Treatment of hemorrhoids, and other non-malignant rectal diseases

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.

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.

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.

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.

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.

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).

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:

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:

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.

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.

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.