Part 1

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.

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.