"The procedure thus far described, it will be noticed, is applicable only to hemorrhoids which can be brought outside the sphincter by an effort of the patient or the surgeon. Manifestly I have described the simplest first. The others, and they are the majority, require some little manipulative skill in the use of the speculum and some deftness of touch.

"When the tumor cannot be extruded it will be necessary to work through a speculum, and one of cylindrical shape as large as can be used without too great stretching and with considerable bevel on the end will best answer the purpose. If the beveled end is introduced to the location of the tumor the latter will readily protrude into it and the subsequent steps are exactly the same as already described in cases where the hemorrhoids protrude from the anus. No forceps for holding the tumor are necessary. The speculum can be controlled with the left hand and the rest of the work done with the right.

"Do not be in haste to remove the speculum after the cattery has been used and before making sure there is not too free hemorrhage. Generally, almost always, the oozing from the puncture will cease as soon as the speculum is withdrawn and the parts return to their normal position, but sometimes there will be enough blood to worry the operator, and while the speculum is still in sit he may think it best to introduce the cattery needle again at the same spot and at a dull red heat to control this bleeding by a fresh cauterization. A better way, however, when the oozing causes anxiety is to introduce a tampon of gauze through the speculum and leave it in contact with the spot. A small tampon will give pressure enough; one which can remain till the patient goes next time to the closet, and very rarely will any at all be necessary.

"The variety of hemorrhoid which causes the most difficulty is that which is in great part composed of the vessels and tissues at the margin of the anus. I do not mean the grape-like external venous tumor, which should always be treated by incision, but the internal tumor of long standing and considerable size, which is only manifest when the patient strains and then shows itself as a swelling on one side of the anus covered by the skin, but which cannot be extruded sufficiently to show the upper part covered with mucous membrane or be distinctly defined. These are apt to cause more trouble by this or any other method of treatment, because any wound (incision, ligature, or puncture) which involves the margin of the anus will always cause more pain and swelling than one confined to the mucosa of the rectum above the sphincter.

In such cases the tumor is best brought within reach with a bivalve speculum, one blade of which is largely defenestrated This should be introduced with the fenestration over the tumor, slightly opened, and then withdrawn until the hemorrhoid is pulled down by it into view. With the speculum holding the tumor thus within reach the eucalypti and cattery are applied exactly as in the other case.

"And now as to results. For at least fifteen years I have practiced this method without an accident. There has never liven an abscess or anything approaching it; never a moment of uneasiness on account of any bad result. A very few times, not more than half a dozen at the outside, have I had to reintroduce a speculum and put in a small tampon, as described, before I cared to allow the patient to leave the office, and this is the only difficulty I have ever encountered. The treatment, if not crowded too frequently, is almost pain-less, both at the time and subsequently, and it will certainly cure any case upon which it is used with sufficient thoroughness. But I do not consider the cure as radical as with either the ligature or the cattery There is by this method a connective tissue tumor left in the rectum where there was before a vascular one. The blood vessels have been in part occluded and there is no more bleeding. The tumor has been so reduced in size that there is no longer any protrusion. The patients are, as far as they know, cured. But I usually warn them that after a few years (three, or four, or five) there may be some return which can easily again be cured by a few more of the same applications. Some of them return. many never do, because they remain without symptoms.

"Finally 1 should like to be understood as not claiming that this, method has any advantages over the clamp and cattery except the single one of avoiding general anesthesia. All I have ever claimed for it is that it is a safe, painless, and efficient method of relieving and curing a great many patients who would otherwise condemn themselves to lifelong suffering simply from an exaggerated fear of a surgical operation under ether.

"While upon this subject it has often been a surprise to me that more advantage is not taken of primary anesthesia. There is a moment in the preliminary stages of weatherization when half the operations upon the rectum can be done without the patient's consciousness, provided the surgeon is a fairly rapid operator and the patient is placed in the proper position before the weatherization is begun. This does not particularly appeal to the patient, however, because to him ether is ether, be it much or little, and an operation is an operation, whether it be done slowly or quickly; but it enables the surgeon to do a good deal of work in his office for which a hospital would otherwise be necessary."