in. A more careful examination 
 may have led us to the real seat of obstruction, 
 but still it is not always possible to diagnose 
 stricture at this spot during life. Curiously 
 enough, I met with just such another case, 
 where a well-known surgeon performed the 
 same operation under similar circumstances; 
 there was the same difficulty in arriving at a 
 correct diagnosis, and recollecting the case just 
 
56 
 
 mentioned, I pointed out to the gentlemen en- 
 gaged in the case, that the obstruction would 
 be found at the junction of the colon and rectum, 
 and there in reality it was found when the ex- 
 amination was made after death. 
 
 The third case which I will relate occurred 
 lately ; the patient was a lady, aged seventy, 
 whom I was requested to see in consulta- 
 tion with her medical attendant. She had 
 been suffering from obstruction of the bowels 
 for four days, and it became a question as to 
 whether anything might be done. The lady 
 was much exhausted, the abdomen enormously 
 swollen, and she was constantly vomiting. On 
 examination per anum, I could not detect any 
 obstruction, but I could feel a somewhat in- 
 durated mass just in front of the upper part of 
 the rectum. It was considered that the case 
 was one where Amussat’s operation should be 
 performed, but the age of the patient, and her 
 exhausted condition, forbade the idea. I made 
 my diagnosis of the case as one where there 
 was some mechanical obstruction of the upper 
 part of the rectum. This lady died within 
 twenty-four hours of the visit. On making the 
 post-mortem examination, it was found that 
 
5 7 
 
 there was an obstruction at the sigmoid flexure 
 of the colon and upper part of the rectum ; it 
 constituted a stricture of the gut through which 
 the contents of the bowel could not pass, and it 
 appeared to have been the result of some in- 
 flammatory adhesion between the bowel and 
 uterus; it did not appear to have been of a 
 malignant character. I did not make the post- 
 mortem examination myself, but a well-known 
 surgeon did, and he informed me that with 
 some difficulty, by introducing the finger, per 
 anum, after death, he could just reach the 
 stricture with its tip, and he was under the 
 impression that during life the obstruction 
 might have been divided ; but I do not think 
 that the use of the knife is at all advisable 
 in cases of stricture seated so high up, and that 
 far the best thing to have adopted here, had the 
 patient been younger, was Amussat’s operation. 
 
 Since writing the above I have met with two 
 instances of simple stricture, where Amussat’s 
 operation was performed, but the obstruction in 
 each was just beyond the rectum, involving the 
 sigmoid flexure. In this first case, which was 
 one of peculiar interest, the patient was a 
 gentleman aged sixty, who had suffered with 
 
58 
 
 chronic partial obstruction of the bowels for 
 several weeks, and acute obstruction for several 
 days. I was associated in the treatment of this 
 case with Dr. Salter, Dr. King Chambers and 
 Mr. Gay. We all had no difficulty in coming 
 to the conclusion that the obstruction was seated 
 in the sigmoid flexure of the colon, and after 
 repeated attempts to procure relief we deter- 
 mined upon opening the colon in the left loin. 
 This was adopted by Mr. Gay with success, 
 as regards relieving the distended intestine, 
 but the patient sank from exhaustion in forty- 
 eight hours ; and on post-mortem examination, 
 a tight stricture resulting from the cicatrization 
 of an old ulcer was found in the sigmoid flexure. 
 
 The second case occurred in King’s College 
 Hospital, and was reported in the * Lancet,’ of 
 November 16th, 1867. The symptoms were 
 very similar to the first case, and pointed so 
 distinctly to the seat of stricture that I had no 
 hesitation to recommend Amussat’s operation, 
 which was done by the house surgeon, Mr. 
 Trevor. Great relief was given, but the patient 
 was old and exhausted, and lived only for a 
 week. After death the obstruction was found 
 to involve the sigmoid flexure. 
 
59 
 
 The observations hitherto made have applied 
 solely to that form of stricture which is of a 
 simple character, and has been produced by 
 some inflammatory deposit. As I have already 
 shown, this affection is a very serious one, and 
 if overlooked or not attended to, begets in time 
 the most troublesome and even fatal symptoms ; 
 but when the stricture of the gut is the result 
 of malignant deposit in the coats of the in- 
 testine we see few cases which in their course 
 and termination are attended with more dis- 
 tressing results ; and, although 1 have little 
 hope of being able to add anything to what is 
 already known in reference to the relief of this 
 disorder, still there are one or two points in 
 connection with it, to which I will briefly 
 allude. 
 
 There is, perhaps, scarcely any part of the 
 body liable to be attacked by malignant disease 
 where the disorder comes on so insidiously as 
 in the rectum, and this is the reason why so 
 many patients present themselves to us with 
 cancer of the rectum, and who have not the 
 slightest notion that there is anything wrong 
 with them beyond some irregularity of the 
 action of the bowels, or some slight discharge 
 
60 
 
 which is considered to be of a heemorrhoidal 
 character. This is especially the case when the 
 malignant deposit takes place some two or 
 three inches from the anus ; from some in- 
 stances which have been submitted to my 
 notice, and where the history has been correctly 
 detailed, I have reason to believe that some- 
 times a patient may be going about with 
 malignant disease of the rectum for years, with 
 scarcely any symptom beyond a slight uneasi- 
 ness and almost imperceptible wasting. It 
 appears to me that one of the most important 
 and interesting features connected with malig- 
 nant deposit in the rectum, relates to its 
 diagnosis in its early stages, and all who have 
 had opportunities of seeing much of this dis- 
 ease must admit that this is often a point of 
 great difficulty. Its importance, too, cannot 
 be over-rated, for patients who suffer from 
 disease in the rectum, which obstructs the con- 
 tents of the bowel, are often most anxious to 
 know our opinion as to whether the affection be 
 of a malignant or simple character, and a vast 
 amount of mental disquietude may be allayed 
 by a correct appreciation of the morbid condi- 
 tion. In the very early stage of malignant 
 
61 
 
 disease, whether it he of a scirrhous nature or 
 epithelioma, it is sometimes impossible to ascer- 
 tain its diagnosis from a simple fibrous deposit'; 
 but, even then, if a very careful examination be 
 made, and the diseased portion of bowel be well 
 within reach of the finger, the peculiar hard 
 irregular deposit arouses our suspicions, and 
 to a practised hand, is different from the 
 regular sharply defined induration which is the 
 result of simple fibrous deposit. 
 
 There is very little else to guide us in our 
 diagnosis until time goes on, and then, if the 
 disease be malignant, the constitution will 
 surely, although perhaps more slowly in this 
 than in any other form of such disease, show 
 some signs of its presence ; these consisting of 
 a slight wasting, loss of muscular energy, and 
 that indescribable anxiety of countenance which 
 attends almost every form of malignant disease, 
 and which can scarcely be mistaken by the 
 careful observer. I have recently met with 
 three cases where the symptoms were so slight 
 and the disorder so tardy in its progress, that 
 it was very difficult to come to a correct dia- 
 gnosis ; but in each the diagnosis was verified, 
 by the death of the patients in two cases, and 
 
62 
 
 the progress of the disease in the other. In 
 the first of the three cases the disease oc- 
 curred in a gentleman, aged sixty-two, who 
 was troubled with what he called a prolapsus, 
 and he sent for me to get it removed. On 
 examination, I found what was, or rather 
 looked like, a small prolapsed portion of mucous 
 membrane with a thickened base, and which 
 appeared should be removed, as the patient 
 suffered very much from it ; but there was an 
 appearance of languor and anxiety about the 
 face which arrested my attention, and I made a 
 very careful examination with the finger, and 
 about one inch and a half from the anus I felt 
 a distinct but irregular induration around the 
 gut, and forming a slight stricture. From the 
 peculiar sensation imparted to the finger, al- 
 though the deposit was very slight, I at once 
 had strong suspicions that the affection was 
 malignant, and refused to perform any opera- 
 tion. My patient was annoyed at this, and 
 sent for a surgeon, who happened to be a 
 great friend of mine, and who had no sus- 
 picion of its malignant character until I 
 acquainted him with the result of my examina- 
 tion ; the wisdom of my advice not to interfere 
 
63 
 
 was shown by the patient gradually getting 
 worse, and dying within a year from the time 
 I saw him. 
 
 In the second case, a gentleman aged fifty 
 complained of a difficulty in passing the con- 
 tents of the bowel, and some uneasiness. These 
 symptoms, had, however, been going on, more 
 or less, for a period of twelve years, but had 
 latterly become aggravated. On examination 
 I discovered a thickening of the coats of the 
 rectum within easy reach of the finger, and 
 some stricture. This patient, who was a 
 highly intelligent man, and whose life was a 
 particularly valuable one, was most anxious 
 to know whether it was of a malignant 
 character. The history of the duration of 
 the disease forbade this idea, and so I told 
 him, but there was in this man’s face that 
 peculiar kind of expression before alluded to, 
 and which, to my mind, so strongly pointed 
 to some malignant affection, and I had strong 
 suspicions that the disorder of the rectum was 
 of this character, but still it was a difficult 
 case to decide upon. Another opinion was 
 obtained, and my view was pronounced to be 
 the correct one, and it proved to be so, for 
 
64 
 
 ere long the disease increased and developed 
 itself in the form of epithelioma, and very 
 recently I saw in the paper the announce- 
 ment of this gentleman’s death. 
 
 In the third case, a healthy-looking country 
 gentleman, the symptoms were but slight, and 
 there was very little constitutional disturbance, 
 and one would scarcely expect to find in 
 such a patient one of the most terrible forms 
 of cancer ; but on careful examination the 
 point of the finger detected the unmistakable 
 hard, irregular mass of scirrhous deposit. The 
 absence of severe symptoms in this case is due, 
 in a great measure, to the fact of the deposit 
 being at a considerable distance from the 
 anus. 
 
 Now I am speaking of the symptoms which 
 a malignant growth in the rectum produces, 
 I will refer to one case of great importance, 
 where there was not any symptom whatever 
 but a chronic diarrhoea. I was called to see an 
 old lady, in the country, who had been con- 
 fined to her bed for some weeks with diarrhoea, 
 for which all sorts of remedies had been used 
 in vain. She was looking remarkably well, 
 and there was no anxiety of countenance, or 
 
65 
 
 anything else, to indicate the presence of 
 cancer. On examining the feces which had 
 been passed, I found them to consist of little 
 more than muco-feculent fluid, and I at once 
 asked the practitioner whether he had ever 
 examined the rectum with the finger ; he 
 replied in the negative. Whereupon I intro- 
 duced the finger, and high up I discovered a 
 mass of scirrhous induration, almost entirely 
 blocking up the passage. Here, then, was a 
 case not quite unlike those instances of obsti- 
 nate obstruction in the urethra, where the 
 bladder has become over-distended for a long 
 time, urine has been dribbling away, and the 
 cause of this incontinence has, unfortunately, 
 been entirely overlooked both by patient and 
 medical attendants. 
 
 The case teaches us never to neglect an 
 examination of the rectum with the finger or 
 bougie in an instance of long-continued and 
 uncontrollable diarrhoea. I may mention that 
 this lady got rapidly worse, and died before 
 many weeks, as remedies were of no service ; 
 but had the cause of the symptoms been 
 detected, as they ought to have been, at an 
 earlier period, a good deal of relief may have 
 
 5 
 
66 
 
 been given — the unfortunate woman, at least, 
 would have been spared the infliction of taking 
 gallons of nauseous medicine. 
 
 These remarks apply solely to malignant 
 disease of the rectum when in its early stage ; 
 for when it has become advanced there ought 
 to be no difficulty at all in the diagnosis. I 
 was, however, called down in the country to see 
 a patient of middle age who had been suffering 
 for some months from what had been considered 
 to be a prolapsus of the rectum. I was espe- 
 cially requested by the gentleman in attendance 
 — and who is one of the most experienced and 
 distinguished of our provincial surgeons — to see 
 the case, and decide whether it was not a very fit 
 instance for the application of strong nitric acid. 
 When I came to examine the case I found that, 
 although there was the appearance of pro- 
 lapsus, the disease was in reality a well-marked 
 example of protruding cancer of the rectum. 
 There was the red, vascular, ulcerating surface 
 of the growth, surrounded by a hard deposit, 
 and in the interior of the rectum similar indu- 
 rations were to be felt. In this case there 
 could not be any doubt as to the character of 
 the disease, and I must confess I was very much 
 
67 
 
 astonished at the mistake in diagnosis which 
 was made by a surgeon of great experience. 
 
 I have^ however, met with two instances in 
 my own immediate practice where there were 
 great difficulties to be encountered in arriving 
 at a correct diagnosis. In the one the disease 
 of the rectum appeared in a healthy young 
 man of twenty-three. The appearance and 
 condition of the ulceration, surrounded as it 
 was by a hard base, together with the history 
 of syphilis, made me conclude that the symp- 
 toms were due to that disorder, and I treated 
 him for it ; but the ulceration would not heal 
 up under the most powerful applications, and 
 although the age and appearance of the patient 
 forbad the idea of cancer, the gradual increase 
 both in the ulceration and the density of the 
 deposit around made me change my views, and 
 impressed me with the idea that, after all, the 
 disease might be of a malignant character. 
 
 In the other instance the skin around the 
 anus was mainly involved in intractable ulce- 
 ration, and a previous history of syphilis here 
 threw great difficulties in the way of coming to 
 a correct conclusion. 
 
 In most cases of scirrhus the deposit increases. 
 
68 
 
 involves the lower portion of the gut* and pro- 
 trudes at the anus, producing extreme sufferings 
 which few of our remedies can allay. It will 
 happen sometimes, however, that an exception 
 to this tendency of the disease to extend down- 
 wards and outwards exists ; and a somewhat 
 curious case of this kind occurred to me some 
 time since. A middle-aged gentleman was 
 sent to me by Mr. Ticehurst, of Hastings, for 
 my opinion regarding the state of his rectum. 
 He had well-marked symptoms of malignant 
 disease, and on examination a scirrhous mass 
 was found within easy reach of the finger. He 
 suffered greatly, both locally and generally. I 
 ordered some appropriate treatment, and sup- 
 posed that the disease would rapidly extend 
 downwards, and involve the anus as is usual. 
 Two months afterwards I had a letter from 
 Mr. Ticehurst, to say that this gentleman had 
 died the day before. And to quote his words, 
 “ After his return the disease in the rectum 
 scarcely troubled him at all ; he had good-sized 
 motions until the last ; but about a month ago 
 his abdomen became hard, and I could dis- 
 cover several tumours in the belly. He had a 
 large number of scirrhous tumours on the 
 
69 
 
 chesty armpit; and outside the abdomen; of 
 various sizes, from that of a pea to that of a 
 nut. His abdomen rapidly increased in size. 
 I quite expected that the disease would have 
 appeared at the anus ; but it seemed to grow up 
 like a mass of mushrooms into the abdomen . 55 
 
 This case illustrates the observation which 
 has been made by most writers on the subject : 
 that where this disease is confined to the upper 
 part of the rectum the suffering is compara- 
 tively slight ; but that when the affection has 
 involved the lower part and the anus itself, the 
 suffering produced is very distressing. 
 
 I may here very appropriately relate a case 
 which illustrates, in a remarkable manner, the 
 truth that a patient may be affected with a 
 cancerous deposit in the rectum to a consider- 
 able extent, and yet when it is situated away 
 from the anus, the suffering may be so slight as 
 to cause no suspicion as to the real state of 
 things. The case also shows another fact, viz., 
 that in some instances the disease may have 
 existed for some time without producing any 
 decided effect upon the system at large. A 
 man aged sixty-two, but looking considerably 
 younger, and having a healthy appearance, is 
 
70 
 
 now seeing me at the Hospital. He complained 
 of difficulty in evacuating his bowels, and con- 
 stant passing of flatus, but scarcely any pain or 
 discharge. There was no appearance of any- 
 thing wrong externally, but on introducing the 
 finger into the rectum its point came into con- 
 tact with a large, hard, scirrhous deposit, 
 through the centre of which I could with 
 difficulty insert the finger, and I then found 
 that the gut was involved in the disease for 
 about an inch and a half. There was scarcely 
 any pain produced by this insertion of the 
 finger, or by the subsequent introduction of a 
 bougie. The lower two inches of the gut were 
 perfectly healthy, and thus was accounted for 
 the almost entire freedom from pain. I pointed 
 out to the pupils how strongly the case illus- 
 trated the fact of there being so little suffering 
 when the malignant deposit was seated some 
 inches away from the anal orifice, and how 
 important it was to make a careful examina- 
 tion of the rectum with the finger in these 
 insidious cases. 
 
 With regard to the treatment of cancer of 
 the rectum, there is little which can be offered 
 here which is not generally known ; but there 
 
71 
 
 is one point on which I would say a word or 
 two, and this relates to the employment of 
 bougies for the purpose of dilating the rectum 
 obstructed by cancerous deposit. I am aware 
 that most writers object to any mechanical 
 means of remedying the symptoms produced 
 by this disorder, and, as a rule, the advice is 
 sound ; but every now and then a case is met 
 with where the obstruction to the passage of 
 the contents of the intestine is very marked, 
 and where ulceration has not yet taken place 
 on the surface of the cancerous mass. Now, in 
 such an instance as this, and more especially 
 if the disease be within easy reach of the finger, 
 there is no possible objection to the cautious 
 use of a wax bougie, and I have seen great 
 comfort produced by the treatment. If, how- 
 ever, the symptoms — such as severe pain, and 
 a constant discharge of sanio-purulent matter 
 — show that ulceration has attacked the part, it 
 is useless and even hurtful to introduce the 
 bougie ; and, indeed, the less interference, even 
 with the finger, the better. 
 
 It has recently been recommended that the 
 operation of opening the intestine above the 
 seat of the disease should be adopted, not 
 
72 
 
 merely for the relief of the fatal symptoms 
 which ensue from complete obstruction of the 
 bowels by the cancerous deposit* but as a 
 means of combating those distressing* but not 
 necessary fatal* sequelae of this disease* such 
 as extreme difficulty in evacuating the bowels* 
 harassing and irritating diarrhoea* and violent 
 pain — symptoms* indeed* which sooner or later 
 lead to death* but which do not of necessity 
 demand an operation. Mr. Erichsen and Mr. 
 Curling have strongly urged this course of 
 action in such cases as a means of temporary 
 relief* and I must warmly support these views ; 
 and I shall not hesitate in the first suitable 
 case which comes under my care attempting 
 to give the relief which most certainly may 
 be better afforded by Amussat’s operation than 
 by any other means. 
 
 I recommended Amussat’s operation* in a bad 
 case of malignant stricture of the rectum* as a 
 means of temporary relief in a man in King’s 
 College Hospital* soon after this Lecture was 
 delivered. The operation was performed by 
 our house-surgeon* Mr. Royes Bell* and the 
 patient got very great relief from his sufferings 
 during the few days that his life was prolonged. 
 
73 
 
 One word or two respecting the recom- 
 mendation which has been made by some 
 surgeons to excise cancerous growths from the 
 anus, and even to remove the lower part of the 
 rectum. I should have thought that this was 
 entirely a part of the surgery of a bygone age, 
 and that the recorded experience of those who 
 had performed these operations in France and 
 in this country would have sufficed to put an 
 end to all such barbarism ; but I was very much 
 astonished not long since at the suggestion of an 
 eminent surgeon of the present day, to perform 
 such an operation. The case was that of a 
 middle-aged gentleman who was affected with 
 epithelial cancer of the rectum about an inch 
 from the anus. I was first consulted about 
 this case, and recommended some simple local 
 and general measures. As no change took 
 place, two other surgeons of larger experience 
 than myself were consulted. They both came 
 to the same conclusion, — that the disease was of 
 a malignant nature, but the more eminent of 
 the two suggested that the growth should be 
 removed by excision. I am glad to say that the 
 third surgeon gave his opinion against this 
 proceeding, which would have been totally 
 
74 
 
 useless even in giving any temporary relief, 
 to say nothing of an ultimate cure of the 
 disorder. 
 
 The subject of polypus of the rectum has not 
 had so much attention paid to it as it deserves. 
 As an illustration of this I may mention that in 
 one of our latest and well-known treatises on 
 diseases of the rectum, comprising upwards of 
 400 pages, five out of these pages only are 
 devoted to the consideration of polypus. My 
 predecessor in office, Mr. Bryant, however, 
 did in this room bring the subject very pro- 
 minently under our notice, in a most excellent 
 and practical paper, and he showed that polypus 
 of the rectum is a disease of much more fre- 
 quent occurrence than it is supposed to be. It 
 is one also which causes a remarkable degree of 
 annoyance and distress, and unless a very 
 careful examination be made, both of the 
 patients symptoms and of the seat of the 
 disease, the real nature of the affection escapes 
 observation. I am quite convinced of the 
 truth of Mr. Bryant’s remarks respecting the 
 frequency of polypus. It has occurred to me 
 to meet with a large number of cases, some of 
 them of a very curious nature, and where, too, 
 
75 
 
 there had not been any suspicion of the true 
 condition of things. In children the small, 
 red, vascular polypus is chiefly met with, and, 
 as a considerable amount of oozing of blood is 
 produced, either after the bowels have acted, 
 or when the patient runs about, the diagnosis 
 of the affection is generally easy ; and the 
 treatment, which consists in ligaturing the 
 pedicle, or tearing the tumour away with the 
 fingers or forceps, always satisfactory. In adult 
 persons, however, the diagnosis is not so easy, 
 and, as I have before stated, the real nature of 
 the affection is overlooked, for the polypoid 
 growths are seldom of the same vascular variety 
 which are met with in children, and sometimes 
 they are situated so high up in the rectum as 
 to escape observation entirely, only producing 
 annoyance when the bowels are acted upon. 
 Not unfrequently a polypoid growth will be 
 associated with a prolapsus of the rectum, and 
 then a vast amount of suffering will be pro- 
 duced by the growth getting nipped within 
 the grasp of the sphincter, whilst the prolapsed 
 portion of the gut is either entirely or partially 
 protruded ; the annoyance caused is extreme, 
 and that it is the polypus and not the prolapsus 
 
76 
 
 which is the seat of the suffering is rendered 
 evident by the result of removing the tumour 
 without, at the same time, doing anything to 
 remedy the prolapsus, for the pain and irrita- 
 tion almost immediately cease so soon as the 
 offending body is removed. The easiest and 
 most satisfactory way of removing the small 
 fleshy polypi which are seen in adults is simply 
 to snip them across with a pair of scissors ; but 
 every now and then they present a more vascu- 
 lar appearance, and in that case it is better to 
 apply a ligature around the base of the tumour, 
 and either allow it to separate, or immediately 
 remove it with scissors. In one such case I 
 did divide the base of the tumour without 
 previously using any ligature, and the bleeding 
 was so smart afterwards that I was compelled 
 to seek for the cut surface and place a ligature 
 around it. 
 
 Every now and then we meet with a large, 
 firm, fleshy polypus of the rectum, and it is 
 seated so high up that it is extremely difficult 
 to diagnose the nature of the complaint ; or 
 there may be more than one of these polypi, 
 and they may be so situated as to escape obser- 
 vation for a time, unless a most careful exami- 
 
77 
 
 nation be made ; and this is especially the case 
 if some more painful affection of the rectum 
 be associated with it. I shall conclude my 
 observations by relating two very interesting 
 cases which occurred in my practice, and which 
 sufficiently illustrate what I have just stated. 
 
 The first case is one where there was extreme 
 difficulty in coming to a correct conclusion 
 as to its real nature, and it occurred in the 
 practice of the late Mr. Beaman, who called 
 me in to see a middle-aged lady, in April, 
 1860. She had been suffering for months, 
 complaining of a protrusion at the time she 
 evacuated her bowels, and a severe pain lasting 
 some time afterwards. On examination I found 
 a large external pile. I removed this, with 
 great relief to her sufferings ; but in the course 
 of a few weeks I was requested to see her 
 again, and I then found her complaining of her 
 old symptoms as much as before. I carefully 
 examined the rectum with the finger, but could 
 not detect anything in the shape of a tumour ; 
 but the introduction produced the intense agony 
 which is noticed in cases of the painful ulcer. 
 Moreover there was a slight crack or fissure 
 posteriorly. Thinking that this latter might 
 
78 
 
 be the cause of all her symptoms, I recom- 
 mended that it should be divided, and ac- 
 cordingly I ran my knife through the fissure— 
 to our mortification, however, there was not the 
 least alleviation of her symptoms, and I was 
 quite at a loss to account for them, until, one 
 day, we fortunately went into the house im- 
 mediately after the bowels had been violently 
 moved by a drastic purgative. The lady was 
 complaining of intense pain, and on examining 
 her there protruded at the anus, what, at first, 
 I supposed to be an ordinary prolapsus, but on 
 introducing the finger I found that I could pass 
 it freely between the tumour and the wall of 
 the gut, and on closer investigation it turned 
 out to be a large fleshy polypus, but at- 
 tached so high up by a long pedicle to the pos- 
 terior wall of the rectum, that the difficulty in 
 coming to a direct diagnosis of this harassing 
 case was at once explained. Fortunately I had 
 the necessary instruments about me, and with- 
 out delay I transfixed the tumour, got it well 
 down, and after a deal of trouble was enabled 
 to get a double ligature high up around the base 
 of the pedicle. These separated on the fifth 
 day and the patient soon got well. 
 
79 
 
 Now, the case, which gave me a great deal of 
 annoyance at the time, appears to me one of 
 great practical interest, as it shows how difficult 
 it may be to ascertain the existence of a polypus 
 of the rectum when it is seated very high up, 
 for I had made very careful examinations, and 
 on one occasion the bowels had been well 
 emptied by an enema beforehand, so that I 
 could not attach any blame to myself. More- 
 over the presence of a large external pile, and 
 of a fissure of the anus, warranted the conclu- 
 sion that the severe symptoms might depend 
 upon these morbid conditions. Curiously 
 enough Mr. Curling mentions* in his work, 
 a very instructive case, where there was an 
 equal, if not a greater difficulty enperienced by 
 himself in detecting a vascular polypus in a 
 young girl. Several examinations were made 
 without anything being discovered, until, one 
 day, Mr. Curling took the opportunity of ex- 
 amining the patient immediately after the 
 bowels had been acted upon by medicine, when, 
 as in my case, the polypus was seen protruding 
 at the anus, and having a long narrow pedicle. 
 This was treated in a similar manner, and the 
 patient soon got well. 
 
80 
 
 The other case which I shall mention, is an 
 example of multiple polypi, and illustrates the 
 occasional difficulties there may be in detecting 
 these tumours, especially when they are com- 
 plicated with other disorders. 
 
 The patient was a young married lady, whom 
 I saw in consultation with Dr. Battershal Gill 
 in the early part of February last. She had 
 been suffering very severely for some time from 
 acute pain after evacuating her bowels, and a 
 great deal of annoyance at other times. On 
 making an examination I found several large 
 excrescences around the anus, and at the poste- 
 rior verge was an ulcer ; and, on introducing 
 the finger, a process causing most intense agony, 
 I ascertained the presence of a foreign body. 
 She was next day placed under the influence of 
 chloroform, and an operation of a somewhat 
 complicated character was performed. In the 
 first place, the external tumours were removed ; 
 then the sphincter was cut through in the site of 
 the ulcer, and two large fleshy polypi, which 
 were pretty easily brought down, were tied 
 and removed. After such a severe business, 
 it was hoped that the patient would be entirely 
 rid of all her sufferings ; and to a certain ex- 
 
81 
 
 tent she was relieved ; for she lost that severe 
 and peculiar pain which is the characteristic of 
 the painful ulcer, and I took my leave in a 
 fortnight. At the end of April, Dr. Gill re- 
 quested me to see his patient again ; and to my 
 surprise I found that she had never been quite 
 free from the symptoms of a sense of protrusion, 
 and that latterly they had increased so much as 
 to convince her that there must be some other 
 growth. I therefore made the most careful and 
 thorough examination, and on introducing my 
 finger very far up, I was enabled to detect a 
 large fleshy polypus. I came prepared to adopt 
 any measure which might be needful, and 
 with some difficulty I seized the tumour and re- 
 moved it, first placing a ligature around its base. 
 
 The patient in this case believed, fortunately 
 for me, that the tumour had grown since the 
 date of the first operation; but I feel sure 
 that the polypus must have been there at 
 the time I removed the others, only being 
 seated high up in the rectum it was com- 
 pletely obscured by them. Moreover, I never 
 dreamed of finding more than two large poly- 
 poid growths in the same person. Equally 
 with the other case, this latter teaches the 
 
 6 
 
82 
 
 necessity of making the most thorough and 
 cautious examination of the rectum in all cases 
 where there is a suspicion of polypus, and of 
 avoiding being misled by the presence of a 
 morbid condition which in reality is only the 
 result of the irritation produced by the descent 
 of the foreign body, but which produces symp- 
 toms much more annoying and painful than 
 those caused by the original malady. 
 
 Since these observations regarding polypi of 
 the rectum were made, it has occurred to me to 
 meet with a great number of instances where 
 these growths have existed, and I have come to 
 the conclusion that perhaps next to haemor- 
 rhoidal disease these polypoid excrescences, in 
 some shape or another, are as frequently met 
 with in the rectum as any other morbid con- 
 dition of this part. It very often occurs by 
 itself in the form of a single or multiple growth, 
 varying from the size of a grape to that of a 
 cricket-ball, and it is as often seen associated with 
 other disorders of the rectum not unfrequently 
 there. Polypi are superadded to haemorrhoids, 
 and it is found that the chief annoyance and 
 suffering are produced not so much by them as 
 by the polypoid growths. A very striking in- 
 
83 
 
 stance of this occurred to me as I am now 
 writing. A young lady, who had endured much 
 misery for years, was compelled to speak to her 
 medical attendant about her complaint. I was 
 referred to, and I found a large mass of disease, 
 consisting of internal haemorrhoids and external, 
 but by far the largest part of the tumour con- 
 sisted of two large polypi, which were attached 
 to the rectum just above the external sphincter, 
 so that they were either constantly protruding 
 partially, or were either wholly outside, and 
 grasped by the sphincter ani, and thus pro- 
 ductive of immense suffering. I removed the 
 polypi and the haemorrhoidal disease at the 
 same time, using the clamp and cautery ; they 
 consisted, as most of them do, of a dense fibrous 
 structure. 
 
 Not uncommonly also these polypoid growths 
 are found to be associated with the painful 
 ulcer of the rectum ; in fact, so frequently is 
 this the case, that I always look for them in 
 this disease, and I should say that in one half 
 of the cases I meet with a polypoid growth 
 also, situated just above the ulcer, and perhaps 
 originally productive of it. I have also met 
 with them in connection with that spasmodic 
 
84 
 
 constriction of the anus which is productive of 
 so much suffering, hut yet unattended with any 
 ulcer of the rectum. Here, as in cases where 
 the ulcer exists, it is absolutely necessary to 
 remove the polypoid growths before any cure 
 can be effected. 
 
 I have recently been consulted as to the 
 advisability of removing a polypoid tumour the 
 size of an egg, growing from the anterior wall 
 of the rectum, and only just within reach of the 
 finger ; and a few months since I saw Sir 
 William Fergusson remove a mass of the size 
 of a man’s fist, which had been growing from 
 the rectum low down, and which had caused 
 serious bleeding and discharge. It was a large 
 fleshy mass, and so circumscribed and attached 
 by such a distinct pedicle that it was clear it 
 was not malignant, although, as it protruded 
 from the anus, it was a very ugly-looking 
 affair. On examination, its central portion was 
 found to be fibro-nuclear. Outside this were 
 branching papillse, and the whole was covered 
 by epithelium. The patient, who had been 
 much pulled down, and had a very malignant 
 aspect, rapidly recovered, and lost his unhealthy 
 appearance. 
 
85 
 
 I have met with two instances of remarkably 
 vascular polypoid growths of large size. In 
 the one I operated with the clamp and cautery; 
 in the other, where the pedicle was not distinct, 
 and where the tumour seemed to be more of a 
 villous character, I destroyed it with repeated 
 applications of nitric acid. In both cases the 
 health had been seriously damaged by the long 
 continued and excessive haemorrhage. 
 
86 
 
 LECTURE III. 
 
 ON THE TREATMENT OF HAEMORRHOIDS AND 
 PROLAPSUS. 
 
 I propose to devote the entire of this third 
 and last Lecture to the consideration of the 
 treatment of haemorrhoids and prolapsus, two 
 forms of disease of the rectum which are, per- 
 haps, more commonly met with than any other 
 in the same locality, and which produce a vast 
 amount of suffering and injury to health, 
 although there are few affections equally severe 
 which are so readily remedied when appropriate 
 measures are adopted. 
 
 The observations which I shall make apply 
 almost entirely to the surgical treatment of 
 these disorders ; it is not my purpose to refer 
 at any length to those cases where the affection 
 is but slight, or comparatively so, and where 
 well-known medical means combined with 
 proper diet and exercise soon give the relief 
 which is sought. The instances to which my 
 remarks will be addressed are those where the 
 
87 
 
 affection in either form has lasted for a length 
 of time, has resisted the ordinary general and 
 local means of treatment, and where in order 
 to effect a permanent cure some strictly surgical 
 operation or appliance is imperatively called for. 
 
 I have but little to say about external 
 haemorrhoids. There is no difference of opinion 
 amongst well-informed surgeons as to the 
 treatment which should be adopted when some 
 strictly surgical measures are called for ; as a 
 general rule, it may be stated that in cases of 
 external haemorrhoids which are causing any 
 annoyance either by their size or other condi- 
 tion, the remedy is excision with the knife or 
 scissors. I refer more particularly to those 
 instances where from repeated attacks of in- 
 flammation and irritation to which these haemor- 
 rhoids have become liable they have been 
 converted into more or less solid tumours, which 
 grow about or completely encircle the anal 
 orifice, are liable to inflame, ulcerate, and be- 
 come fissured ; hence any other treatment but 
 excision is merely palliative, and will be of 
 no permanent benefit. The morbid growths 
 should be separately removed by means of a 
 vulsellum and sharp curved scissors. The 
 
88 
 
 wounds generally heal up very rapidly, and 
 enormous relief is very quickly experienced. 
 
 But there is one caution which observation 
 has taught me, and which I will venture to 
 suggest to you, and this is that we must take 
 care even in this simple operation that we do 
 not make matters much worse ; for if too 
 much of the tissue around be taken away at 
 the same time that the tumours are removed, a 
 firm unyielding cicatrix, in which the anal 
 orifice is involved, takes place in the course of 
 time, and the patient will suffer from stricture 
 of the bowels — a more formidable disease than 
 external piles. I have witnessed this occur- 
 rence after a careless operation of this kind ; 
 but in no instance was it more striking and 
 sad than in a case which I have related in the 
 third edition of my book on Haemorrhoids/ 
 and which I will briefly refer to here. 
 
 A lady in the prime of life and maturity 
 suffered severely from external haemorrhoidal 
 tumours, and knowing little of the various 
 departments of our profession, unfortunately for 
 herself, placed herself under the care of a well- 
 known “ lady’s doctor,” as our worthy friends 
 the accoucheurs are styled by the public. 
 
89 
 
 This gentleman recommended an operation, 
 but instead of getting some surgical colleague 
 to see the case, operated upon the poor woman 
 himself, cutting away right and left and sever- 
 ing everything, tumours, skin and all from 
 around the margin of the anus. This was in 
 April. In June she was suddenly seized with 
 almost fatal obstruction of the bowels, and on 
 examination it w’as found that the anus was 
 nearly closed. Treatment was commenced, 
 and in the course of time the patient could 
 pass a bougie for herself, and partly recovered 
 her health. In September she consulted me, 
 and I found her in a miserable plight. The 
 natural folds about the anus were completely 
 destroyed. There was a dense firm cicatrix on 
 the site of the operation ; and on introducing 
 my finger, which was a work of extreme diffi- 
 culty to myself and pain to the patient, I found 
 that the cicatrix had involved nearly one inch 
 of the bowel. She had great difficulty in 
 evacuating her bowels, was compelled to pass 
 a bougie every day, and her health was 
 shattered by the physical and mental suffering 
 to which she was continually subjected. I 
 promised her considerable relief if she would 
 
90 
 
 allow me to divide the stricture, but she had 
 such a horror of any more operative interfer- 
 ence, that she declined my services and con- 
 tented herself with the daily use of the bougie, 
 'which of course she must not omit during the 
 rest of her life. 
 
 The great point in doing this operation is 
 to take away all redundant and hypertrophied 
 tissue, but not to encroach upon the healthy 
 skin, except in those cases where there is a 
 very great relaxation of the sphincter; then, 
 indeed, the excision of something more than 
 the hsemorrhoidal tumours themselves may 
 not only be not hurtful, but will be productive 
 of much good in causing a contraction and 
 strengthening of the anal orifice. 
 
 There is one other point in connection with 
 external haemorrhoids I will briefly refer to, 
 because I find that both in a pathological and 
 therapeutical view there is much error. 
 
 We are called, not unfrequently, to see a 
 patient who is suffering most acutely from an 
 attack of external haemorrhoids. On examina- 
 tion it is found that there exists at one or at 
 more than one part of the anus a circumscribed 
 blueish swelling, perhaps the size of the top of 
 
91 
 
 the thumb, and covered by a tense thick skin. 
 The patient has been confined to his bed for 
 several days, trying all sorts of remedies, local 
 and general, without any relief. Leeches have 
 for the most part been employed, but still the 
 sufferings of the patient have continued. The 
 remedy in such a case is of the simplest kind, 
 and is founded entirely upon a correct appre- 
 ciation of the pathology of this simple though 
 very painful affection. The fact is that the 
 tumour in question consists essentially of 
 coagulated blood. One or more veins have 
 become enlarged, and, from some cause or 
 other, irritated ; the blood has either become 
 coagulated in the vein itself, or, what most 
 probably oftener occurs, the coats of the 
 dilated vein have given way and the fluid has 
 escaped into the surrounding tissue, has set up 
 further irritation, has formed for itself a coagu- 
 lum ; the skin around is irritated, distended, 
 and pressed upon, and the most exquisite pain 
 produced. Neither leeches, lotions, nor opiates, 
 will give any relief ; the tumour must be cut 
 fairly into, and the result is that a coagulum 
 of blood, varying from the size of a pea to that 
 of a nut, will be turned out, and the relief to 
 
92 
 
 the patient’s sufferings will be immediate. I 
 have seen most extraordinary errors in prac- 
 tice amongst men who ought to know better 
 in such cases, and producing much prolonga- 
 tion of suffering to the unfortunate patient. 
 
 One of the last and most striking cases, 
 however, to which I was called, occurred in 
 the person of a homoeopathic practitioner, who 
 had been confined to his bed for several days 
 before he sent for me. When I got to the 
 sick man’s bed I found things exactly as I 
 have described. The patient, unlike, I believe, 
 the majority of his colleagues, submitted him- 
 self to the treatment of a fellow-believer in the 
 same absurdity which he practises himself, 
 and, as may be well supposed, the knowledge 
 of pathology in this practitioner’s possession 
 was very limited ; the globules and all other 
 means failed, and my patient was obliged, 
 nolens volens , to apply to the resources of 
 legitimate surgery. I made a simple incision 
 into the tumour, let out a coagulum of blood, 
 and in a very brief period the patient was up 
 and about. 
 
 There is really nothing else worth calling 
 your attention to in connection with the 
 
93 
 
 subject of external haemorrhoids, even had I 
 the time ; therefore I will at once proceed to 
 bring under your notice the treatment of 
 internal haemorrhoids. In the majority of 
 cases it is seldom that the operating surgeon 
 is consulted until the disorder has lasted for 
 years, and been productive of much suffering 
 and depression of health, and therefore there 
 is little call for any other treatment but that 
 which radically and permanently cures the 
 affection. I have, in a work which is well 
 known to the profession, very strongly insisted 
 upon the excellent results which are produced 
 by the use of the strong nitric acid in certain 
 instances of very vascular and bleeding haemor- 
 rhoidal tumours. At one time, indeed, I treated 
 a large proportion of cases of the kind by the 
 application of the nitric acid, and got most 
 favorable results from this plan ; and I agree 
 with my friend, the author of ‘ The Surgeon's 
 Vade Mecum,’ that it is difficult to exaggerate 
 the benefits of this plan of treatment; but a 
 very large and careful observation has taught 
 me that for this treatment the cases must be 
 well selected, and that it is mainly in that 
 class of the disorder in which the tumours are 
 
94 
 
 small, granular, very vascular, and easily 
 bleeding, where the remedy acts with any- 
 thing like efficiency and permanency as regards 
 cure. In such cases, as Dr. Druitt says, and 
 as has been abundantly recorded in my little 
 work, the effect of this agent is perfectly 
 remarkable. By two or three careful appli- 
 cations of the acid, haemorrhage which has been 
 going on for months or years becomes com- 
 pletely arrested, and the size of the tumours 
 materially reduced, if not altogether destroyed. 
 And even if after a time any fresh symptoms 
 of haemorrhage or protrusion appear, one or 
 two applications of the remedy will produce 
 the same beneficial effects. 
 
 In by far the majority of cases of internal 
 haemorrhoids, however, this disease is not of 
 that character which can be effectually reme- 
 died by the application of nitric acid alone. 
 There are very frequently distinct tumours, 
 of more or less magnitude, instead of the 
 bright-red, vascular, sessile tufts which cause 
 so much annoyance, and yet are so amenable 
 to nitric-acid treatment. I have, in the work 
 already alluded to, and in my article on “ Dis- 
 eases of the Rectum ’ 5 in Holmes’ ‘ Surgical 
 
95 
 
 Dictionary, 5 drawn the distinction between the 
 different kinds of hsemorrhoidal tumours. And 
 I need only state here that in those of a bright- 
 red vascular character the arterial structure 
 chiefly predominates, whereas in those in 
 which the tumours are of a darker colour, and 
 not unlike a mulberry in appearance, they are 
 composed of veins to a large extent, although, 
 doubtless, the arteries enter as well into their 
 formation. It is very important, in a practical 
 point of view, to bear in mind this distinction, 
 especially with reference to the employment 
 of nitric acid, for in the last-mentioned cases 
 this agent will generally be of no use what- 
 ever, whereas in the former it is all-powerful 
 in remedying the malady. 
 
 Although since the use of an operation to 
 which I shall refer very specially by-and-by, 
 I have not employed nitric acid so much as I 
 did in former years, still I have had a very 
 large experience of it under circumstances 
 which would thoroughly test the value of the 
 agent. And I have never witnessed any 
 serious results from it, such as have been 
 alluded to by some writers ; and as regards 
 the so-called torture which is produced by it. 
 
96 
 
 all I can say is that, if the acid be applied, as 
 I recommend, to the diseased part through a 
 speculum previously introduced into the bowel, 
 the patient cannot tell whether the surgeon be 
 applying the acid or merely touching the 
 diseased part with a piece of lint. I have 
 over and over again verified this in my own 
 practice. Of course, if the acid be allowed to 
 come into contact with the sensitive skin of 
 the anus, the pain is really very severe for 
 some time ; but then this mistake should not 
 and will not occur in the hands of a careful 
 surgeon ; and it may be stated, as a rule, that 
 nitric acid should never be applied to burn off 
 external piles, nor should patients ever be 
 allowed to apply it themselves. 
 
 Until within a few years almost the sole 
 means of destroying those haemorrhoidal 
 tumours which could not be remedied by 
 nitric acid was the use of the ligature, and 
 even now most of our hospital surgeons, at 
 least, will use no other remedy, so wedded do 
 people become to old-established methods of 
 treatment ; and in the various works on 
 diseases of the rectum very little is said of 
 any other mode of treatment than this. The 
 
97 
 
 reasons for this predominance of the ligature 
 over other methods are to be found in the 
 fact that, as a rule, it is a successful means 
 of curing internal haemorrhoids, and, moreover, 
 it took the place of a treatment which was in 
 fashion at the beginning of the present 
 century, and which consisted in cutting away 
 the tumours with the knife, without, at the 
 same time, resorting to any means to prevent 
 haemorrhage. The result of this was that some 
 very valuable lives were lost from bleeding ; 
 but, thanks, chiefly, to the candour of the late 
 Sir Astley Cooper, this dangerous mode of 
 treatment was done away with, and the liga- 
 ture was made to supersede it, and until within 
 a few years this has been the only operation 
 which the majority of surgeons have thought 
 of adopting for the cure either of haemorrhoids 
 or of prolapsus of the rectum. 
 
 Admirable and permanent in its result 
 though the application of the ligature proved 
 to be, it was found that there were many dis- 
 advantages connected with it, and that it 
 would be desirable if some other means of 
 treatment, equally efficacious, could be put in 
 force. Every now and then a fatal case 
 
 7 
 
98 
 
 occurred quite suddenly and unexpectedly after 
 the operation. In some instances a prolonged 
 convalescence followed, the patient being con- 
 fined to bed for many weeks, whilst in others 
 it happened that the wounds resulting from 
 the separation of the ligatures would not heal 
 up for a long period, and the patient would be 
 subjected to much painful suffering, necessi- 
 tating, perhaps, some other operation. About 
 thirty years ago the late Mr. Cusack suggested 
 the employment of the clamp and cautery as 
 a means of destroying haemorrhoidal tumours, 
 and his practice was followed by other sur- 
 geons in Dublin. In this country Mr. Henry 
 Lee adopted the method of using the clamp, 
 cutting off the tumours, and then stopping the 
 haemorrhage with the actual cautery. The 
 results of this gentleman’s experience induced 
 me to put the plan in force, and in the first 
 cases which occurred in my practice I was so 
 satisfied with the treatment, and so convinced 
 of its superiority over the ligature, as regards 
 the important elements of safety to life, free- 
 dom from suffering, and saving of time, that 
 I determined to treat in this method those 
 cases, both of haemorrhoids and prolapsus, where 
 
99 
 
 I thought the ligature was inadmissible, or 
 where the patient objected to it, as well as 
 those wherein the application of nitric acid 
 alone would not suffice to bring about a 
 cure. 
 
 I was not long, however, in finding out 
 that the clamps hitherto used were capable of 
 being greatly improved, for these were either 
 of an awkward shape, were so constructed as 
 regards the apposition of their edges, and so 
 totally unfurnished with regulating power, that 
 the efficiency of the instrument and value of 
 the treatment were much impaired ; so I sug- 
 gested to Mr. Matthews to make me an 
 instrument shaped somewhat like the ordinary 
 clamp Mr. Curling uses for applying nitric 
 acid ; but the edges, instead of being ser- 
 rated, or not meeting in their entire length, 
 as in an instrument used by Mr. Henry Lee 
 were to be so constructed that they accu- 
 rately fitted their whole extent by means of a 
 groove on one blade and a raised surface 
 on the other. I soon found the value of this, 
 for the mucous membrane or tumour to be re- 
 moved could be thoroughly compressed, and 
 there was no fear of the bleeding which would 
 
100 
 
 take place when the clamps with serrated 
 edges were used and the tumour excised. I 
 next improved the instrument by furnishing it 
 with a catch, and by this I was greatly as- 
 sisted ; but when the pressure was taken off the 
 divided base of the tumour the cut surface 
 would suddenly recede from the grasp of the 
 blades, and if some vessel not thoroughly cau- 
 terized, should bleed, it was difficult to get hold 
 of the part again ; so, to meet this emergency, 
 I had a light but powerful screw added to the 
 handles of the instrument, by means of which 
 I could so regulate the power of the blades as 
 to take the pressure off the cut surface of the 
 rectum gradually, instead of suddenly, so that 
 if any portion of the divided surface was not 
 thoroughly cauterized the bleeding point would 
 show itself, although still retained within the 
 grasp of the blades, and by the slightest turn 
 of the screw it could be secured and the bleed- 
 ing vessel be entirely sealed up. This addi- 
 tion to the instrument I consider to be of the 
 utmost importance, and, indeed, I never think 
 of performing an operation without employing 
 the instrument furnished with the screw. 
 There are one or two other improvements which 
 
101 
 
 have suggested themselves to me in the course 
 of my practice, and one of these consists in 
 the addition of a spring at the junction of the 
 
 i 
 
 blades and handles, so that the former may 
 more readily open when the screw is turned. 
 Mr. Matthews has also made the instrument 
 latterly with the raised edge of the blades 
 
102 
 
 marked or roughed with numerous small 
 grooves, so as to retain the tissues more readily. 
 I cannot see that there is room for any further 
 improvement, the instrument, in my opinion, 
 being now as well adapted for its purpose as it 
 possibly can be. It is very essential for the 
 right action of the clamp that the blades 
 should be so constructed as to have their 
 parallelism complete when they meet, other- 
 wise some portion of the enclosed membrane 
 may slip after the tumour or prolapsus has 
 been cut away. 
 
 The operation, whether for haemorrhoids or 
 prolapsus, is very simple, and consists of the 
 following manoeuvre : — The diseased portions, 
 being well brought down previously by an 
 injection, are separately seized with a vulsel- 
 lum and handed to an assistant. The part 
 is then enclosed within the blades of the 
 clamp, which are screwed home quickly and 
 thoroughly ; the prominent portion of the pile 
 or prolapsus is then cut away by a sharp pair 
 of scissors, the cut surface is next dried by a 
 piece of lint or sponge, and either the strong 
 nitric acid or the actual cautery, so shaped as 
 to come into contact with the whole of the raw 
 
103 
 
 tissue* is applied ; when this is effected the 
 blades are gently and slowly unscrewed* and if 
 there is no bleeding the part is well oiled and 
 allowed to return within the cavity of the gut ; 
 if* however, any bleeding point is seen* the 
 blades are quickly screwed together* and 
 the cautery is applied until the vessel be 
 thoroughly sealed up. The finger is then 
 introduced well up into the rectum. This step 
 serves the triple purpose of returning all the 
 parts well* of compressing any point which 
 might possibly bleed* and of exciting the 
 sphincter to healthy action. I generally 
 introduce at the same time a suppository of 
 opium. 
 
 Now* it might appear to some that this 
 operation would be very painful* but* singular to 
 relate* if great care be taken not to include 
 any of the integument within the blades* and 
 not to allow the nitric acid or cautery to 
 come into contact with it* the patient does not 
 feel much pain* and really does not know 
 when the heated iron is being applied. If* 
 however* the cautery be kept in contact with 
 the blades of the clamp for more than a few 
 moments* the patient will suffer pain by the 
 
104 
 
 transmission of heat through the contact of 
 the metallic surfaces, and therefore it has been 
 suggested to me to have some non-conducting 
 medium applied to the under part of the 
 blades. It is possible that I may make some 
 alteration in this presently ; but a grave ob- 
 jection lies in the fact that by this means the 
 size and thickness of the blades would be 
 materially increased. 
 
 Since the above was written I have made 
 this addition to the clamp and have found it 
 answer the purpose required most admirably. 
 Mr. Matthews has so managed as to cover the 
 blades, both posteriorly and laterally, with a 
 thin layer of ivory. The thickness of the 
 instrument is not so much increased by this addi- 
 tion, and the heat from the cautery is prevented 
 being conducted to the neighbouring parts. 
 I am not now in the habit of applying the 
 cautery at a red heat, finding that when the 
 iron is heated just below this every purpose is 
 answered. By these two modifications it will 
 be found that the operation is nearly painless, 
 if no external tissue requires interference. 
 
 Since the last edition of these lectures were 
 published I have made what I consider to be a 
 
105 
 
 valuable addition to the clamp. I requested 
 Mr. Matthews not only to cover the blades pos- 
 teriorly and laterally with ivory, but to extend 
 
 the ivory for at least half an inch from the metal 
 of the blades, so that in a prolonged operation, 
 or where the cautery requires to be applied very 
 freely, the heat cannot be conducted to the 
 surrounding tissues, which would be the case if 
 
106 
 
 only the blades themselves were protected. I 
 have found these wings to he of immense service 
 in some severe cases, and if the patient does 
 not take chloroform I always use an instrument 
 so constructed. 
 
 Now that I have described so fully the 
 mechanism of this operation and of the instru- 
 ment which goes under my name, I shall 
 explain the reasons why, in my humble opinion, 
 and, indeed, in the opinion of most who have 
 seen me use it, the operation of removing 
 haemorrhoid al tumours and prolapsus of the 
 rectum by this improved clamp possesses such 
 superior advantages over the operation by the 
 ligature, and in order to do so effectually I 
 shall have to contrast the two kinds of opera- 
 tion, by bringing forward cases of each, and, 
 finally, I shall furnish you with the whole of 
 my experience of this treatment during the 
 period I have been adopting it, viz., for the last 
 three years. 
 
 In one case where I applied the ligature, a 
 patient of the late Dr. Wildbore, an old lady, 
 very nearly lost her life from secondary 
 haemorrhage and sloughing about the time the 
 ligature was separating. By very great care. 
 
107 
 
 however, she rallied, and ultimately, after a 
 protracted convalescence, recovered. 
 
 In another case, which occurred in the per- 
 son of a middle-aged lady, a patient of Drs. 
 Beaman and Vine, the ligature was applied 
 most carefully by myself, for a mass of interna- 
 haemorrhoids which had bled profusely for 
 years, and had reduced the patient to such a 
 state as to produce oedema of the legs. Every- 
 thing went on well until the separation of the 
 ligatures, and, indeed, until nearly three weeks 
 had elapsed from the operation, when I was 
 requested by Dr. Vine to see the lady again, 
 and, to our great disappointment, the haemor- 
 rhage had returned as profusely as ever. We 
 were certain that every portion of the disease 
 had been removed. 
 
 This patient was kept very quiet in bed, 
 and the most powerful astringent injections 
 were used, but in vain. The bleeding went 
 on as badly as ever, and reduced her so that 
 Dr. Beaman thought she would die. At the 
 end of a week I carefully examined her with 
 the speculum, and, finding a spot of ulceration 
 whence one of the ligatures had separated, 
 applied the strong nitric acid. This had no 
 
108 
 
 effect, for at the end of a week the haemorrhage 
 was as profuse as before, and a second careful 
 application of nitric acid was made, although 
 there was no hsemorrhoidal tumour to be seen. 
 This second application seemed to lessen the 
 bleeding somewhat, but at the end of another 
 week the bleeding came on again very badly, 
 when I made a third very careful and free 
 application of the acid to the entire of the lower 
 portion of the bowel through the speculum. 
 Fortunately this succeeded in arresting the 
 bleeding, but this lady had gone through great 
 danger and her convalescence was sadly pro- 
 tracted, and it is impossible to estimate the 
 anxiety and annoyance to which Dr. Vine and 
 myself were subjected, because the especial 
 feature which drove this lady to submit to the 
 operation was the excessive and debilitating 
 hsemorrhage, and which 1 confidently promised 
 would be thoroughly put an end to by the 
 operation in question. 
 
 There is another condition which, every now 
 and then, obtains after the use of the ligature, 
 causing great suffering and protracting for a 
 long time the convalescence. I refer to the 
 ulceration which sometimes remains unhealed 
 
109 
 
 for a long period after the separation of the 
 ligature. I have met with two or three such 
 cases. Not long since I was requested to see 
 a gentleman who had six weeks previously 
 undergone the operation of ligature for internal 
 haemorrhoids by a first-class surgeon ; every- 
 thing had gone on well, and the patient 
 returned home, but he began to suffer excru- 
 ciating pain each time the bowels were 
 evacuated, and his surgeon failed to give him 
 any relief. When I saw him I found him in 
 bed, his countenance wearing the expression of 
 much pain ; and on examination I found a 
 small unhealed ulcer, just at the upper edge of 
 the sphincter. His medical attendant, whom 
 I met in consultation, suggested that the 
 muscle should be divided, but, as the patient 
 did not relish the idea of another operation, I 
 recommended delay, and amongst other things 
 ordered the use of some chloroform ointment. 
 This, especially, gave great relief ; and in a 
 short time the patient got quite well, but his 
 convalescence was very protracted. 
 
 In another case the use of the ligature was 
 followed by a great deal of suffering and the 
 formation of an ulcer at the site of ligature. 
 
no 
 
 which remained unhealed and caused severe 
 pain for many weeks after the operation. The 
 patient was a lady sent to me by Dr. Hensley, 
 and I applied a ligature to one internal pile on 
 May 11th. Complete retention of urine 
 followed for a week ; subsequently there was 
 great pain at the seat of operation. An 
 abscess formed between the mucous and 
 muscular coats of the gut, and after this had 
 discharged, a large painful ulcer remained. It 
 was very slow in healing ; the lady could not 
 leave her bed for six weeks, and was not able 
 to be moved to the seaside until the end of 
 June. In August I examined the part carefully 
 and then found that, although she was in good 
 health and did not suffer any pain, still the 
 ulcer had not healed, being then as large as a 
 sixpence. 
 
 I may mention another case to illustrate the 
 tedious recovery which sometimes occurs after 
 the use of the ligature. It was also in the 
 person of a lady, a patient of Dr. Brodie 
 Sewell, on whom I operated for prolapsus of 
 the rectum by the ligature. Nothing par- 
 ticular occurred immediately, and the liga- 
 tures separated in a few days, hut there was 
 
Ill 
 
 extreme suffering in the part operated upon, 
 defying most of our remedies, and it was quite 
 six weeks before this lady was able to be 
 moved away, and at that time she was in an 
 extremely feeble and irritable condition. 
 
 As an illustration of the severe effects which 
 may follow on the use of ligatures, I mention 
 also the following case : 
 
 A widow lady, set. 46, consulted me in 
 September, 1865. She was dreadfully blanched 
 by long-continued bleeding from the rectum 
 which had been going on severely for upwards 
 of a year. A few years previously, she was 
 operated on in the country by the ligature, 
 but only got partial relief. On examination 
 I found a large tumour composed of several 
 internal piles, and so vascular were they that 
 a considerable impulse similar to that of an 
 ordinary aneurism was transmitted to the mass, 
 and on straining large jets of arterial blood 
 were emitted. Under these circumstances, and 
 with my, at that time, comparatively limited 
 experience with the clamp, I thought it safest 
 to apply the ligature. I performed this opera- 
 
112 
 
 tion on Saturday, October 6th, under chloro- 
 form, tying four large piles and cutting off 
 the thickened skin around. This operation 
 was long and tedious, and the patient lost 
 much blood. 
 
 This operation was followed by the most 
 severe symptoms, notwithstanding the em- 
 ployment of large and continued doses of 
 opium and the local application of ice. The 
 pain was most intense, and the constitutional 
 disturbance in a corresponding degree severe. 
 The pulse became rapid and wiry, and the 
 countenance anxious. This state of things 
 continued for nearly a week after the operation, 
 when the ligatures began to separate, and by 
 the tenth day they had all come away, and the 
 pain subsided, but she continued very feeble 
 and required large doses of brandy and opium. 
 Between the third and fourth week she was 
 attacked with obstruction of the left femoral 
 vein and swelled leg, and it was not until six 
 weeks had elapsed that she was able to go 
 out for a drive. 
 
 At one time I was afraid this patient would 
 have died, and I have no doubt that her 
 life was placed in great peril. It is true 
 
113 
 
 she was in a most unfavorable state to bear 
 any severe operation. I was afraid at that 
 time to operate with the clamp, not having 
 sufficient confidence in the power of the 
 cautery to arrest the bleeding from such large 
 vessels as entered into the formation of the 
 tumours. 
 
 Another case, also, in which I operated with 
 the ligature shows the severe results occasion- 
 ally attending this proceeding. 
 
 I was called down into Northamptonshire to 
 see a middle-aged gentleman who had been 
 suffering severely from haemorrhoids for twenty 
 years. I saw him with Mr. More, of Roth- 
 well, on July 25th, and found that there was a 
 large tumour consisting of external and internal 
 piles ; there was, moreover, a large polypoid 
 growth not unlike a bunch of warts growing 
 from the rectum. I thought it at that time 
 too severe a case for the clamp, and accord- 
 ingly operated with the ligature ; it was needful 
 to apply several as the mass was so large. 
 
 This gentleman suffered a great deal of pain 
 after the operation, and his pulse became and 
 continued very rapid. On the 29th he became 
 
 8 
 
114 
 
 very restless, perspired profusely, and became 
 delirious. This condition became aggravated 
 and caused much anxiety ; there was picking 
 at the bed-clothes and profuse perspiration. 
 Large quantities of stimuli were given and 
 were well borne. Nevertheless, on August 
 5th, traumatic delirium fully developed itself ; 
 he tossed about at night in a restless manner, 
 and picked at the bed-clothes. This delirium 
 continued more boisterous, and the patient got 
 much weaker and remained in the same state 
 until August 17th, when Dr. More wrote that 
 “ a slight improvement had taken place , ” and 
 from this date, although he continued very 
 feeble and suffering from want of sleep, he 
 slowly recovered, but was not able to go out 
 in his carriage until September 27th, two 
 months after the operation. 
 
 This gentleman evidently had a very narrow 
 escape of his life, and, of course, we cannot 
 attribute his dangerous symptoms to anything 
 else than the particular kind of operation he 
 underwent. It is true, like the last case, it 
 was one of exceptionable severity, but the 
 patient was in fair health and had not been 
 much reduced by bleeding. 
 
115 
 
 I am sorry to say that, in addition to these 
 two cases which caused myself and Dr. More 
 so much anxiety, I have to relate two cases 
 where death followed the use of the ligature. 
 To the first of the two cases I wish to direct 
 particular attention, as at the time it caused 
 considerable sensation, the patient being a 
 member of our profession, and as I had used 
 the clamp on one side, it was stated that death 
 had been produced by the use of this instru- 
 ment. I therefore related the case at a full 
 meeting of the Fellows of the Medical Society 
 of London, when it was fully admitted that the 
 fatal event was due not to the use of the clamp 
 but to the ligature, which unfortunately, in a 
 moment of indecision and want of confidence 
 in the power of the clamp and cautery, I had 
 employed for the removal of the greater portion 
 of the tumour. 
 
 Mr. F — , aet. 30, had suffered terribly from 
 bleeding piles for many years, and had under- 
 gone one or two operations with partial relief. 
 He applied to me in September, 1865, and 
 requested me to use the clamp and cautery as 
 he had suffered so much pain when the ligature 
 
116 
 
 was applied. He wished me to defer any 
 examination until I was prepared to operate. 
 I went prepared to do so on September 19th, 
 and on making a thorough examination whilst 
 the patient was under the influence of chloro- 
 form, I found, to my astonishment, two very 
 large excrescences protruding on each side and 
 attached to the rectum by a broad and thick 
 base, I enclosed the smaller of the two in the 
 largest clamp I had and removed it, but the 
 other one was so large and had such an exten- 
 sive base that I dared not trust to the clamp, 
 and accordingly ligatured the mass in the 
 ordinary way and cut it off close. 
 
 He did not suffer much after the operation, 
 but in a few days a good deal of swelling took 
 place, and on the 29th there was an extensive 
 phlegmonous inflammatory swelling of the 
 buttock on that side where the ligature had 
 been applied . On the 31st this had increased 
 to such a degree that I made a deep incision 
 into it, but did not evacuate any pus. I also 
 removed with the scissors some of the thickened 
 integument from around the anus. 
 
 The patient remained in a weak unsatis- 
 factory state until October 13th, when I again 
 
117 
 
 saw him and found him very low ; he had had 
 a rigor the day previously* and on examination 
 of the anus there was a large unhealthy ulcer- 
 ated surface in the situation of the ligature* 
 and a profuse discharge issued from it. He 
 got worse and died on the 18th. 
 
 This was clearly a death from pyaemia* and 
 there can be no doubt from the circumstances 
 noted that the cause of mischief was the pre- 
 sence of the ligature : for even assuming that 
 the pyaemic mischief resulted from the second 
 operation of making the incision* that step was 
 undertaken for the relief of the inflammatory 
 action which had set up on the side of the 
 buttock where the ligature had been used ; 
 whereas* on the other side where the clamp 
 and cautery had been employed* no such action 
 had occurred. I deeply regretted I had not 
 used the clamp for the larger tumour, ybut 
 at that time I had not sufficient confidence 
 in it. 
 
 The second fatal case occurred in July* 1866* 
 and was a very sad case. The patient was a 
 gentleman, aged 35* who was seen by me in 
 consultation with Dr. Budd and his two medi- 
 cal attendants. He had suffered a long time 
 
118 
 
 from most exhausting haemorrhage* and when 
 I saw him he was in such a feeble condition 
 that he looked like a person about to sink from 
 some malignant disease. He had had a tre- 
 mendous attack of haemorrhage only two days 
 before we saw him* and he was in such a state 
 that it appeared as though another such attack 
 would destroy him. It was Dr. Budd’s opinion 
 that an operation should be undertaken as soon 
 as possible* in order to prevent such another 
 occurrence ; but on all of us consulting* it was 
 thought better to keep the patient at perfect 
 rest* nourish him well* and delay a few days. 
 There was a large mass of mucous membrane 
 protruded at each action of the bowels* and 
 the act itself was very painful and exhausting. 
 
 On the 25th I operated with the ligature. I 
 found the parts in such a vascular condition 
 thafe large quantities of blood escaped through 
 the punctures made by the needle. The 
 operation itself was a prolonged one* in con- 
 sequence of the size and number of the 
 tumours necessary to be ligatured* and the loss 
 of fluid — for it could hardly be called blood — 
 from the vessels was large. I took the pre- 
 caution of tying the ligatures very tightly* but 
 
119 
 
 an oozing went on after the operation, and it 
 was necessary to plug the rectum in about 
 four hours ; there was no rallying at all, and 
 the patient died next day. 
 
 It might appear to some that this patient 
 was not in a condition to bear any surgical 
 operation, but it was a question whether he 
 should stand the chance of one or die from 
 another attack of haemorrhage ; the former 
 alternative was, without hesitation, agreed 
 upon. 
 
 I did not use the clamp and cautery, because 
 I was not even at that time sufficiently ac- 
 quainted with its power, and of necessity the 
 operation would be a very prolonged one ; but 
 I question very much now whether the styptic 
 power of the actual cautery would not have 
 completely commanded the bleeding, and I am 
 perfectly certain that by this latter operation 
 the bleeding during the proceeding would not 
 have been anything like so great ; in fact, with 
 a well-made clamp and very careful execution, 
 no blood at all should be lost during the 
 process. 
 
 I dare say that my experience with the 
 ligature has been unfortunate in an especial 
 
120 
 
 manner ; for doubtless there are surgeons who 
 have operated in many cases and have not 
 met with any fatal result. Still this occurs 
 every now and then* and if it does take place 
 in private practice, it is not known except to 
 those immediately concerned ; thus, for in- 
 stance, I may mention that one of my own 
 patients, whom I was treating with nitric acid, 
 suddenly got tired of me and my plan of treat- 
 ment, and in a few days I heard of his death, 
 which had followed the operation of the liga- 
 ture in three days. 
 
 The operation by the improved clamp, as 
 above described by me, offers, then, the great 
 advantage of safety above the ligature, for 
 there has not been any death from the opera- 
 tion in my hands, nor have I heard of one 
 occurring in the practice of those other 
 surgeons who have employed it, and it seems 
 hardly possible that any danger can be con- 
 nected with the proceeding beyond that of 
 haemorrhage ; and to prevent that has been 
 the especial object of the alteration in the 
 mechanism of the instrument; and all those 
 who have seen me perform this operation are 
 well aware that this object has been fully 
 
121 
 
 attained. Haemorrhage, as a result of the pro- 
 ceeding, can only he due to a want of care 
 on the part of the surgeon — that is, if he 
 employs the clamp I describe — for he has no 
 business to finish the operation until every 
 bleeding point be cauterized. It will he seen 
 that in one of my earlier cases considerable 
 amount of blood was lost, but this was the 
 result partly of haste and carelessness, and of 
 the use simply of nitric acid as a cauterizing 
 agent. I am more particular in insisting upon 
 the freedom from haemorrhage, during and after 
 this operation as I am aware it has been 
 assumed that such may occur. Even so ex- 
 cellent a surgeon as Mr. De Morgan, in some 
 clinical remarks published lately, held this out 
 as the great objection to the use of the clamp 
 and cautery ; but I maintain that if the sur- 
 geon uses such ordinary care as he adopts in 
 other cases, and employs well constructed in- 
 struments, any great or even moderate loss of 
 blood is impossible at the time of the opera- 
 tion, and as to its occurrence as a secondary 
 phenomenon it has not been my lot to meet 
 with a single instance out of all the cases of 
 haemorrhoids and prolapsus where secondary 
 
122 
 
 bleeding has taken place. Of course if a sur- 
 geon is careless and does not adopt the proper 
 means, haemorrhage will ensue here as at any 
 other operation where important vessels are 
 interfered with ; but then he must be careful 
 not to omit any of those precautions which are 
 found necessary. It is necessary to see that 
 the clamp be well screwed up before the tumour 
 be cut away, and above all the cautery must be 
 liberally applied, in severe cases especially, and 
 the blades of the clamp must be gently and 
 gradually released by means of the screw in 
 the handles, so that if any vessel be unsealed 
 it can be at once recognised and closed by the 
 hot iron. I know there has been severe bleed- 
 ing in some cases, but I am sure the precau- 
 tions I have been sketching have not been 
 followed out. It is not probable that either 
 tetanus or pyaemia, the two most formidable 
 results of the ligature, can occur after this 
 operation, because the condition which pro- 
 duces the former affection does not obtain, viz., 
 the presence of an irritating substance around 
 the nerves for several days ; and pyaemia, or 
 other inflammatory affections, will be effectu- 
 ally prevented as the exposed surface is de- 
 
123 
 
 prived of its vitality and the veins are blocked 
 up by the cauterization. Another and great 
 advantage is, as I shall be able to show you, 
 that patients are not detained above half 
 the time in bed as is consumed when the 
 ligature is applied, and the convalescence 
 altogether is much more rapid ; and in this 
 hard-working age the saving of time is of the 
 utmost importance to a patient who is com- 
 pelled to give up his business or other occupa- 
 tions for the purpose of undergoing an opera- 
 tion; indeed, in many instances patients are 
 debarred from submitting to the operation of 
 the ligature in consequence of the necessary 
 time consumed in the convalescence. 
 
 I have detailed some cases where the ligature 
 was used, and where the patients were con- 
 fined to bed or to their house for a period of 
 many weeks, and in numerous instances where 
 the hsemorrhoidal tumours, or the prolapsus, 
 is large, a week or ten days elapse before the 
 ligatures entirely separate, and as much more 
 time goes away before the patient is able to 
 leave his bed ; whereas in by far the majority 
 of cases where the same disorders have been 
 treated by the clamp the patients have been 
 
124 
 
 able to get out and about in from four to seven 
 days. In some cases, even after the first 
 evacuation of the bowels, which is generally 
 obtained by the action of medicine on the 
 fourth day, the patient feels able to get out 
 of his bed and to walk about ; and I have 
 more than once known patients insist upon 
 travelling home long distances on this occur- 
 ring, because they feel so well. It is quite 
 evident to all who have watched the course 
 of cases equally severe, treated by the liga- 
 ture and the clamp, that there is not anything 
 like that impression upon the nervous system 
 after the latter proceeding which is produced 
 as a result of the former, and which occasion- 
 ally causes death. It is impossible for any 
 surgeon conscientiously to tell his patient that 
 there is no danger whatever after the ligature ; 
 but this may be most truthfully stated with 
 regard to the operation by my improved clamp 
 if the most ordinary precautions are taken to 
 prevent bleeding. I have often been asked 
 whether any secondary bleeding has occurred, 
 or is likely to occur ; but to this question I 
 may answer that I have not had a case of 
 secondary haemorrhage proper ; in two or three 
 
125 
 
 instances a more or less quantity of blood has 
 discharged itself on the first evacuation of the 
 bowels, but I have every reason to believe that 
 this was some blood which had collected in the 
 rectum, at the time or immediately after the 
 operation ; there may, of course, be a possibility 
 of some secondary bleeding, but, when we con- 
 sider the action of the cautery when thoroughly 
 applied, we can understand how extremely 
 unlikely such an occurrence is. 
 
 When I first began to remove hsemorrhoidal 
 tumours with the clamp I used as the styptic 
 agent the strong nitric acid, and in certain 
 cases I found that if the raw cut surface was 
 fairly and thoroughly impregnated with it the 
 haemorrhage would be effectually arrested. I 
 continued using it in several instances until an 
 occurrence, which I will mention by-and-by, 
 took place, which determined me to employ 
 the actual cautery in all the more severe cases ; 
 and although the nitric acid serves the pur- 
 pose of stopping the bleeding in instances 
 where the part to be removed is not large 
 and not very vascular, as a general rule I 
 would recommend the employment of the 
 actual cautery, not heated to quite a red heat. 
 
126 
 
 as then the tissues are not too extensively 
 burned. 
 
 This treatment is equally applicable for the 
 removal of internal haemorrhoids or prolapse of 
 the rectum; in the one instance the entire of 
 the tumours are taken away, and in the other 
 the redundant tissue, which forms the disorder, 
 may be also thoroughly removed. In those 
 cases, however, of prolapsus where the affection 
 is associated with or has been produced mainly 
 by a dilated and weakened state of the ex- 
 ternal sphincter, the surgeon must not be con- 
 tent with alone removing the mucous mem- 
 brane, he must at the same time take away 
 with a curved pair of scissors three or four 
 folds of the loose skin over the sphincter, 
 otherwise the prolapsus will return in course 
 of time, and discredit will be thrown upon 
 the treatment. Should there also be any re- 
 dundant tissue in the form of tumours or con- 
 dylomatous growths, it should be also taken 
 away. In those cases where the prolapsus is 
 associated with distinct hsemorrhoidal growths 
 it will be sufficient to remove these, and then 
 the prolapse will be cured without any other 
 treatment, unless there be at the same time a 
 
127 
 
 great relaxation of the sphincter* when, of 
 course, some of the integument must be taken 
 away, the incisions being made at right angles 
 to the anal orifice. 
 
 In order to prevent the possibility of any 
 contraction of the rectum from a too free 
 ablation of the mucous membrane, I almost 
 invariably make my patients pass for them- 
 selves a full-sized, black-wax rectum bougie 
 two or three times a week. This treatment 
 is serviceable, both in healing any ulceration 
 which may have remained as the result of 
 the operation as well as in preventing the 
 occurrence of any contraction, should exten- 
 sive removal of tissue have been needful ; and 
 with reference to any ulceration remaining 
 after this operation, I may with truth say I 
 have never met with anything of the kind 
 after my own operations. Sometimes, when 
 the disease has been extensive, the ulceration 
 necessary on the employment of the clamp and 
 cautery may not have entirely healed up for 
 three or four weeks, but I have not seen any 
 of my own cases where an ulcer has remained 
 unhealed, as occurs after the separation of 
 the ligature. I saw one case where a medical 
 
128 
 
 practitioner, in the country, had operated for 
 haemorrhoids two months previously with the 
 clamp and cautery, and when the patient con- 
 sulted me he was complaining of a good deal 
 of pain on evacuating the bowels, and on ex- 
 amination I found an ulcerated surface on the 
 anterior part of the rectum, probably an un- 
 healed portion of the sore left by the opera- 
 tion, but of this, even, I could not be sure, as 
 I did not see the patient before. 
 
 I shall now give, briefly, the details of my 
 experience on the use of the clamp in haemor- 
 rhoids and prolapsus, and you will have an 
 opportunity of judging how far correct are the 
 anticipations of those surgeons who, like myself, 
 consider that this treatment is, as regards safety 
 to life, freedom from unpleasant and annoying 
 consequences, and rapidity of cure, far superior 
 in a large proportion of cases to the employ- 
 ment of the ligature. 
 
 Since the period at which I commenced the 
 use of the clamp, which was in July, 1861, I 
 find that I have treated thirty-five cases either 
 of internal haemorrhoids or prolapsus of the 
 rectum in this way. All of these cases required 
 some surgical operation ; some of them were 
 
129 
 
 very severe instances of the disorders, and I 
 doubt not that in every instance most surgeons 
 would have employed the ligature. I shall 
 now give, briefly, the details of each, reserving 
 any comments for those cases which are more 
 particularly worthy of attention. 
 
 Case I. — An old Indian officer, aged seventy, 
 had suffered for many years from haemorrhoids 
 and prolapsus. Latterly they had troubled 
 him to a great extent, protruding whenever he 
 took exercise. On examination I found a pro- 
 lapse of the mucous membrane on the right 
 side, and on the left was an haemorrhoidal 
 tumour of a dark-blue colour, nearly as large 
 as a walnut. I operated upon him July 31st, 
 1861, compressing the tumour within the clamp, 
 and after removing it applied nitric acid, which 
 arrested the bleeding. No bad symptoms fol- 
 lowed ; the bowels were acted upon by castor 
 oil on the fourth day, with scarcely any pain, 
 and the patient was up on the fifth day. He 
 called on me in two weeks, and said he was 
 quite cured. I saw this gentleman in May, 
 1864 ; he remained quite well. 
 
 9 
 
130 
 
 Case II. — A gentleman* aged fifty* long resi- 
 dent in India* consulted me for prolapsus of 
 the rectum* which had annoyed him very much 
 of late. On examination there was a large 
 protrusion of the mucous membrane* and very 
 vascular. I operated on March 7th* 1862* 
 with the clamp* applying the strong nitric acid 
 to the cut surface. There was some smart 
 bleeding at the time of the operation* but it 
 was effectively arrested. This patient rapidly 
 recovered* and was out on the sixth day. 
 
 Case III. — A gentleman* aged forty-seven* 
 long resident in the East* suffered from bleed- 
 ing piles for fifteen years* but for the last three 
 years the haemorrhage has been constant and 
 accompanied with painful protrusion; the health 
 was much deteriorated ; he was pale and blood- 
 less. On March 9th* 1862* I operated upon 
 him with the clamp* removing four very vas- 
 cular internal haemorrhoids and applying nitric 
 acid. No bad symptoms resulted* and he came 
 up from the country to see me on the 20th. 
 The bowels acting naturally* without pain* pro- 
 trusion* or bleeding. 
 
131 
 
 Case IV. — A lady, aged fifty, consulted me 
 for the relief of an haemorrhoidal tumour of 
 the size of a cherry which bled and had annoyed 
 her for several years. I operated on her March 
 20th, 1862, with the clamp, using nitric acid 
 to the bleeding surface. The haemorrhage was 
 effectually arrested, and she suffered scarcely 
 any pain. This lady called on me in ten days, 
 quite well. 
 
 Case Y. — M. D — , aged forty-five, consulted 
 me for two internal vascular piles, for which 
 he had been treated by nitric acid without 
 benefit ; he had been annoyed for a long time 
 with them. I operated on him April 7th, 1862, 
 with the clamp, using nitric acid as the styptic. 
 Although the tumours were very vascular, the 
 bleeding was effectually arrested. This patient 
 was up in five days, and left London for Scot- 
 land in ten days. I heard from him a few 
 weeks ago ; he tells me he has remained quite 
 well ever since. 
 
 Case VI. — Mr. P — , aged fifty, was ope- 
 rated upon for a very vascular haemorrhoid 
 and prolapsus, May 18th, 1862, by the clamp 
 
132 
 
 and nitric acid. This patient was out of my 
 hands by the 26th. Two tumours were re- 
 moved. I saw the patient in November ; he 
 remained quite well. 
 
 Case VII. — A middle-aged lady, long resi- 
 dent in India, had complained of haemorrhoids 
 for many years ; during the last two years they 
 protruded so much, even when she began to 
 walk, that she was compelled to wear a rectum 
 truss, which probably only increased the mis- 
 chief. She was in a very feeble, miserable 
 state, and on examination I found three large 
 internal haemorrhoidal tumours. It was a very 
 severe case, and I was anxious that she should 
 have the ligature applied, but she could not 
 overcome her dread of it, and I therefore 
 operated on her by the clamp, removing the 
 three tumours, and applying nitric acid on the 
 25th of June, 1862. The haemorrhage was 
 exceedingly smart, and, as the patient was so 
 weak, and the nitric acid did not appear 
 thoroughly to control it, I, for safety 5 sake, in- 
 cluded two or three bleeding vessels in a thin 
 ligature. The operation was of necessity a 
 very severe one, but no bad symptoms came 
 
133 
 
 on, and, although her convalescence was pro- 
 tracted over three weeks, she made an excel- 
 lent recovery, being completely cured of her 
 haemorrhoids. 
 
 Case VIII. — M. S — , aged forty, had three 
 internal haemorrhoidal tumours of long stand- 
 ing. I operated on them July 29th, 1862, 
 applying nitric acid, and completely arresting 
 the bleeding. This gentleman did so well that 
 he left London for the north of England in 
 exactly one week. 
 
 This was the first case in which I used the 
 clamp with the screw attached to it ; and this 
 improvement was suggested to me by the 
 result of the case last detailed, where I was 
 obliged to tie the bleeding vessels. The great 
 value of this addition to the instrument was 
 at once perceptible to myself and those gentle- 
 men who were in the habit of assisting me. 
 
 Case IX. — A middle-aged lady, in a very 
 weak and nervous condition, from long persist- 
 ing hsemorrhoids, was operated upon by the 
 clamp and nitric acid, July 30th, 1862. Two 
 large internal tumours were removed, no 
 
134 
 
 haemorrhage followed, and, although the con- 
 valescence was protracted for a period of three 
 weeks, she returned home free from protrusion. 
 
 Case X.— Mr. B — , aged thirty, was 
 operated upon by the clamp and nitric acid 
 for a considerable prolapsus of the rectum, 
 August 11th, 1862. No unpleasant result 
 happened, and he was at the Exhibition on the 
 sixth day. 
 
 Case XI. — A gentleman, aged fifty, was 
 operated upon by the clamp and nitric acid, 
 August 18th, 1862. I removed a large pro- 
 lapsus on one side and a heemorrhoid from 
 the other. This gentleman had been operated 
 on three years previously by a well-known and 
 able surgeon, who had used the ligature. No 
 bad result followed my operation. Bowels 
 were opened on the fourth day, and on the 
 sixth he returned home into the country, taking 
 a long journey. 
 
 Case XII. — C. M — , aged forty, was 
 operated upon by the clamp and nitric acid for 
 a severe prolapsus, in King’s College Hospital, 
 
135 
 
 August 23, 1862. There was no haemorrhage; 
 the bowels were opened on the fourth day, and 
 on the next day he was discharged from the 
 hospital. 
 
 Case XIII. — A man, aged forty-five, suffer- 
 ing from severe prolapsus, consisting of the 
 entire circumference of the mucous membrane, 
 very vascular, was operated upon by the clamp 
 and nitric acid, in King’s College Hospital, 
 Sept. 5th, 1862. The operation was a severe 
 one ; three clamps were used at three different 
 points ; the bleeding was smart, but the nitric 
 acid effectually checked it, and the patient 
 suffered very little. The bowels were opened 
 on the fourth day, and the patient was 
 discharged on the seventh. I saw this man a 
 year afterwards ; he was quite well, and had 
 had no return of the prolapsus. 
 
 Case XIV. — A gentleman, aged forty-eight, 
 was operated upon by the clamp and nitric 
 acid, Sept. 20, 1862. There were two internal 
 haemorrhoids of long standing situated very 
 high up, and so close together that I was 
 tempted to include the two in one clamp ; 
 
136 
 
 and haying removed them* I applied the nitric 
 acid thoroughly. Two hours after the operation* 
 I was summoned* and found unmistakeable 
 signs of haemorrhage. On introducing a bivalve 
 speculum* a large quantity of blood came away* 
 but by pressing the blades well up against the 
 sides of the gut* and introducing ice* the 
 bleeding was soon arrested ; there was* how- 
 ever* loss of blood to a considerable extent. 
 But the patient did not keep to the house 
 more than a week* and seemed to suffer very 
 little. I have recently seen this gentleman* who 
 tells me the cure has remained permanent. 
 
 Now* I must say a word or two about this 
 case* which would seem to favour the view of 
 those who agree that haemorrhage is one of the 
 objections to this operation ; the fact is* the 
 occurrence was entirely the result of my own 
 carelessness and haste. I attempted to clamp 
 the two tumours together* which was a great 
 mistake ; for after excision a portion of the cut 
 surface* in which there must have been some 
 considerable vessel* had escaped from the grasp 
 of the blades* and had not been cauterized. 
 Moreover* I think that in such cases as this 
 the nitric acid should not have been used 
 
137 
 
 — the actual cautery should have been em- 
 ployed. 
 
 Case XV. — An elderly man was operated 
 upon by the clamp and nitric acid for a 
 prolapsus, in the out-patient room of King’s 
 College Hospital, December, 1862. He walked 
 home some distance the same afternoon, and 
 visited me on the fourth day without any com- 
 plaint. He said he had suffered very little 
 after the operation. 
 
 This is the only instance in which I have 
 operated and allowed the patient to walk out 
 on the same day ; although the case succeeded 
 very well, I do not think it was a very wise 
 experiment, nor would I recommend such a 
 course of proceeding. 
 
 Case XVI. — General C — , aged seventy- 
 two, was operated upon with the clamp, for 
 extensive prolapsus of the rectum, on December 
 21st. The whole circumference of the bowel 
 was down constantly, causing much annoyance. 
 The parts were very vascular. I accordingly 
 applied the actual cautery to the raw surface. 
 The pain was but slight, and the bleeding was 
 
138 
 
 thoroughly arrested. The General kept his 
 bed for three entire days only, was up at my 
 house on the fourth day, and on that evening 
 travelled 300 miles by the night mail. 
 
 Case XVII. — A man, between fifty and 
 sixty, with a very bad prolapsus of the rectum, 
 was operated upon with the clamp and actual 
 cautery, January 15th, in King’s College 
 Hospital. Three large portions of mucous 
 membrane were removed. On the fourth day 
 the bowels were acted upon without any sign 
 of prolapse, and he left the hospital eight days 
 after the operation, quite convalescent. In 
 October following I saw him; there was no 
 trace of the disorder. 
 
 Case XVIII. — This patient was not strictly 
 under my care, but I was called into consulta- 
 tion upon it by my friend, Dr. Wiblin, of 
 Southampton, who had seen me operate with 
 the clamp at the hospital, and was so pleased 
 with what he saw that he was determined to 
 adopt it on the first occasion. Captain S — , 
 aged forty, had suffered for many years from 
 an immense prolapsus, attended with profuse 
 
139 
 
 bleeding, but had always been frightened to 
 undergo any operation. The nature of the 
 proceeding by my clamp was explained to him, 
 however, by Dr. Wiblin, and' he consented. 
 Accordingly, on February 7, 1863, 1 went down 
 to Southampton, and assisted Dr. Wiblin in 
 the operation. There were four distinct large 
 protuberances forming the tumour which 
 required removal ; each of these was separately 
 clamped and removed, and the actual cautery 
 was carefully applied. The vascularity was 
 excessive, but the cautery sufficed to arrest all 
 bleeding. The operation was of necessity a very 
 severe one, and the patient would take chloro- 
 form. Everything went on well afterwards; 
 the bowels were opened by medicine on the 
 fourth day without pain, haemorrhage, or pro- 
 lapse ; and I met him at Dr. Wiblin’s house 
 two weeks after the operation, perfectly well. 
 Dr. Wiblin was in London lately, and in- 
 formed me that Captain S — remains per- 
 fectly well. 
 
 Case XIX. — John Baker, aged forty-nine, 
 had been a patient under the physicians at 
 King’s College Hospital, with pyrosis and indi- 
 
140 
 
 cations of some organic diseases. He was weak, 
 emaciated and sallow, and was terribly troubled 
 by a large prolapse of the whole circumference 
 of the mucous membrane of the rectum. He 
 was in that condition which would entirely 
 forbid any operation by the ligature, but I did 
 not hesitate to employ the clamp, much to the 
 astonishment of some of my friends at the 
 hospital. I removed the entire disease, April 
 11th, 1863, using the actual cautery. I re- 
 moved three segments or tumours, and found 
 the parts so exceedingly vascular that one 
 vessel gave me a great deal of trouble, and 
 seeing that the patient was so feeble I did not 
 like to chance the risk of any bleeding, and 
 accordingly included this vessel within a liga- 
 ture. The bowels were opened on the fourth 
 day, and the man left the hospital all right in 
 two weeks. 
 
 Case XX. — Mrs. P — was operated on with 
 the clamp and cautery for a single haemor- 
 rhoidal tumour, April 21st, 1863. She was 
 walking about on the fourth day. 
 
 Case XXL — Mr. S — , aged sixty-nine, was 
 
141 
 
 operated upon for two large haemorrhoidal 
 tumours , April 30 th, 1863, by the clamp and 
 actual cautery. Everything went on well. 
 The bowels were acted upon on the third day 
 without pain or bleeding, and he walked out 
 on the sixth day. 
 
 Case XXII— Major C — , aged fifty, came 
 to me, from Italy, for a prolapse of considerable 
 size. I operated upon him with the clamp 
 and cautery, removing two segments of dis- 
 eased membrane, May 13th, 1863. Bowels 
 were opened on the fourth day without bleed- 
 ing. On the sixth day the Major was at my 
 house, convalescent. 
 
 Case XXIII. — Dr. — was operated upon 
 with the clamp and cautery for a large inter- 
 nal haemorrhoidal tumour, August 24th, 1863. 
 On the fourth day he called upon me at my 
 house, and on the same day attended to his 
 hospital duties, and in five more days he got 
 married. I saw this gentleman the other day. 
 He remains quite well. 
 
 Case XXIV. — A man, aged twenty-six. 
 
142 
 
 was operated upon with the clamp and cautery, 
 September 1st, 1863. A large internal pile 
 was removed. He walked up to my house, a 
 distance of a mile, on the fifth day. I saw him 
 lately. He remains quite well. 
 
 Case XXV. — J. W — , aged forty, was ope- 
 rated upon with clamp and cautery, at King’s 
 College Hospital, September 6th, 1863. Two 
 large haemorrhoids being removed, the patient 
 left the hospital on the fifth day. 
 
 Case XXVI. — Rev. Mr. L — , aged forty- 
 one, almost bloodless from long-continued 
 haemorrhage, coming from a large mass of 
 internal piles, was operated upon with the 
 clamp and cautery, November 10th, 1863. It 
 was a very severe operation ; five distinct 
 tumours were removed, one of them as large as 
 a pullet’s egg. The haemorrhage was thoroughly 
 arrested. Retention of urine followed this 
 operation, but the patient was walking out in 
 a week. I saw this clergyman a few weeks 
 since, and he continues quite well. 
 
 Case XXVII. — Mr. G — was operated upon 
 
143 
 
 by the clamp and cautery, November 20th, 
 
 1863. Three internal haemorrhoids were re- 
 moved. Bowels were acted upon on the fourth 
 day* and on the sixth day he went out on a 
 visit. 
 
 Case XXVIII. — Mrs. S — was operated 
 upon with the clamp and cautery, November 
 22nd, 1863. This was a very bad case. The 
 woman had been much weakened by haemor- 
 rhage, and there were five distinct tumours. 
 No bad results followed, and she was up at 
 the end of a week, attending to her house 
 duties. 
 
 Case XXIX. — Mrs. S — was operated upon 
 by the clamp and cautery, February 6th, 1864. 
 Two large haemorrhoids were removed. She had 
 chloroform. She was up on the sixth day. 
 
 Case XXX. — Mr. S — was operated upon 
 by the clamp and cautery, September 13th, 
 
 1864. Three internal haemorrhoids were re- 
 moved. The patient lay in bed two days only, 
 and in a week he was quite convalescent. 
 
144 
 
 Case XXXI. — Mr. P — , aged sixty-three, 
 was operated on by the clamp and actual 
 cautery, October 1st, 1864. This was a very 
 severe case. Three large internal hsemorrhoids 
 were removed. There was such a large artery 
 divided in one of the tumours, that on un- 
 screwing the blades of the clamp it bled 
 furiously, and it was necessary to apply the 
 cautery repeatedly before it was sealed up. 
 The bowels were opened on the fifth day with- 
 out bleeding. The convalescence lasted over a 
 fortnight in this case, the patient being ex- 
 tremely weak and bloodless. 
 
 Case XXXII. — Rev. Mr. C — was operated 
 upon by the clamp and cautery for very severe 
 prolapsus of the rectum, November 7th, 1864. 
 Three large portions of mucous membrane were 
 removed. One part was very high up, and 
 unscrewing the blades of the clamp, a large 
 vessel bled fast. It was a very dark morning, 
 and the patient had undergone a long operation; 
 I therefore put a ligature around the vessel. 
 Retention of urine followed in this case for 
 five days. His bowels were acted upon on the 
 fourth day, a good deal of coagulated blood 
 
145 
 
 coming away. On the eighth day he called 
 upon me convalescent. 
 
 Case XXXIII. — Mr. H — was operated 
 upon by the clamp and cautery, November 8th, 
 1864. Two large internal haemorrhoids were 
 removed ; retention of urine followed for 
 twenty-four hours ; bowels were acted upon on 
 the fourth day, and on the fifth day he went 
 out. 
 
 Case XXXIV. — A man aged sixty-one was 
 operated upon by the clamp and cautery, in 
 King’s College Hospital, November 28th, 1864, 
 for very severe prolapsus of the rectum, of 
 twenty-five years’ standing. Three large pen- 
 dulous folds were removed. On the sixth day 
 he was up, and on the eighth day he was dis- 
 missed. He showed himself at the hospital 
 last Monday quite well. 
 
 Case XXXV. — A young married woman 
 was operated upon in King’s College Hospital, 
 for very bad prolapsus of fifteen years 5 standing, 
 December 10th, 1864. It was the last and 
 worst case I have ever operated upon by the 
 
 10 
 
146 
 
 clamp. It presented a good example of those 
 cases where the prolapsus is dependent — not 
 so much upon a morbid condition of the 
 mucous membrane, as upon a weakened state 
 of the sphincter — in this case, the anal orifice 
 was so dilatable that I could pass the whole 
 hand into the rectum. The poor woman could 
 not move about without the bowel constantly 
 descending, and she suffered much. I operated 
 upon her, taking away three large sections of 
 the mucous membrane ; and this part of the 
 operation being finished, I removed by curved 
 scissors, four long slips of integument from 
 over the sphincter, at right angles to the anal 
 orifice. She was under chloroform. No bad 
 results followed this severe operation. The 
 bowels were opened on the fifth day without 
 any sign of prolapsus ; and on the tenth day, 
 finding that the wounds were nearly healed, I 
 ordered her to get up. The anal orifice had 
 already become much more contracted. She 
 left the hospital in a fortnight after the opera- 
 tion quite well. 
 
 I have now given, as briefly as possible, the 
 record of my experience of this mode of treat- 
 ing cases of haemorrhoids and prolapsus ; and 
 
147 
 
 it appears to me that the result must be to 
 prove to the most sceptical that* at all events* 
 the treatment by the clamp and cautery 
 possesses the signal advantages which I have 
 claimed for it — viz.* safety* freedom from 
 subsequent annoying and serious consequences* 
 and saving of time. As regards permanency 
 of cure* the same result will obtain as after the 
 ligature for the affection is bodily removed 
 after the one operation as by the other ; and if 
 the disease should return at some future time, 
 the mode of operation should not be blamed* 
 because we know that very often the same 
 causes which originally produced the disorder 
 are still at work* and* in course of time, 
 if they are not obviated* they will be likely 
 to beget a similar condition of things* no 
 matter whatever plan of treatment has been 
 adopted. 
 
 Since these lectures were delivered I have 
 had much larger opportunities of testing the 
 value of the treatment by the clamp and cau- 
 tery. I have now treated by this means alto- 
 gether 120 cases* and* being emboldened by my 
 success* I have operated upon some of the most 
 
148 
 
 severe instances which can occur , and where 
 the parts were most vascular and supplied with 
 large vessels ; but I am happy to say I have not 
 met with a single case where any bad or even 
 unpleasant results have followed. I have used 
 the clamp in cases where I would not have 
 dared to do so at the times these lectures were 
 delivered, as I did not have sufficient faith in the 
 styptic action of the hot iron in instances where 
 there was reason to suppose there would be 
 considerably sized vessels divided ; I have, 
 however, succeeded in arresting the hsemor- 
 rhage in all cases, although I must confess that 
 in a few the vessels were so large that it was 
 needful to apply the cautery in a most liberal 
 manner and repeatedly before the bleeding 
 could be arrested. I believe, however, that I 
 err upon the side of a too free use of the cautery, 
 especially in private practice, and I think this 
 is proved by the fact that in my hospital cases 
 I use the hot, iron much less freely, feeling that 
 if anything should occur there is assistance to 
 be immediately obtained ; nevertheless, it has 
 not once occurred that bleeding has taken place 
 after the operation from the mucous membrane. 
 I would not, however, wish to recommend a 
 
149 
 
 careless use of the cautery, because it un- 
 doubtedly might happen that if great care be 
 not employed, bleeding might, to say the least, 
 be very troublesome, if not serious. 
 
 I have had occasion to perform the operation 
 on two patients twice within a period of six 
 months, the reason of this being that the 
 sphincter ani was so powerful that the parts 
 could not be well protruded before the opera- 
 tion in either case, and a haemorrhoidal tumour 
 was overlooked, and in course of time descended 
 and rendered it necessary that I should apply 
 the clamp again. 
 
 I have not met with a single case where any 
 contraction of the bowel has taken place, and 
 in one instance where the patient died twelve 
 months after a most severe operation from ma- 
 lignant disease of the bladder, I was enabled 
 to examine the part operated on, and the bowel 
 was apparently in quite a natural condition. 
 
 Since the last edition of these Lectures -were 
 published I have had a much further experience 
 of this operation, and I have operated between 
 two and three hundred times in every kind of 
 case, and in some of the utmost severity, and of 
 enormous size, and at all ages, from the 
 
150 
 
 beginning of manhood to its very extreme ; and 
 I am glad to say that this extended experience 
 convinces me more and more of the value of 
 this plan of treating severe cases of haemor- 
 rhoids and prolapsus, and of its applicability, 
 especially to cases of this disease, where the 
 surgeon would not venture to perform the 
 operation by the ligature. I am glad to find 
 that the operation is practised by many not 
 only in Great Britain, but also over our colonies 
 and in America. The numerous communica- 
 tions I have received bear witness to the 
 estimation in which this plan of treatment is 
 held. I still insist upon the almost absolute 
 safety of the operation itself, although in two 
 instances death followed it. I felt it my duty 
 to make these two cases known to the pro- 
 fession, and a reference to the details, published 
 in my article on the “ Diseases of the Rectum/’ 
 in Holmes’ f System of Surgery,’ will show 
 that the cases were quite exceptional, and that 
 the deaths were due to causes independent of 
 the operation itself. I may mention that I 
 have not had a single case where any of those 
 particular effects which ensue upon the ligature 
 has happened, viz. pyaemia, tetanus, secondar 
 
151 
 
 haemorrhage, or long continued ulceration and 
 abscess. 
 
 I shall not detail many of the cases on which 
 I have operated since the lectures were deli- 
 vered, but shall pick a case here and there out 
 of my note book, which will further illustrate 
 the value of the treatment in the more severe 
 forms of these diseases. 
 
 Case XLI. — Mrs. F — > aged fifty-five, was 
 recommended me by Mr. Altmann, of Caroline 
 Street, Bedford Square. 
 
 April, 1865. — She was in a deplorable con- 
 dition, having suffered for two years from hae- 
 morrhage from the rectum. On one occasion 
 her life was greatly imperilled by the large 
 quantity of blood lost. Previous to my being 
 consulted she had seen an eminent physician, 
 who considered that she was suffering from 
 some malignant disease of the liver ; but as she 
 was so much reduced by haemorrhage, it was 
 thought justifiable to perform an operation. 
 
 On the 25th I operated with the clamp and 
 cautery, removing one large internal pile — there 
 was no haemorrhage nor other bad result. And 
 although this lady was in a wretchedly weak 
 
152 
 
 condition from the draining of blood which had 
 been going on, she was able to walk about in 
 two weeks after the operation. Mr. Altmann 
 wrote to me some time afterwards to say that she 
 had gone quite well, and that her supposed 
 malignant disease of the liver had entirely 
 vanished since the haemorrhage had been 
 stopped. 
 
 This was a case well showing the value of 
 the treatment, for the patient was in such a 
 state that any prolonged suffering after the opera- 
 tion might have produced serious consequences. 
 Moreover, from the great loss of blood expe- 
 rienced, she would be especially prone to pyaemia 
 from the use of the ligature. 
 
 Case XLVIII. — Mr. M — , aged forty-eight, 
 sent to me by Dr. Reginald Read. This gentle- 
 man was in a weak and exhausted condition from 
 the effects of haemorrhage which had been going 
 on from the rectum. He had suffered more or 
 less from prolapsus for nearly twenty years, and 
 he had consulted an eminent surgeon some time 
 previously, for the purpose of having something 
 done, but being informed that the operation — 
 that by ligatures — would necessitate with- 
 
153 
 
 drawal from business for two or three weeks he 
 would not consent. 
 
 I operated on 28th July, removing the entire 
 circumference of the rectum ; there was not 
 any bad symptom following, and he was able 
 to go to his place of business on August 1st. 
 
 This case illustrates one great point upon 
 which I have insisted, and this is, that the con- 
 valescence is much shorter than when the liga- 
 ture is used, and although this may be a matter 
 of no moment to some, it is all important to 
 men like this patient, who had a very large 
 business to superintend personally. 
 
 Case XLVIII. — Mrs. M — , aged seventy- 
 four, had been troubled with a large prolapsus of 
 the rectum accompanied with profuse discharge. 
 She w r as sent to me by her son, a physician, who 
 wished me to operate with the clamp if 1 thought 
 fit. Although she was so aged, I did not hesi- 
 tate to recommend the operation, and on Sep- 
 tember 20th I removed three large segments 
 of mucous membrane by the clamp, wdiilst she 
 was under the influence of chloroform. The 
 operation was a severe one ; but the bleeding 
 was completely commanded, not a single bad 
 
154 
 
 symptom came on, and the old lady was down 
 in her drawing-room in a week. 
 
 This case shows the advantage of this plan 
 of operating on old persons. I suppose there 
 are few surgeons who would like to operate in 
 a severe case with the ligature, on a patient of 
 seventy-four. 
 
 Case L. — Mr. S — , aged fifty-two, had suf- 
 fered from haemorrhoids for many years, and 
 when I saw him in September he showed me a 
 large mass composed of several internal piles, 
 one of which was nearly as big as an egg and 
 very vascular, the whole forming a large tumour. 
 
 He was a very nervous, highly scientific 
 man, knew all about the particular kinds of 
 operation for these diseases, and on my telling 
 him that I would not object to use the clamp 
 in his case, he elected to submit to this 
 operation, which I performed on Sept. 21st, 
 while he was under chloroform. The tumours 
 were so large and so very vascular that the 
 operation was of a very prolonged and severe 
 character, the cautery being required repeatedly 
 before I could arrest the bleeding ; this, how- 
 ever, was done effectually, and not a single bad 
 
155 
 
 symptom arose, and he was walking about his 
 garden exactly one week after this severe 
 operation. 
 
 This was the most severe case I had operated 
 upon with the clamp, and the fact of my being 
 able completely to control the bleeding in this 
 instance gave me such confidence, that I felt I 
 might be able to remove with the clamp any 
 hsemorrhoidal tumour, however large or vas- 
 cular. 
 
 Case XCVII. — Mr. D — , aged seventy-five, 
 consulted me in May, 1867. He had a large 
 prolapsus which had troubled him for many 
 years, and had now become unbearable. I 
 operated May 4th, removing several folds of 
 mucous membrane. He was able to walk out 
 on the 9th. 
 
 This case also shows the safety of this kind 
 of operation at an age where it would not' be at 
 all prudent to use the ligature. 
 
 Case Cl. — Rev. M. B — , aged sixty, came 
 to me from the West Indies, May, 1867. He 
 had suffered terribly from prolapsus of the 
 rectum for many years. About twenty years 
 
156 
 
 before, he had been operated on by the ligature 
 in Edinburgh, with only partial relief. His 
 complaint returned in the West Indies, and 
 latterly became so unbearable that he was 
 determined to throw up his duties and come to 
 England. Dr. Dennehy, of the Royal Mail 
 Service, sent him to me. 
 
 The prolapsus was enormous, nearly as big 
 as the fist, and I almost hesitated to use the 
 clamp ; however, the sphincter ani was so 
 dilated, and there was so much loose skin 
 around, that it appeared to me the employment 
 of the clamp, together with the liberal use of the 
 scissors outside, might offer a fair chance of 
 cure, and I therefore proceeded to operate May 
 29th. I removed three large segments of 
 mucous membrane with the clamp, and applied 
 the cautery liberally. The bleeding was very 
 free, and one vessel especially gave me a deal 
 of trouble, but the haemorrhage was thoroughly 
 arrested, and did not recur. This patient 
 suffered but little after this severe operation. 
 I made him keep very quiet, and on the 7th of 
 June I completed the operation by removing 
 freely with the curved scissors all the redundant 
 tissue around the anus. 
 
157 
 
 A good deal of irritation followed this second 
 operation, and a return of the prolapsus took 
 place, and I was fearful that here at least I 
 should meet with a failure ; but I carefully 
 reduced the prolapsus, which I found to be in 
 a sloughy condition, and kept the bowels com- 
 pletely locked up for several days. They were 
 acted upon by castor oil on the 13th without 
 any recurrence of the prolapsus, and on the 
 15th he was able to take a drive. He went off 
 to his native city, Edinburgh, in a few days 
 more, and wrote to me thence a month after to 
 say that he was quite recovered, and had not 
 had any return of his prolapsus. 
 
 If any case were needed to show the value of 
 this treatment in the most severe forms of the 
 disease, we have it here. It is impossible to 
 exaggerate the severe nature of the case ; and, 
 although I do not think that the employment 
 of the clamp and cautery alone would have 
 sufficed to bring about a cure, it formed a most 
 important part of the treatment. 
 
 Case CXX. — Mrs. — , aged forty, was 
 admitted into King’s College Hospital, in 
 September, under my care, in the most deplor- 
 
158 
 
 able condition from prolapsus both of the 
 uterus and rectum* to an immense extent* and 
 of long duration. On examination there was 
 a most extraordinary appearance of two large 
 tumours* or rather one bilobed tumour ; the 
 anterior consisting of the prolapsed uterus, the 
 posterior of the whole of the lower portion of 
 the rectum* the latter being remarkable by the 
 bright* soft velvety appearance of the mucous 
 membrane* which was quite healthy. On 
 further examination* it was found that the 
 anus was greatly distended* and the sphincter 
 correspondingly weakened* so as to give no 
 support whatever. In fact* the poor woman 
 was in a most pitiable state. 
 
 As the mucous membrane of the rectum 
 seemed in a healthy state* and the prolapsus 
 was dependent in a great measure on the 
 weakened state of the sphincter* I thought it 
 might be remedied by removing longitudinal 
 folds of the skin at right angles to the anus* 
 and then applying strong nitric acid to the 
 mucous membrane in order to ensure contrac- 
 tion. I performed this operation a few days 
 after her admission* and kept the bowels quiet 
 for some time. The effect of this proceeding was 
 
159 
 
 to produce some improvement, and lessen the 
 size of the prolapsus ; hut after the wounds had 
 fairly healed I found that there was still con- 
 siderable prolapsus when the bowels were acted 
 upon. Accordingly, on Nov. 9th, I operated 
 with the clamp and cautery, removing four 
 large segments of mucous membrane ; there 
 was great vascularity, and one artery bled so 
 freely after the clamp had been removed, that 
 I was obliged to apply the cautery again very 
 freely. No further bleeding took place, and 
 when the bowels acted on the fourth day there 
 was no prolapse whatever ; the remedy was 
 further severely tested by a violent diarrhoea 
 which attacked her eight days after the opera- 
 tion, but which produced no return of the 
 malady, and she was dismissed from the 
 hospital on the twelfth day, freed from the 
 annoyance of the prolapse of the rectum. 
 
 This severe case also illustrates the necessity 
 of a combination of the clamp and scissors ; the 
 free use of the latter, together with the nitric 
 acid only, gave some relief; but when the 
 superfluous mucous membrane was removed, 
 the contraction which was produced both in- 
 ternally and externally, was sufficient to pre- 
 vent the gut from falling. 
 
160 
 
 One of the advantages which I claim for this 
 operation is, that it may be applied in certain 
 cases where it would not be prudent to use the 
 ligature in consequence of the very slight 
 constitutional disturbance which is produced. 
 Thus, we every now and then meet with in- 
 stances of severe haemorrhoids or prolapsus 
 where the local complaint is most distressing, 
 and where at the same time there are some in- 
 dications of some mischief in the brain or spinal 
 cord. Now, in such cases where it becomes 
 almost absolutely necessary to perform "some 
 operation, I believe that the application of 
 ligatures would be attended with considerable 
 danger, but I would not hesitate to use the 
 clamp. I will give illustrations of two such 
 cases. 
 
 Case CLXXYIII. — A labouring man, aged 
 56, was sent into King's College Hospital, in 
 September, 1869, with a very severe prolapsus 
 of the rectum, which troubled him very much ; 
 but in addition to this, he had a very curious 
 kind of paralytic affection which had existed 
 for about three years. He could scarcely walk 
 across the ward without assistance. As his 
 
161 
 
 prolapsus was so troublesome to him I did not 
 hesitate to recommend the removal of the pro- 
 lapsus by the clamp and cautery. I performed 
 this operation on the 25th. I had to remove 
 four large folds of mucous membrane ; not the 
 slightest bad symptom of any kind occurred, 
 and the patient left the hospital in a fortnight. 
 
 Whilst this case was under treatment, one of 
 a very similar character, and in like manner 
 illustrating the peculiar advantages of this 
 operation, occurred in private. 
 
 Case CLXXX. — Mr. W— , aged 56, was 
 sent to me by Mr. Johnson, of Congleton. The 
 patient had been for many years a great 
 sufferer from prolapsus of the rectum, accom- 
 panied at former times with severe bleeding ; 
 this, however, had latterly altogether ceased, 
 but as usual under such circumstances the 
 local malady had become much more trouble- 
 some, and he was compelled to wear a pessary, 
 which, however, gave him no comfort. He 
 had, moreover, of late years become affected 
 with a kind of general paralysis, being able to 
 move only with difficulty, and scarcely able to 
 dress or undress himself. In other respects 
 
 11 
 
162 
 
 the health was good, and the intelligence was 
 quite clear. 
 
 On September 30th I operated on the patient, 
 whilst he was under the influence of chloro- 
 form, and I removed four large folds of mucous 
 membrane with the clamp, using the cautery 
 very freely. Not a single bad symptom 
 occurred ; the patient was out for a drive in 
 eight days, and he returned to Cheshire before 
 a fortnight from the date of operation. 
 
 Now, in both of these cases, but more espe- 
 cially the latter, I would not have dared to use 
 the ligature, because such a large mass of tissue 
 would have to he tied in either case, and we 
 know that the effect of this operation, as well 
 as the continued presence of the ligatures, is to 
 produce a considerable shock upon the nervous 
 system, and if there be — as in a case which I 
 know of where death occurred suddenly after 
 the ligature — some decided symptoms of disease 
 of the nervous centres, it would be most 
 imprudent to use the ligature, but as I have 
 repeatedly shown that the use of the clamp and 
 cautery is scarcely ever followed by any amount 
 of constitutional disturbance, I have no hesi- 
 
163 
 
 tation in preferring this operation in instances 
 where relief is urgently called for. 
 
 It is not necessary for me to detail more cases. 
 Those related will, I trust, well illustrate the 
 truth of my propositions— that the treatment by 
 the clamp and cautery, if properly adopted, is 
 free from danger, that it is followed by much 
 less suffering than if the ligature were em- 
 ployed, and that in general the convalescence 
 is much shorter. 
 
 PRINTED BY J. E. ADLARD, BARTHOLOMEW CLOSE.