Surgery of the Rectum and Anus. By ~IR. ~ED. HAMILTON. 329

population deteriorated, puerperal fever epidcmlc. Chloroform with some is a very petty subject, not of" more moment than shaving the pubis for u hernia operation--a subject of no literary interest, one not to be found in the classics of` Sydenham or Abernethy. I have even heard it urged, at our first London hospital, that as our "grand- mothers" did without it, so ought the women of the present day; but such arguments would equally apply to metallic ligatures, or ligatm'es at all in surgery, as our predecessors stopped hemorrhage with actual cauteries--they would apply to the use of vaccination; they, in a word, stop all progress, and our science if not progressive is mischievous. Indeed, our want of" progress in anesthetics in England is leading to the quacks undertaking i t - - a curious and instructive fi~ct, but one we have not any desire here to follow. Morton's battle in America this year, in the Congress, as to the original discovery of` the anesthetic properties of` ether, the greatest event of the nineteenth century, excites no interest comparcd to our " shopkeeplng" esteem for secret compounds of chloroform (discount off f`or ready money), and encouraging prejudices against its use, especially in obstetric practice. The right observer rather studies nature and asserts what is true, avoiding prcjudlce and popular error, caring not for repulse or fashion.

" Nec sumit, aut ponlt secures Arbltrio popularis aurm."

ART. XVII.--Contributions to the Surgerj of the Rectum and Anus. By EDWARD HA)IILTON, F.R.C.S.I . , one of the Surgeons to Steevens' Hospital.

/

The T~eatment of ttemorrl~oids by tile ]s sweeping denunciations which have been uttered against this mode of treating piles by some authors of high practical character have created a strong prejudice against its employment, and tended much to restrict its f`air t r ia l ; though for some time biassed by these opinions, more matured experience and extended obscrvation have convinced me that were the merits of` the 5crascur to stand on this one application to the purposes of practical surgery, it would be ~airly entitled to a place in our armamentaria cldrurgica. Mr. Ashton thus stigmatizes the instrmncnt : ~ " Anot]ter plan for tlte removal of hemorrhoids and ot]ter growt]ts emanated in Paris,

330 Contributions to the Snrge~ of the

and became a fashion for a time, but happilj, in England, at least, is now little practised. I allude to their ablation by that crushing, laeeratinj, and unscientific machine, the deraseur, which in appearance and operation suggests the idea of belonging rather to the tortnre chamber qf by-gone clays than qf beinfl an i~strument qf modern surgery, i}[. Au reports that maw/ who have been o])erated on bj it are now the victims of traumatic stricture of the rectum." An able reviewer of Mr. Ashton's book in the pages of this journal designates it as " a recent innovation not likely to find fi~vour in our sight." Mr. Curling objects to its use, as being sometimes followed by hemorrhage; being tedious, and being likely to be the cause of contraction of the anal aperture.

To claim for the dcraseur that its operation is always fi'ee from untoward results, would be to assert what is equally untrue of the l igature--of every surgical appliance to which we resort, as well as of everything human--but I am fiflly satisfied that under impartiM trial in cases to which it is not inapplicable, it will realize an amount of success, at least, equal to the mcthod so fl'equently placed in antagonism to it.

Ligature is only applicable to internal piles; and when employed fbr the removal of the external form of the disease has produced a train of consequences which have, without due discrimination, been blindly attributed to the ligature however applied, and have been urged against its use altogether. The same train of f'fllacious reasoning has been adopted against the dcraseur, which should only be employed in internal piles ; and of these there are certain varieties with a broad base in which ligature or some other mode of treat- ment would be preferable; our plan of operation must be suited to each particular case, as thcre is nothing more calculated to impede the progress of enlightened surgery than the blind pursuit per fas ant nefas of special modes of treating particular diseases, to the exclusion of all other means. The fiact which I would place before the profession is this, that in cases where it is applicable, which experience teaches me it is in the great majority of cases of internal hemorrhoids, the 4crascur is nmch to be prefbrred to the ligature.

Le t us for a moment dispassionately examine in detail the objections which have been urged against its use.

Hemorrhage, primary or secondary, is only likely to occur where the movcment of' the instrmnent has been made with too great rapidity; and although blood to a small amount does issue from the

Rectum and Amts. By MI~, ED. HAMILTON. 331

surf~ace of the pile during its removal, or from those adjacent to it, from contact with the chain of the instrument, even this may, with care, be avoided, and I have never seen it cause any trouble. Secondary hemorrhage has not presented itself in any of the cases in which I have employed this instrument. The instances in which it has been recorded may be explained by some unusual coincidence ; possibly some peculiarity of the patient's constitution, or too hasty an application of the instrmnent, as it is an established fact, that in the rcmovM of other growths equally vascular, immunity from hemon'hage, primary and secondary, has been very generally accorded to the dcraseur by the weight of surgical authority. While, on the other hand, cases have occurred in which very severe and alarming hemorrhage has been known to follow the use of the ligature, both at the time of its application and subsequently at its separation, so much so that Mr. Salmon advises that for several hours after the operation by ligature the patient should not be left without some one at his bed-side capable of acting in the event of this contingency. Thus, hemorrhage may be the result of one operation as of the other--in both, however, being the ex- ception, not the rule. The second objection to the instrmnent, that its application is tedious and clumsy, is, I think, equally un- founded, as, assuredly the five or ten minutes required for the removal of piles by the dcraseur can be most favourably contrasted with the time required for the perfect securing of the ligatures, the painful gash at the side of the bowel, the tightening of the cords in the open wound, and the ten days necessary fbr their detachment, during which period they relnaln in the reetmn receptacles of filth--a source of unceasing irritation and distress; whereas on the second or third day after the operation by the dcraseur all soreness has passed away, and the patient suffers no further inconvenience, and his mind is set at rest when he is satisfied that the operation is completed.

Let us now pass to the third and most serious charge laid at the door of this operation--its tendency to cause contraction of the anal orifice. The authority of M. Nelaton has been put prominently forward in support of this objection. He states (I quote fl'om Mr. Curling, being unable to lay my hand on the particular number of the Gazette des H~pitanx) : --" During about a twelvemonth I have seen a great number ofpatlents, who have come to me in order to u~dergo an operation to remedy lids u~jbrt~tnate eonseque~ce of tl~e removal of hemorrlwidal tumours. The stricture sometimes scarcelg admitting

332 Surgery of tl~e Rectum and :t nus. By MR. ED. HA~IILTON.

the passoffe of a quill." But M. Nelaton, further on, states what has not been quoted by some of those who cite l~s authority : --" I t l~as arisen because not only the mucous projection, which alone constitutes the disease, ]~as been removed, but, al.~o, a more oz' less co~siderable portion of t]~e skin at tke orifice of tbe anus." Thus it appears either that the 4craseur was employed in the removal of external piles, for which it is comparatively unsuited, or else was manipulated without the ordinary caution which even the simplest and most trifling operation requires at the hands of the conscientious surgeon.

The same imprudent destruction of the iutegmnent, at the verge of the anus, whether brought about by the ligature, by caustics, by the knlfc, or by the (~erascur, will alike produce the same untoward and discreditable consequences.

These views have not been put forward rashly, or without having been submitted to the test of absolute practical observation for a considerable time.

The writer has employed this treatment in ahnost evm T case of internal piles, before large classes of students and practitioners ir~ the surgical wards of Stcevens' Hospital, and with a degree of success which encourages him to continue the practice; the field of observation being peculiarly favourable--the greater number of cases occurring among the Constabulary patients, who are under constant surgical supervision during their entire service in the force, and would have been returned to the hospital had they experienced any of the serious results attributed to the operation, which they themselves would not be likely to conceal; and I am not aware of a single instance in which the disease has reappeared, or the patient has applied for the relief of symptoms which could be attributed to the use of the 6eraseur. In private practice it is often difficult to determine the resnlt of such operations; as, should they be attended with want of success, or any bad after-con- sequences, the patient is not likely again to consult the same practitioner; which is also much the ease even with our ordinary applicants for hospital relief.

In the management of these cases one or two matters demand careful attention in order to ensure success. As before stated, this instrument should, almost entirely, be restricted to the removal of internal piles of the longitudinal and peduneulated variety. The broad fiat pile at the verge of anus, denominated, by Mr. B. Cooper, the intero-external pile, may best be treated by transfixion with needles coated with nitrate of silver, leaving the points bare--a

Dn. WEBE~ on the Climate of tl~e Swiss Aljos, ~'e. 333

plan first brought under my notice by my esteemed colleague, Dr. ~Vilmot, and which I have seen carried out with the best results, and have myself frequently practised. In the ulcerated bleeding pile, or the vascular excrescence, no method has yet been devised equal to nitric acid, as recommended by Mr. Cusaek and Mr. Houston. The administration of chloroform is not desirable in this operation, unless in very nervous or excitable individuals, as the pain of operating on internal piles does not usually require it; and it is open to the objection that it certainly induces excessive prolapse of the bowel, whereby the surgeon is often led to remove too much of the mucous membrane and sub-mucous tissue. Chlorofi)rm, likewise, appears very much to increase the congestion of the parts, and thus to develop

tcndcncy to hemorrhage. For similar reasons it is not, in the generality of cases, necessary, nor is it expedient, to draw down the piles with harpoon-like hooks or forceps. As in all operations on the rectum the bowels should b~ wcll cleared out bv a brisk purge on the morning of the operation, chalk mixture and tincture of opium being administered on that and the following day. A pledget of fine cotton wool may be placed on the small wound, which I have never seen attended with any trouble or difficulty in healing. T],e ~craseur with a double action is to bc preferred to that in which one end only of thc chain is acted on, as in this movement it passes over the pcdicle of' the pile after the manner of a saw, producing laceration and a more open wound, with greater disposition to hemorrhage, although I have mysclf used the latter as being of ~iner make.

ART. X V I I I . - - N o t e s on tlze Climate of tlte Swiss Alps, and on Some of tl~eir Ifealtlz Resorts and Spas. By HERBIANN ~VlgBER, M.D.; F.R.C.P. , London; Physician to the German Hospital in London.

(Continued frown No. LXXIII.--Feb., 1864.)

IT is not my intention to give, in the present communication, a description of the health resorts and spas of the whole of the Swiss A1ps; but, I shall confine myself principally to the eas~ern portion of Switzerland, and especially to the cantons of the Grisons, of St. Gall, and Appenzell. These cantons are much less frequented by the English than the regions of Central and Western Swltzcr- land, but they contain some of the most valuablc spas and health resorts; their scenery is, at the same time, in many parts, of

VOL. XXXVII., NO. 74, ~. S. 2 A