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Injection treatment of hemorrhoids
INJECTION
TREATMENT
OF HEMORRHOIDS*
A. W. MARTIN MARINO, BROOKLYN,
ORGAN of Dublin1 in 1869 was the first to use a soIution of persuIphate of iron in the injection treatment of hemorrhoids. This method of injection therapy, as reported by Anderson,’ had been used in the treatment of nevi since 1836. Edmund Andrews2 stated that MitcheII of CIinton, IIIinois, in 1871, conceived the idea of treating hemorrhoids by the hypodermic injection of a mixture of carboIic acid and oIive oil. It was a secret method and the right to practice it, together with the formula, couId be bought by anyone. It thus came about that bIacksmiths, drug cIerks, farmers and quacks obtained knowIedge of this method and they began to reckIessIy and indiscriminateIy inject every anorectal condition that feI1 into their hands. It was not Iong before traveIIing mountebanks began injecting carcinoma and poIypi, thereby “curing” the countryside of piIes. The method feI1 into disrepute, and reguIar practitioners condemned the procedure. AI1 this took pIace about sixty years ago. Andrews2 coIIected 3304 cases from this type of practitioners, with the folIowing resuIts :
M
Deaths........................... EmboIism of Iiver.. Sudden and dangerous prostration. Abscesses of Iiver.. Dangerous hemorrhage.. Permanentimpotence.............. Stricture ofthe rectum.. Violent pains.. . CarboIic acid poisoning. Failed to cure.. Severe inffammation . SIoughing and other accidents.
.
13
8
I I IO
I
z 83
I 19 I0
- 35 184
N.
M.D.,
F.A.C.S.
Y.
In 1925, E. H. TerreI13 of Richmond, Virginia, presented to the American ProctoIogic Society his paper on the “Treatment of Hemorrhoids by Injection.” He began his work in 19 I 3 and he had treated over 3000 cases by 1925. In his paper he made the IogicaI observation that aIthough the condemnation of the resuIts was justifiabIe, the fauIt lay with the peopIe who used the method rather than with the method itseIf. He further observed that it was truIy remarkabIe that the method survived at a11 under those circumstances; a11 of which is good evidence that there is something of value in it. Up to- 1913, aIthough a variety of chemicaIs was used. carboIic acid in various strengths and combinations was the solution of choice. As a matter of fact it is stiI1 extensiveIy used here and abroad. In 1923 MorIey4 pubIished a book on hemorrhoids. He advocated injections with 20 per cent soIution of carbolic acid in equa1 parts of glycerine and water. In 1913 TerreII” introduced the use of urea and quinine, 5 to I0 per cent soIution. When we estabIished the recta1 cIinic at The BrookIyn HospitaI in 1925, urea and quinine hydrochIoride was decided upon because we feIt that we wouId be Iess apt to run into compIications than if carboIic acid were used. We have used pheno1 5 per cent in either C. P. cottonseed or aImond oi1 with resuIts as good as with urea and quinine hydrochIoride. We prefer a soIution of the Iatter because it is less troubIesome to handIe, and our experience with it has been most gratifying. RATIONALE
The wonder is that the resuIts were not worse, but of course, we must consider the source of the information of these statistics. * From the SurgicaI Service, Division of Proctolog.y,
OF THE
INJECTION
METHOD
The object of the injection treatment of hemorrhoids is to set up an inffammatory
Brooklyn HospitaI, Dr. Ernest K. Tanner, Chief Attending Surgeon. Read before the Sixth Annual Joint Meeting of the ItaIian Medical Society of BrookIyn with the Association of ItaIian Physicians in America ApriI 17, 1933. 366
NEW S,atut.s
Vo..
,Xx111,
No.
2
Marina---Treatment
reaction within the hemorrhoida mass, thereby causing an obliteration of its vesseIs by thrombosis followed by fibrosis.
of Hemorrhoids
A m&can Journni of Surgery
367
habits and genera1 physica status must be taken into consideration. and Anderson1 in EngIand, MorIey4
Frc. I. Armamentarium for injection treatment of hemorrhoids. (I, z,3) Set of anoscopes; (4) Murphy headlight; (sj mercurochrome z per cent soIution; (6) carbolic acid 5 per cent in aImond oiI; (7) 2 C.C. Luer syringe with extension shank and 24 gauge needle (for injecting 5 per cent urea and quinine hydrochIoride); (8) Vim syringe with Iong needIe (for injecting 5 per cent phenot in almond oil); (9) swabs; (IO) 2 C.C. ampuIe of 5 per cent urea and quinine hydrochIoride.
The injection can be made either into the substance of the piIe tumor, or just above the hemorrhoid and immediately underneath the mucosa, that is, submucousIy. In either event the injection is not made into the bIood vesseIs but into the tissues surrounding them. SELECTION
OF
CASES
Th e prrme ’ requisite is a proper diagnosis. Treatment of any anorecta1 condition shouId never be attempted without a proctoscopic examination, besides the usua1 inspection and digita expIoration.5 The patient’s occupation, temperament,
and TerreII,3 Hirschman, Yeomans,;’ FansIers and other exponents of the injection method in this country, a11 agree that externa1 hemorrhoids shouId never be injected. We have seen externa1 piIes so treated and the resuIts have been such as to require surgica1 intervention. This injection method is appIicabIe onIy to uncompIicated interna hemorrhoids, and it is suitable to onIy 50 per cent of cases seen. If the condition is compIicated by fistuIa, fissure, poIypi, hypertrophied anal papiIIae, cryptitis, ana or recta1 tumors, it wouId be useIess to treat the hemorrhoids by injection, for these conditions require surgery and the hemorrhoids can be removed al
368
American
Journal
of Surgery
Marino-Treatment
the same time. Thrombosed, uIcerated, stranguIated and gangrenous or fibrotic cases demand surgery; injection therapy is contraindicated. ARMAMENTARIUM
This consists of a suitabIe anoscope, a good light, suitabIe syringe, and sohrtions. We have deveIoped an anoscope in our cIinic which has been found the most usefu1 for our purpose and which is used for either examination or treatment. It consists of a chromium-pIated meta conicaI cylinder with a sIot and a ffange to which the handIe is attached. Introduction is made easy with a perfectIy fitted hard rubber obturator. To suit the variabIe types of anus and Iength of the ana cana1, the instrument comes in three sizes as shown in Figure I. There are some characteristics of these specuIa which are worth mentioning. The angIe and width of the Aange is so buiIt as to heIp retract Iarge buttocks. The diffrcuIty with most ana instruments is that the buttocks foId in over the opening of the specuIum. The handIe comes from the ffange at the same angIe as the Iatter so that the instrument can be inserted its fuI1 Iength without being impeded at the handIe region by Iarge buttocks. The sIot is of uniform Iength in a11 three sizes, but the cyIindrica1 portion of the instrument is made of graded varying Iengths so that the smaIIest is 2 inches Iong, the next is 2% inches Iong and the Iargest is 3 inches Iong. Thus we have a suitabIe instrument for a short, a medium sized or a Iong ana cana1. There are peopIe who have a short ana cana but with funne1 shaped buttocks. In these peopIe the Iargest anoscope is the onIy one which wiI1 properIy expose the termina1 rectum. The sIot is l%s of an inch at the termina1 end, semiIunar in shape at the proxima1 end and 13% inches Iong. One-quarter of the circumference of the termina1 rectum and ana cana can be exposed with ease, and the construction of the instrument is such that it can be rotated whiIe inserted
of Hemorrhoids
FEBRUARY,
without the necessity reintroduction. TECHNIQUE
AND
of withdrawa
,934
and
PROCEDURE
Anesthesia is not empIoyed. A cathartic or enema is not given before each treatment, for we have found that their action usuaIIy takes pIace when manipuIation of the anorecta1 region is begun. We prefer to have our patients report without preparation. With the patient in the inverted, knee-chest or in the Sim’s position, whichever is best suited to the patient, an anoscope of our set is seIected according to the requirements and it is inserted to expose the hemorrhoids. It makes littIe difference whose anoscope is used, but we prefer the one which we have deveIoped. Good iIIumination is necessary. The Iargest piIe is seIected and the anoscope is steadied in position. If a bIeeding piIe is present, that takes precedence over the others. A Iarge swab is used to cIeanse the mucosa of mucus, particIes of feces or bIood. The exposed area is next painted with 2 per cent mercurochrome. Perhaps that is a futiIe gesture so far as steriIity is concerned, but we at least have the feeIing that we do not introduce infection through the mucosa when the sohrtion is injected. A 2 C.C. Luer syringe is empIoyed with a 24 or 2.5 gauge needIe on an extension shank. The syringe is charged with 5 per cent urea and quinine hydrochIoride. The needIe is pIunged into the uppermost part of the hemorrhoida mass and inserted to a depth as near the center of the mass as it is possibIe to gauge. The depth of introduction of the needIe, of course, depends upon the size of the mass. Before injection is begun it is we11 to withdraw the piston to make certain that a vesse1 has not been entered. The injection is made sIowIy and enough soIution is used to distend the hemorrhoid moderateIy, without bIanching. We fee1 that it is safer to err on the side of injecting too IittIe. From 35 to 2 C.C. of soIution may be necessary to distend the mass.
N,
2
Marino-Treatment
The needle is permitted to remain in situ for thirty seconds or more to prevent Ieakage of solution. If the injection is properIy done there is no immediate pain. A transient feehng of fuhness in the rectum foIIows the introduction of the solution. It is we11 to insert the finger into the rectum and with gentIe massage of the injected area spread the liquid immediateIy after the injection. If the patient is attending to duties which require much activity, onIy one hemorrhoid is injected at a sitting. If, on the other hand, the patient is not actively engaged, then two or more hemorrhoids, or if they are smaI1, a11 the interna hemorrhoids that are present, may be injected at the same sitting. If there is any tendency to prolapse of recta1 mucous membrane, instead of injecting into the piIe mass, we insert the needIe just above the piIe through and underneath the recta1 mucous membrane, and the soIution is injected submucousIy. The interva1 between injections is usuaIIy one week, but in cases where the hemorrhoids are not very large, two injections per week may be given. One injection may cause a piIe to disappear, but at times a second injection is necessary. Before a piIe is re-injected it shouId be determined by digita examination that no induration is present. The induration must subside before the second injection is given. From six to eight treatments may be necessary before the hemorrhoida masses disappear, which means that it takes from three to eight weeks to compIete a course of treatments. A chart is kept to record the site and date of each injection and the quantity, strength and kind of soIution. A circIe, the circumference of which is divided into four or eight equa1 parts, suffices for this purpose. AFTER-CARE
The patient is instructed to avoid severe physica effort. MineraI oi1 is given by mouth to make bowe1 movements easier.
of Hemorrhoids
A m&m
Journnl of Surperv
ReguIar diet is permitted. The warned to repIace immediateI? trusion which may occur.
369
patient is any pro-
COMPLICATIONS Idiosyncrasy: Before beginning treatment, it is we11 to determine the patient’s susceptibility to quinine. We know of nothing more disconcerting than to have a patient have a convuIsion in the office. Where such susceptibility exists, we use 3 per cent phenoI in vegetable or almond oil instea.d of urea and quinine hydrochIoride. Pain: There shouId be no pain at the time of injection if the treatment is properIy given. If the injection is given without regard to the anatomy of the anorecta1 region, pain is sure to ensue. Most certainIy, the solution must not be injected into the anal cana nor in such a way as to encroach upon the anal vaIves or crypts of Morgagni. If the needle is not pIunged high enough up in the terminal rectum, some of the soIution wiI1 trickle down or gravitate and find its way beneath the covering of the ana cana1. To avoid pain it is necessary to inject slowly and we11 above the dentate Iine. Bleeding: At times, bIeeding may occur after withdrawa of the needle. This bleeding usuaIly stops of its own accord or can be checked by pressure. Very infrequentIy bIeeding may be such as to require eIectrocoaguIation or even cIamping with Iigation. MorIey4 cites one case where he was unabIe to check bIeeding with cIamping and he had to pack the rectum. Suture Iigature may be necessary; and then, of course, the method is no Ionger painless. BIeeding sometimes may foIIow sIoughing. Slough: Too Iarge an amount or too strong a soIution wiI1 result in sIough. We advise the use of a weaker soIution even if one must re-inject rather than the production of a sIough through using too strong a soIution. Injection into the mucous membrane or muscIe or into a hemorrhoida mass which is stiI1 indurated
370
American
Journal
of Surgery
Marino-Treatment
from previous treatment wiI1 resuIt in sIough. &reduced Prolapse: A prolapsing pile can usuaIIy be injected in such a way as to make prolapse aImost impossible, but some wiI1 proIapse no matter what is done. It is very important to warn the patient about replacing a proIapse if it shouId occur, for if the piIe is allowed to remain down, stranguIation and gangrene wiI1 foIIow. Stricture: This can foIIow cicatrization as a resuIt of sIough, or through tumefaction of indiscriminate injection of oiI. Infection: The presence of infection in the anorecta1 region is a contraindication for injection, for aIthough the rectum is pecuIiarIy resistant to infection, an abscess may form. Submucous, perirecta1, periana1 or margina abscess formation may be foIIowed by fistuIa. Recurrence: It has been estimated that recurrences in two to five years occur in about 15 per cent of the cases. It must be borne in mind, however, that inasmuch as the treatment is painIess, gives symptomatic reIief, and does not detain patients from their duties, they fee1 kindIy toward the treatment and wiI1 return for another course, if necessary, without condemning the method.
of Hemorrhoids
FEBRUARY, 1934
We have a vaIuabIe means at our command of treating uncompIicated interna
hemorrhoids. This method demands the attention and respect of every practitioner of medicine, and aIthough, according to JeIks,g it may have been “conceived in quackery, hatched in quackery and nurtured in quackery,” honest evaIuation makes it most acceptable when used with discretion. The method is not without danger, and has its limitations which must be understood before its use is undertaken. SurgicaI judgment as we11 as ski11 and knowIedge are essentia1, for although the method seems simpIe, unIess one understands the rationaIe and technique, disappointment and compIications resuIt. When compIications arise, the treatment becomes worse than the disease, and convaIescence is Ionger than if a surgica1 operation had been performed. The method wiI1 never repIace a properIy performed hemorrhoidectomy but it has a place in the debilitated and anemic, the diabetic, the aged, and in that Iarge group who refuse hospitaIization and surIt is vaIuabIe, aIso, for gica1 operation. interna hemorrhoids compIicating pregnancy, but instead of the quinine preparation in these cases, a soIution of carboIic acid shouId be used for obvious reasons. FinaIIy, we know with what horror a patient looks upon the prospect of reoperation for recurrence of any condition. In this method, we have a most satisfactory means of deaIing with hemorrhoids recurring after hemorrhoidectomy.
1. ANDERSON, H. G. The treatment of haemorrhoids by submucous injections of chemicals. Brit. M. J., 2: IOo-102, 1924. 2. ANDREWS, E. Recta1 and AnaI Surgery. Ed. 3, Chicago, Keener, I 892. 3. TERRELL, E. H. Treatment of hemorrhoids by injection. Trans. Am. Proctol. Sot., 1925. 4. MORLEY, A. S. Haemorrhoids. Oxford Med. Pub., 1926.
5. MARINO, A. W. M. Diseases of the rectum and anus. Long Island M. J., Vol. 24: No. 4, 1930. 6. HIRSCHMAN, L. J. Handbook of Diseases of the Rectum. St. Louis, Mosby, 1921. 7. YEOMANS, F. C. ProctoIogyi N; Y., Appleton, 1929. 8. FANSLER, W. A. Persona1 communication. g. JELKS. J. S. Discussion of: TERRELL, E. H. SeIecting the treatment for hemorrhoids. Trans. Am. Proctol. Sot., 1931, p. 172.
CONCLUSIONS
TREATMENT
OF HEMORRHOIDS*
A. W. MARTIN MARINO, BROOKLYN,
ORGAN of Dublin1 in 1869 was the first to use a soIution of persuIphate of iron in the injection treatment of hemorrhoids. This method of injection therapy, as reported by Anderson,’ had been used in the treatment of nevi since 1836. Edmund Andrews2 stated that MitcheII of CIinton, IIIinois, in 1871, conceived the idea of treating hemorrhoids by the hypodermic injection of a mixture of carboIic acid and oIive oil. It was a secret method and the right to practice it, together with the formula, couId be bought by anyone. It thus came about that bIacksmiths, drug cIerks, farmers and quacks obtained knowIedge of this method and they began to reckIessIy and indiscriminateIy inject every anorectal condition that feI1 into their hands. It was not Iong before traveIIing mountebanks began injecting carcinoma and poIypi, thereby “curing” the countryside of piIes. The method feI1 into disrepute, and reguIar practitioners condemned the procedure. AI1 this took pIace about sixty years ago. Andrews2 coIIected 3304 cases from this type of practitioners, with the folIowing resuIts :
M
Deaths........................... EmboIism of Iiver.. Sudden and dangerous prostration. Abscesses of Iiver.. Dangerous hemorrhage.. Permanentimpotence.............. Stricture ofthe rectum.. Violent pains.. . CarboIic acid poisoning. Failed to cure.. Severe inffammation . SIoughing and other accidents.
.
13
8
I I IO
I
z 83
I 19 I0
- 35 184
N.
M.D.,
F.A.C.S.
Y.
In 1925, E. H. TerreI13 of Richmond, Virginia, presented to the American ProctoIogic Society his paper on the “Treatment of Hemorrhoids by Injection.” He began his work in 19 I 3 and he had treated over 3000 cases by 1925. In his paper he made the IogicaI observation that aIthough the condemnation of the resuIts was justifiabIe, the fauIt lay with the peopIe who used the method rather than with the method itseIf. He further observed that it was truIy remarkabIe that the method survived at a11 under those circumstances; a11 of which is good evidence that there is something of value in it. Up to- 1913, aIthough a variety of chemicaIs was used. carboIic acid in various strengths and combinations was the solution of choice. As a matter of fact it is stiI1 extensiveIy used here and abroad. In 1923 MorIey4 pubIished a book on hemorrhoids. He advocated injections with 20 per cent soIution of carbolic acid in equa1 parts of glycerine and water. In 1913 TerreII” introduced the use of urea and quinine, 5 to I0 per cent soIution. When we estabIished the recta1 cIinic at The BrookIyn HospitaI in 1925, urea and quinine hydrochIoride was decided upon because we feIt that we wouId be Iess apt to run into compIications than if carboIic acid were used. We have used pheno1 5 per cent in either C. P. cottonseed or aImond oi1 with resuIts as good as with urea and quinine hydrochIoride. We prefer a soIution of the Iatter because it is less troubIesome to handIe, and our experience with it has been most gratifying. RATIONALE
The wonder is that the resuIts were not worse, but of course, we must consider the source of the information of these statistics. * From the SurgicaI Service, Division of Proctolog.y,
OF THE
INJECTION
METHOD
The object of the injection treatment of hemorrhoids is to set up an inffammatory
Brooklyn HospitaI, Dr. Ernest K. Tanner, Chief Attending Surgeon. Read before the Sixth Annual Joint Meeting of the ItaIian Medical Society of BrookIyn with the Association of ItaIian Physicians in America ApriI 17, 1933. 366
NEW S,atut.s
Vo..
,Xx111,
No.
2
Marina---Treatment
reaction within the hemorrhoida mass, thereby causing an obliteration of its vesseIs by thrombosis followed by fibrosis.
of Hemorrhoids
A m&can Journni of Surgery
367
habits and genera1 physica status must be taken into consideration. and Anderson1 in EngIand, MorIey4
Frc. I. Armamentarium for injection treatment of hemorrhoids. (I, z,3) Set of anoscopes; (4) Murphy headlight; (sj mercurochrome z per cent soIution; (6) carbolic acid 5 per cent in aImond oiI; (7) 2 C.C. Luer syringe with extension shank and 24 gauge needle (for injecting 5 per cent urea and quinine hydrochIoride); (8) Vim syringe with Iong needIe (for injecting 5 per cent phenot in almond oil); (9) swabs; (IO) 2 C.C. ampuIe of 5 per cent urea and quinine hydrochIoride.
The injection can be made either into the substance of the piIe tumor, or just above the hemorrhoid and immediately underneath the mucosa, that is, submucousIy. In either event the injection is not made into the bIood vesseIs but into the tissues surrounding them. SELECTION
OF
CASES
Th e prrme ’ requisite is a proper diagnosis. Treatment of any anorecta1 condition shouId never be attempted without a proctoscopic examination, besides the usua1 inspection and digita expIoration.5 The patient’s occupation, temperament,
and TerreII,3 Hirschman, Yeomans,;’ FansIers and other exponents of the injection method in this country, a11 agree that externa1 hemorrhoids shouId never be injected. We have seen externa1 piIes so treated and the resuIts have been such as to require surgica1 intervention. This injection method is appIicabIe onIy to uncompIicated interna hemorrhoids, and it is suitable to onIy 50 per cent of cases seen. If the condition is compIicated by fistuIa, fissure, poIypi, hypertrophied anal papiIIae, cryptitis, ana or recta1 tumors, it wouId be useIess to treat the hemorrhoids by injection, for these conditions require surgery and the hemorrhoids can be removed al
368
American
Journal
of Surgery
Marino-Treatment
the same time. Thrombosed, uIcerated, stranguIated and gangrenous or fibrotic cases demand surgery; injection therapy is contraindicated. ARMAMENTARIUM
This consists of a suitabIe anoscope, a good light, suitabIe syringe, and sohrtions. We have deveIoped an anoscope in our cIinic which has been found the most usefu1 for our purpose and which is used for either examination or treatment. It consists of a chromium-pIated meta conicaI cylinder with a sIot and a ffange to which the handIe is attached. Introduction is made easy with a perfectIy fitted hard rubber obturator. To suit the variabIe types of anus and Iength of the ana cana1, the instrument comes in three sizes as shown in Figure I. There are some characteristics of these specuIa which are worth mentioning. The angIe and width of the Aange is so buiIt as to heIp retract Iarge buttocks. The diffrcuIty with most ana instruments is that the buttocks foId in over the opening of the specuIum. The handIe comes from the ffange at the same angIe as the Iatter so that the instrument can be inserted its fuI1 Iength without being impeded at the handIe region by Iarge buttocks. The sIot is of uniform Iength in a11 three sizes, but the cyIindrica1 portion of the instrument is made of graded varying Iengths so that the smaIIest is 2 inches Iong, the next is 2% inches Iong and the Iargest is 3 inches Iong. Thus we have a suitabIe instrument for a short, a medium sized or a Iong ana cana1. There are peopIe who have a short ana cana but with funne1 shaped buttocks. In these peopIe the Iargest anoscope is the onIy one which wiI1 properIy expose the termina1 rectum. The sIot is l%s of an inch at the termina1 end, semiIunar in shape at the proxima1 end and 13% inches Iong. One-quarter of the circumference of the termina1 rectum and ana cana can be exposed with ease, and the construction of the instrument is such that it can be rotated whiIe inserted
of Hemorrhoids
FEBRUARY,
without the necessity reintroduction. TECHNIQUE
AND
of withdrawa
,934
and
PROCEDURE
Anesthesia is not empIoyed. A cathartic or enema is not given before each treatment, for we have found that their action usuaIIy takes pIace when manipuIation of the anorecta1 region is begun. We prefer to have our patients report without preparation. With the patient in the inverted, knee-chest or in the Sim’s position, whichever is best suited to the patient, an anoscope of our set is seIected according to the requirements and it is inserted to expose the hemorrhoids. It makes littIe difference whose anoscope is used, but we prefer the one which we have deveIoped. Good iIIumination is necessary. The Iargest piIe is seIected and the anoscope is steadied in position. If a bIeeding piIe is present, that takes precedence over the others. A Iarge swab is used to cIeanse the mucosa of mucus, particIes of feces or bIood. The exposed area is next painted with 2 per cent mercurochrome. Perhaps that is a futiIe gesture so far as steriIity is concerned, but we at least have the feeIing that we do not introduce infection through the mucosa when the sohrtion is injected. A 2 C.C. Luer syringe is empIoyed with a 24 or 2.5 gauge needIe on an extension shank. The syringe is charged with 5 per cent urea and quinine hydrochIoride. The needIe is pIunged into the uppermost part of the hemorrhoida mass and inserted to a depth as near the center of the mass as it is possibIe to gauge. The depth of introduction of the needIe, of course, depends upon the size of the mass. Before injection is begun it is we11 to withdraw the piston to make certain that a vesse1 has not been entered. The injection is made sIowIy and enough soIution is used to distend the hemorrhoid moderateIy, without bIanching. We fee1 that it is safer to err on the side of injecting too IittIe. From 35 to 2 C.C. of soIution may be necessary to distend the mass.
N,
2
Marino-Treatment
The needle is permitted to remain in situ for thirty seconds or more to prevent Ieakage of solution. If the injection is properIy done there is no immediate pain. A transient feehng of fuhness in the rectum foIIows the introduction of the solution. It is we11 to insert the finger into the rectum and with gentIe massage of the injected area spread the liquid immediateIy after the injection. If the patient is attending to duties which require much activity, onIy one hemorrhoid is injected at a sitting. If, on the other hand, the patient is not actively engaged, then two or more hemorrhoids, or if they are smaI1, a11 the interna hemorrhoids that are present, may be injected at the same sitting. If there is any tendency to prolapse of recta1 mucous membrane, instead of injecting into the piIe mass, we insert the needIe just above the piIe through and underneath the recta1 mucous membrane, and the soIution is injected submucousIy. The interva1 between injections is usuaIIy one week, but in cases where the hemorrhoids are not very large, two injections per week may be given. One injection may cause a piIe to disappear, but at times a second injection is necessary. Before a piIe is re-injected it shouId be determined by digita examination that no induration is present. The induration must subside before the second injection is given. From six to eight treatments may be necessary before the hemorrhoida masses disappear, which means that it takes from three to eight weeks to compIete a course of treatments. A chart is kept to record the site and date of each injection and the quantity, strength and kind of soIution. A circIe, the circumference of which is divided into four or eight equa1 parts, suffices for this purpose. AFTER-CARE
The patient is instructed to avoid severe physica effort. MineraI oi1 is given by mouth to make bowe1 movements easier.
of Hemorrhoids
A m&m
Journnl of Surperv
ReguIar diet is permitted. The warned to repIace immediateI? trusion which may occur.
369
patient is any pro-
COMPLICATIONS Idiosyncrasy: Before beginning treatment, it is we11 to determine the patient’s susceptibility to quinine. We know of nothing more disconcerting than to have a patient have a convuIsion in the office. Where such susceptibility exists, we use 3 per cent phenoI in vegetable or almond oil instea.d of urea and quinine hydrochIoride. Pain: There shouId be no pain at the time of injection if the treatment is properIy given. If the injection is given without regard to the anatomy of the anorecta1 region, pain is sure to ensue. Most certainIy, the solution must not be injected into the anal cana nor in such a way as to encroach upon the anal vaIves or crypts of Morgagni. If the needle is not pIunged high enough up in the terminal rectum, some of the soIution wiI1 trickle down or gravitate and find its way beneath the covering of the ana cana1. To avoid pain it is necessary to inject slowly and we11 above the dentate Iine. Bleeding: At times, bIeeding may occur after withdrawa of the needle. This bleeding usuaIly stops of its own accord or can be checked by pressure. Very infrequentIy bIeeding may be such as to require eIectrocoaguIation or even cIamping with Iigation. MorIey4 cites one case where he was unabIe to check bIeeding with cIamping and he had to pack the rectum. Suture Iigature may be necessary; and then, of course, the method is no Ionger painless. BIeeding sometimes may foIIow sIoughing. Slough: Too Iarge an amount or too strong a soIution wiI1 result in sIough. We advise the use of a weaker soIution even if one must re-inject rather than the production of a sIough through using too strong a soIution. Injection into the mucous membrane or muscIe or into a hemorrhoida mass which is stiI1 indurated
370
American
Journal
of Surgery
Marino-Treatment
from previous treatment wiI1 resuIt in sIough. &reduced Prolapse: A prolapsing pile can usuaIIy be injected in such a way as to make prolapse aImost impossible, but some wiI1 proIapse no matter what is done. It is very important to warn the patient about replacing a proIapse if it shouId occur, for if the piIe is allowed to remain down, stranguIation and gangrene wiI1 foIIow. Stricture: This can foIIow cicatrization as a resuIt of sIough, or through tumefaction of indiscriminate injection of oiI. Infection: The presence of infection in the anorecta1 region is a contraindication for injection, for aIthough the rectum is pecuIiarIy resistant to infection, an abscess may form. Submucous, perirecta1, periana1 or margina abscess formation may be foIIowed by fistuIa. Recurrence: It has been estimated that recurrences in two to five years occur in about 15 per cent of the cases. It must be borne in mind, however, that inasmuch as the treatment is painIess, gives symptomatic reIief, and does not detain patients from their duties, they fee1 kindIy toward the treatment and wiI1 return for another course, if necessary, without condemning the method.
of Hemorrhoids
FEBRUARY, 1934
We have a vaIuabIe means at our command of treating uncompIicated interna
hemorrhoids. This method demands the attention and respect of every practitioner of medicine, and aIthough, according to JeIks,g it may have been “conceived in quackery, hatched in quackery and nurtured in quackery,” honest evaIuation makes it most acceptable when used with discretion. The method is not without danger, and has its limitations which must be understood before its use is undertaken. SurgicaI judgment as we11 as ski11 and knowIedge are essentia1, for although the method seems simpIe, unIess one understands the rationaIe and technique, disappointment and compIications resuIt. When compIications arise, the treatment becomes worse than the disease, and convaIescence is Ionger than if a surgica1 operation had been performed. The method wiI1 never repIace a properIy performed hemorrhoidectomy but it has a place in the debilitated and anemic, the diabetic, the aged, and in that Iarge group who refuse hospitaIization and surIt is vaIuabIe, aIso, for gica1 operation. interna hemorrhoids compIicating pregnancy, but instead of the quinine preparation in these cases, a soIution of carboIic acid shouId be used for obvious reasons. FinaIIy, we know with what horror a patient looks upon the prospect of reoperation for recurrence of any condition. In this method, we have a most satisfactory means of deaIing with hemorrhoids recurring after hemorrhoidectomy.
1. ANDERSON, H. G. The treatment of haemorrhoids by submucous injections of chemicals. Brit. M. J., 2: IOo-102, 1924. 2. ANDREWS, E. Recta1 and AnaI Surgery. Ed. 3, Chicago, Keener, I 892. 3. TERRELL, E. H. Treatment of hemorrhoids by injection. Trans. Am. Proctol. Sot., 1925. 4. MORLEY, A. S. Haemorrhoids. Oxford Med. Pub., 1926.
5. MARINO, A. W. M. Diseases of the rectum and anus. Long Island M. J., Vol. 24: No. 4, 1930. 6. HIRSCHMAN, L. J. Handbook of Diseases of the Rectum. St. Louis, Mosby, 1921. 7. YEOMANS, F. C. ProctoIogyi N; Y., Appleton, 1929. 8. FANSLER, W. A. Persona1 communication. g. JELKS. J. S. Discussion of: TERRELL, E. H. SeIecting the treatment for hemorrhoids. Trans. Am. Proctol. Sot., 1931, p. 172.
CONCLUSIONS