TRSAT^s.v O *.Y ro A/- /"v ■:» £> %t/*" t r\<^ 3Y «NJE3 YO'JNT. NLM DD13bDT7 b SURGEON GENERAL'S OFFICE LIBRARY Section Form 113c W.D..S.G.0 iVo. JjJ.lPS.. GOVERNMENT PRINTING 0IT1CI NLM001360976 N health, no person feels that he pos- ses one organ more than another, un- less he has some disease of that organ. And hence the first intimation of impair- ment of health is the recognition of the fact that there is a preponderance of sens- itiveness, or some abnormal sensation in one member of the body. So in rectal diseases the fact is always present to the mind of the sufferer that he has an anus.—Allingham. I- -^IbTHE^v- TREATMENT OF HEMORRHOIDS 5 Il?JE0TIOCS OF GA^BOLIG A8ID ABD * -^llOTHE^ SUBSTABSES.lK- Silas T. Yount, M. D. in PHYSICIAN OF ST. ELIZABETH'S HOSPITAL, MEMBER AMERICAN MEDICAL ASSOCIATION, MEMBER INDIANA STATE MEDICAL SOCIETY AND MEMBER OF THE TIPPECANOE COUNTY MEDICAL SOCIETY. THE ECHO MUSIC CO. PRINTERS. LaFayette, Indiana. 1887. WXB Ye/* /SS7 Entered According to the act of Congress, in the year 1887, by Silas T. Yoant, in the office of the Librarian of Congress at Washington. a fVitt TO 9»9A*-q George F. Beasley, M. D. AS A GRATEFUL ACKNOWLEDGEMENT OF HIS GENEROSITY TO THE YOUNGER MEM- BERS OF HIS PROFESSION AND HIS MANY PERSONAL KINDNESSES THIS LITTLE VOLUME Is JVJost P^ectionately fretlicatefl ■—-S-BY-H—■ THE AUTHOR. < EBgJEKgS? INTRODUCTION. CHAPTER I. Examination of Patients.— History. — Light. — Specula.— Operating table.— Cut of authors Speculum. CHAPTER II. Instruments.— Medicines.— Position.— Use of the Speculum.— How to Avoid Unpleasant Sensa- tions on Inserting Speculum,—Covers. CHAPTER III. Haemorrhoids.— External Haemorrhoids.— Inter nal Haemorrhoids. CHAPTER IV. Internal Haemorrhoids.— Capillary Haemorrhoids. Arterial Haemorrhoids.—Arterial Haemorrhoids. —Veinos Haemorrhoids Symptums. CHAPTER V. Treatment.—Palliative Treatment Mineral Waters. — Chloride of Ammonium.—Oil of Sandalwood. Zinc Valerinate.— Prescription for Constipation. — Rectal Treatments. — Faradization for Con- stipation, Enemata. — Massage.— Haemorrhage Inflamed and Strangulated Haemorrhoids. CHAPTER VI. Curative Treatment. —History of use of Carbolic Acid Injections for the Cure of Haemorrhoids. — Strength of Solutions of Carbolic Acid. — The Operation. — How to Introduce the Needle. — The Depth the Needle Should be Inserted.—The Treatment of Capillary Haemorrhoids. — Time Required to cure. CHAPTER. VII. General Remarks. 9 INTRODUCTION. AEMORRHOTDS are so common that many of the laity imagine that they are a normal part of the human anatomy. No disease can come on so insidiously, and spring forth without a mom- ents warning, a veritable fountain of pain send- ing forth showers of agony, mingled with misty vaporings of suffering mortals. The Clamp.— The Cautery.— The Ligature, and caustics have had their day,owing to the severe pain, distress, loss of time and even risk to life. Empyrics, first used injections of Carbolic Acid in solutions into pile tumors. Heralding it to the unitiated as a cure without blood pain, or loss of time. The method was a success and there has been more "Fundament Renovators" since then than ever before. At last scientific men, began using the remedy, and under their study, practice and skill have reduced the method down to a fine point. By the injection of Carbolic Acid into the pile tumors, the disease is cured practically without pain, loss of time or inconvenience. The benefits derived from this method are almost incalculable. Many persons submitting to this treatment that could not possibly have been treated by any other means, on account of loss of time, pain, and ner- .vousness. In a little town not many miles from here, as I 10 write this, lives a young man suffering untold ago- nies from ligated haemorrhoids. He has already been confined to his bed for three weeks, and the operation will not be a success, for the reason that only part of the tumor has come away. A resi- dent of the same town had his piles injected the same day. He has not lost any time and has suf- fered no pain to amount to anything. Judging from these too cases; both alike, as to severity and previous health. Which operation would you prefer to have practiced on yourself, the ligature or the injection? Undoubtedly you take the road that brings you back to health, the quickest, safest, and with the least pain and trouble,and that road is by the injection ofcarbolic acid into the pile tumor. Do not understand from this, that I consider this mode of treatment a specific. The day of specific, medication has not been reach- ed, even our old friend Blue Ointment will not all- ways cure the "Itch" or Quinine stop the Ague. Yet one may expect, a reasonable amount of suc- cess from this treatment if used carefully, judicious- -< ly and in sufficiently diluted state. In fact, the results are more uniformly successful than by any other operative procedure heretofore used. My sole excuse for issuing this little mono- graph, is the frequency that I have seen inquiries asked for, in the different medical Journals, for some information on this subject. If I have thrown any light on the subject, then my object has been fulfilled. AUTHOR. CHAPTER I. XAMINATION of Patients.—In the treatment of rectal diseases do not rely wholly or in part on symptoms. The pa- tient may give you a tolerable idea of what is the matter, but that does not tell what complications or other troubles may be associated with the disease in question. And the man or woman who is not willing to be examined, have not reached the point which admits of treatment. Still it is of the utmost importance to obtain a com- plete history of the case. Of how long standing. The character of the pain whether sharp or dull. Constant or inter- mitent. Whether it is increased by de- fecation or whether the pain is before or after passages. The first thing then after obtaining the history of the case, is to make an ex- amination. Now an examination can be 12 made thoroughly, or incompletely. It is a failing among physicians generally when rushed with business, to imperfectly examine the case trusting more to the history than to the eye and touch. Extensive or expensive apparatus are not essential to a thorough and critical ex- amination. True, a fine surgical chair, a gorgeous display of plated instruments and a strong reflected light have a cer- tain moral effect, which is to a certain ex- tent salutary. The most essential thing in all exami- nations of this character, is a good strong light. The next essential is a good spec- ulum. The next a good chair or table. Light.—May be obtained from win- dows or better still a good reflected one. If you have a laryngoscope always use it. Specula.—Are almost as abundant as the sands on the seashore. There are bivalves, and trivalves. There are double and single slides. In fact there are oceans of them. But you want the one that will give the best satisfaction. There are only five that possess certain l3 points that make them valuable in the treatment of Haemorrhoids. The Pratt speculum is a triavalve, and'gives good re- sults. The only objection is the distal end is very large. So large that it will nine times out of ten cause pain and dis- comfort on introduction. Besides it has a large spring and mechanism underneath the large end or base that cannot but catch and retain secretions and germs of disease. These springs cannot well be cleansed. Hence this objection. The Rorick speculum is a slide specu- lum, but the distal end is quite large. The points being made by a piece of hard rubber that fastens into the base and must be moved as soon as introduced. Besides, this speculum is not sold only in a case with other rectal instruments, and is con- sequently not in the reach of the ma- jority of Physicians. The Aloe is a single slide speculum, entirely too large and cannot be intro- duced without pain. Of course there are three sizes but both the medium and large sized are too large in H in of in- most cases. Besides the slide does not extend clear to the end. The Brinkerhoff speculum is the oldest slide speculum. This speculum is not sold in the Instrument stores, but must be 'bought a case surgical s t ruments, along with the count}'1 right, to use it and the rem- edies that go with it. The speculum preferred by the author is his own small distal end, wedge shaped doubleslide speculum. Its advantages, are, ease of introduction. It has extra reflecting powers and it never pinches the mucous mem- brane. The slides throughout the entire ment, never pulls or the piles down, is construction, there being no extend instru- drags simple plugs, i5 catches, springs, rachets or screws to catch and carry disease from one pa- tient to another: A very good operating table may be inprovised by covering the top of a good strong table with quilts, or best of all a good Gynaecological chair. I use and prefer the Clark improved surgical chair. CHAPTER II. Instruments, Medicines and Posi tion.—For the examination and treatment of haemorrhoids, the following instruments and medicines are needed ; One rectal speculum, one glass or hard rubber syringe, small or medium size, an ordinary probe, cotton, sponges and an applicator (an or- dinary stiff wire will do for an applicator), an ordinary hypodermic syringe, with short or long needles. It is handiest and best to have a long needle, say 2^ to 3 inches long, but the ordinary needle and syringe that you carry with you every day will do well enough. You will also want two wide-mouthed bottles, one containing a 3 or 5 per cent, solution of carbolic acid, and the other olive oil. Expensive outfits, of course, add to the appearance of things and may be handier, but six dollars will furnish everything needed for the success- ful treatment of any case of haemorrhoids. i7 Position. — For mere inspection of anus and surrounding parts, lying on the back is as good a position as any, and per- mits a digital examination as readily as any other. For introduction of speculum or pas- sage of a bougie, the patient should lie on the side, with buttocks well elevated ; the thigh which is uppermost should be strongly flexed on abdomen with the breast resting on the table. When the speculum is first introduced it generally produces a feeling as if the bowels were going to move, and when the speculum is withdrawn, and especially if it is allowed to touch the buttocks, the pa- tient is liable to think that he has befouled* himself. This was my experience, and great was my relief when I found nothing soiled. This feeling in the examination of ladies has a tendency to prevent them from straining down, and causes them to close the sphincter too firmly, which no word from the physician can overcome. To ob- viate this trouble I am in the habit of using about a four per cent, solution of cocaine i8 in olive oil, injected into rectum, say five minutes before introducing speculum. In examining women, have a sheet or special covering to throw over their whole body. Then push up the clothing, and by the use of towels prevent exposing the per- son at all. Many physicians are careless about this apparently trifling matter, yet it is often of great importance, and should not be overlooked even in the most lowly. I generally use a sheet with a small slit in it. By this means I do away with so many towels, and never expose my patients the slightest particle. Digital Examination.—In making a digital examination, use the index finger. and lubricate well with vaseline or olive oil, Carefully separate the parts and press the ball of the finger gently but firmly against the sphincter until it relaxes. Do not hurry, or act like you were pushing the finger into a Dutch cheese. If the patient is young and strong, it may take some time before the sphincter relaxes. If the subject be old and feeble, there is generally very little resistance. Unless there is an obstruction, *9 the finger can be carried well up the bowel, and the distance may be increased by hav- ing the patient stand up and strain down upon the finger. In this way 3*^ or 4 in ches of the rectum maybe explored. Still, by this means one cannot, to a certainty tell whether there are internal piles or ulcera- tion of rectum, inasmuch as the piles are often soft and the folds of membrane are apt to confuse the examiner. In examining the rectum, it is import- ant to bear in mind that force is never jus- tifiable, no matter what disease is suspect- ed. With the patient in proper position, on the side, and with the aid of proper light and speculum, the rectum may be thoroughly examined for 4 or 5 inches. It is always advisable before making an examination to have the patient use an en- ema of warm water to cleanse the rectum. CHAPTER III. HAEMORRHOiDS.-Haemorrhoids or piles are nothing more nor less than a varicose condition of the rectal vessels. Haemorrhoids are either external or in- ternal. An external haemorrhoid is a vari- cose condition of the subcutaneous veins surrounding the anus, entirely external to the sphincter ani muscle, and though it may be covered by mucous membrane, it does not come from the rectum proper, nor can it be forced above the external sphincter muscle. Internal haemorrhoids always orig- inate within the rectum, and may exist in- definitely without appearing externally. When they do appear on the outside of anus, it is generally the result of straining, increase in size or a relaxed condition of sphincter. An internal pile, after long exposure externally, changes altogether in appear- ance, the mucous membrane looking like integument. 21 The following rule always holds good: "Any pile that originates below the exter- nal sphincter is an external pile, and any one that originates above the external sphincter is an internal pile." In external piles there is a varicose con- dition of the external haemorrhoidal vein, a disease of the general veinous circula- tion. An internal pile is a varicose condi- tion of the middle or internal haemorrhoidal vein, and belongs, consequently, to the vis- ceral veinous system. There may be in- termediate piles, i. e., piles arising between the external and internal dividing line, and partaking of the character of both. External Hemorrhoids.—The late Dr. James R. Wood, of New York City, was wont to say in his lectures on haemor- rhoids : " Show me a man or woman of middle age that has not external or inter- nal piles, and I'll show you a duck that won't swim." In fact, it is one of the most common affections to which flesh is heir. The majority of people rarely consult a physician for piles alone. It is only when 22 they become inflamed or painful, or because they become run down and debilitated from the loss of blood, that they consult a phy- sician. The causes of piles are as various as the colors of the rainbow—affecting alike the rich and poor, the old and young, the weak and strong, the temperate and intemperate, and those that sit as well as those who stand. Constipation, pregnancy, a relaxed con- dition of the system generally, and congest- ed state of the liver, are the most promi- nent causes that I know of. A weakened or dilated heart has a tendency to favor the development of piles. They are often sec- ondary to diseases of the bladder, stricture, enlarged prostrate gland, and stone in bladder. They are also associated with diseases of the uterus, especially with cer- tain displacements. The external haemorrhoid originates in two ways : either by the dilatation of a vein, or the rupture of a vein and the ex- travasation of blood into the adjacent tis- sues. Often a patient while straining at stool 23 will feel a sharp, tingling sensation around the anus, when, on examining for the cause, he finds a bluish, round tumor of variable size, just at the verge of anus. This undoubtedly is due to the rupture of a previously weakened vein. The pain in such cases is usually quite severe. If this tumor be split open with a sharp knife and the clot turned out, the tension will be re- lieved as well as the pain. The incision should radiate with the folds of the anus. It is often a good plan to insert a pledget of borated cotton into the cut to prevent too rapid union of the wound. In case the tumor is not slit open, it will either termi- nate in suppuration or by shriveling up and becoming a cutaneous tag.' On the other hand, if the pile be due to a varicose condition of a vein, it comes on slowly, with little or no apparent dis- comfort. This will sometimes remain for a week or a month, and then gradually shrivel up, leaving only an external tag. If this pile becomes inflamed it will terminate in one of three ways: by resolution, indu- ration or suppuration. Cutaneous tags, H when free from pain or discomfort, should be left untouched, inasmuch as the simple operation of cutting them off is often fol- lowed by severe suffering and great pros- tration. Yet if there are repeated inflam- matory attacks, that do not yield readily to emollient applications, cutting them off with sharp scissors or a knife is the proper course to pursue. CHAPTER IV. Internal Haemorrhoids.—Internal piles originate solely from - the superior haemorrhoidal veins. The superior hemor- rhoidal veins commence at the upper bor- der of the external sphincter and lie imme- diately under the mucous membrane of the rectum. These veins run up the rectum about four inches, where they abruptly perforate the muscular coats, and unite to form the five or six large veins found in the meso rectum. These then join the in- ferior mesenteric veins, which pass into the splenic and portal veins, and thus enter the liver. This shows conclusively that there is a close relationship between inter- nal piles and diseases of the liver. The causes of internal piles are nominally the same as those mentioned as causing or fa- voring the development of the external. Internal piles vary much in size. They may be simply a deep red velvety spot on 26 the mucous membrane, or they may be as large as a quail egg. Some bleed profuse* ly, while others do not. Some have haem- orrhage of an arterial character, while in others it is altogether veinous. Internal haemorrhoids may be classified under three heads: capillary, arterial and veinous. Capillary haemorrhoids might with propriety be called rectal naevi, for in structure they are almost entirely hyper- trophic capillary vessels and spongy con- nective tissue. They are always small and bleed readily and freely when touched. They never protrude unless accompanied by some other rectal disease, because they are situated very high up in the rectum. With this form of pile there is always daily haemorrhage, and the loss of blood sooner or later renders the patient incapable of attending to his usual business affairs. The extreme debility and pallor is often fright- ful. In fact, all the bad symptoms result- ing from capillary piles is due to the daily loss of blood. They are so small that they cause no inconvenience, pain or any other 27 bad symptoms. In women, the capillary haemorrhoid is generally situated on anterior wall of rectum. The capillary haemorrhoid after a certain length of time may become an arterial haemorrhoid; that is, the capil- lary net-work disappears and a mass of ar- teries and veins bound together by connect- ive tissue takes its place, changed in ap- pearance altogether, being round, smooth hard and shiny. The connective tissue be- comes more abundant, and an exudation of plastic, lymph and fibrous matter takes place beneath the mucous membrane, ob- literating the capillaries and arresting the bleeding from the surface. These bleed readily when scratched, and you can feel at the upper part of each haemorrhoid a dis tinct arterial pulsation, Sometimes as strong- ly marked as the radial pulsation. This symptom is never absent, and is of value in the diagnosis and treatment of the disease. Arterial haemorrhoids are thus de- veloped from the capillary, and the arteries and veins in such tumors are invariably di- lated and varicose. The bad symptoms in the capillary 28 haemorrhoid, as before stated, are due to the excessive loss of blood. While on the other hand, in the arterial haemorrhoid the bad symptoms and suffering result from the hemorrhoid itself, either from inflam- mation, ulceration, or from the action of the sphincter ani muscles. These piles are apt to protrude at stools, on stooping over, and even in assuming the upright position. There is generally an acid, gummy discharge from the rectum, which causes excoriations around anus, and favors the growth of warty vegetations and produces that extremely irritating and annoying itching so common in such cases. If the spincter be strong, the piles when they come down are harder to reduce and more apt to become strangulated. If the sphincters are loose, the piles are apt to come down when there is the least provo- cation, coughing, sneezing or stooping over being sufficient to bring them down. When these tumors become ulcerated or denuded, alarming haemorrhage often ensues. If they prolapse and the sphincter be strong, and they are not promptly re- 29 d uced, a very painful strangulation will en sue. Veinous haemorrhoids consist sim- ply of a dilatation of large veins beneath the mucous membrane of the rectum. La- ter these become hardened and hypertro- phied by certain changes in the mucous membrane and sub-mucous connective tis- sue until they are a bluish hard tumor of variable size, smooth to touch, and pro- lapsing when the bowels move. They are not sensitive, do not erode or ulcerate, and are not prone to bleed. All three varieties may appear in the same person at the same time. Symptoms.—Internal piles come on in- sidiously. The person affected rarely re- alizes that there is anything the matter with his rectum until, perhaps, he is startled by a profuse haemorrhage or he is annoyed and worried by the loss of his sexual pow- ers. Again, the acid discharge may cause intense itching and so much discomfort that he seeks his physician for treatment. There is, in fact, little or no pain associated 3° with internal haemorrhoids until the the tu- mor and its attached mucous membrane become prolapsed and is caught in the sphincter and so tightly squeezed that it becomes strangulated and painful. Then it is that he consults his physician. Then follows the sensation of the rectum being insufficiently evacuated. Following this we have debility from loss of blood, insuf- ficient control of bladder, together with certain nervous disturbances, despondency, sleeplessness, dyspeptic troubles, and many other annoying and unpleasant symptoms. CHAPTER V. TTf reatment.—In the treatment of &\(s) internal haemorrhoids there are two indications to be considered namely. Palliative and curative. Palliative Treatment.—Rarely in- deed, in advanced cases of piles, can the cure be effected without resort to operative procedure. Still it is always advisable to try some remedial measures, especially in mild cases. Again no operation should be performed for the cure of haemorrhoids that depends on other diseases until those diseases are cured or alleviated. For- instance a patient presents himself for treatment for haemorrhoids, you on in- quiry find that he has been a long time sufferer from stricture of the urethra, and has to pass water very frequently, straining hard, each time; in this case it would be sheer folly to proceed to operate for the cure of his piles until his stficture 32 is cured, you may cure one but in a weeks time another one appears, until dis- couraged and he seeks another physician. I remember well my first case of this kind. A wealthy gentleman from a distance came to me to be treated for a severe case of internal Haemorrhoids of long standing. I was doubly anxious to cure him, because I wanted the big fee he offered me, and besides his recommend- ations would be worth much. Pile after pile did I inject. Three were ligated, but alas every time I examined his rectum a new pile would show up. What was' the matter ? Finaly one day he complained of a great deal of trouble in making water. He said he had had gonorrhea some years ago, and during the last four years had great trouble in passing water, remarking that he had to strain much before the water would come. The clouds had now lifted and I saw my way clear. The stricture was divulsed, and before he knew it piles and stricture were well. Just so in the successful treat- ment of hemorrhoids in women. If they 33 are due to a retroverted or an anteverted uterus. You may inject, ligate and cauterize from now until! doom's-day and your patient will continue to have piles. Replace the uterus, and they, the hem- orrhoids,can surely be cured. In pregnancy when the piles are very distressing and especially if the loss of blood is fast under- mining your patient's health and strength; then you are justifiable in operating at once. The records show that there is no danger of bringing on premature labor. In such cases you can inject, ligate, or use actual cautery and clamp. The plethoric, the very corpulent, the heavy eater, and the habitual beer drinker, all are hard to cure. In such the muscu- lar coats of the vessels are lax and the walls of the rectum flabby, and without lime. In such cases you will do well not to guarantee a perfect cure, unless they will eat and drink less and take more exercise, even then you will often fail and and wish that you had never seen them. It is in the various varieties of internal haemorrhoids that medicines and certain 34 mineral waters have a salutary and often a most happy effect: especially so in persons of a bilious temperament, or when there is torpidity of the liver asso- ciated with constipation. In these cases you will very often get excellent results from drinking enough Carlsbad orFried- richshall water, to keep the motions liquid. The use of these waters should be long continued. The water of Tate Epson Spring, Tenn, and French Lick Springs, Indiana, are about as efficicaous as the Carlsbad and Fredrichshall. Three or four grain doses of chloride of am- monium twice or thrice daily also has a good effect in such cases. Oil of Sandalwood too, justly deserves mention as a remedy that relieves con- gestion and engorgement of the portal system, and also depurates the blood generally. Small doses of blue mass taken nightly for three or four nights, of- ten relieves the patient wonderfully, .and favors the curative process. Valerianate of zinc in one or one and a half grain doses, four times daily has 35 given better results in certain cases, than any other remedy. How it acts, to pro- duce its benefical results I do not profess to know, but I do know well, that in cases, where there is little or no hemorrhage with much nervous disturbance, that its effects are prompt and satisfactory. Aloes has long been in disrepute as an agent in the treatment of constipation associated with piles. True in drastic doses it inflames and congests them: but any other carthatic or laxative would do the same thing, if not given in proper doses. Ext. of aloes given in one eighth or one quarter grain doses, two or three times a day, acts fully as well as any remedy to regulate the bowels. Of late aloin is used in prefer- ence to the extract. Wyeth and Warner both make a belladonna, aloin and stryc- hniae pill, that answer well as a laxative. Fl. ext. cascara sagrado in dram doses is highly recommended by some, but the very disagreeable taste renders it nauseous to many. One of the happiest combination of 36 drugs and one very potent and reliable is the following: Ext. Nucis Vomicae gr. x. Ext. Belladonnae gr. x Ext. Physostygmatis gr. iv Aloin gr. v. Met Ft. Caps No. XX- Sig, One night and morning or as needed to regulate the bowels. In cases where there is considerable rectal tenesmus, associated with an acid mucous discharge, as generally accom- pany arterial haemorrhoids, or in common, parlance. "White piles'! the following prescription will be found of signal value: Acidi Sulphuric dil three drams. Magnesiae Sulph. one ounce. Aquae Chloroform three ounces. Sqr Limonis —one ounce. Aquae qs ad six ounces. M. Et. Sig: Tablespoonful two or three times a day in one quarter glass of water. Gentle faradization daily, will often re- lieve obstinate constipation. It is best done by inserting an electrode into the 37 rectum and to this attach the negative pole. While the right pole is attached to an electrode either with a sponge or metallic end. The positive electrode is now slowly passed along the course of the ascending, transverse, and descending col- on. The seance should last from fif- teen minutes to half an hour. The strength of the current should, at the first sitting be mild and pleasant, say eight or ten cells, gradually increasing to twelve or fifteen. Massage along the course of the colon will stimulate peristaltic action, and also favor the flow of blood through the portal system. Enemata. Injections of different flu- ids into the rectum for the purpose of moving the bowels is as old as the hills. It is a remedy of great val- ne when used rightly, and a danger- ous one, too, if not used correctly. To accomplish good, an enemata should be copious, at least a pint and a half or a quart at each time. Ordinarily the fluid should be about milk warm, but in cases where the piles and mucous membrane pro lapse very readily, then it is best to use 3« cold water. The injection of ice cold water is not contraindicated in many cases. I have used injections of ice water in a six months old infant, and copious ice water in- jections in weakened jaundiced persons with good results. Care should always be taken in giving ice cold or even cold injec- tions. Never have your patients take cold injections immediately after eating. It is dangerous. I have seen some very alarm- ing attacks of collapse, and congestion of the bowels result from such practices. Al- ways have the patient take his enemata be- fore breakfast. Instruct him to inject slowly, and not like he was pumping water to put out a fire. Enemas should be taken when lying down with the hips elevated. Hemorrhage. It is the loss of blood that plays havoc with many. To arrest it, use suppositories of subsulphate of iron from two to five grains in each. Sub- sulphate of iron is a decided sedative in these cases. Or you may use one or two drams of monsels solution to three ounces of water and inject into rectum. If the haemorrhage 39 comes from a capillary haemorrhoid, the application of nitric acid will arrest the haemorrhage and often benefit the patient but it does not cure. In the other varieties of internal haemorrhoids, nitric acid never benefits, but does positive damage. Inflamed and strangulated hem- orrhoids. If from any cause inter- nal haemorrhoids become prolapsed, inflamed and strangulated an effort should be made, at once, to reduce them. To reduce piles, when caught in a strong sphincter and held as in a vise, place the patient on his face with his hips well elevated, smear vaseline or olive oil freely over them. Pass one finger into the rectum and with the other hand gently ap- ply pressure, If they are too much in- flamed, and exquisitely painful, apply clothes wrung out of hot hop tea, or ice bags, or an ointment of equal parts of ex- tract belladonnae, extract opii and ex- tract aconite. Leeches applied at the verge of anus often afford considerable re- lief. Slitting the tumor open with a sharp knife and turning out the clot gives much relief. CHAPTER VI. Curative Treatment.—After palli- ative measures have been tried sufficiently, with no appreciable results, or the pallia- tive treatment has been directed toward removing the primary cause, the question naturally arises, how can this patient be cured the quickest, surest, and with least pain? The clamp and cautery, the liga- ture and nitric acid treatment, are very painful and invariably confine the patient to the bed for the space of from one week to one month. The treatment of haemor- rhoids by injection of carbolic acid into the pile tumor is comparatively painless, does not confine the patient to the bed, and is sure and quick. This remedy, then, an- swers the question, and we will only con- sider the subject of the curing haemorrhoids by the injection of carbolic acid. Dr. Kelsey, of New York City, the au- thor and celebrated specialist on rectal dis- eases, in his last volume on Diseases of 4i Rectum and Anus, says: " The treatment of haemorrhoids by injection of certain substances, chief of which is carbolic acid, may now, I believe, be accepted as a sur- gical procedure of a certain definite value, and one worthy of a place among the rec- ognized means of cure at our command. "Originating as it did among quacks, it has been looked upon with suspicion and its adoption by the profession has been fol- lowed by the accidents which generally at- tend a new remedy, before its application is fully understood, but this does not di- minish its real value. * * * * For the past year I have treated nearly every case of internal haemorrhoids for which I have been consulted, by this method alone, and the favorable view regarding it in my former edition has only been confirmed by subsequent experience." The use of carbolic acid as an injection into pile tumors dates as far back as 1870. About that time the newspapers were filled with cards announcing that Dr. So-and-so cured piles without knife, pain or haemor- rhage, or confinemedt to bed. A Dr. 42 Brooks, hailing from Southern Illinois, claims to have first used it. He sold state and county rights for the use of his pre- scription, which was a 30 per cent, solution of carbolic acid in olive oil. The formula was given me in 1876, and was tried at once on three patients. It worked very well in two of them, but the other one had a huge slough form, that laid him up for a month. It was apparent to me at once that the solution was too strong. I now tried a 20 per cent; then a 15 per cent, solution. These gave much better results; still there was too much smarting at the seat of injection. Since 1885 I have rarely used a stronger solution than 5, and very often only 3 per cent. To make a 5 per cent, solution: Add carbolic acid— grains 24 to aqua distill. 1 ounce; or, to make a 3 per cent, solution, add carbolic acid 14^2 grains to aqua distill, one ounce. I mention specifically how many grains to the ounce,in these solutions, because I have known of two mistakes being made recent- ly, that of 1^ drachms of carbolic acid to the ounce of water intended for a five 43 percent solution. Aside from the prick of the hypodermic needle there is no pain whatever, save a slight momentary sting- ing or burning sensation. In fact, with these weak solutions, even in the most sen- sitive and nervous subjects, they only say, " that stings just a moment." There is no shock and no nausea from the inhalation of ether, as in the other cu- rative measures. The operation is finished in a few minutes, and your patient can go about his business, forgetful that he has had an operation performed on his rectum. Be- fore injecting haemorrhoids, as in every op- eration on the rectum, the bowel should be washed out with a little tepid water. The Operation.—Having placed the 'patient in proper position. Take your hard rubber syringe and inject about a dram or so of olive oil into rectum. Now oil the speculum and gently introduce it. The slide is now drawn partly out and the pa- tient told to strain down. If there are any piles on that side they will drop down into opening. If you have a long hypodermic needle, you can inject the pile in situ. 44 If you have no long needle, then you must pull or drag the tumor down, using a ten- aculum or forceps to do it. In case it is neces- sary to drag the pile down the patient will be saved needless pain, by saturating a pledget of cotton with a 10 per cent solution of cocoaine and applying it for a few minutes. When the pile has been prolapsed either by straining, dragging with forceps, or fingers, the needle can then be inserted. If the pile tumor be long and pedunculated, insert the needle at its apex and run it down perpendicularly to the base. If the pile tumor be round or oval in shape it is best to insert the needle at the longer diame- ter on a level with the mucous membrane of the rectum. If it be a capillary haemorrhoid, small, slightly elevated, looking like a rasp- berry and bleeding freely on touch insert the needle, if the mass be small, into the centre and push perpendicu- larly down to the base. If the mass be large insert the needle into the edge, at the widest part,on a level with the mucous mem- brane of the bowel, and push the point hor- izontally into the base. After having care- 45 fully expelled all the air from the syringe that contains the desired solution, insert the needle into the point selected on the pile and push it down to the base at one movement. Now force the piston down slowly and easily, until from three to twenty drops of the solution is injected. The amount injected will always depend on the strength of the solution and the size of the haemorrhoid. Care must be taken that the point of the syringe reaches the very base of the tumor, else there will be only sloughing of the mucous membrane, with a tendency to severe haemorrhage and much unnecessary suffering. The base and foun- dation of the haemorrhoid would still re- main intact and another operation would be necessary to cure it It is a matter therefore of the greatest importance that the needle be run deep enough. In fact the success of the operation depends more on reaching the proper depth, the very base of the pile, than on anything else. If the pile is large and it is desirable in your judgement, to inject a strong solut- ion, say ten, fifteen or twenty percent, you 46 can doit best in the following manner. In- sert the point of the syringe into the pile tumor and push it well to the base inject-. ting from 10 to 20 drops of a 3 or 4 per cent solution of cocoaine; unscrew the syringe from the needle and fill the syringe with the desired solution of carbolic acid. Screw the syringe on to the needle and after waiting five minutes, inject the re- quisite amount of the solution. In using the weak solutions of carbolic acid (three or five per cent) the previous injection of cocoaine is not necessary, neither is it neces- ary in cases where a seven percent solution is used, unless the subject very nervous or sensitive. All solutions ranging from ten per cent upwards, should be preceeded by injections, as before described, of a co- coaine solution. In injecting pile tumors, with ergot, a combination with cocoaine to form about a five per cent solution of the latter drug, renders the pain trifling and of very short duration. Never inject more than one large haemorrhoid at a time- Strong solut- tions have no better effect than weaker 47 ones. In fact they are never justifiable un- less the pile tumor is of extraordinary size or very vascular. Unless cocoaine inject - tions precede a fifteen or thirty per cent solution of carbolic acid the pain is severe and almost unbearable, for from a half to two hours. Again, the sloughing and ul ceration is. always very considerable, and the annoyance often persistent; severe blad- der troubles some times follow strong solu- tions. On the other hand, with weak solu. tions, the preparatory injection of cocoa ine ( which is painful ) is unnecessary. There is no suffering, no sloughing, no ulceration to speak of,and no bladder troub le. In view of these facts why should one inflict pain unnecssarily. Why cause intense pain in a so called painless operation? Some have recommended that the needle be turned around and twisted in different directions while inserted into haemorrhoidal tumor, in order that the acid may reach all parts of the pile. But this, in my ex- perience, is all unecessary and besides causes much pain. If on withdrawing 48 the needle from the pile, there is a tendency for the acid to ooze out of the wound, mixed with bloody serum, it is of- ten advisable to lay some absorbent cotton around and over the pile. If a strong solu- tion is being injected it is a good practice to smear vaseline or oil on the mucous membrane of the rectum surrounding the pile, in order that what little of the acid that does escape, will not burn or cause dis- comfort. Again, if there are no haemor rhoidsin upper part of the rectum, pull the slide completely out, and again have the pa- tient to strain down. In the lower part of the rectum,the hemor- rhoidal tumors can be readily injected, in place, without prolapsing, with any ordina- ry hypodermic needle. When a pile is dragged down and injected, it must be quick- ly pushed up in to place, or else you will have a strangulated and inflamed pile on hand to treat. It is best not to inject too many piles at one sitting, two small ones or one large one being sufficient. If the injected haemorrhoids have been .prolaps- ing very easily,it is advisable to lock up ,* *♦ At6 23 ||g/ 94 the bowels for afewdays in order to prevent their coming down and getting strangulated. It is seldom necessary to insert supposito- ries of opium or other substances after the injection of haemorrhoidal tumors, although some physcians make a practice of doing so in each case. In capillary haemorrhoids where the haemorrhage is profuse and exhausting, I apply first nitric acid, c. p. with a cot- ton tipped probe. The haemorrhage stops ,and in about a week ortendays,inject a few drops ( 3 or 5 ) of a five per cent solution, of carbolic acid. This will gen- eraly suffice for the permanent cure. It is in this variety of haemorrhoids that nitric acid often acts like magic in controlling the haemorrhage and starting the patient on the road to recovery. In this variety it is most important to get the injection deep enough, for if superficial it will cause a slough ,and a most alarming haemorrhage is liable to ensue. You must reach the cap- illary net work with your injections if you would get satisfactory results, in these, as well as in other varieties of haemorrhoids. 5° A report of a few cases here, might not be out of place, and may serve to illustr- ate what results can be expected from the treatment under consideration. Prof. L. W.--------called on me for treatment January, 1880. He was 60 years old and had suffered from piles for ten years. They prolapsed and bled oc- casionally, and he was very much emaciated. I injected at first the largest one,on poster- ior wall with a ten per cent solution. In two weeks more I injected a couple of small ones; in about a month, the mem brane ceased to prolapse so badly and the old gentleman gradually became restored to health. A small slough on posterior wall following third injection was the only un- favorable event in the history of the treat- ment of this case. This slough healed readily, and caused little trouble. Jno. B-------, a farmer, 29 years old,- came to me June, 10, '83, with an aggrava- ted case of haemorrhoids, and prolapsus of rectal mucous membrane. He was weak iand debilitated from excessive loss of blood. His bowel, as he told me at the time, would 51 come down almost a fingers length on the slightest cause. He was treated by inject ions of a five per cent solution and progress- ed favorably and rapidly,with the exception that after the third injection into the pile tumor, the injected mass became prolapsed and as he lived some miles in the country it was some hours before I reached him. Long before I saw him the injected pile had become swollen and irreducible. After the tumor had been slit open and the clot turn- ed out he became easier, though he was con- fined several days in his bed. With this exception, he was discharged cured in a- bout nine weeks. Miss A---, aged twenty two, seamstress, was finally compelled to seek a physician, owing to a severe and exhausting haemor- rhage. She was very much emaciated and almost colorless. On examination a straw- berry like tumor, of velvety nature, only slightly elevated above the surrounding mu cous membrane was discovered. From it, blood oozed on the slightest touch. Recog- nizing it as a capillary haemorrhoid, I at once applied nitric acid. She returned in 52 a week feeling much better, and reported only one small haemorrhage. I now inject- ed the pile with a ten per cent solution of carbolic acid. I entered the needle at the edge of widest part of mass, and on a level with the mucous membrane of the bowel,and pushed the needle in, until the point had fairly reached the centre of the pile. The piston was then pushed home and the op eration was complete. In this case a small but deep slough formed which required a- bout a month to heal. She has not in three years, had any return of the old trouble and is in excllent health. Mrs. R-, married aged 28,has had much trouble with her rectum. Six years ago she had an irritable ulcer,due to a polypoid grow- th. The growth was removed,the sphincter stretched and for a time she was well. Fi- nally she became constipated and as a re- sult strained with each stool; this caused the piles to become prolapsed and strangulated. After her recovery from this she had a lit- tle rest for a few months. About eight months ago she consulted me and on exam- ination I found a mass of haemorrhoidal 7 53 tumors, numerous and large. She was; nervous, almost hysterical at times. She had great trouble and exqusite pain whenever she passed water; at the same time there was decided vaginismus. Pile after pile was injected, and each day she became better, and at the end of six weeks she could > pass water without pain or discomfort. She was under treatment about four months,and was entirely free from any rectal or bladder trouble the last time I saw her. W. B. C. aged 22 married, suffered for three years with internal haemorrhoids. During the last six months before treat- ment he became very much exhausted owing to great loss of blood. Commen- ced treating him August, 14th, 1885, using the three percent solution. Dis- charged him cured without any loss of time on September 28; there was no slough- ing or pain in connection with the treat- ment. R.J. S ----aged 36. Has had piles for several years. First consulted me for loss of sexual power. On obtaining a complete history I was sure that part of his trouble 54 was due to one great mass of piles. Commenced injecting them with a five per cent solution. He progressed rapidly without any unfavorable symptoms and was discharged cured in about two months, without sloughing or loss of time. F. E,----- Married, aged thirty- of Monitor, Ind. consulted me in 1879 ^or continued and alarming haemorrhage from the rectum. He was pale and weak, and walked with tottering gait. On examina- tion I found two small capillary haemor- rhoids on anterior wall of rectum. Applied first, nitric acid, c. p. This arested the haemorrhage, and in about a week I injected both with a ten per cent solution. In this case I pushed the needle through the center of the pile and the haemorrhage that fol- lowed was very copious, and oozed for a- boutaday. He returned in about three weeks and having had no pain or haemorrhage. The place, where the piles had been, was still visable, being much redder than the surrounding tissue. The application of a solution (30 grains to ounce) of nitrate of silver three or four times, removed all signs > 55 of the piles. He was discharged cured in two months. Jno. L ------ Mulberry, Ind. aged thirty, called on me last August, (1886) and showed up the finest crop of piles ever seen in any one person. He had had nitric acid applied, and as a result two of the piles were ulcerated, bleeding and pain- ful. These were attacked first with a five per cent solution, both were injected the same day. He returned in about two weeks,and this time I injected P. D. & Co., Liq. Ergot purificatus, five drops. He said it smarted only a little more than the acid. The result in three weeks time was equally as good as with the carbolic acid. He was treated in this manner first using the carbolic acid solution, and then the ergot,until he was discharged. There was no sloughing or any loss of time. C. C. T., aged 33,single,farmer; consult- ed me about his piles a little over a year ago. They did not bleed but came down badly, and had become strangulated once. They were small and hard, of the arterial variety. They were injected with a two 56 per cent solution of acetic acid. The water used in making this solution was carbol- ated, as are all my hypodermic solutions. The result was very satisfactory, and complete, but much more pain was suf- fered at the time of injection. He was discharged cured in about six weeks. A. C ----- called on me January ioth 1880, suffering from internal haem- orrhoids. Dr.------had ligated his brother's piles, and he was confined to his bed for three weeks. During the first part of his confinement his sufferings were horrible, and when A. C------called, he said, "I don't want any ligation in mine." He was about thirty eight }rears old and had suffered with piles for years, but the dread of an operation had caused him to postpone the operation until now. The piles and membranes would complete- ly prolapse on the slightest provocation, such as sneezing coughing &c, At first I injected the two piles nearest the sphin- cter. In two or three days I injected twenty- drops of liq. ergot purificatus. P. D. & Co's at verge of anus. One more large 57 pile tumor was injected in ten days. At the same time injections of ergot into the tissues near anus, (% inch from anus) were kept up until fourteen injections had been made. At that time ,he had for the first time in five years, a pass- age without any prolapsing of bowel. He was discharged, perfectly well and free from any rectal disease, whatever after three months treatment. The only pain he suffered was from the injections into the tissues surrounding the anus. G. W. L-----of Odell, Ind. came to me, Sept. ioth 1885 suffering from piles. His rectum was relaxed and protruded fully 2*^ inches with each stool. And as a result he was nervous, worn out and despondent. He visited me twice a month for three month and said he felt as well as ever. Still in my judgement he was not well. I did not see him any more until a- bout March, 1, '86. He was then much more despondent than ever;saying he knew that his case was hopeless now. His bow- el prolapsed and he had had two haemor- rhages recently. On examination I found 58 two small elevations,hard and ulcerated on surface. These were the bases of the last two piles I had injected. They had not been injected deep enough to cause the pile to entirely disappear, but to simply slough off and leave the base of pile tumor, the same as before the operation. I now injected deeply, into the base of these stumps, a solution of carbolic acid, about six and one half per cent, and had him come in every ten days to have an inject- ion, in to the tissues around the anus, for the cure of the prolapsus. He was dis- charged cured about the last of April. This case will show how important it is to have the injection deep enough. Accord- ing to Kelsey, carbolic acid injections while curative for haemorrhoids, have at the same time a curative action on the prolapsed rectal mucous membrane. This is my experience also. By curing the haemorrhoids you lessen the cause and re- move the tendency to prolapse, and at the same time seems to restore tone to the muscular walls. How and by what means these results are obtained, I do not pro- 59 fess to know. Still any one that has treat ed haemorrhoids by carbolic acid injection, has noticed how readily and promptly the prolapsed membrane acquires tone, and ceases to come down as much as formerly, becoming better with each injection. The tendency to prolapse though, will continue in a modified degree, until all the piles are cured. Then a few inject- ions of carbolic acid or ergot into tissues around the verge of anus will give tone and cure the prolapsus without any trouble or delay. In cases where the rectal mucous mem- brane, uncomplicated with piles, prolapse either partly or completely, the best of re- sults may be obtained from injections of either carbolic acid solutions, varying from five to ten per cent, or Parke Davis & Co's Liq. ergotae purificatus in from ten to thirty drops. The injections to be made into tissues about one quarter of an inch from verge of anus. These injections should not be too strong, nor repeated too of- ten nor of too large an amount. It is best not to inject oftener than once each week1 6o More or less pain always follows these in- jections, and I have as a rule of late always combined enough cocoaine with each sub- stance used, either carbolic acid or ergot, to make the strength four per cent of cocoaine to each solution. The needle should be run down into tissue about one quarter or one half inch. Generally speaking, while you are curing the haem- orrhoids by injection you are also curing and restoring tone to the prolapsed rectal membranes. About the first question asked by the patient will be! How long will it take you to cure me ? Well that depends entirely on the patient, his habits, the severity of the case and his general condition. Gen- erally it will take from two to four months. It is not a good idea to inject piles oftener that once in two or three weeks. CHAPTER VII. General remarks. Never inject a pile when inflamed. It will only aggravate the trouble and perhaps confine your patient to his bed and there by bring yourself and method into disrepute. Never inject external cutaneous tags. It will only cause the skin to become in- flamed and perhaps supurate, causing pain and suffering for naught. Never use a stronger solution of carbolic acid than ten per cent. There is nothing to gain and much to loose by stronger inject- ions. Always aim to cure your patients with as little pain as possible and that ob- ject is only attained by using weak in- jections. External cutaneous tags can be almost painlessly removed by first injecting them with a four or six per cent solution of co- coaine and then cutting them off with sharp scissors. In selecting hypodermic needles for in- 62 jecting haemorhoids always get the small- est. Do not push the piston of the syringe down rapidly because you may inject too much fluid before you are aware of it. In injecting strong solutions of carbolic acid always stop when the pile tumor begins to turn a grayish white. A persistent diarrhoea following a case of haemorrhoids, that has been treated by carbolic acid injections indicates a slough or a rectal ulcer. Repeated haemorrhage from rectum in persons that have been treated or are under treatment by carbolic acid inject- ions, indicates a superficial slough resulting from a too shallow injection into pile tum- or or a deep slough from too strong a sol- ution. It is not necessary to lay down elabor- ate rules of diet, but simply tell your patients to keep regular hours, to avoid alcoholic drinks, and not to over load the stomach. The bowels should be kept liquid. Excessive venery and exercises should be avoided. In other words to be temperate in all things. 63 During the last two years I have in- jected several different medicines into haemorrhoidal tumors. The following brief summary gives the results of my treatment with other remedies. Glacial acetic acid in from one to three per cent solutions is equally as effect- ive as carbolic acid, only much more pain accompanies its use. Next to acetic acid in value may be mentioned Tanrets Ergotine or Parke Davis & Co's. Liquor Ergot purificatus, used undiluted in from 3, 5 or 8 drops. I never had any slough- ing from the ergot or ergotine, and only one case of sloughing on a small scale from acetic acid. To make the operation for a case of piles a success, one must look to the most trifling details. Decide first of all the cause, and when possible remove it, Then you can operate with every promise of suc- cess. It is also advisable to keep your eye on the patient for a time after the piles are cured, and make him understand that the haemorrhoids are liable to return if he does not look well to the condition of his bowels, his liver and his general health. . NLM001360976