EXAMINATION.
After obtaining something of a history of the case, you will have ascertained whether or not there is an inordinate protrusion at stool, its nature and if it has to be replaced. In the latter event the patient is directed to go to the closet or use a commode and make an effort to strain out the bowel. If not successful, use an injection of warm water, or select a time immediately after the usual hour for evacuation, which, if it occurs early in the day, may be deferred by the will power of the patient to a later hour.
This will bring to view any and all large hemorrhoids located on the upper margin of the internal sphincter, as well as those situated between the sphincters, their being caught in the grasp and button-holed like by the external muscle.
Should the prolapse not be sufficiently great or the piles sufficiently large to be thus caught and held out for inspection, let the patient lie on either side, with knees well drawn up, and instructed to strain down and extrude the parts as much as possible, assisting by gently pulling down and everting the mucous membrane at the verge of the anus with the thumbs. It is always better to precede by an injection of warm water, which may not only unload the rectum and give the patient greater confidence in the effort to extrude the parts, but washes away the mucous and retained feces in and about the sphincters. When the examination has been carried to this point and no satisfactory cause found to explain the trouble complained of, the finger and speculum will be required to complete the diagnosis.
The finger is of little use in diagnosing soft hemorrhoids that form on the upper margin of the internal sphincter and lay back in the rectal pouch; being hindered by the pressure of the muscles and a like feel imparted by the bowel.
Bear in mind that you need not look for hemorrhoids higher up than the upper margin of the internal sphincter, a distance of not more than an inch from the verge of the anus, and if of any appreciable size, will always show at stool. Where to look, what to look for, and how to find it, is a question that often confronts the beginner, and it will not be out of place here to firmly impress the following rule: See all that can be seen and treat all that can be treated without the aid of a speculum.