HEMORRHOIDS AND THEIR TREATMENT. BY G. H. KIRWAN, M.D., WILKES-BARRE, PA. FROM THE Medical and Surgical Reporter, October 27, 1888. From the Medical and Surgical Reporter, October 27, 1888. HEMORRHOIDS AND THEIR TREATMENT.1 BY G. H. KIRWAN, M.D., WILKES-BARRE, PA. The subject assigned for to-day's paper and discussion is one of such importance to prac- tical physicians and surgeons that it might wisely have been assigned to some older and abler member than I; but, appreciating the honor you conferred in selecting me, I have done with the subject the best that, with a very limited practical experience, I could, viz-given you in what follows a compilation from some of the best authori- ties, and a resume of some of the different recent methods of treatment, together with a comparison of the results obtained from each; and finally, have drawn conclusions therefrom. Hemorrhoids, hemorrhoidal tumors, or the hemorrhoidal disease are medical terms used to define a diseased condition of the lower extremity of the rectum : the morbid condition that exists is almost always a dila- tation or varicosity of the blood vessels; but 1 Read before the meeting of the Luzerne Co. Pa. Medical Society, September, 1888. 2 these changes vary, according to the kind of hemorrhoidal tumor present, and will be described in defining the different varieties. Hemorrhoids are classified as internal and external, according as they are within or with- out the external anal sphincter. Such a divis- ion, however, is a merely arbitrary one. Of the so-called external hemorrhoid there are two varieties: the one a mere cutaneous teat or tab of redundant tissue so often observed about the margin of the anus ; this variety, which is painless, may be present for years without giving any trouble, and is frequently simply the remains of the second variety after absorption has taken place; the second variety is a tense, bluish, smooth tumor due to dilatation alone, or to dilatation and sub- sequent extravasation of venous blood. A more scientific classification of hemor- rhoids, however, is one based upon the patho- logical changes that have led to their pro- duction. Considering them from this stand- point we have of internal hemorrhoids three distinct varieties, viz.: the Capillary, the Arterial, and the Venous hemorrhoid. The capillary hemorrhoid is really an erectile tumor (though never very large), composed of the terminal branches of the arteries and veins and the capillaries that unite them. It strongly resembles an ordinary small arte- rial neevus, and bleeds upon the slightest touch, hemorrhage being the chief symptom which distinguishes this variety. When it exists, hemorrhage always follows defecation, and this is the form ordinarily known as bleeding pile. The arterial hemorrhoid is composed of a mass of freely anastomosing, tortuous, and varicose arteries and veins, bound together by connective tissue. The veins may be dilated into sacs or pouches, and the artery which enters at the base is of large calibre. Such a hemorrhoidal tumor is of large size and smooth surface, and is liable to inflam- mation, hemorrhage, and prolapse. The venous hemorrhoidal tumor consists entirely at first of a simple varicose condition of the large veins beneath the mucous mem- brane of the rectum ; later the veins undergo degenerative changes until a large, bluish, hard tumor is formed, which always comes out of the anus on defecation and assumes, from repeated exposure, a cutaneous char- acter. All the best authorities insist that these three varieties of internal hemorrhoids are well marked, and may exist at the same time, but they must be distinguished from each other in treatment. The ordinary symptoms of internal hem- orrhoids are a feeling of weight or fulness with a throbbing sensation in the rectum-in fact, a continual consciousness (not observed in health) that one has a rectum and anus, and that something is the matter with them. Bleeding upon defecation, and in some cases for a little time after it, is another symptom, not, however, constant in all cases. Other 3 4 symptoms are: constipation; a feeling of weight and heaviness about the parts; a frequent desire to go to stool, with the belief that a full and free movement of the bowels will take place and relieve the sensation of uneasiness; and lastly, a protrusion of the hemorrhoidal tumors through the anal sphincter. The feeling of weight and uneasiness hardly ever amounts to pain; if there is severe pain, it will usually be found after dilatation that a fissure or ulcer exists as a complication. When the hemorrhoidal tumors come down and are caught in the grip of the sphincter, there will be, of course, quite severe pain, which is immedi- ately relieved by replacing the tumors within the bowel. I have gone thus lightly and rapidly over the definition, varieties, pathology, and symptoms in order to devote most of my space to what I take it should be the princi- pal part of all papers read before this Society, namely, treatment. On the medical treatment of hemorrhoidal tumors or the hemorrhoidal disease, but a few words are necessary, as perhaps no case of well-developed internal hemorrhoidal disease has ever been cured by medical treatment alone, and but very few are even benefited by it, except temporarily. If hemorrhoids depend on congested or diseased conditions of the liver, or upon obstruction to the portal circulation from 5 any cause, the relief of this condition by appropriate treatment will materially benefit the hemorrhoidal disease. In the relief of obstinate constipation, special attention should be given to the state of the bowels ; the recumbent position should be assumed at stool; unstimulating food and, if addicted to its use, complete abstinence from alco- hol should be advised. Locally, some astringent ointments or suppositories, and the injection into the rectum of very cold, even iced, water may be employed. These are about the usual remedies, but any or all of them as a rule frequently fail even to relieve, and, I repeat, rarely if ever effect a cure in advanced internal . hemorrhoidal disease. In coming now to the most important part of our subject, the surgical treatment of hemorrhoidal tumors for their radical cure, I have selected for consideration, from the dozen or more surgical procedures sug- gested and practiced, only four, viz. : i. The Injection Method, sometimes called Kelsey's. 2. The Clamp and Cautery Method, called Smith's. 3. Mr. White- head's Operation. 4. The Ligature Method, with incision, Mr. Allingham's. The injection method is performed as follows : An enema of hot water having been used and the patient having forced down the tumors into view as much as pos- sible by straining, about five drops of a fifteen, thirty-three, or even fifty per cent. 6 solution of pure carbolic acid is injected into the substance of the largest of the tumors. After this the tumor is replaced within the bowel. If by the second day after this injection no pain or soreness exists, a second tumor is similarly dealt with, and so on till all are treated. Dr. Charles B. Kelsey, of New York, whose name is intimately connected with the treatment of hemorrhoids by injection, has materially modified his views as to the effectiveness of this method in all cases since the publication by him in 1885 of 200 cases treated in this way. He says in the latest edition of his work on Hemorrhoids, ' ' that he has since had pain, marginal abscess, ulceration and fistula follow its use, ' ' and that " the treatment by injection may not result in a radical cure." He further says: " In a word, the question narrows itself down to this: on the one hand we have a method safe, certain, and practically painless (the clamp and cautery method), but which involves the administration of ether and the performance of what the patient dreads -a surgical operation and a certain con- finement to the house for a few days; on the other hand, a method which involves fully as much of an operation as the other, only more quickly performed, and without ether, and which is neither radical nor cer- tain in its results." And he further says: "All the patient actually gains in the most favorable case is the avoidance of a safe 7 operation, which he fears, to submit to an uncertain one, which he does not fear because of his ignorance." Dr. Bodenhamer, of New York, an emi- nent specialist, says : " Never having treated a case of hemorrhoids by the injection method, I have therefore no experimental knowledge of it; but of its bad sequelae I have abundant experience and proof, having since 1875 treated thirty-five cases of patients who had submitted to this operation, but who were not only not cured but much injured in various ways by it. The most of these cases had anal abscesses and anal fist- ulae to follow it; others had anal fissure to result from it; others again had a thickening and induration of the coats of the lower portion of the anal canal, which interfered greatly with the normal action of the external sphincter. In some of the cases the operation was followed by extensive slough- ing of the cellular membrane in the vicinity of the tumors, and by persistent hemorrhage, and others have had hard nodules follow the treatment. In all these cases, as far as I could learn, carbolic acid in different degrees of strength was the agent which had been used. In 1875 I made the following remarks in the New York Medical Record: 'The method of treating hemorrhoidal tumors by injecting them with coagulant hemostatic and cicatrizant solutions is of quite recent date. From the great excitement recently manifested by a few fanatics concerning this 8 method, some were inclined to raise the cry " eureka," or led to believe that it, like Aaron's rod, was destined to swallow up all other methods. It may be remarked, how- ever, with regard to this new candidate for fame, that as yet it has no status in surgery, and it is questionable whether it ever will prove a real benefit to, or an advancement in, that science as it regards a safe and certain remedy in the treatment of hemorrhoids especially.' " Mr. Allingham says of this method of treatment: "I have tried the injection plan in many cases. The result was generally much pain ; more inflammation than was desirable; a lengthy treatment; and the result doubtful - certainly not a radical cure." Andagain: "All attempts to destroy vascular growths by causing coagulation of blood or inflammation in them while they are not shut off from the general circulation must be fraught with danger. You can have no guarantee that the coagulum may not break down and minute particles of dead tissue find their way into the vascular or lymphatic systems and result in embolism, or pyaemia, or both." The clamp and cautery method is a well- known form of treatment which has many eminent advocates. The name of Mr. Henry Smith, of London, is most frequently associated with it. " In its performance each pile is seized by a volsellum and drawn well down. The clamp is then applied so 9 as to embrace its base; the portion above the clamp is cut off with scissors, and the stump cauterized, usually with a Paquelin instrument." Mr. Allingham says of this operation : "In my opinion it has little to recommend it: as regards danger to life (after all, the issue of the greatest moment), as far as my most careful researches have led to a conclusion, it is quite six times as fatal as the ligature properly and dexterously- applied ; there are, moreover, these disadvan- tages : the burning causes very great pain after the operation, especially if the skin is involved; secondly, hemorrhage is more likely to occur than after the best mode of operating, greater sloughing of the parts takes place, and a longer period is required for healing." Dr. Kelsey, of New York, gives as his views a directly opposite opinion ; he says : " I prefer the clamp and cautery to all other radical measures, as being less painful and giving a quicker recovery. ' ' Mr. Whitehead's operation is a plastic operation for the radical cure of hemor- rhoids of recent date, it being little more than a year ago that its originator, Mr. Walter Whitehead, of London, first called attention to it. It is performed as follows: The pile-bearing mucous membrane is dis- sected off from the skin border of the anus all around, after the manner of performing total extirpation of the rectum (except, of course, more superficially), and all the pile- 10 bearing area removed. All bleeding vessels are twisted, and the mucous membrane above the pile-bearing surface is brought down and stitched to the skin border. Dr. Robert F. Weir, of N. Y., has performed this operation for hemorrhoids many times, and I believe gives it his preference in all suita- ble cases. Mr. Whitehead himself claims many points of advantage for it over all other surgical procedures, but those gener- ally conceded are that the hemorrhage is trifling, the union is primary, and retention of urine very rare. For those who prefer the very latest in the surgical treatment of hemorrhoids, this operation is here given. The Pittsburgh Medical Review, in a late comment upon Mr. Whitehead's operation and Dr Weir's method of performing it, says: "It is certainly a much more sur- gical method than the old ligature operation, but to all appearances offers no special advantages beyond the satisfaction it affords the surgeon in performing a plastic opera- tion, and freedom from subsequent reten- tion of urine.'' Mr. Allingham's objections to this operation are that it is in most cases a more formidable undertaking than the existing condition warrants; that the length of time required for the operation, and the excessive hemorrhage as compared to the ligature method, make it inferior to other methods in most cases. We come now to the consideration of what I believe from a careful study of this 11 disease is the operation for the radical cure of hemorrhoidal tumors; although, of course, it will be understood that no one method can be applicable to all cases. Exempli gratia, take the small capillary hemorrhoid described; one application to it of fuming nitric acid, properly made, cures it forever. We will now consider the treatment of hemorrhoidal tumors by the ligature ; and when I speak of the ligature operation I mean the operation by incision and liga- ture known as Mr. William Allingham's. He thus briefly describes it in his works: " After the patient is etherized and placed in position, gentle but complete dilatation of the sphincters is done." (I desire here to impress upon all who do not know it from experience, the very great importance of gentle but entirely complete dilatation, and consequent temporary paralysis of the sphincters before any operative interference.) "The hemorrhoidal tumors are brought down one by one; then, with a pair of sharp scissors, the pile is separated from connection with the muscular and submucous tissues. The cut is made in the sulcus, or white mark which divides skin from mucous membrane. This incision is carried a dis- tance up the bowel until only an isthmus of vessels and mucous membrane is left; a strong silk ligature is placed at the bottom of the groove, and, the assistant drawing the pile well out, the ligature is tied high up at the neck of the tumor as tightly as possible. 12 A portion of the tumor may now be cut off, or the whole returned within the bowel. After all tumors are thus treated, a suppository of morphia is placed in the rectum, a pad of antiseptic wool is placed over the anus, and a tight T bandage completes the dressing. ' ' This briefly is the ligature operation, and it probably has effected more cures of hemorrhoidal disease than all the other surgical procedures combined. That this operation is grounded upon a sound surgical basis no practical surgeon can dispute. Mr. Allingham (than whom there is perhaps no greater authority living) has performed this operation in private and hospital practice more than two thousand times with but three deaths, and he says of it: "I do not think in the whole range of surgery there is any procedure worthy of the name operation which can show a greater amount of success or smaller death-rate than the ligature of internal hemorrhoids." And again he says: "It is both the safest and quickest operation to perform in all cases of well-formed hemorrhoidal tumors." Dr. Bodenhamer, of N. Y., says: "I have yet to encounter my first serious accident." Dr. Gross says: "The operation is as simple of execution as it is free from danger and certain in its results." Recognizing that a paper of this kind should contain something more than a mere compilation from books accessible to all of us, and being able to give very little from 13 personal experience, I took the trouble to obtain by correspondence the following opinions upon the subject from eminent men, which certainly embody more recent views as to treatment than any of the text- books. I submitted, to the men whose names follow, the following five questions on mooted points in the surgical treatment of hemor- rhoidal tumors. I will read you the first question and their separate replies. The first question was : " To what extent do you carry out in your surgical treatment of hemorrhoids the principles of antisepsis as ordinarily employed in operation wounds?" i. "Only in having my instruments and the water used aseptic."-D. Hayes Agnew, Philadelphia. 2. "General cleanliness."-Thomas G. Morton, Philadelphia. 3. " Thorough cleansing before, and frequent irrigation after operation, with bichloride solution."-Louis McLane Tif- fany, Professor of Surgery, University of Maryland, Baltimore. 4. "I treat antiseptically as far as the nature of locality permits-using corrosive sublimate cloths, iodoform, etc."-John H. Brinton, Professor of Clinical Surgery, Jefferson Medical College. 5. "To its fullest extent."-Joseph D. Bryant, Professor of Clinical Surgery, Belle- vue Hospital Medical College. 6. "I use all necessary antiseptic precau- tions."-Dr. William Bodenhamer. 14 7 and 8. Mr. Allingham, of London, and Dr. Kelsey, of N. Y., in reply to my queries kindly mailed me their latest books from which their views are to be taken. Neither refers to the antiseptic principle at all in his book. 9. "To obtain as much cleanliness as is possible in this part of the body-bichloride solution externally and Thiersch's solution within the rectum and anus."-John A. Wyeth, N. Y. The second query was: "Do you rely entirely, or at all, on cocaine or any form of local anaesthesia in your surgical proced- ures for the cure of hemorrhoids?" 1. Dr. D. Hayes Agnew, of Philadelphia, says: "No." 2. Dr. Thomas G. Morton, Surgeon to Pennsylvania Hospital, says : "No. Often do not use anaesthetic for internal, but always for external hemorrhoids." 3. Dr. Louis McLane Tiffany says: "Compression by clamp." 4. Dr. John H. Brinton says: "I have employed local, but prefer general anaes- thesia from ether inhalation." 5. Dr. Wm. Bodenhamer, of New York, says: "I now use cocaine as a local anaes- thetic in all cases in which general anaes- thesia is not particularly indicated. I have found it of much value." 6. Mr. William Allingham, of London, says "No. It is only of use when mucous surfaces are to be operated upon - as 15 cocaine does not sufficiently deaden the sensibility of the skin to make it of practical service." 7. Dr. John A. Wyeth says : " I have used cocaine (4 per cent, solution), but lately have found that most patients do not suffer more from the carbolic mixture than from the distention by cocaine. When I do the ligature operation, ether narcosis." 8. Dr. Charles B. Kelsey says : " In minor operation the drug used hypodermically is perfectly satisfactory. In larger ones it is not to be relied on absolutely, and may have to be supplemented with ether." 9. Prof. Joseph D. Bryant says: "I have done so, but do not make it a practice- can be done easily if case be a simple one." The third question asked was: "Are you convinced from experience of the perma- nency of the cure of hemorrhoids by the injection method of treatment?" 1. Dr. D. Hayes Agnew : "Yes, in well- selected cases." 2. Dr. Thomas G. Morton: "By no means. ' ' 3. Dr. L. McLane Tiffany: " My experi- ence does not justify an opinion." 4. Dr. John H. Brinton: "I have seen cases operated on by others where the hemorrhoids still existed, but I knew nothing of the extent of operation. I have seen the saddest results in the way of sloughing from the injection of carbolic acid. If used at all, believe it should only be when pile is 16 thoroughly clamped before injection. I would only resort to this method in excep- tional cases." 5. Dr. Joseph D. Bryant: "Am con- vinced that in selected cases this method causes as good results as any; but it cannot produce better final results than tying." 6. Dr. W. Bodenhamer: I have given Dr. Bodenhamer's views under the descrip- tion of this operation, in which he condemns it in severe and measured terms. 7. Dr. C. B. Kelsey says: " It is neither radical nor certain in its results." 8. Mr. William Allingham : " The injec- tion of carbolic acid into the interior of piles may in some instances stop the bleeding for a time, yet it cannot and does not in any way remove the tumors." 9. Dr. John A. Wyeth : " I believe injec- tion will cure a hemorrhoid thoroughly injected. The process of cure demands inflammation (preferably sub-acute) and cicatrization (or shrinking)." The fourth question was : " Did you ever know personally of a permanent cure of internal hemorrhoids by simple dilatation of the sphincters alone?" This query was asked because in this city during the early spring and summer this method was practiced by a notorious quack on many people, who, after submitting to it, believed themselves cured ; but in several of them, to my personal knowledge, recurrence has taken place-not, however, until the dis- 17 appearance of their former medical attend- ant and their cash. This method has some legitimate foundation, however, having been advocated by Verneuil and other eminent French surgeons. i. Dr. D. Hayes Agnew says in reply to it: "No." 2. Dr. Thomas G. Morton: "No." 3. Dr. L. McL. Tiffany: " No experi- ence." 4. Dr. John H. Brinton: "I cannot answer positively." 5. Dr. Joseph D. Bryant: "Have known relief to follow, but not a permanent cure." 6. Dr. Bodenhamer : "I never did." 7. Dr. John A. Wyeth : " No; and despite Verneuil's statement, cannot believe it possi- ble." 8. Mr. Allingham: "It will give won- derful relief in selected cases." The fifth and last question was: " What surgical procedure do you consider the safest, most generally applicable, and yield- ing the best permanent results in the sur- gical treatment of hemorrhoids?" , 1. Dr. D. H. Agnew: "When large, I prefer the ligature." 2. Dr. Thomas G. Morton: " My uni- versal practice is the ligature for internal and the ligature and excision for the exter- nal variety." 3. Dr. L. McL. Tiffany: " I probably use clamp and cautery as often as any other. ' ' 4. Dr. John H. Brinton : "I prefer liga- 18 tion of internal hemorrhoids. I use a fine linen cord soaked in sublimate solution, and when the hemorrhoid has a partial cutaneous covering I form a track with knife in the skin covering, to divide nerves, and thus avoid pain after the old method." " My opinion is decided in my preference for this method." 5. Dr. Joseph D. Bryant: "Ligation with cat-gut." 6. Dr. Bodenhamer: "I consider liga- tion, if judiciously and properly applied, the simplest, safest, most certain, and most effectual of all known methods. It has the recommendation, the advocacy, and the indorsement (with but few exceptions) of all the leading surgeons of Europe and Amer- ica." 7. Dr. John A. Wyeth: "Allingham's operation-ether narcosis. ' ' 8. Dr. Charles B. Kelsey : "I prefer the clamp and cautery to all other radical meas- ures, as being less painful and giving a quicker recovery." 9. Mr. Allingham: "Ligature with incision, for reasons given under the descrip- tion of the operation." From a careful review of the best recent works on the subject, from a very limited personal experience, and from the very able opinions obtained by correspondence and just read to you, I have drawn the following conclusions: 1. The principles of antisepsis should be 19 carried out (as far as possible) in this as in all other surgical operations. 2. Local anaesthesia is not to be relied upon in surgical procedures for the radical cure of hemorrhoids. 3. The injection method of treating hem- orrhoidal tumors is not reliable, not safe, and not comparable with safer and surer methods. 4. Simple dilatation of the sphincters alone probably never cured a case of' well- developed hemorrhoidal tumors. 5. Mr. Allingham's operation by the lig- ature with incision is beyond a doubt the safest, most generally applicable, and yield- ing the best permanent results in the sur- gical treatment of internal hemorrhoidal disease.