CHAPTER IT. (Part 7)

by any pain or soreness, and this not very marked in charac- ter; and after three months the man was discharged cured, there being no longer any bleeding or descent of the haemorrhoids at defecation. The man, who was a fireman, was at no time during the treatment un- able to attend to the active duties of the service. Case VII. — Male. Age, thirty-eight. In this patient anything like a cutting operation was out of the question. He had been a hard drinker for years, and was suffering from phthisis, cirrhosis of the liver, and albuminuria. The haemorrhoids were of long standing; the whole circle of mucous membrane prolapsed with them; ai^d the sphincter had lost its contractile power. The man was under treatment three months, and during that time six. injections of carbolic acid were made, and each one was followed by more or less pain and by sloughing of the haemorrhoid. The pain was not, however, so great as to counterbalance the relief the patient experienced from the cessation of the bleeding and the decrease in the^ protrusion, and the treatment was gladly persisted in by him, till in the end he considered himself as cured and ceased to attend. I have no doubt that in this case the sloughing of the tumor, which each time left a dirty sore after the introduction of the acid, was directly due to the patient's condition; but he was sustained with generous diet and suitable tonics, and, as I say, did very well — much better than he would have done by any other plan of treatment which it was safe to try; and, but for it, I should have confined myself strictly to palliative measures. Case VIII. — Male. Age, fifty- two. General health excellent. Haem- orrhoids well-developed and prolapsing. Having had considerable experi- ence with this method of treatment by this time in dispensary practice. 104 DISEASES OF THE RECTUM AND ANUS. I yentnred to try it in a private patient, and to promise an easj and painless cure. A single injection was therefore made., and for the first forty-eight hours there was little trouble; but at the end of that time I received a telegram from the gentleman that he was suffering great and constantly increasing pain — he having left me on the day following the injection to return to his home in a neighboring city. I went to him and found, to my disgust, that the injection had in his case also caused a slough, and that he was suffering intense pain at each acb of defecation. Suitable treatment with laxatives and anodyne suppositories was at once instituted, but his sufferings continued for many days, and he finally went off to the mountains where he remained till the ulceration had healed. Needless to say he refused to continue this ^^ painless " method of cure, and I lost my patient and not a little reputation, the man being rich and influential. Case IX. — Male. Age, fifty-three. Also a private patient, and in fair general condition, but with old and severe basmorrhoids and partial prolapse, and weakening of the sphincter. I was first called to see him in the night when he was suffering from strangulation of the entire mass, and a week later I began the use of the acid. This was fol- lowed very cautiously and with abundant intervals of rest after each injection, and in a very short time the relief was very apparent in the diminution of the size of the protrusion. There was no pain at any time during the treatment, and only a slight nipping sensation for an hour or 80 after each injection. In the end he was entirely cured, all hsemor- rhage and protrusion of thQ tumors having ceased, though the anus was still surrounded by the redundant circle of half skin and half mucoua membrane which remained from the former condition of prolapse. Here then was an old case of large prolapsing haemorrhoids in a pri* vate patient who would submit to nothing which he considered as surgical treatment, apparently cured without any pain, without any of the usual accessories of an operation, and without a single day's detention from his ordinary pursuits — a result for which surgery has been waiting a long time. I say apparently cured, for the one doubt which remains in my own mind regarding this treatment is as to the permatiency of the cure. This I have not as yet had time to test. I have seen nothing to make me doubt its being permanent; and considering what Yidal has accom- plished with injections in cases of long-standing and extensive pro- lapse, I see no reason why it should not be permanent; but I have not as yet had a chance to examine any of my own cases after an interval of years which is the only way of positively deciding the question. Beginning this plan of treatment, as I did, without very much confi- dence in it and with the fear of causing great pam and perhaps dangerous sloughing constantly before me, I can only say that the method is con- stantly growing in favor with me personally, and that the more I. practise it the more confidence I gain in it. With solutions of the proper strength HJBMOBBHOIDS. 105 the danger of causing slonghing of the tumors is very slight; and I am not at all sure in my own mind that once more surgery is not indebted to the quacks for a valuable discovery which may do much to modify the at present accepted plans of treatment of this disease. There are no objections to this method which do not apply equally to others. I have once seen considerable ulceration result from it in the hands of another^ but I have seen an equal aYnount follow the application of the ligature; and I do not consider this as a danger greatly to be feared when injections of proper strength are introduced in the proper way. It is applicable to all cases; is especially adapted to bad cases; and may be used^ as in the second case, where a cutting operation is inadmissible. It acts by setting up an amount of irritation within the tumor which results in an increase of connective tissue, a closure of the vascular loops, and a consequent hardening and decrease in the size of the hadmorrhoid. Except when sloughing occurs, the tumors are not, therefore, removed, but are rendered inert so that they no longer either bleed or come down outside of the body. In cases in which the sphincter has become weak- ened by distention, the injections will also have a decided effect in con- tracting the anal orifice as do injections of ergot or strychnine in cases of prolapse. I have used this method of treatment now many times and, except in the third case reported here, have never had reason to regret using it, or to be dissatisfied with its results as far as I have been able to follow them. Although I should be very slow to advocate any one treatment of this affection to the exclusion of all others, I now often adopt this where AUingham's operation is declined by the patient, and as yet I have not known it to fail. Its advantages over all other methods, provided its re- sults prove equally satisfactory, are manifest to all. The patient is not terrified at the outset by the prospect of a surgical operation, is not con- fined to his bed, and is not subjected to any suffering. The cure goes on painlessly and almost without his consciousness. The method requires some practice and some skill in manipulation in getting a good view of the point to be injected and in making the injec- tion properly. In the first three cases reported, the solution employed was one part of pure carbolic acid to three of glycerin and three of water; in the last, the carbolic acid was decreased one-half and this is a better solution to use. The amount injected each time was about five drops. The instrument used was an ordinary hypodermic syringe with a good sized needle through which the solution would readily pass. When the tumor to be injected is prolapsed, the needle may be thrust into it without difficulty, and after the injection is made the tumor should be gently re- placed. If it be allowed to stay out of the anus for a few moments it will be seen to swell up and become black and hard with venous blood. There is seldom any haemorrhage from the operation, but occasionally a few drops of blood will follow the puncture. If the tumor is not protruded 106 DISEASES OF THB BEOTUM AND ANUS. at the time of operation it may be seized with toothed forceps and drawn out and held while the injection is made. The injection should be landed as nearly as possible in the centre of the hadmorrhoid, the needle being entered perpendicularly from the apex^ and not passed upward under the mucous membrane in a longitudinal direction. If the acid be placed simply under the mucous membrane the latter will die and an ulcer result^ but if placed more deeply the danger of an ulcer is much decreased. Used in this way and in the strength last indicated the acid will not be followed by any great amount of pain. Each injection should be followed by a day's rest in the horizontal position. No change need be made in the ordinary diet of the patient provided the bowels act regularly every day. Only one tumor should be injected at a time and I seldom repeat the injections oftener than once a week. It will sometimes be found necessary to inject the same tumor twice or three times when it is a large one. It will be observed that in the cases reported the length of time dur- ing which the patient was under treatment was in each case except the second about three months. I have no doubt that this could be much shortened, were it necessary; but where the patient is at no time confined to the house, time is of little consequence, and I seldom repeat the appli- cations oftener than once a week, preferring to see the full effect of each one before giving a second. Still, were there any reason for haste, I should not hesitate to shorten this interval, and I am led to believe that in the hands of the quacks the time is considerably shortened. I believe also that with them it is the custom to produce a sloughing of each tumor by the strength of the injection, and once or twice I have had patients come to me in this condition. But no such use of the acid is necessary to effect a cure, and this result is one which I try very carefully to avoid. Treatment by Ligature. — This is the method of treatment which has been brought to such perfection by AUingham, and which usually passes by his name. It consists in partially cutting through the haemorrhoid at its base, and tying the remainder. It is performed in the following manner. As in all operations on the rectum, the bowel should be thoroughly cleared by a cathartic on the previous day and by an enema just before operating. The patient may be placed either on the side or in the lith- otomy position; personally I prefer the latter. The sphincter should be carefully dilated, as already described, and this is a step of great practi- cal importance, as the securing of complete paralysis of the muscle will do more than anything else to prevent pain and spasm after the operation. In cases where the tumors were large and prolapsed readily, I have seen this step in the operation omitted as unnecessary by good surgeons; and I have seen a week of great suffering to the patient follow the omission. So important is this step in the operation for the relief of pain, that in HEMORRHOIDS. 107 some cases in which the tumors were so extensiye and the sphincter so dilated that they xjould easily be removed without it, I have first cut off the haemorrhoids and then stretched the sphincter. It is rather a reyer- sal of the regular order, but it illustrates the fact that stretching the mus- cle should not be omitted. If the muscle is forcibly and suddenly torn apart by the operator, a fissure may result, and may require a subsequent operation for its cure after recovery from the original operation. The tumors being thus brought into full view by the introduction of a specu- lum, one is seized and drawn down with a toothed forceps. The selec- tion of a good forceps for this purpose is a matter of considerable import- ance. In my own operations, I use those figured below. The hold is firm and the handle sufficiently long for the hand of the assistant to be out of the way of the operator in the subsequent steps. Fig. 35. Having secured a good firm hold on the tumor, the surgeon transfers the forceps to the left hand, and with a strong and long pair of straight scissors cuts the hsemorrhoid away from its attachments for a certain dis- tance, beginning from below and cutting upwards. In this way the mass is entirely cut off except at its upper end, where the artery or arteries which feed it enter it from above. It is to prevent haemorrhage from these vessels that the ligature is applied instead of completely cutting off the mass; and this is done by the operator after transferring the forceps to the assistant. The ligature should be of stout hemp, something stouter than ordi- nary ligature silk being necessary. The string should be tied very tightly, and after it is secured, the pile may be cut off to remove as much as possible of the dead tissue from the rectum. Each hasmorrhoid is thus treated in succession, and after all are removed, a suppository of opium is introduced, and a T-bandage tightly applied over a compress of lint and a napkin. The suppositories, which pay be repeated each night for two or three days, will serve to keep the bowels confined; and when the patient begins to experience a desire to go to stool, a laxative may be administered. There may or may not be some pain when the bowels first move, and this will depend very much upon the thoroughness with which the alimentary canal has been emptied before the operation. I have seen as a result of neglecting this previous cathartio a female patient have to rid herself of a hardened mass of faeces of the size of an egg at the first motion of the bowels after the operation, and the suffering was simply 108 DISEASES OF THE RECTUM AND ANUS. atrocious. If there be a little blood with the first passage^ it is a matter of no importance. The ligatures will generally come away about the end of the first week, and the patient should be kept in bed or on the lounge for a week longer. This in an active person will sometimes be difficult to manage; but no other course should be sanctioned by the surgeon, for the reason that when the ligature comes away, an ulcerated spot is left: and under certain circumstances, the most effective of which is active exercise, these little wounds may grow larger instead of smaller. In this way a case of internal haemorrhoids may be turned by an operation into one of ulcera- tion of thQ rectum, and the change is not to the advantage of the patient. One such case I have had in my own practice in a debilitated patient in poor general health; and a long course of careful treatment was necessary to effect an ultimate cure. Nothing has been said regarding primary or secondary hasmorrhage, for the reason that it is not a complication to be looked for. When re- tention of urine occurs, as it often will, it must be met in the usual way. The diet for the first few days should be chiefly fluid. This operation, thanks to Mr. AUingham, is now so well and so favor- ably known, that but little need bo said in addition. It is as safe as any operation in surgery, and by It the surgeon may promise his patient an absolute and permanent cure of his troubles in every case. This is saying a great deal, but not too much. It has been followed by fatal results — but so has every other minor surgical operation; and the chance of such a ter- mination is so slight that it need not enter into the calculation of the operator. Of all the operations for the cure of internal haemorrhoids it will be found the most satisfactory, the least liable to complications in its performance, and to unfortunate after-consequences. Once in my own practice after applying it to an old case of haemorrhoids with slight pro- lapse and almost completely surrounding the whole circumference of the anus with ligatures, I have been obliged to subsequently use a bougie to prevent a threatened contraction; but this I rather expected to be obliged to do at the time, and injurious contraction need not be feared in any ordinary case. I can confirm Mr. AUingham's statement that the opera- tion, when performed with a proper regard to minor details, is not fol- lowed by any considerable amount of suffering. I have had patients assure me that the first day following its performance was one of perfect comfort — in fact of greater ease than any they had experienced for weeks previous. Operation with the clamp and cautery. — This is generally known as Smith's operation, because he has advocated it so