TREATMENT OF HEMORRHOIDS,
AND OTHER
Non-Malignant Rectal Diseases.
BY
W. P. Agnew, M. D.
SAN FRANCISCO, CAL.
R. R. PATTERSON, PRINTER, 429 MONTGOMERY STREET,
1890.
Entered according to Act of Congress, in the year 1890, by
W. P. Agnew, M.D., in the office of the Librarian of Congress at
Washington.
INTRODUCTORY.
In preparing this hand-book, the object will be to give in plain
and comprehensive language, as briefly as possible and with little
discussion, a few general rules, which if even approximately observed,
can but lead to success in the treatment of all non-malignant rectal
diseases commonly known, and for which the general practitioner will not
infrequently be called upon for relief.
Hemorrhoids, being by far the most common among this class of ailments,
and the greatest bone of contention regarding the best manner of
effecting a radical cure, will take precedence in our consideration, and
receive the attention that their importance and dignity justly merits.
It is an indisputable fact that until within the past few years,
an operation for the radical cure of hemorrhoids was considered so
formidable an undertaking, that their treatment, outside of palliative
measures, was almost entirely eschewed by the general practitioner.
“No fact is better known to the profession,” says Dr. S. S. Turner, U. S.
Army, “than that nearly all men, doctors not excepted, will suffer more
than the pain and inconvenience of a thousand operations, rather than
undergo an operation for removal by any of the methods in vogue. The fame
of some specialists who are distant enough to ‘lend enchantment to the
view,’ will generally induce people of large means when life has become
something of a burden, to place themselves under their care and take what
they offer.”
“But unfortunately, piles are by no means limited to people of large
means. The greater number of sufferers must take what the general
practitioner can give and will not take the cutting and crushing
operations until compelled by dire necessity, and are only too glad of a
less heroic alternative which offers them hope of relief. For this body
of sufferers, the operation by carbolic acid injection offers a means
of relief to which they will readily submit. In a sufficient number and
variety of cases to justify me in having an opinion upon the question of
its merits, I have never met with anything which I have regretted.”
With these stubborn and uncompromising facts confronting us on the one
hand, and a full appreciation of the superiority, the simplicity, the
safety and certainty of the operation by carbolic acid injection on the
other, the writer has no alternative other than to espouse, and proclaim
his honest conviction and hearty support in favor of the latter method
of cure; and essays to point out in this little publication, in a plain,
comprehensive and a practical way, what has been acquired by personal
observations and experiences, and all in all, believed to be the best
manner of applying this truly scientific and greatly superior method. A
method, the discovery of which, I feel prepared to say, marks an epoch in
the history of medicine, unrivaled in advancement by the treatment of any
other disease or class of diseases to which the human family is subject.
“There is no organ that is so prone to become diseased as the rectum.
There is no class of cases so little understood and treated as rectal
diseases. There are no diseases so annoying and painful, and at the
same time producing such dire results on the general system, directly
and reflexly, as rectal diseases. For years Rectal Surgery has been
principally in the hands of itinerants, whose remorseless greed for
money has caused them to treat for revenue only, and to play the vampire
on all that fall into their clutches. It is high time for the general
practitioner to gather up all the information possible, in order to be
able to treat all patients suffering from rectal disease, and thereby
drive the itinerants back to their previous occupation of tilling the
soil.”—(Yount.)
Nowhere in medical lore do we find suitable instructions whereby
the beginner may knowingly and intelligently engage in a rectal
examination—what to expect, where and how to find it, and how to pursue
each succeeding step in applying the treatment. Writers either presume
too much on the part of those who have not had experiences, or, are so
habituated to the use of general anæsthesia in accomplishing the objects
sought, that milder means have been seriously neglected. Finding many,
otherwise well informed practitioners, at a great disadvantage in this
respect, was a leading incentive to the hurried preparation of the
following few pages.
HEMORRHOIDS.
The division of piles into internal and external, is naturally suggested
by their observation and study, and clearly defined by designating
all hemorrhoidal tumors originating above and within the grasp of the
external sphincter as internal, while those situated external to or
outside of the external sphincter, when the latter muscle is closed and
the bowel not protruded, are external.
It matters not what form of tumor presents itself for treatment, whether
of the capillary variety, distinguishable in being of small size, flat
or sessile, made up of the terminable branches of the arteries, the
beginning of the veins and the capillaries which join them, punctated,
granular surface with thin covering and likely to bleed on the least
provocation, or the arterial hemorrhoid with the arteries and veins
freely anastomosing, larger, and presenting the glazed appearance of
a very ripe strawberry, liable to inflammation, erosion, prolapse and
hemorrhage; or the venous hemorrhoid, hard or soft, not very sensitive,
blue and sluggish, which Kelsey says may result from the other two
varieties or arise _de novo_ and bleed _per saltum_; or any form of
external hemorrhoid, cutaneous tag or like redundant tissue, they are all
treated alike and with like good results, by the operation of injection
and the use of the preparation herein recommended.
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.
DIAGNOSIS.
There is not much probability of confounding hemorrhoidal tumors with any
other abnormality in the vicinity of the rectum. The different varieties
of internal hemorrhoids, a description of which is given on page 7,
may confuse, but as stated before, no discrimination is necessary in
applying the treatment for the purpose of effecting a radical cure, the
one great object to be attained. Where several distinct tumors exist,
they are usually arranged in rows on either side, not up and down, but
antero-posteriorly, with the long diameter of each tumor at its base,
parallel to the antero-posterior diameter, or, if the muscles were
dilated, to the circumference of the rectum.
If situated on the upper margin of the internal sphincter there may be
several isolated tumors thus arranged on one side, while they may have
all coalesced, or originally have formed into one continuous hemorrhoidal
mass on the opposite side, Fig. 1. Or there may be one continuous
hemorrhoidal mass on either side, separated only by an anterior and
posterior commissure, Fig. 2. In some instances when the bowel is
prolapsed and constricted by the external muscle, the branches of the
middle hemorrhoidal veins that anastomose and encircle the upper part of
the internal sphincter, may be so dilated and distended as to present an
unsightly appearance, reminding the anatomist of the circle of Willis;
at the same time a few capillary or sessile tumors may be seen studded
around at different points.
[Illustration: FIG. 1.—Internal hemorrhoids prolapsed and held out by the
constriction of the sphincter. J. Junction of skin with mucous membrane.
E. Everted bowel.]
There can be no mistake in discriminating between a large hemorrhoid
and the bowel, but to distinguish a small, blanched hemorrhoid, located
on the upper margin of the internal sphincter from an irritated and
saggened portion of the bowel, when looking through a speculum, is more
difficult. The bowel presents a more smooth and continuous surface,
while the hemorrhoid is more uneven and irregular, and bleeds freely
when scratched. Sometimes a victim of piles will call and speak of his
piles having come down and are hanging out. On inspection a large fold
of mucous membrane will be seen protruding on one side, which has been
mistaken by physicians for a hemorrhoid, but the tumor will be found
immediately above and possibly on the opposite side.
From polypi hemorrhoids may be distinguished by their spongy like
texture, easy to bleed when scratched, more painful, history, shape,
manner of arrangement, etc. Polypi are considered as a hypertrophy of
the normal elements of the mucous membrane and the sub-mucous connective
tissue. If originating from the former they are soft, if from the latter
hard and fibrous, are often pediculated or club-shaped, sometimes grow
rapidly, not painful unless within the grasp of the sphincter, may arise
entirely above the sphincters, and are rarely of a glandular, villous
or bleeding surface. Should a mistake be made and a polypus thoroughly
injected, the result would be nothing more than a permanent removal of
the offending growth.
[Illustration: FIG. 2.—Prolapsed internal hemorrhoids, showing a
continuous hemorrhoidal mass on either side, with an arterial pile on the
left, all completely eradicated by two operations.]
The external hemorrhoid does not elicit the thought or command the
dignity of his neighbor, the internal pile, but usually makes himself
known more forcibly in his incipient stage of formation, caused by
the rupture of a venule of the inferior hemorrhoidal vein, allowing
extravasation and infiltration, which may lead on to inflammation and
suppuration, or the clot absorb and result in an external cutaneous
tag, subject to œdema, itching, induration, etc. On pulling down the
mucous membrane at the verge of the anus, sometimes a slight fullness
or bulbous-like expansion of an exposed part of a superficial vein will
be seen, which should not be mistaken by the novice for an incipient
hemorrhoid.
TREATMENT.
It is quite common for those afflicted with piles to call for treatment
while suffering from an attack, sometimes called the hemorrhoidal state.
This is not a favorable time to operate. Reduce all local congestion and
inflammation first, by palliative measures, such as hot water douches,
injections into the rectum of equal parts of Fl. Ext. Hamamelis and
Pinus Canadensis (dark) in a little water, or water and glycerine if the
latter is not repelled by an irritated bowel. At the same time open up
the portal circulation by the use of equal parts of sulphur and cream of
tartar, a teaspoonful in syrup or mixed with sugar, once or twice a day
for a few days, or any other suitable means to put the bowel and piles at
rest. Often patients will know what will relieve them of this condition
better than the physician, as what relieves one will sometimes aggravate
another.
In all cases of large growths, whether the patient is in a comparative
state of ease or not, a similar preparatory treatment before operation
will shrinken the tumors and lessen the tendency to local congestion and
pain. Sulphur should not be taken within two or three days of operation
since it continues its action about that length of time after dosage; but
the bowels should be sufficiently evacuated previously to enable them
to be held for four days afterwards, by any agreeable cathartic, or by
_flushing of the colon_. This will be unnecessary in the treatment of
small growths.
The same course should be pursued to expose the tumors for operation, as
was named under the head of examination. In some instances, where the
tumors are not very large but exceedingly irritable (arterial), it might
be quite difficult, even though the bowel be partially prolapsed, to
expose them sufficiently for a good operation. In such event, paint the
protrusion with a 5 per cent. solution of cocaine and allow the patient
to sit, for a few moments, over a vessel containing a small quantity of
steaming hot water. This will engorge the tumors, relax and materially
aid in handling the parts.
As a precautionary measure in _all operations by injection_, to prevent
the medicine from extending too deeply into the tissue of the gut by
gravity, or the overflow from running down on the outside of the pile and
over the bowel, let the patient lie on the side opposite to the tumor to
be treated, so that the preparation will gravitate to the apex rather
than its base of attachment.
[Illustration: FIG. 3.]
Smear vaseline on the opposite side of the bowel and anus and over any
piles that may show on that side, which, as the patient is now placed,
are on the lower or under side and will catch any and all waste and
overflow of medicine. As a further protection pack or hold absorbent
cotton underneath the tumor being operated upon. If the tumor be small
and partially obscured, the end of the finger may be held back of it to
act as a counterforce while introducing the needle; or a double, slide
tenaculum may be used to pull and hold it down for the same purpose,
being careful not to remove the tenaculum when once applied until after
the operation, as the least prick or scratch of a hemorrhoid will cause
a free flow of blood and greatly hinder the sight when it is desirable to
watch the action of the injection compound.
Should any portion of the injection compound fall on the muco-cutaneous
surface, unless the latter be heavily coated with vaseline, or protected
with cotton, it will excoriate and probably cause a great deal more pain
and soreness than the operation itself. In operating through a speculum
such risk is avoided by the sides and floor of the instrument, which
afford a protection to the surrounding parts; that is, if the precaution
regarding position when operating is duly observed, to wit: always
operate with the tumor pendent, or with its attachment on the upper side.
FORMULA.
Make a glycerite of tannin in the proportion of 4 drachms (Squibb’s)
tannic acid to 1 oz. (Price’s) glycerine. When the solution is complete,
add 2 drachms each of (Squibb’s) salicylic acid and borax, putting in the
salicylic acid first; stir over lamp, using a glass rod and porcelain
dish, until dissolved, being careful not to burn. If any dirt or sediment
be seen it had better be strained now through a piece of wet cheese
cloth, while yet hot, into a two-ounce vial.
Select a No. 1 grade of carbolic acid, say Calvert’s, and barely liquify
it by distilled water. Pour ½ ounce of the liquified carbolic acid in
a clean graduate, and add ½ ounce of the glycerite of the salicylate
of borax and tannin, previously made. Do not be sparing in giving the
carbolic acid full measurement, if not a little in excess.
When the combination is effected with the acid, a floculent precipitate
will occur, which should all clear up within two or three days,
otherwise something will be found wrong either in the purity of the
chemicals used or the manner of effecting the combination.
Too much importance cannot be attached to the purity of the ingredients
entering into this preparation, as anything unnecessarily irritating
should be scrupulously avoided. I have tried synthetic carbolic acid and
found the odor of tar decidedly stronger, and believe it much more acrid
and irritating than the commoner preparations. Neither can I see that
anything is gained in using vegetable glycerine.
Inject from 3 to 30 minims, or more, according to the size of the tumor.
There is no rule to regulate the quantity by count. The object is to
inject a sufficient quantity to permeate the entire substance of the
tumor, its texture being much more spongy than the surrounding tissue,
and not extend beyond its base of attachment.
Here is where many make a mistake in the injection of hemorrhoids. Some
are prone to use too much, even though the solutions be weak, and apply
it too deeply, reaching to and destroying the muscular coat of the bowel,
causing prolonged pain, deep sloughing, etc. While others use too little,
which may act as a foreign body or local irritant, producing a central
slough and a slow breaking down of the disturbed growth.
A tumor, properly injected, cannot inflame, because there is nothing
to inflame, the circulation is stopped and thus it is as effectually
strangulated as by a ligature, with the advantages of the immediate local
_anæsthetic_, _antiphlogistic_, _auterant_ and _antiseptic_ properties
of carbolic acid. The base of attachment heals, while the dead tissue,
which is rendered non-inflammatory and antiseptic, disintegrates and is
thrown off between the third and fourth day, a process that fortifies
against secondary hemorrhage.
There is a medium ground to be taken, in regard to the quantity as well
as the strength of carbolic acid to be used, with a little room for
variation on either side; yet there must, in point of reasoning and fact,
be a limit somewhere. If a little more should be used than is necessary
to permeate the entire substance of the tumor, the result will not be
disastrous, but may excite a little more local disturbance and pain. On
the other hand, if a little less be used, the operation will be equally
as effective and is probably the better side to err upon, provided the
discrimination be not carried too far.
A similar dilemma confronts us respecting the strength. After trying the
weaker solutions and watching their effects, I have concluded that the
solution should contain not less than fifty per cent. of carbolic acid,
combined with the glycerine of the salicylate of borax and tannin,[1]
the latter in such proportions as to produce an immediate astringent
effect. Tannic acid not only keeps the carbolic acid within limits by
its non-irritating astringent effect, but of itself combines with a
certain portion of the albumen of the blood and other tissue, forming an
_insoluble albumenoid_. The salicylic acid and borax, original with Dr.
Q. A. Shuford, of Tyler, Texas, gives the preparation more consistency
and seems to lessen the irritative properties of the carbolic acid.
[1] Original.
A weak, thin, watery solution, aside from doing poor work, is much more
liable to diffuse itself and be carried into the circulation like a
hypodermic of morphia, than a solution sufficiently strong to act as a
cauterant, destroying the tissue, forming a compact and an insoluble
coagulum and strangulating the circulation at once.
A solution, weak or strong, when deposited to any depth beneath the
surface, with live tissue and the circulation passing on all around
it, will of necessity excite pain, inflammation and a slough, the same
as a splinter in the flesh. The properties of carbolic acid being
non-inflammatory in their nature, will often, where a small quantity
is used diluted, produce an adhesive inflammation, an induration and a
contraction in a tumor, by destroying the capillaries where applied.
[Illustration: FIG. 4.—External hemorrhoid before operation.]
[Illustration: FIG. 5.—Three days after operation, with coagulum still
attached by pedicle.]
It is always desirable, when operating on external hemorrhoids, to see
that quite a goodly portion of the cutaneous surface, especially at
the summit, is effected by the preparation applied inside the capsule;
otherwise it will become inflamed in order to let out the interior
coagulum, which I have often seen come out on the third day intact, and
in one unbroken cystic-looking mass, Fig. 5. The same rule obtains
regarding internal hemorrhoids, having thick, unyielding coats.
Puncture the tumor at the most accessible point, preferably with the
needle, nearly parallel with, or at an acute angle to its base, carrying
the point of the needle to about the center of the tumor, if it be globe
shaped, or equi-distant from base to apex, if it be elongated, with the
face or opening of the needle toward the apex. Be sure the needle is
inserted beyond the proximal end of its opening, which is not always
observable in treating small growths; but may be tested by forcing the
piston of the syringe a little, and if the end is not sufficiently buried
the medicine will show around it on the outside.
Inject the first few drops the same as you would a hypodermic of morphia,
then slowly, drop by drop, watching its action by change of color on the
surface of the pile. This change of color on the surface is quite marked
with hemorrhoids of delicate covering, less so with those possessed
of more tough and fibrous coats. Hold the needle in position a moment
and if the quantity injected does not appear sufficient, turn the nut
on the piston with which you have previously gauged approximately the
quantity to be injected, back a few rounds and throw in more. Puncture
large elongated tumors in two, three, or four places. The compound
diffuses itself slowly and no doubt extends some farther than is always
apparent at the time of operation. Withdraw the needle carefully; it may
be necessary to force out a few drops of the preparation at the point
of entrance, for the purpose of sealing up the puncture to prevent the
escape of blood and medicine together, which, however, never amounts
to much. If, after withdrawing the needle, some of the injection fluid
runs out, unmixed with blood, take it up with absorbent cotton, since it
indicates that the quantity at that particular part is superfluous. Now
dry the surface of the tumor or tumors with absorbent cotton, smear with
vaseline and return within the bowel.
A tumor properly injected immediately becomes hard. There are septa or
compartments in elongated growths which do not permit the medicine to
pass through readily, and if a soft section is noticed, it has not been
penetrated, although will doubtless break down with the general mass.
I have seen a liberal injection into the middle one of three tumors
connected and arranged in a row, so cut into those on either side that a
single reddened column like appeared afterwards on the extreme outside,
(Figs. 6 and 7).
[Illustration: FIG. 6.—Three internal hemorrhoids before operation.]
[Illustration: FIG. 7.—After a liberal injection into the middle tumor.]
Large hemorrhoids must not be exposed too long after injection, since
there is always more or less swelling produced around the tumor by the
stoppage of circulation and the presence of a foreign body. Return the
side not operated upon first, then the other, and if the tumor has
considerable length, let it go in endwise. The patient can often return
the protrusion with least pain.
A little practice will enable any one to see the simplicity of the
entire procedure. If you should make a mistake when operating through a
speculum, and land the whole charge into a fold or saggened portion of
the bowel do not be alarmed, as it will only be a little more painful and
longer in healing. Injection into internal hemorrhoids is not painful to
any degree, therefore if the patient complains much you might suspect
that you are invading the tissue of the bowel. With some, the injection
into external hemorrhoids is quite painful at the first contact of
medicine, but immediately thereafter subsides. Where the tumor is very
sensitive, external or internal, precede by a hypodermic of from three
to five minims of a five per cent. solution of cocaine. Introduce the
needle point barely underneath the covering of the growth and force out
one drop. This will anæsthetize enough to allow further penetration, when
another drop can be thrown in. By this time you can approach the interior
to a sufficient depth to inject from three to five drops more, and
anæsthesia will be immediate and complete. There need be no fears from
cocaine absorption, since the carbolic acid compound will catch and hold
the cocaine all within the body of the tumor before it can be absorbed
and enter the general circulation.
From one to two hours after operation, the carbolic acid looses its local
anæsthetic effect and what I have called the after pain commences, caused
by the presence of a foreign body acting on the peripheral nerve at a
point where the line of demarkation forms. This pain varies in intensity
with the sensibility of the patient and surface of attachment of the
tumor or tumors. Some will not complain at all, saying the discomfort is
not as great as the suffering from an attack of piles; while others will
make considerable fuss, requiring an opium and belladonna suppository:
℞ Opii Pulv. Optim. gr. xii
Ext. Bellad. gr. iv
Ol. Theobrom. ʒ iii
M. et Ft. Sup. No. xii.
The pain does not usually continue longer than from twelve to fourteen
hours, unless aggravated by undue exercise, or other similar causes,
being replaced by a feeling of soreness, which is sometimes reflected
down the limb or up to the bladder.
The treatment after the operation should be markedly palliative: hot
water sponge compresses, hot water sitz-baths, and hot poultices are
great as long as pain and soreness are complained of, together with opium
suppositories, _pro re nata_. If the extent of the operation requires
constipation of the bowels, enemas should be dispensed with until after
the expiration of four days. Then hot slippery elm water, flaxseed tea,
or corn starch as prepared for stiffening clothes, may be used, as well
as a soothing suppository:
℞ Bism. Subnit.
Iodoformi ā ā ʒ i
Opii Pulv. gr. v-x
Ext. Bellad. gr. v
Ol. Eucalypti gtt. vi
Ol. Theobrom. ʒ iiss
Ol. Olivæ gtt. x
M. et Ft. Sup. No. xii.
The oil of eucalyptus will almost completely disguise the odor of
iodoform.
In old people who lack sufficient vitality to quickly heal a broken
surface, coat with bismuth, bismuth and oxide of zinc ointment, oxide of
zinc powder, reduced resin cerate, eucalyptol, etc.
Eucalyptol is a sovereign remedy to stimulate healthy granulatious,
after a broken surface has lost its freshness or acquired some age, in
the proportion of ½ dr. to 1 oz. oxide of zinc ointment, containing a
small quantity of stramonium or opium and belladonna. Or, ½ dr. to 1 oz.
vaseline with 1 dr. oxide of zinc.
Anything that excites and keeps up pain is hurtful. Severe, continuous
and prolonged pain is an indication that the changes are not going on in
a satisfactory manner. It should always be subdued as much as possible.
Suppositories containing glycerine, castor oil, or anything productive of
much pain, should be wholly discarded.
Temporary sympathetic paralysis of the bladder, or spasmodic stricture of
the urethra may occur, being relieved by hip baths or the catheter; the
latter is very seldom required. Enjoin as little straining as possible.
Many of the worst cases, in otherwise healthy people, will speak of
holding the bowels as being the greatest difficulty encountered during
the entire course of treatment. A little flatus will sometimes produce an
annoying titilation of the muscles. It has been suggested that a small
tube be introduced at such times for relief.
A certain amount of moisture begins to exude the second day after
operation, particularly noticeable from external hemorrhoids, and a
peculiar smell when the coagulum is thrown off. This should not be
interpreted as suppuration.
It would not be reasonable to suppose that all cases will behave alike.
The local and constitutional disturbance will, of course, depend upon the
size or surface of attachment of the tumor or tumors and the nervous and
physical condition of the patient. It is best to require patients to lay
up for a few days after operation on large hemorrhoids, or when more than
one of small size are taken, even though they do not complain.
In people enjoying average health, with internal hemorrhoids located
on both sides, take one side at a time, making two operations of the
treatment. In a case like Figure 1, not an uncommon form, it will be
better to operate on all the five smaller tumors first, while they are
exposed and kept out by the aid of the large one on the opposite side.
Should the large growth be taken first, it may be impossible for the
patient to hold down the bowel sufficiently afterwards to operate on any
one of the five small fellows, and a speculum will be called into use;
this will prolong the treatment, as few will submit to the operation on
and the manipulation of all five tumors through the slot of a speculum
at one sitting. Small isolated piles can be treated singly, and the
patients allowed to go about their business. It is these bad cases, where
the patient knows the importance, prepares and lays up for treatment,
that we should make as short work of as possible; those who have been
great sufferers, and possibly the operation on one small tumor would so
arouse the others that the suffering would be as much, if not more, than
if all had been treated at the same time. Not unfrequently the piles on
the opposite side, and left for a second operation, will set up the howl
and cause more pain and suffering than the side treated; especially may
you look for such alarm if you allow any of the injection compound to
fall on their unprotected surface. A patient once observingly remarked
that it must be a peculiar kind of medicine that caused pain when brought
in contact with the outside of a pile, but none when applied to the
interior.
As regards pain, it might be briefly stated that little can be done in
the vicinity of the rectum, it matters not what strength of carbolic
acid is used, or plan of treatment adopted, without causing more or less
discomfort in all cases, amounting to actual pain and suffering for a
brief period in others. Not at the time of operation, for that in itself
is practically painless, but during the process of cure.
This cannot be wondered at, when considering the extreme sensibility of
the parts and amount of tissue involved and actually removed by a radical
operation. Yet it is no greater in the majority of instances and not as
much in extremely _irritable piles_, as that caused by the periodical
squirting in of a few drops of carbolic acid and water, extending over
a period of weeks, and even months, that is neither safe, certain,
or otherwise satisfactory; and often brings discredit upon a process
which, if properly understood and rationally applied, has no approach to
comparison in any other method of cure.
Some physicians fear to use anything stronger than a little carbolized
water and glycerine, lest they produce carbolic acid poison, embolism or
a slough. This is a mistake, the dangers they seek to avoid are coupled
with such uncertain and illogical practice.
Dr. E. H. Dorland, Chicago, Ill., says: “When a compact coagulum is
formed, and the muscular layer of the bowel is not touched by the styptic
it is impossible to do harm, all the learned theory to the contrary,
notwithstanding. A weak solution forms little globules in a tumor, and we
can imagine one so small as to be carried into the circulation.”
To effect a radical cure, it is desirable to get rid of the tumor bodily,
not by shrinking or contraction into a hard knot, or by inflammatory
destruction, but by a separation of the spongy and vascular growth
from the normal tissue of the body, the same as if dissected off root
and branch. This is obtained by putting a sufficient quantity of the
preparation recommended just where you want it, and such results will
invariably follow. I have seen internal hemorrhoids, about the third
day after operation, become so friable that they could be crumbled off
similar to a piece of cheese. The preparation can be relied upon to
extend just as far as you put it and no farther, and will remove as much
of the tissue as permeated. It will extend farther, and permeate more
readily the structure of a pile than the sound tissue, because the former
is much more spongy and cellular, allowing the preparation to be easily
forced and diffused throughout its integrity (Fig. 8). A pile, properly
injected, should appear the next day after operation perfectly dead, as
if boiled or cooked, and of a leaden color.
NEEDLE AND SYRINGE.
A gold or platinum pointed needle should be used, fitted with a screw
to gauge the depth of insertion, and of sufficient caliber to allow the
preparation to pass through freely. There are several makes admirably
adapted to this purpose, Fig. 9. A common hypodermic would be utterly
useless.
[Illustration: FIG. 8.—Section of hemorrhoid showing internal spongy
structure (Esmarch).]
A common glass barrel, metal bound, hypodermic syringe is all that is
needed. It should be provided with side handles. Draw the medicine
into the syringe before screwing on the needle, force out the air and
gauge the nut on the piston for about as many minims as thought will be
required.
When a syringe is not kept in constant use the piston will dry out and
stick to the barrel. This is remedied by setting the nut on the piston
when laying the syringe away, so that the piston will not quite go to the
bottom of the barrel. When it is desired to use the syringe, screw back
the nut, say sixteenth of an inch, and take up the syringe with thumb
on the piston handle and finger on the cap at the other end, and press
together, thus freeing the piston.
[Illustration: FIG. 9.—Syringe, needle and flexible silver canula.]
A heavy, open face watch glass with a center facet is a good receptacle
for the injection compound before drawing it up in the syringe.
ACCIDENTS
MARGINAL SWELLING AND ABSCESSES.
Marginal swellings and abscesses, appearing the third or fourth day
after operation, are produced by excessive irritation. I have never seen
them occur except when the patient disobeyed instructions and exercised
inordinately. One instance, in a case of long standing, where the piles
occupied both sides of the rectum between the sphincters, I operated
on both sides and injected every tumor at one sitting, enjoining rest
and quiet. He afterwards rode a long distance and walked a half mile,
which caused an unusual amount of pain and soreness; not content with
this he took a dose of castor oil, when a very painful marginal swelling
occurred. Being a strong man up to this time he had used no palliative
measures whatever, and only then informed me of his suffering. Hot water
and a sponge soon eased the pain and a superficial abscess developed; it
was slit up and a good recovery followed.
According to my observation and belief, piles situated just above the
verge and in proximity to the network or plexus of nerves surrounding
the anus, are more prone to cause a marginal swelling than others,
particularly if improperly or two deeply injected, and an irritating
quality of carbolic acid be used. It might also be stated that pain
varies in intensity as it approaches the verge, one of the most acutely
sensitive surfaces of the body. A small sensitive pile not larger than
a salmon egg, situated within the grasp of the external sphincter, will
keep up a titilation and contraction of the muscle sufficient to disturb
and put ill at ease the entire animal economy.
A swelling or lump which often appears immediately after injection of
piles of any considerable size just above the verge, is of no consequence
and will subside within a few days. A similar swelling sometimes results
from a severe attack of internal hemorrhoids, which some speak of as the
developing of an external pile, but I do not see that such formations are
anything more than marginal swellings, caused by the irritation above.
SECONDARY HEMORRHAGE.
About the time the tumor is thrown off, between the third and fourth
day, and sometimes later, before the healing surface becomes strong, or
should the portal circulation become obstructed and the hemorrhoidal
vessels congested, secondary hemorrhage may rarely occur. It is easily
controlled by the use of Monsel’s Salt, to which a little morphia should
be added, carried in a small piece of wet absorbent cotton, and held
on the ruptured vessel by the end of the finger until the hemorrhage
ceases. A few minutes will usually suffice. Knowing where you operated
will be a guide to the place of application. The injection of a strong
solution of tannic acid will be sufficient in mild cases. I have never
known a secondary hemorrhage, following carbolic acid injection, amount
to anything more than an easily controlled venous hemorrhage. Am inclined
to think secondary hemorrhage is most likely to occur when a pile breaks
down from a partial injection, leaving the vessels unprotected in places,
or from an injection too deeply into the substance of the bowel; yet, I
have seen all these conditions time and again without the least tendency
to hemorrhage.
CARBOLIC ACID POISON AND EMBOLUS.
With a fifty per cent. solution of carbolic acid and the combination
given, carbolic acid poison and embolus are entirely out of the question.
The only danger of embolus lies in the too sparing use of a weak solution
of carbolic acid, injected slowly into the unobstructed calibre of a
coursing vein. While a strong solution quickly and generously applied
would destroy the tissue and obliterate the vessel as effectually as the
hot iron.
SLOUGHING.
The extensive sloughing that I have heard of so much I have never
experienced, and am not able to conceive of such an occurrence, except
it be in a very low state of vitality; but can imagine how a pile would
slough if a few drops of carbolic acid were deposited in the center, or
deeply into its base, leaving the apex and greater portion of the growth
with a free circulation. A weak solution taking effect in the interstices
of the most tender part of a hemorrhoid, but not sufficiently strong to
attack the more fibrous portion, would doubtless result in inflammation
and slough. A pile with a thin delicate covering and internal structure
can be cured by an injection of water, while those of a more tough and
fibrous character would only be exasperated by such annoying treatment
and behave in a bad manner.
In looking over the comments of Kelsey, Andrews and others regarding the
injection of hemorrhoids, it appears quite evident that they have not
given the subject scientific study. It would seem that representative men
and authorities, after a knowledge of the brilliant results following
the treatment in many cases, attended by accidents in others, would seek
to know and try to obviate the cause or causes of these unexplained
irregularities.
They never improved upon the method in its primitive and undeveloped
state, but seemed willing to magnify and enlarge upon all the accidents
and complications arising from and following the indiscriminate use
of all sorts of injection compounds, in the hands of the ignorant and
inexperienced, and in diverse and unfavorable conditions for treatment.
How about the old methods? Only a few months since my attention was
attracted to a gentleman of prominence, in middle life, strong body
and good habit, who had been operated upon for the removal of piles
by ligature. He was seven months in recovering, during which time two
fistulas developed. I do not mention this case as an isolated one,
because we all know that excessive and prolonged pain, causing in some
instances lock-jaw and death, retention of urine, sloughing and stricture
by contraction of tissue, abscess, fissure, fistula, intractable
ulceration, hemorrhage, immediate or secondary, great and lasting
prostration and slow recoveries, saying nothing about the dangers of
anæsthesia etc., are not uncommon when the old methods are practiced.
About the time that Kelsey, after having deposited five drops of a
carbolic acid solution in the center of a large tumor, observed it
looking dark, angry and inflamed from the intrusion of a foreign
substance, would have been a fitting moment for a full dose of carbolic
acid, of suitable strength and in sufficient quantity to pervade
the entire structure and form a compact coagulum; strangulating the
circulation, cauterizing the tissue and thereby checking the inflammatory
action at once; then followed up by the liberal application of hot water
and a sponge.
The method that I adopt and recommend for the removal of piles, not only
does the work neater and cleaner than the more heroic measures in vogue,
but robs the patient of the terrors of etherization, as well as the
dreaded consequences incumbent upon and more or less inseparable from
operations of violence, in a peculiarly organized and sensitive locality;
and, as Dr. E. F. Hoyt, of New York, says: “There is not a hemorrhoidal
case possible but what can be obliterated by this means; and I am at a
loss to explain why so many cling to methods that carry so much havoc
and suffering. If every college in the land would have this subject
demonstrated by men of experience and learning, all other means would
soon lose recognition.”
I shall not take up time and space in enumerating cases but will briefly
mention three of quite recent date, and of more than common interest on
account of some of the associated history given.
Manuel L., aged 39, capitalist, had arranged his business affairs and
prepared for the possible results of a ligature operation. All being in
readiness, he was placed on the operating table by a prominent surgeon,
who, upon examination, found the hemorrhoids to look so formidable in
appearance that he refused to proceed further, stating that the operation
might prove fatal.
On his first visit to me, he was asked to use the commode and strain out
the piles, which presented to view a large, continuous hemorrhoidal mass
encircling nearly one-half the bowel on one side, with five distinct and
typical tumors on the other, similar to Fig. 1. He was directed to lie
on the operating chair with the large growth oil the upper side, and
about 30 minims of the carbolic acid preparation was injected in three
different places in the mass, the protrusion returned and the bowels
constipated for four days; after which the bowels were moved by an enema
of slippery elm water, when not a vestige of the growth could be seen,
and no pain.
He put his hand back to push in the bowel, as he had been accustomed for
the past eight years, and found it gone; whereupon he said if this had
occurred in the day of miracles, he would think me Jesus Christ. One
operation is all that is required for the remaining five tumors, and both
piles and prolapsus are cured by two operations. In fact, the smaller
tumors should have been taken first, when the opportunity to get at them
was much better.
The only inconvenience suffered was from an effort to hold the bowels,
and the after-pain, which lasted about 14 hours, but was not severe;
during which time an opium suppository was introduced every two or three
hours. He stated that he was just getting over an attack of _La Grippe_
and had been purged pretty freely, consequently did not evacuate the
bowels previous to operation, but advised a liquid diet for the first
three days.
George P., aged 37, druggist, had a continuous hemorrhoidal mass
occupying both sides of the bowel when protruded, being separated only by
an anterior and a posterior commissure. Glaring fibrous bands seemed to
bind down the enlargements in places, presenting anything but an inviting
case. He also had an arterial hemorrhoid attached just above the verge,
constantly hanging out and exciting the external sphincter; looked like
and was about as large as a medium sized strawberry, irritable and eroded.
The history of the case and the extreme ungainly appearance of the
protrusion induced me to have it photographed. It is approximately
represented in Fig. 2, but does not show the fibrous bands. The patient
was placed on the side opposite the larger mass, which was injected at
four different points. The bowels were constipated for four days by the
occasional introduction of an opium suppository and then moved by enema,
when the man shed tears of joy on having no pain at stool and finding
no protrusion on that side. The next operation took the other side,
together with the strawberry, and the case discharged, cured of piles and
prolapsus.
Both of these gentlemen had been told time and again that the carbolic
treatment was ineffectual and dangerous. One ex-army surgeon and college
professor said he would not attempt any of the heroic operations in the
second case, as there was too much tissue involved; that he would only
agree to treat it by making local applications twice a week.
And further, he would not promise any results inside of ten months,
asking twenty dollars per month. He would not swerve from his opinion,
and could not say that a permanent cure would then be effected.
Mrs. Jane D., nearly 80, afflicted many years, had consulted fifteen
different physicians, all of whom refused anything more than temporary
relief because of extreme age; having always been considered delicate,
with cataract now forming in both eyes. Would be satisfied if she could
live not more than two years after a cure.
The tumors were “old bronzed veterans,” tough and unyielding. One side
was taken at each operation and although confined to the bed mostly for
the first seven or eight days after operation, could get out and in at
any time without assistance. Had no constitutional disturbance, never
missed a meal and was able to get up and down stairs inside of eight days
unattended.
The dead piles embraced in the coagula were much longer in separating
from the bowel, and base of attachment longer in healing than in the
average case. Hot water sponge compresses were used frequently, together
with opium suppositories for the first 24 hours, then occasionally for
the next three days; after which hot water irrigation and iodoform
suppositories. Later bismuth, eucalyptol and oxide of zinc ointment. An
occasional dose of sulphur and pot. bitart. was given and the bowels
moved by flushing of the colon; which was resorted to but twice.