The most convenient way, perhaps, of applying nitric acid, when the tumours can be protruded, is to encircle their base with an instrument which will at the same time hold them in their situation, and make sufficient pressure to prevent hemorrhage in case they should be disposed to bleed. If necessary, any portions of the hemorrhoidal tumours, or of the mucous membrane, may be removed with a pair of curved scissors, and the cut surfaces immediately wiped dry, and touched with the acid. If the application of the acid be made before any bleeding has taken place, the blood in the divided vessels will become coagulated, and the vessels permanently healed.

Care must be taken in performing this operation, when any portions of mucous membrane have to be excised, that the pressure completely commands the hemorrhage; for if any blood escape from the part it will become mixed with the acid, and thus prevent it from effectually acting upon the surface to which it is applied. The instrument

which is best adapted for restraining the hemorrhage under these cirstances, and for holding the prolapsed tumour in position, consists of two parallel curved plates of steel with their internal edge slightly indented. These are connected together at their extremities, and by means of a screw or spring may be made to exert the exact degree of pressure required.

There is a large class of cases which generally pass under the common name of piles, which have not an inflammatory origin, and are not connected with any particular enlargement of the hemorrhoidal veins. In the cases alluded to, the inconvenience arises from portions of the relaxed mucous membrane becoming inverted and being griped by the muscular fibres situated at the lower part of the rectum.

The insensibility of the mucous membrane in this complaint frequently causes the symptoms to be referred to the neighbouring parts, and therefore the disease may exist without being recognised. A patient will complain of a dull pain over the sacrum, or a heavy aching pain in the perineum which neither he nor his surgeon can satisfactorily account for. In the course of time some other symptom presents itself, which draws attention to the rectum. The usual internal remedies for piles may now be administered, but these are found to produce no ultimate benefit, since the disease depends upon a mechanical cause.

In cases where the mucous membrane of the rectum has thus acquired an habitual disposition to “bag,” it frequently happens that no medicine applied either generally or locally will afford permanent relief. The loose folds of membrane, which may or may not be connected with hemorrhoidal tumours, will descend again and again, and sometimes keep up irritation in the part for years.

Permanent relief in such cases can only be afforded by such means as tend permanently to brace the mucous membrane of the bowel. The simplest, as well as the most efficacious method of accomplishing this is to remove one or two longitudinal folds of mucous membrane in

the same way as above recommended for the removal of hemorrhoidal tumours. It is not necessary to remove the precise portion of membrane which has been protruded. The destruction of any portion after the wound has healed will have the effect of bracing the remainder. In this, as in the operation for hemorrhoidal tumours, it is the process of cicatrisation which cures the disease.

These observations, published in 1848, have been fully confirmed by increased experience. The application of the strong nitric acid to hemorrhoidal tumours of all kinds has now become very general, and there appears at present some danger lest this very useful remedy should be brought into discredit by being indiscriminately applied to all cases.

No satisfactory account has, as far as I know, been hitherto published, giving a description of those cases in which the application of the nitric acid alone is required, and those in which this will not prove effectual. To attempt to supply this deficiency and to describe the mode of proceeding which I have adopted where the application of the nitric acid alone is not sufficient, are the principal objects of the present communication.

A distinction might be drawn between different kinds of hemorrhoidal tumours founded on their different anatomical characters; but since these characteristics are themselves continually undergoing changes, such a distinction would be of little practical value.

The cases which are met with in practice may be much more simply and conveniently divided for the purpose of treatment into those which bleed, or are composed of a soft vascular substance; and those which do not bleed, or are formed of firmer tissue.

1. For the first of the two classes of cases, the application of the nitric acid is an excellent remedy, and in the great majority of instances no other means of surgical treatment are required. The nitric acid, when applied, penetrates the substance of the tumour, and produces its effect as described by Dr. Houston, either by causing a superficial slough or by obliterating the vessels of the part. It possesses the very great advantage of giving very little pain if properly applied, of not requiring the confinement of the patient, and of being, as far as I have seen, perfectly safe.

[Where the mucous membrane, by exposure and by constant attacks of inflammation, has lost its character and become more of an articular character, though the application of nitric acid does no harm, yet it does not effect much good, because it does not cause contraction by producing a cicatrix.]

Whenever there is reason to believe that the application of the nitric acid alone will not act sufficiently upon the mucous membrane, the plan I have now for some time adopted is as follows:-the affected parts are first made to protrude, and then embraced by a broad forceps, made upon the plan of the instrument described by me in 1848.

The instrument consists of two parallel thin blades, with their opposed surfaces roughened, and closing by means of a spring. This may be made to exert any degree of pressure which may be required. With this instrument the prolapsed part is seized, and such a portion of it as may be deemed expedient is cut off on the side of the "clamp" next to the operator with a curved knife made for the purpose. The cut surface is then touched with the strong nitric acid, or with the actual cautery. The parts are returned into their natural position, and the operation is completed. This plan is equally adapted for the removal of hemorrhoidal tumours, and the excision of portions of relaxed mucous membrane, where no hemorrhoidal tumours apparently exist. The forceps retain their hold of the base of the prolapsed part after the requisite portion is removed. The cut surface is thus prevented from either bleeding or retracting, and it is held in a convenient position for the application of the cautery or caustic. This application is as essential a part of the operation, as securing any bleeding vessels is after an operation in any other part of the body.

It will frequently happen that the parts cannot be sufficiently protruded to be conveniently seized by the forceps which I have described. I have then performed the operation very satisfactorily in the following way: a rectum speculum has a slide upon one side which may be removed; this is made to fit accurately into grooves on each side, so that by being withdrawn to a greater or less extent, a corresponding aperture is left in the side of the instrument. When the speculum is introduced, the slide is partially withdrawn, and the instrument moved about until the tumour, or the portion of mucous membrane required to be removed, closed, and the tumour is firmly held between it and the rest of the instrument; the projecting portion may then be cut off within the speculum by a long narrow knife, and the cut surface touched as before with the nitric acid, or with the actual cautery. Or, in case it should be deemed advisable to remove a longitudinal portion of the mucous membrane, the operation may be varied as follows:-the speculum, instead of being made single, is made double; that is there is one speculum within another so arranged that the outer one will revolve upon the inner. Each part

projects into it. The slide is then

has an oval aperture at its side; when these apertures correspond, a tumour, or portion of relaxed mucous membrane, will readily project into the speculum. When the part to be removed has thus passed through the corresponding apertures, the different portions of the instrument are made to revolve upon each other, and thus the aperture is diminished, until the condemned part is embraced between its opposite sides. Being thus firmly held, the operation is completed as above described,

All the instruments which I have mentioned, are made by Mr. Matthews, of Portugal Street; and although they appear very simple now that they are finished, yet a considerable amount of time and patience have been required in order to get them adapted to their intended purpose.-Association Medical Journal, March 10, 1854, p. 211.

115.-TREATMENT OF HEMORRHOIDS BY THE GALVANIC CAUTERY.

By RICHAND STEEL, Esq., Abergavenny.

[In the present case the concentrated nitric acid had been applied, but had failed. It was determined to try the galvanic cautery.]

The apparatus which we have used for igniting the coil of platinum wire has been made by myself, and consists of a modification of Wollaston's battery of a dozen pairs, so contrived as to admit of being conveyed from place to place with the certainty of not deranging it; and it is set in action with ease and readiness when required. I had previously used a Grove's battery, which I had by me, but felt it desirable to arrange a battery better suited to be sent to a distance from home, and then found immediately ready for use.

The idea of using this plan of treatment for hemorrhoids was suggested to my mind on learning the satisfactory results of the galvanic cautery as used by Mr. Marshall, of University College Hospital, for the destruction of morbid growths, also for producing artificial contraction of mucous membrane, especially of that lining the vagina for the cure of prolapsus uteri. Having repeatedly employed the method so suggested for removing erectile tumours and semi-malignant growths, I was struck with the comparative painlessness of the application, and at once conceived the idea of applying it to the treatment of hemorrhoids. I was confirmed in the idea on examining a case requiring an operation, and which presented so large a mass of redundant matter, that I was anxious to avoid, if possible, inflicting the severe pain involved in the repeated use of the acid on the one hand, and the danger of hemorrhage following excision on the other. Here was a diseased mass to be destroyed, and relaxed mucous membrane producing prolapsus to be contracted; the loss of substance caused by the actual destruction of diseased tissue primarily, and subsequently

by the separation of sloughs, secured the first indication; the contraction of the cicatrices secured the second. The ignited platinum coil being applied more or less deeply, or over greater or less surface, will produce any amount of destruction of parts or of contraction that may be necessary. The smaller amount of pain and of danger to the patient is such, that I shall in future use it in the treatment of this disease, in preference to any other method with which I am at present acquainted.—Association Med. Journal, March 17, 1854, p. 246.

116.-Case of Hemorrhoidal Tumours treated by the Galvanic Cautery. By ELMES Y. STEEL, Esq., Abergavenny. In this case the patient had suffered from the tumours with prolapsion for thirteen years. He was so distressed with the complaint, that he had been compelled to leave the army. He had been under treatment in London, but had not obtained relief. Mr. Steel says:]

On examination, I found a mass, fully of the size of a cricket-ball, consisting of hemorrhoidal tumours, varying in intensity of colour and in degree of hardness, but all exquisitely tender to the touch. Having found by experience that the operation by ligature, however modified, was often followed by intense suffering, inducing irritative fever, whereas the application of concentrated nitric acid was always safe, certainly less painful, and frequently quite as successful, I determined upon using the latter method in the first instance.

Accordingly, on the 29th of last November, I applied the acid freely to the more prominent parts of the internal mass, avoiding the outer ring, which I had smeared with oil in the usual way. The pain thus occasioned was severe at the time, and continued for some hours, not altogether subsiding for several days, although not such as to require confinement to bed.

On December 4th, I found the hemorrhoidal mass somewhat lessened. A second and third application, at intervals of ten days, were followed by similar results; the hemorrhoidal tumours having sensibly yielded to the treatment, but still presenting a formidable appearance.

At this time, the suggestion of the galvanic cautery having been made to me by my cousin, Mr. Richard Steel, and he having supplied me with a battery of his own contrivance for the purpose, I determined upon resorting to it for the further treatment of the case.

On Jan. 18th, I proceeded to touch the more prominent of the remaining tumours with the ignited coil. The pain was comparatively so trifling, as to be thought insignificant; and immediately after the return of the gut, my patient walked about the house as if nothing had been done.

On February 8th, the parts which had been touched by the cautery were found to have sloughed away, leaving sulci, which will, I doubt not, on cicatrisation becoming complete, have effectually promoted the contraction of all redundant mucous membrane. The cautery was a