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Progress in the management of hemorrhoids
-
PROGRESS IN THE MANAGEMENT T.
EDWARD
WHITNEY,
M.D.
AND
UCH
A PLEXUS
OF VARICOSITIES
REDUNDANT
MUCOUS
BENEATH
MEMBRANE
A hemorrhoid is a redundant pouch of rectal mucous membrane or anaI skin containing a pIexus of varicose venuIes. EarIy recognition of the fact that it is a pIexus of very smaI1 varicosities and not one Iarge vein wiII banish some of the confusion. Furthermore, an understanding of the genesis of such a condition wiI1 aIso heIp but this requires a knowIedge of certain aspects of the anatomy, physioIogy and pathoIogica1 states of the anus and Iower rectum. THE
VEINS
INVOLVED
The cIosure of the anus is accompIished by the tonic contraction of the sphincters which causes the mucous membrane of the much larger rectum to be thrown into a number of folds caIIed the coIumns of * Statistics
ANGELO,
M.D. *
MASSACHUSETTS
progress has been made in the treatment of hemorrhoids since suppositories and the clamp and cautery were the soIe forms of therapy. In fact, we now know that suppositories are practicaIIy worthIess except, possibIy, as a palliative measure and the treasured pearlhandIed cautery cIamp gathers dust in the usua1 hospita1 dispIay of antique instruments. And yet, there is a surprising amount of confusion among the medical profession as to just what hemorrhoids are and as to how they shouId be handIed.
M
GASPAR
Assistant Surgeon, Rectal Clinic, Boston Dispensary
Surgeon-in-charge, Recta1 Clinic, Boston Dispensary BOSTON,
OF HEMORRHOIDS
Morgagni. Beneath the mucous membrane of these coIumns, there is a vast network of venules which coIIects the bIood from this region and deIivers it into the porta venous system by way of the superior hemorrhoida veins. This bIood has to be raised approximately a foot from anus to heart and yet no part of the porta venous system is protected by vaIves. Furthermore, the superior hemorrhoida veins Iie for the most part within the abdomen on the waIIs of the rectum but, just above the Iocation of the coIumns of these veins penetrate these Morgagni, waIIs to enter the rectum where they then Iie just beneath the mucous membrane of the Iatter. (Fig. I.) Above this penetration they are protected by the intra-abdomina1 pressure but beIow it they, at times, Iose this protection as, during defecation, straining at stoo1 and forcibIe breaking of wind, when this pressure is exerted against a11 of the contents of the rectum incIuding any redundant mass of varicosities. It is no wonder, therefore, that these IittIe thinwalled veins easiIy succumb to any factors tending to produce proIonged dilatation and varicosity whether the Iatter are confined IocaIIy to the porta venous system or whether they affect a11 the more dependent veins of the body. GENESIS
OF
THE
Those factors which proIonged over-dilatation
VARICOSITIES
tend to produce within the porta
in the text referring to the Cambridge HospitaI were compiIed by Dr. AngeIo who is in charge of the Recta1 Clinic at the Cambridge HospitaI, Cambridge, Mass. 296
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venous system aIone accomphsh this by increasing the intravenous pressure within that system. This over-diIatation is seen behind an hepatic cirrhosis, behind a cardiac decompensation, in aIcohoIism, overeating, etc. On the other hand, conditions which tend to produce varicosity generaIIy throughout the more dependent veins of the body, do so by weakening the vein waIIs so that the Iatter are unabIe to withstand the norma intravenous pressure. The Iatter agents may be either nutritiona or endocrine. Nutritiona deficiencies produce both atony of the smooth muscIe and atrophy of the connective tissue sheath of the vein waI1 with ensuing weakness of both. An exampIe of an endocrine influence may be seen in the excessive diIatation of the veins of the Iegs and anus during pregnancy, a condition which, we beIieve, is caused by the secretion of the hormone reIaxin during this period.’ This hormone is intended to of the Iigamentous, produce reIaxation capsuIar and other connective tissue attachments of the peIvis in order to mobiIize the Iatter somewhat in preparation for deIivery. The same effect exerted on the connective tissue structures of the veins wouId expIain the marked increase of varicosities during pregnancy. The end resuIt of any one or combination of these processes is the production of a pIexus of varicose venuIes beneath the mucous membrane of the coIumns of Morgagni in the Iower rectum. GENESIS
OF
THE
MUCOUS
REDUNDANCY
OF
THE
MEMBRANE
However, another process must occur before this state of varicosity is productive of a hemorrhoid; the mucous membrane end skin overIying these venuIe varicosities must become redundant. The mucous membrane and skin of the rectum, anus and peri-anum are fixed in various degrees to the Iatter structures and these fixations have to be stretched or aboIished before the mucous membrane and skin can become redundant and form a pouch. The aboIition
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of these fixations is brought about by various forces singIy or in combination. The varicosities themseIves do considerabIe dissecting beneath the mucous membrane and the same nutritiona and endocrine factors which weaken the vein waIIs aIso weaken these fixations and aIIow the varicose dissection to progress even more easiIy. Straining of course heIps. INFLUENCE
OF
LONGITUDINAL
THE
CONJOINED MUSCLE
This process of detachment can proceed rapidIy beneath the mucous membrane of the rectum and beneath the peri-ana skin but not so rapidIy in the region of the anus itseIf which is the reason why we have severa different kinds of hemorrhoids; interna1, externa1, proIapsed, etc. The skin of the anus has inserted into it the conjoined, IongitudinaI muscIe of the bowe1 waI1 which fixes it very firmIy to the sphincters at the intermuscuIar septum.2 (Fig. I .) This muscIe is a continuation and confluence of the IongitudinaI bands of the Iarge intestine and of the Ievator ani. It compIeteIy surrounds the Iower rectum, ensheaths the three portions of the externaI sphincter and then becomes inserted principaIIy into the skin of the anus at and just below the intermuscuIar septum.‘O The firm fixation of the ana skin in this region prevents the downward extension of the varicose process which started in the coIumns of Morgagni so that for some time the process is confined to the rectum and is caIIed an interna hemorrhoid. (Fig. I.) However, if the redundancy of the mucous membrane in this region becomes extreme, it may form so Iarge a pouch that the Iatter can proIapse down through the Iumen of the anus thereby producing a proIapsed, interna hemorrhoid. On the other hand, in some individuaIs the strands of IongitudinaI muscIe inserted into the skin of the anus can be overstretched3 by straining and separated by the dissecting action of the venuIes themseIves, thereby aIIowing extension of the
298
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Angelo-Hemorrhoids
process into the peri-anaI area where once more the skin is IooseIy attached and once more a redundant pouch is easily produced
preceded and produced by hemorrhoid. FinaIIy, in some individuals,
an
internal
the interna
FIG. z. A proIapsed double hemorrhoid. The dark colored mass in the center is the dusky red, internal hemorrhoid which has intussuscepted down through the anus. This is surrounded by the Iighter coIored, external hemorrhoids which have reaIIy been transformed into fibrotic skin tabs.
FIG. I. A diagram iltustrating two types of hemorrhoids by means of a sagittat section down through the rectum and anus. On the Ieft is a simpIe internal hemorrhoid while on the right a doubIe hemorrhoid is depicted. It will be noted that the superior hemorrhoida vein pierces the recta1 wad just above the hemorrhoids to lose its intra-abdominal support and become subject to the strains and stresses of the lower rectum and anus. The insertion of the conjoined longitudinal muscle into the skin of the anus is indicated and it wiIl be seen how this controls the progress of the hemorrhoida process and consequently governs the type of hemorrhoid produced. On the right, this insertion has been pierced and weakened and the skin has been detached from the anal wall allowing the formation of an externa1 hemorrhoid as we11 as an interna one.
but this time whoIIy extra-ana1. When this occurs, in addition to the interna hemorrhoid, we have an externa1 hemorrhoid. (Fig. I.) Such a condition, however, is reaIIy a doubIe hemorrhoid as an external hemorrhoid rareIy exists without being
part of such a doubIe hemorrhoid becomes so redundant that it aIso intussuscepts through the Iumen of the anus producing a 2 proIapsed, double hemorrhoid. (Figs. and 9.) There are, therefore, four varieties of hemorrhoids : interna1, proIapsed interna1, doubIe and proIapsed doubIe. The externa1 thrombotic hemorrhoid (so-caIIed) is seIdom a rea1 hemorrhoid. It is nothing more than a thrombosis within some peri-ana venuIes. It reaIIy shouId be simpIy caIIed an externa1 thrombosis. INJECTIONS
VERSUS
OPERATION
This much of the pathoIogica1 process and anatomy must be kept in mind when it comes to seIecting the proper method of therapy. The majority of proctoIogists treat hemorrhoids by both injections and operation depending upon the type of hemorrhoid encountered so that in this articIe, we shaI1 not consider the other more rareIy used methods such as “eIectroIysis” (gaIvanism), diathermy, etc. The
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question is constantIy being asked as to where the Iine should be drawn between those cases suitabIe for injection and those
American
Journal
of surgery
or so above this Iine. Injection made above this demarkation sensation otherwise pain and
299
must be Iine of sIoughing
FIG. 3. Diagrams iIlustrating the effects of an injection on an interna hemorrhoid. The diagram on the left represents a redundant pouch of varicosities prior to injection. The middle one portrays the primary reaction following injection. Sclerosis of the varicosities and induration of the spaces between them has taken place. On the right is shown the end result. The sclerosed veins have been absorbed and the induration has been transformed into fibrosis which has contracted and, in addition to further obliterating the vessels, has reattached the mucous membrane onto the rectal v&I.
requiring surgery. As wiI1 be seen subsequentIy, some definite ruIes can be made to govern this seIection. MANAGEMENT
OF
SIMPLE
INTERNAL
HEMORRHOIDS
Most a11 simpIe uncompIicated interna hemorrhoids can be obIiterated by injection with suitabIe chemicaIs.4’5’6 How Iong this obliteration remains or how Iong other unobIiterated veins in the rectum remain free from varicosity varies with the individua1. UsuaIIy, examination and injection routinely every few years maintains contro1 of the condition.5 The injection is made into the interna hemorrhoida mass or pouch as high up as possibIe. No attempt is made to put the soIution into a vein; the veins are too smaI1 for this. TheoreticaIIy, there are no nerves of sensation above the mucocutaneous (pectinate) Iine which is at the IeveI of the interna sphincter about one-fourth inch above the intermuscuIar septum. PracticaIIy, however, it is found that there is some sensation for about one-fourth inch
wiI1 occur. From this statement it can be inferred that no injection can be made directIy into the externa1 hemorrhoid and, therefore, any attempt to cure the Iatter by injection must be made via obIiteration of the interna hemorrhoid. As this mucocutaneous Iine is somewhat indistinct at times, we usuaIIy advise the novice to ask the patient if he feeIs the touch of the swab putting antiseptic on the spot where the needIe is to be inserted and, if he does, the injection must be made higher up. Large boggy interna hemorrhoids may have to be injected two or three times3,4’7 and this should be done systematicaIIy, the first injection being introduced into the uppermost poIe and subsequentIy, after the Iapse of a suitabIe time varying with the type of solution used and the amount of contraction obtained, a second or third injection is made Iower down or just to either side. There are two soIutions in genera1 use: 5 per cent pheno1 in vegetabie GiI and 5 per cent auinine and urea hvdrochIoride. From I to ~‘cc. of the pheno1 rn oil and from I to
3oo
American
Journal
01 Surgery
Whitney,
AngeIo-Hemorrhoids
of the quinine is the usua1 dosage. Most proctoIogists give the other more widely advertised soIutions a tria1 but 2
cc.
DECEMBER, 1943
FoIIowing this primary induration, there occurs a Aattening of the hemorrhoid due to fibrous contraction about and obIiteration of the varicose venules. (Fig. 3.) Reattachment of the mucous membrane onto the rectal waI1 wiI1 take pIace if the fibrosis is extensive enough within the hemorrhoid to contact the muscIe of the waI1. In a Iarge interna hemorrhoid, this does not aIways occur at first as the first injection produces onIy a baI1 of fibrosis in its center which must be fixed to the muscIe by one or more subsequent injections. This fact is often overIooked. MANAGEMENT
OF
PROLAPSED,
INTERNAL
HEMORRHOIDS _’ 1 ’
FIG. 4. A photograph illustrating two types of external hemorrhoids. The upper, bluish, patulous hemorrhoid is soft and reducible and would be benefited somewhat (perhaps markedly) by injections. The lower, Iighter coIored mass is hard and fibrotic, is irreducibIe and would be affected in no way by injections. However, operation is indicated on both types in the absence of contraindications, as even in the upper hemorrhoid the insertion of the conjoined longitudinal muscIe has been irreparably weakened and detached aIlowing easy recurrence.
something usuaIIy turns out to be unsatisfactory. These two soIutions have stood the test of time and experience. FoIIowing the injection, there is a primary induration of the tissues beneath the mucous membrane composed of edema and inflammatory ceIIs (mostIy round ceIIs). This primary induration can be paIpated as a semi-firm Iump on the waI1 of the rectum. (Fig. 3.) With the quinine soIution, this Iump disappears in a few days or at the most in a coupIe of weeks but with the phenoI it Iasts for a month or two which is the reason why we, personaIIy, prefer the former. Sometimes severa injections must be made in rapid succession and, if each one produces a Iump and if each Iump remains in existence for severa weeks, the Iumen of the rectum soon becomes so surrounded or fiIIed with Iumps that evacuation becomes diffIcuIt.
Contrary to expectation, a simpIe, prointernal hemorrhoid wiI1 often lapsed, compIeteIy disappear upon injection especially if it is not too big or not of too Iong standing. It is surprising to see an angry, secreting, poIypoid, proIapsed, interna hemorrhoid disappear within a day or two of an injection of its upper pole. Recurrence in two or three years wiI1 often but, if the primary follow however3*j fibrosis is made firmIy adherent to the recta1 waI1 by repeated injections and, if routine injections are made periodicaIIy every year or two, contro1 of the condition can usuaIIy be maintained. In case of repeated recurrence or in oId, Iarge proIapses, operation is necessary. The Iatter is aImost painIess as it simpIy consists in transfixing the mass as high up as possibIe and excising it. As this a11 takes place above the mucocutaneous Iine where sensation is absent or nearIy so, very IittIe discomfort or disabiIity resuIts. MANAGEMENT
OF
DOUBLE
HEMORRHOIDS
Often an externa1 hemorrhoid wiI1 be improved as the result of injecting the interna one. The fibrous contraction and reattachment foIIowing an injection pulls from a11 directions. Sometimes this is redundant, enough to cause a sIightIy external hemorrhoid to puI1 up in. This obIiteration, however, may not be perma-
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nent and onIy in earIy cases wiI1 it occur Remember that this injection anyway. does nothing to the overstretched insertion of the IongitudinaI muscIe, so that, dissection of a new varicosity down through the Iatter is easiIy and quickIy possibIe. Of course, one might simphfy the probIem of whether to operate or to inject by insisting upon operation on a11 doubIe hemorrhoids. However, especiaIly in regards to chnic patients, various reasons are constantIy arising for avoiding operation such as contraindications, insuffrcient money, unavaiIabIe time, etc. We, therefore, have formulated the foIIowing ruIe to cover such cases: If the external hemorrhoid is reasonably smaII, is soft, is reducibIe and is of a normaI or bluish coIor, injection of the interna hemorrhoid may be tried although the patient shouId be told that a permanent cure by this method will probably be unattainabIe. On the other hand, if the externa1 hemorrhoid is quite Iarge, is irreducible or is fibrotic or grayish in coIor (Fig. 4), or if the interna hemorrhoid has also proIapsed (Figs. 2 is definitely indicated and 9), operation and, furthermore, is insisted upon. PERCENTAGE MUST
OF CASES BE
IN WHICH
OPERATED
American Journal
with other previousIy reported statistics since a11 of the cryptic tabs’ which were formerly diagnosed as double hemorrhoids have been cIeaned out of the cIinic. There TABLE DIAGNOSIS THE
ON
l,Wj6
BOSTON
I*
CONSECUTIVE
DISPENSARY
HOSPITAL
AND
RECTAL
Both Camb. and B.D.
87
323
4’0
.39
32
220
272
.26
28
127
.12
15
119
.I1
bridge
Hemorrhoids (primary diagnosis). . fissures, fkCryptitis, tulas, etc.. Kecto-sigmoidal pathology.. Pruritis-ani. Thromboses, misc., exams. Total. Hemorrhoids diagnosis).
(secondary
CLASSIFICATION
OF THE
128
18
-‘_-
200
32
ABOVE
INTO
CAMBRIDGE
B.D.
’ Cam-
By Groups
ADMISSIONS THE
CLINICS
856
1056
‘73
205
HEMORRHOIDS
Per Cent
j
.IZ I.
00
ACCORDING
TO TYPE
Cornbined
PATIENTS
I
Intermit (simple). , InternaI (prolapsed). . Double (simple and prolapsed).
Per Cent I
l-.-l--
UPON
Having thus roughly outlined which patients may be handled satisfactoriIy with injections and those which must be pertinent to operated upon, it becomes know what percentage of each are ordinariIy encountered in proctoIogic practice. ConsequentIy, we have reviewed the cIassification of 1,056 consecutive patients coming into the Recta1 Clinics of the Boston Dispensary and the Cambridge HospitaI. The results of this review can be seen by referring to TabIe I. It wiII be noted that 615 or 58 per cent of these patients had hemorrhoids. Of the Iatter, 161 were doubIe hemorrhoids, the majority of which needed operation. This is 26 per cent of a11 the hemorrhoids or 15 per cent of the total 1,056 rectal patients. Our percentage of double hemorrhoids is Iow as compared
of Surgery 3or
.
438 16
.7’ .o3
161
.26
615
1.00
-Total.............................
* It will be noted in the upper part of the tabIe that of the r,o56 consecutive cases, 410 had “hemorrhoids” as the primary diagnosis while an additiona ao5Tcases aIso had hemorrhoids although the latter were secondary to some other more urgent condition. AI1 together, of the 1,056 cases, there were 615 or 58 per cent which had hemorrhoids. In the lower part of the table, these 615 hemorrhoids are cfassihed according to type. It wiII be observed that some 26 per cent of them were double hemorrhoids in which operation had to be considered. This is 15 per cent of the total 1,056 cases.
were aIso some sixteen patients with prolapsed internal hemorrhoids, some of which, may become or even may have already become surgica1 cases but, as any definite information on this is as yet
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unavailable, they have not been included in this consideration. This review, therefore, shows that ap-
DECEMBER,19,s~
comfort and prolonged disabilitv from the hemorrhoidectomy operation. It-is a matter of making the operation as simple as pos-
FIG. 5. A diagram iIlustrating the technic of introducing the oil anesthesia. Through one needle hole in the posterior commissure, the sphincters on each side of the anus, the sacral nerve supplies on each side and the levator-ani in the region of the posterior commissure, can be injected. However, to some it might be easier to inject all of these areas through two nredle holes, each to one side of the posterior mid line. This blocking of the sacral nerves with a long lasting anesthetic has encouraging possibilities and calls for further investigation.
proximately 58 per cent of a11 patients with rectal compIaints have hemorrhoids and that at least a quarter of the Iatter require operation. TAKING
THE
PAIN
OUT
OF
HEMORRHOIDECTOMY
In cases in which a hemorrhoidectomy the patient accepts it more is necessary, readily if he can be assured that it wiII not require etherization, that postoperative pain has been practically ehminated, that the stay in the hospita1 is at Ieast one-half what it was twenty years ago and that absence from work wiII probabIy not be longer than two weeks. However, there is no miracIe in this removal of pain, dis-
sible, of using accepted improvements in technic and of paying attention to details. The foIIowing is a Iist of the more progressive and usefu1 measures in the order of their importance : (I) A posterior sphincterotomy or “pectenotomy”; (2) use of oi1 anesthesia; (3) a11 sutures above area of sensation ; (4) cIean cut, systematic (5) successfu1 pre- and intrasurgery; operative narcosis; (6) regiona1, spina and caudal anesthesia; (7) inteIIigent postoperative dressings; (8) prevention of compIications, and (9) management of the postoperative stoo1. Posterior Sphincterotomy. One of the most important, recent advances in proctoIogy is the posterior sphincterotomy and
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our experience has proved it to be a very necessary addition to a hemorrhoidectomy. As the Iiterature covering this operation
American
Journal ol Surgery
portion of the external sphincter Iatter location, each stroke being by the Ieft index hnger. (Fig.
303
at the guided 7.) The
t Intact
Peripnal
Ill useulature.
Poster’rov
Sphimcterotohy.
FIG. 6. Diagrams ihustrating what is severed as the result of a posterior sphincterotomy. A, the perineal muscles; B, the Ievator ani; c, the superhcia1 and deep portions of the external sphincter; D, the subcutaneous portion of the external sphincter; E, Minor’s triangle or the posterior triangular space; F, the coccyx; G, the glutei. The posterior sphincterotomy simpIy incises the subcutaneous portion of the extcrna1 sphincter (n) and also further separates, somewhat, the two legs of the superficial portion of the external sphincter (c) as they go off at a tangent to form Rlinor’s triangle (e) and become attached to the coccyx (F).
is not extensive, we wiI1 describe it in some detai1. The most superficia1 portion of the external sphincter, calIed the subcutaneous sphincter ani, is that portion which is feIt first by the finger upon entering the anus. It is this muscIe which goes into spasm folIowing infection or trauma in this region. Previously, this spasm was overcome by so diIating or stretching the muscIe that it became paraIyzed temporariIy but today such a resuIt is more effectiveIy and safely obtained by means of incising it either at the posterior commissure (Figs. 6, 7 and 8) or in one of the anteroIatera1 quadrants. We prefer the former Iocation. The left index finger is introduced into the anus up to the IeveI of the intersphincteric septum which is that depression existing between the interna and the external sphincters but detected best in the region of the posterior commissure. The scaIpe1 then incises, by successive strokes, the skin and this subcutaneous
interna sphincter and the major portion of the externa1 sphincter are in no way affected as the incision is carried down onIy to the dista1 tip of the interna sphincter and passes backward between the two tangentia1 Iegs of the superficia1 portion of the externa1 sphincter. (Fig. 6.) Following incision of the muscIe, the overIying skin edges are cut back somewhat on each side in order to prevent too rapid reapposition. Th e severed muscIe unites again within a week or ten days and re-epitheIiaIization takes pIace in from two to six weeks depending upon the amount of skin removed, the depth of the incision and heaIing powers of the patient. Sometimes cevitamic acid is needed. We cannot emphasize too strongIy the advantages of such a posterior sphincterotomy in a hemorrhoidectomy. It may be done as a first step whenever exposure is dificuIt to obtain, as obtains in some cases in which the anus is abnormaIIy long and the interna hemorrhoids are far up inside.
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AngeIo-Hemorrhoids
But it shouId aIways be done either prior to or after the hemorrhoidectomy for the foIIowing reasons : It prevents the onset
DECEMBER, ,943
premature formation of such a band foIIowing the hemorrhoidectomy. Oil Anesthesia. Another important re-
FIG. 7.
FIG. g.
FIG. 8.
FIG. IO.
FIG. 7. Doing a posterior sphincterotomy. FIG. 8. Finish of the posterior sphincterotomy. FIG. g. Before operation. FIG. IO. Three weeks after operation.
of any postoperative spasm as mentioned above; it prevents edema from forming in the strips of ana skin Ieft between the excised hemorrhoids (Fig. IO) ; it opens up the anus so that a pressure dressing can be appIied and maintained where needed most, thereby eIiminating the necessity for intra-ana drains, packs, “ whistIe tubes,” etc. ; and finaIIy it quite def?niteIy prevents stricture formation in two ways: first, by so Iaying the anus open that no faIse apposition occurs across from one raw area to another prior to epitheIiaIization, and second, it severs any pre-existing fibrous pecten bandgTIO and prevents the
cent advance in proctoIogy is the use of a IocaI anesthetic in oi1. When this was first introduced by GabrieI” it was greeted with much approva1 but soon feI1 into disfavor foIIowing the occurrence of sIoughs and abscesses. However, the current soIutions now in use and their proper empIoyment have been so perfected that the latter are rarities. PersonaIIy, we have used between 400 and 500 ampuIes of a certain oi1 anesthetic* with onIy one compIication, an abscess out in the buttock which more probabIy was caused by infection carried there by the needle. We are certain that * Proctocaine. Columbus Pharmacal Company.
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the use of such an anesthetic not onIy enhances the regiona and bIock anesthesia and the sphincter reIaxation during the operation but it aIso definiteIy reduces postoperative pain, discomfort, tension and diffIcuIty with bowe1 movements for at Ieast five days. But to obtain these benefits and to avoid complications, the proper technic of injection is required. The syringe used shouId be a dry one, the needle a No. Ig gauge, and the site of injection shouId be resteriIized. OnIy one or two needIe hoIes are necessary about an inch behind the anus. One cc. of oil is injected, from this Iocation into each of five different pIaces : into the sphincters on both sides of the anus, into the sphincters and Ievator ani behind the anus and out into both buttocks as described Iater in the description for injecting novocaine. (Fig. 5.) No oil is pIaced superficiaIIy beneath the skin. After withdrawa of the needIe, the whoIe area is massaged we11 to prevent unavoidabIe pooIing. In many patients an onset of symptoms occurs five or six days postoperativeIy which is an indication that the oi1 anesthesia had been operating previousIy. These patients shouId be given codeine for a day or two. Place Sutures in Non-sensitive Area. A suture producing tension within the area of sensation at the anus is a constant source of pain for severa days, especiaIIy upon motion of the gIutea1 and back musthe dissection of the cIes. Therefore, externaI hemorrhoid shouId be carried up to and beyond the mucocutaneous (pectinate) Iine so that the suture transfixing the pedicIe wiII be above any area of sensation. Active bIeeders shouId be transfixed, of course, but such transfixations do not seem to have the same disabIing effect as do pedicIes cIamped and tied too Iow. In the usua1 hemorrhoidectomy technic, the cIosure of the anus brings the skin edges together as much as is desired so that any stay or approximating sutures are unnecessary. If the Bacon method” is used, it wiI1 be seen that the approximating sutures pIace no tension on the skin edges.
American
Journal
of Surgery
305
Clean-cut Surgery. By cIean cut surgery, we mean the carefu1 excision of a11 so-caIIed cowIs, skin tabs, tits of skin, etc., on the edges of the incision as they have a tendency to become edematous and Iater persist in the form of skin tabs. This appIies to any and a11 methods of performing a hemorrhoidectomy. We herewith present no preference for any one technic other than that it be simpIe, aIIow pIenty of drainage and produce no tension on the anal skin. Preoperative Narcosis. The secret of a successfu1 preoperative narcosis is the use of smaI1 doses of severa synergistic drugs at the proper time. There are many variations but the foIIowing is an exampIe which has most patients nearIy asIeep on arrival at the operating room and in sIumber by the time the IocaI anesthesia has been injected : DiIaudid gr. pi2 or morphine gr. fC and ScopoIomine gr. fi50-$$00 S.C. I hour before operation SeconaI or nembuta1 gr. 1% p.o. $5 hour before operation We Iike diIaudid because it seems to cause Iess postoperative nausea than does morphine. The proper timing is important as has been made pIain by Leigh.” The opiates seem to require at Ieast an hour to produce their anaIgesic effects whiIe the short acting barbiturates require onIy onehaIf an hour. In our experience, one-haIf the dosage of a11 these drugs shouId be given to those over sixty, to the frai1 and debiIitated and to those having had cardiac decompensation. Anesthesia. One of the authors (G. A.) prefers spina anesthesia. This can be given in a smaI1 dose to produce onIy a “saddIe” area of anesthesia. It gives exceIIent reIaxation and exposure. Hirschman13 recommends a cauda1 anesthesia but we have found the waiting period, before the novoto be irritating. However, Caine “takes,” the same resuIts can be had with regional and bIock anesthesia if the proper technic is used. (E. T. W.) From 30 to 50 cc. of 2 per cent novocaine with adrenaIin is
306
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required. We have had no one “feeI” the adrenalin and its incIusion is very necessary to prevent any aIIergic or toxic reaction from too rapid absorption of the novocaine. We wish to repeat this admonition: Never inject novocaine, without adrenaIin in it, into the tissues about the anus as the bIood suppIy is so great that it can be taken up too quickIy. The injection must be made systematicaIIyunder the peri-ana skin, into the sphincters and out into the buttocks. A three-inch needIe (No. 20 gauge) is quickIy inserted through the skin about an inch behind the anus in the posterior commissure and from this one position IO to 20 cc. of novocaine are injected beneath the perianal skin nearIy a11 the way around the anus. A little may have to be injected anteriorIy through other needIe hoIes. Injecting beneath the skin does not aboIish the Iandmarks. SecondIy, 5 to IO cc. are injected into the sphincters IateraI to the anus first on one side of the anus and then on the other side (Fig. 5) and aIso deepIy into the sphincters and the Ievator ani behind the anus. FinaIIy, 5 to IO cc. are fanned out into each buttock to anesthetize the sacra1 nerves which emerge from beneath the gIutea1 muscIes, thereby producing a bIock anesthesia. (Fig. 5.) The Ieft index finger in the rectum guides the introduction of the needIe into these various Iocations. Postoperative Dressings. The postoperative dressings are necessary 0nIy to prevent oozing as a11 major bIeeding points are supposedIy tied off as mentioned in a preceding paragraph. The posterior sphincterotomy aIIows pressure by means of dressings to be appIied right up to the interna sphincter and in many cases even up to the Iocation of the Iigated pedicIes. This pressure is heId in pIace by adhesive, not by a T binder. No rubber drains of any kind are needed. Prevention of Complications. The comphcations of a hemorrhoidectomy incIude postoperative bIeeding, urinary retention, infection and stricture. Postoperative
DECEMBER. ,943
bIeeding can be controIIed by adequate care of bIeeding points and transfixations during operation and by giving an ampuIe of vitamin K routineIy prior to operation in order to overcome any decrease of thrombin production caused by the administration of the barbiturates.14 The problem of postoperative catheterization is a serious one in recta1 work. The nervous inter-reIationship between the anus and the urinary bladder causes pain and spasm of the anus to throw the urinary sphincter into spasm and paralyzes the detrusor muscIe. Theoretically, the better the sacra1 nerves in the buttock are anesthetized by oi1 anesthesia, the Iess the urinary nervous system wiI1 be disturbed and, of course, aI1 of our pain and spasm preventing measures heIp. NevertheIess, retention stiI1 occurs. However, we have had considerabIe success in reducing this by using an ampuIe of doryI15 prior to catheterization. Woodruff et aI.“j have suggested instiIIing an ounce of 0.5 per cent aqueous mercurochrome into the bIadder at the time of operation to stimuIate the detrusor muscIe. We have used this routineIy in a11 of our recent cases done under spinal anesthesia with a definite decrease in the need of catheterization. However, in our cases in which IocaI anesthesia is used, mercurochrome is not instiIIed at the time of operation because catheterization at that time is as bad as it is eight hours Iater. However, when the Iatter is necessary we promptly start a urinary antiseptic. As the resuIt of Ieaving the wounds open and as the resuIt of the earIy institution of the hot sitz bath (second day after operation) we see practicaIIy no infection. Stricture is prevented in three ways: (I) by care during the operation to Ieave two or three paraIIe1 strips of skin and mucous membrane running up from the peri-anum into the rectum; (2) by the use of the posterior sphincterotomy and, (3) by frequent postoperative digita examinations and the breaking down of faIse appositions.
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Postoperative Stool. The postoperative stoo1 is had forty-eight hours after operation by means of an oil retention enema foIlowed in an hour by a saIine enema (foIIowed by a hot sitz bath). Mineral oiI (s ounce nightIy) is started even before operation and continued until healing is had. This much oil will not leak and does soften the stool. MEASURING
PROGRESS
Progress in the management orrhoidectomy can be gauged
DAVS
of the hemby examina-
TABLE II* OF HOSPlTALlZATION OF NINETY-SIX
HOSPITAL THE
SERVlCE YEARS
1$,21-1942
FOURTY-FIVE AS
Cambridge
1$&Z-192$,
30 cases 10.7
CAMBRIDGE
HEMORRHOIDECTOMIES AS
SERVICE
OUTLINED
HospitaI
IN
DURING
COMPARED
CASES THE
WITH
HANDLED TEXT
I
Service
Our Service
1926-1935, 36 cases
‘936-1942. 30 cases
‘941-1942, 45 cases
8.3
7.7
4.4
* If we may cite the above figures as a criterion, the ordinary hospita1 service hemorrhoidectomy was requiring, roughly, an average of eleven days’ hospitalization some twenty years ago and less than eight days now. As a result of the various measures outlined in the text, our service cases are confined an average of Iess than five days.
tion of TabIe II which shows how the length of stay in the Cambridge Hospitai of ordinary service hemorrhoidectomies has decreased during the past twenty years from 10.7 days in the early Igzo’s to 7.7 days in the earIy 1940’s. However, when the preventive measures, which we have outlined, are consistentIy applied, as has been done in our service cases during rg4 I to 1942, the Iength of the hospita1 stay has been reduced to 4.4 days which is nearIy one-haIf that of the cases at the Cambridge Hospital. SUMMARY
Much progress has been made in the treatment of hemorrhoids during the past few years and, yet, there is stiI1 a surprising
Americxn
Journal
of Surgery
307
amount of confusion with reference to the subject among the medica profession. A review is made of the anatomy, physioIogy and pathoIogica1 conditions of the anus and their effect on the genesis of the various types of hemorrhoids. Selection of the proper form of therapy is discussed. SimpIe, interna hemorrhoids are injected; frank doubIe hemorrhoids are excised. A review of 1,056 consecutive recta1 cases admitted to the Boston Dispensary and the Cambridge HospitaI was made in order to ascertain the percentage having double hemorrhoids and therefore needing operation. Of the 1,056 patients, 615 or 58 per cent had hemorrhoids in one form or another. Of the 615 hemorrhoids, 161 were of the doubIe variety. This is 26 per cent of the total number of hemorrhoids or 15 per cent of the tota number of 1,056 patients with recta1 complaints. It is concluded, therefore, that approximateIy 58 per cent of a11 patients with recta1 complaints have hemorrhoids and that at Ieast a quarter of the Iatter require operation. When a hemorrhoidectomy is indicated, the Iayman accepts it more readiIy when he can be assured that the dreaded postoperative pain, discomfort and disability of the past has been practicahy eliminated. The Iatter has been accompIished, not as the resuIt of some new operation, but mainIy as the resuIt of using those advances made recently in proctoIogy which are applicable to a hemorrhoidectomy. These are to be found both in the field of technic and in our newer knowIedge of the anatomy of the anus. They incIude the posterior sphincterotomy, the use of an oil anesthesia, careful surgery with the main transfixing sutures above the area of sensation, prevention of postoperative complications and intelligent management of the first stoo1. REFERENCES I.
ROBERTS, S. M., and WILSON, P. D. ReIaxation of pelvic joints in pregnancy. Surf., Gynec. fl Obst., 58: 595-613. 1934.
ABRAMSON,
D.,
308
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2. GORSCH, R. V. Perineopelvic Anatomy. P. 78. New York. Tilghman Co. 3. MORGAN, C. N. Hemorrhoids. Brit. M. J., 4077: 399, 1939; 4078: 459, 1939. 4. BACON, H. E. and WOLFE, F. D. The injection treatment of hemorrhoids. Illinois M. J., 8 I : 202, ‘942. J. GABRIEL, \V. B. Treatment of hemorrhoids. hit. M. J., 2: 1266, 1939. 6. CORBETT, J. J. Offrce treatment of hemorrhoids. Am. J. Surg., 50: 641, 1940. 7. ROSSER, CURTICE. The rational management of hemorrhofds. Texas State J. Med., 34: 484, 1938. 8. WHITNEY, E. T. and KEANE, J. F. PerianaI cryptic tabs. New England J. Med., 22 I : 303-306, 1939. 9. ABEL, A. L. The pecten: the pecten band: pectenosis and pectenotomy. .!xncef, I : 7 14-7 I 8, 1932. IO. WHITNEY, E. T. Fissure-in-ano. Am. J. Surg., 59: 9-17.
‘943.
DECEMBER, ,943
I I. GABRIEL, W. B. The treatment of pruritis-ani and anal canal fissure. &if. M. J., 2: 1070, 1929. and postoperative 12. LEIGH, M. D. Preoperative medication. Canad. M. A. J., 47: 150-152, 1942. 13. HIRSCHMAN,L. J. The technic of a simpIe and effective hemorrhoidectomy. J. Kansas M. Sot., 43: 45-48, 1942. 14. FITZGERALD, J. E. and WEBSTER, AUGUSTA. Obstetric significance of barbiturates and vitamin K. J. A. M. A., 119: 1082-1085, 1942. 15. SHULZE, E. Zur BehandIung der Harnver haItung im R’ochenbelt und nach gynakologischen operationen. Miincben. med. Wcbnscbr., 82: 1358, 1935. 16. WOODRUFF, J. D. and TELINDE, R. W. The postoperative care of the urinary hIadder. J. A. M. A., 1’3: ‘45, 1939. 17. BACON, H. E. Anorectal operative procedures with special reference to the avoidance of pain. J. A. M. A., I 16: 363-366, 1941.
Correction: In the article, “Carcinoma of the Tip of the Tongue,” by Dr. Fink and Dr. Garb, which appeared in our October 1943 issue, the authors wish to draw the readers’ attention to an error they made on page 141. The sentence, “Ochsner and DeBakey reported a series of 3,047 coIlected cases of primary carcinoma of the tongue . . . ” shouId have read, “3,047 coIIected cases of primary carcinoma of the lung.”
PROGRESS IN THE MANAGEMENT T.
EDWARD
WHITNEY,
M.D.
AND
UCH
A PLEXUS
OF VARICOSITIES
REDUNDANT
MUCOUS
BENEATH
MEMBRANE
A hemorrhoid is a redundant pouch of rectal mucous membrane or anaI skin containing a pIexus of varicose venuIes. EarIy recognition of the fact that it is a pIexus of very smaI1 varicosities and not one Iarge vein wiII banish some of the confusion. Furthermore, an understanding of the genesis of such a condition wiI1 aIso heIp but this requires a knowIedge of certain aspects of the anatomy, physioIogy and pathoIogica1 states of the anus and Iower rectum. THE
VEINS
INVOLVED
The cIosure of the anus is accompIished by the tonic contraction of the sphincters which causes the mucous membrane of the much larger rectum to be thrown into a number of folds caIIed the coIumns of * Statistics
ANGELO,
M.D. *
MASSACHUSETTS
progress has been made in the treatment of hemorrhoids since suppositories and the clamp and cautery were the soIe forms of therapy. In fact, we now know that suppositories are practicaIIy worthIess except, possibIy, as a palliative measure and the treasured pearlhandIed cautery cIamp gathers dust in the usua1 hospita1 dispIay of antique instruments. And yet, there is a surprising amount of confusion among the medical profession as to just what hemorrhoids are and as to how they shouId be handIed.
M
GASPAR
Assistant Surgeon, Rectal Clinic, Boston Dispensary
Surgeon-in-charge, Recta1 Clinic, Boston Dispensary BOSTON,
OF HEMORRHOIDS
Morgagni. Beneath the mucous membrane of these coIumns, there is a vast network of venules which coIIects the bIood from this region and deIivers it into the porta venous system by way of the superior hemorrhoida veins. This bIood has to be raised approximately a foot from anus to heart and yet no part of the porta venous system is protected by vaIves. Furthermore, the superior hemorrhoida veins Iie for the most part within the abdomen on the waIIs of the rectum but, just above the Iocation of the coIumns of these veins penetrate these Morgagni, waIIs to enter the rectum where they then Iie just beneath the mucous membrane of the Iatter. (Fig. I.) Above this penetration they are protected by the intra-abdomina1 pressure but beIow it they, at times, Iose this protection as, during defecation, straining at stoo1 and forcibIe breaking of wind, when this pressure is exerted against a11 of the contents of the rectum incIuding any redundant mass of varicosities. It is no wonder, therefore, that these IittIe thinwalled veins easiIy succumb to any factors tending to produce proIonged dilatation and varicosity whether the Iatter are confined IocaIIy to the porta venous system or whether they affect a11 the more dependent veins of the body. GENESIS
OF
THE
Those factors which proIonged over-dilatation
VARICOSITIES
tend to produce within the porta
in the text referring to the Cambridge HospitaI were compiIed by Dr. AngeIo who is in charge of the Recta1 Clinic at the Cambridge HospitaI, Cambridge, Mass. 296
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venous system aIone accomphsh this by increasing the intravenous pressure within that system. This over-diIatation is seen behind an hepatic cirrhosis, behind a cardiac decompensation, in aIcohoIism, overeating, etc. On the other hand, conditions which tend to produce varicosity generaIIy throughout the more dependent veins of the body, do so by weakening the vein waIIs so that the Iatter are unabIe to withstand the norma intravenous pressure. The Iatter agents may be either nutritiona or endocrine. Nutritiona deficiencies produce both atony of the smooth muscIe and atrophy of the connective tissue sheath of the vein waI1 with ensuing weakness of both. An exampIe of an endocrine influence may be seen in the excessive diIatation of the veins of the Iegs and anus during pregnancy, a condition which, we beIieve, is caused by the secretion of the hormone reIaxin during this period.’ This hormone is intended to of the Iigamentous, produce reIaxation capsuIar and other connective tissue attachments of the peIvis in order to mobiIize the Iatter somewhat in preparation for deIivery. The same effect exerted on the connective tissue structures of the veins wouId expIain the marked increase of varicosities during pregnancy. The end resuIt of any one or combination of these processes is the production of a pIexus of varicose venuIes beneath the mucous membrane of the coIumns of Morgagni in the Iower rectum. GENESIS
OF
THE
MUCOUS
REDUNDANCY
OF
THE
MEMBRANE
However, another process must occur before this state of varicosity is productive of a hemorrhoid; the mucous membrane end skin overIying these venuIe varicosities must become redundant. The mucous membrane and skin of the rectum, anus and peri-anum are fixed in various degrees to the Iatter structures and these fixations have to be stretched or aboIished before the mucous membrane and skin can become redundant and form a pouch. The aboIition
American ~~~~~~~ of
surgery 297
of these fixations is brought about by various forces singIy or in combination. The varicosities themseIves do considerabIe dissecting beneath the mucous membrane and the same nutritiona and endocrine factors which weaken the vein waIIs aIso weaken these fixations and aIIow the varicose dissection to progress even more easiIy. Straining of course heIps. INFLUENCE
OF
LONGITUDINAL
THE
CONJOINED MUSCLE
This process of detachment can proceed rapidIy beneath the mucous membrane of the rectum and beneath the peri-ana skin but not so rapidIy in the region of the anus itseIf which is the reason why we have severa different kinds of hemorrhoids; interna1, externa1, proIapsed, etc. The skin of the anus has inserted into it the conjoined, IongitudinaI muscIe of the bowe1 waI1 which fixes it very firmIy to the sphincters at the intermuscuIar septum.2 (Fig. I .) This muscIe is a continuation and confluence of the IongitudinaI bands of the Iarge intestine and of the Ievator ani. It compIeteIy surrounds the Iower rectum, ensheaths the three portions of the externaI sphincter and then becomes inserted principaIIy into the skin of the anus at and just below the intermuscuIar septum.‘O The firm fixation of the ana skin in this region prevents the downward extension of the varicose process which started in the coIumns of Morgagni so that for some time the process is confined to the rectum and is caIIed an interna hemorrhoid. (Fig. I.) However, if the redundancy of the mucous membrane in this region becomes extreme, it may form so Iarge a pouch that the Iatter can proIapse down through the Iumen of the anus thereby producing a proIapsed, interna hemorrhoid. On the other hand, in some individuaIs the strands of IongitudinaI muscIe inserted into the skin of the anus can be overstretched3 by straining and separated by the dissecting action of the venuIes themseIves, thereby aIIowing extension of the
298
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DECEMBER. rrJ43
Angelo-Hemorrhoids
process into the peri-anaI area where once more the skin is IooseIy attached and once more a redundant pouch is easily produced
preceded and produced by hemorrhoid. FinaIIy, in some individuals,
an
internal
the interna
FIG. z. A proIapsed double hemorrhoid. The dark colored mass in the center is the dusky red, internal hemorrhoid which has intussuscepted down through the anus. This is surrounded by the Iighter coIored, external hemorrhoids which have reaIIy been transformed into fibrotic skin tabs.
FIG. I. A diagram iltustrating two types of hemorrhoids by means of a sagittat section down through the rectum and anus. On the Ieft is a simpIe internal hemorrhoid while on the right a doubIe hemorrhoid is depicted. It will be noted that the superior hemorrhoida vein pierces the recta1 wad just above the hemorrhoids to lose its intra-abdominal support and become subject to the strains and stresses of the lower rectum and anus. The insertion of the conjoined longitudinal muscle into the skin of the anus is indicated and it wiIl be seen how this controls the progress of the hemorrhoida process and consequently governs the type of hemorrhoid produced. On the right, this insertion has been pierced and weakened and the skin has been detached from the anal wall allowing the formation of an externa1 hemorrhoid as we11 as an interna one.
but this time whoIIy extra-ana1. When this occurs, in addition to the interna hemorrhoid, we have an externa1 hemorrhoid. (Fig. I.) Such a condition, however, is reaIIy a doubIe hemorrhoid as an external hemorrhoid rareIy exists without being
part of such a doubIe hemorrhoid becomes so redundant that it aIso intussuscepts through the Iumen of the anus producing a 2 proIapsed, double hemorrhoid. (Figs. and 9.) There are, therefore, four varieties of hemorrhoids : interna1, proIapsed interna1, doubIe and proIapsed doubIe. The externa1 thrombotic hemorrhoid (so-caIIed) is seIdom a rea1 hemorrhoid. It is nothing more than a thrombosis within some peri-ana venuIes. It reaIIy shouId be simpIy caIIed an externa1 thrombosis. INJECTIONS
VERSUS
OPERATION
This much of the pathoIogica1 process and anatomy must be kept in mind when it comes to seIecting the proper method of therapy. The majority of proctoIogists treat hemorrhoids by both injections and operation depending upon the type of hemorrhoid encountered so that in this articIe, we shaI1 not consider the other more rareIy used methods such as “eIectroIysis” (gaIvanism), diathermy, etc. The
NEW
SERIES VOL. LXII. No.
Whitney,
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AngeIo-Hemorrhoids
question is constantIy being asked as to where the Iine should be drawn between those cases suitabIe for injection and those
American
Journal
of surgery
or so above this Iine. Injection made above this demarkation sensation otherwise pain and
299
must be Iine of sIoughing
FIG. 3. Diagrams iIlustrating the effects of an injection on an interna hemorrhoid. The diagram on the left represents a redundant pouch of varicosities prior to injection. The middle one portrays the primary reaction following injection. Sclerosis of the varicosities and induration of the spaces between them has taken place. On the right is shown the end result. The sclerosed veins have been absorbed and the induration has been transformed into fibrosis which has contracted and, in addition to further obliterating the vessels, has reattached the mucous membrane onto the rectal v&I.
requiring surgery. As wiI1 be seen subsequentIy, some definite ruIes can be made to govern this seIection. MANAGEMENT
OF
SIMPLE
INTERNAL
HEMORRHOIDS
Most a11 simpIe uncompIicated interna hemorrhoids can be obIiterated by injection with suitabIe chemicaIs.4’5’6 How Iong this obliteration remains or how Iong other unobIiterated veins in the rectum remain free from varicosity varies with the individua1. UsuaIIy, examination and injection routinely every few years maintains contro1 of the condition.5 The injection is made into the interna hemorrhoida mass or pouch as high up as possibIe. No attempt is made to put the soIution into a vein; the veins are too smaI1 for this. TheoreticaIIy, there are no nerves of sensation above the mucocutaneous (pectinate) Iine which is at the IeveI of the interna sphincter about one-fourth inch above the intermuscuIar septum. PracticaIIy, however, it is found that there is some sensation for about one-fourth inch
wiI1 occur. From this statement it can be inferred that no injection can be made directIy into the externa1 hemorrhoid and, therefore, any attempt to cure the Iatter by injection must be made via obIiteration of the interna hemorrhoid. As this mucocutaneous Iine is somewhat indistinct at times, we usuaIIy advise the novice to ask the patient if he feeIs the touch of the swab putting antiseptic on the spot where the needIe is to be inserted and, if he does, the injection must be made higher up. Large boggy interna hemorrhoids may have to be injected two or three times3,4’7 and this should be done systematicaIIy, the first injection being introduced into the uppermost poIe and subsequentIy, after the Iapse of a suitabIe time varying with the type of solution used and the amount of contraction obtained, a second or third injection is made Iower down or just to either side. There are two soIutions in genera1 use: 5 per cent pheno1 in vegetabie GiI and 5 per cent auinine and urea hvdrochIoride. From I to ~‘cc. of the pheno1 rn oil and from I to
3oo
American
Journal
01 Surgery
Whitney,
AngeIo-Hemorrhoids
of the quinine is the usua1 dosage. Most proctoIogists give the other more widely advertised soIutions a tria1 but 2
cc.
DECEMBER, 1943
FoIIowing this primary induration, there occurs a Aattening of the hemorrhoid due to fibrous contraction about and obIiteration of the varicose venules. (Fig. 3.) Reattachment of the mucous membrane onto the rectal waI1 wiI1 take pIace if the fibrosis is extensive enough within the hemorrhoid to contact the muscIe of the waI1. In a Iarge interna hemorrhoid, this does not aIways occur at first as the first injection produces onIy a baI1 of fibrosis in its center which must be fixed to the muscIe by one or more subsequent injections. This fact is often overIooked. MANAGEMENT
OF
PROLAPSED,
INTERNAL
HEMORRHOIDS _’ 1 ’
FIG. 4. A photograph illustrating two types of external hemorrhoids. The upper, bluish, patulous hemorrhoid is soft and reducible and would be benefited somewhat (perhaps markedly) by injections. The lower, Iighter coIored mass is hard and fibrotic, is irreducibIe and would be affected in no way by injections. However, operation is indicated on both types in the absence of contraindications, as even in the upper hemorrhoid the insertion of the conjoined longitudinal muscIe has been irreparably weakened and detached aIlowing easy recurrence.
something usuaIIy turns out to be unsatisfactory. These two soIutions have stood the test of time and experience. FoIIowing the injection, there is a primary induration of the tissues beneath the mucous membrane composed of edema and inflammatory ceIIs (mostIy round ceIIs). This primary induration can be paIpated as a semi-firm Iump on the waI1 of the rectum. (Fig. 3.) With the quinine soIution, this Iump disappears in a few days or at the most in a coupIe of weeks but with the phenoI it Iasts for a month or two which is the reason why we, personaIIy, prefer the former. Sometimes severa injections must be made in rapid succession and, if each one produces a Iump and if each Iump remains in existence for severa weeks, the Iumen of the rectum soon becomes so surrounded or fiIIed with Iumps that evacuation becomes diffIcuIt.
Contrary to expectation, a simpIe, prointernal hemorrhoid wiI1 often lapsed, compIeteIy disappear upon injection especially if it is not too big or not of too Iong standing. It is surprising to see an angry, secreting, poIypoid, proIapsed, interna hemorrhoid disappear within a day or two of an injection of its upper pole. Recurrence in two or three years wiI1 often but, if the primary follow however3*j fibrosis is made firmIy adherent to the recta1 waI1 by repeated injections and, if routine injections are made periodicaIIy every year or two, contro1 of the condition can usuaIIy be maintained. In case of repeated recurrence or in oId, Iarge proIapses, operation is necessary. The Iatter is aImost painIess as it simpIy consists in transfixing the mass as high up as possibIe and excising it. As this a11 takes place above the mucocutaneous Iine where sensation is absent or nearIy so, very IittIe discomfort or disabiIity resuIts. MANAGEMENT
OF
DOUBLE
HEMORRHOIDS
Often an externa1 hemorrhoid wiI1 be improved as the result of injecting the interna one. The fibrous contraction and reattachment foIIowing an injection pulls from a11 directions. Sometimes this is redundant, enough to cause a sIightIy external hemorrhoid to puI1 up in. This obIiteration, however, may not be perma-
NEW SERIES VOL. LXII,
Whitney,
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AngeIo-Hemorrhoids
nent and onIy in earIy cases wiI1 it occur Remember that this injection anyway. does nothing to the overstretched insertion of the IongitudinaI muscIe, so that, dissection of a new varicosity down through the Iatter is easiIy and quickIy possibIe. Of course, one might simphfy the probIem of whether to operate or to inject by insisting upon operation on a11 doubIe hemorrhoids. However, especiaIly in regards to chnic patients, various reasons are constantIy arising for avoiding operation such as contraindications, insuffrcient money, unavaiIabIe time, etc. We, therefore, have formulated the foIIowing ruIe to cover such cases: If the external hemorrhoid is reasonably smaII, is soft, is reducibIe and is of a normaI or bluish coIor, injection of the interna hemorrhoid may be tried although the patient shouId be told that a permanent cure by this method will probably be unattainabIe. On the other hand, if the externa1 hemorrhoid is quite Iarge, is irreducible or is fibrotic or grayish in coIor (Fig. 4), or if the interna hemorrhoid has also proIapsed (Figs. 2 is definitely indicated and 9), operation and, furthermore, is insisted upon. PERCENTAGE MUST
OF CASES BE
IN WHICH
OPERATED
American Journal
with other previousIy reported statistics since a11 of the cryptic tabs’ which were formerly diagnosed as double hemorrhoids have been cIeaned out of the cIinic. There TABLE DIAGNOSIS THE
ON
l,Wj6
BOSTON
I*
CONSECUTIVE
DISPENSARY
HOSPITAL
AND
RECTAL
Both Camb. and B.D.
87
323
4’0
.39
32
220
272
.26
28
127
.12
15
119
.I1
bridge
Hemorrhoids (primary diagnosis). . fissures, fkCryptitis, tulas, etc.. Kecto-sigmoidal pathology.. Pruritis-ani. Thromboses, misc., exams. Total. Hemorrhoids diagnosis).
(secondary
CLASSIFICATION
OF THE
128
18
-‘_-
200
32
ABOVE
INTO
CAMBRIDGE
B.D.
’ Cam-
By Groups
ADMISSIONS THE
CLINICS
856
1056
‘73
205
HEMORRHOIDS
Per Cent
j
.IZ I.
00
ACCORDING
TO TYPE
Cornbined
PATIENTS
I
Intermit (simple). , InternaI (prolapsed). . Double (simple and prolapsed).
Per Cent I
l-.-l--
UPON
Having thus roughly outlined which patients may be handled satisfactoriIy with injections and those which must be pertinent to operated upon, it becomes know what percentage of each are ordinariIy encountered in proctoIogic practice. ConsequentIy, we have reviewed the cIassification of 1,056 consecutive patients coming into the Recta1 Clinics of the Boston Dispensary and the Cambridge HospitaI. The results of this review can be seen by referring to TabIe I. It wiII be noted that 615 or 58 per cent of these patients had hemorrhoids. Of the Iatter, 161 were doubIe hemorrhoids, the majority of which needed operation. This is 26 per cent of a11 the hemorrhoids or 15 per cent of the total 1,056 rectal patients. Our percentage of double hemorrhoids is Iow as compared
of Surgery 3or
.
438 16
.7’ .o3
161
.26
615
1.00
-Total.............................
* It will be noted in the upper part of the tabIe that of the r,o56 consecutive cases, 410 had “hemorrhoids” as the primary diagnosis while an additiona ao5Tcases aIso had hemorrhoids although the latter were secondary to some other more urgent condition. AI1 together, of the 1,056 cases, there were 615 or 58 per cent which had hemorrhoids. In the lower part of the table, these 615 hemorrhoids are cfassihed according to type. It wiII be observed that some 26 per cent of them were double hemorrhoids in which operation had to be considered. This is 15 per cent of the total 1,056 cases.
were aIso some sixteen patients with prolapsed internal hemorrhoids, some of which, may become or even may have already become surgica1 cases but, as any definite information on this is as yet
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unavailable, they have not been included in this consideration. This review, therefore, shows that ap-
DECEMBER,19,s~
comfort and prolonged disabilitv from the hemorrhoidectomy operation. It-is a matter of making the operation as simple as pos-
FIG. 5. A diagram iIlustrating the technic of introducing the oil anesthesia. Through one needle hole in the posterior commissure, the sphincters on each side of the anus, the sacral nerve supplies on each side and the levator-ani in the region of the posterior commissure, can be injected. However, to some it might be easier to inject all of these areas through two nredle holes, each to one side of the posterior mid line. This blocking of the sacral nerves with a long lasting anesthetic has encouraging possibilities and calls for further investigation.
proximately 58 per cent of a11 patients with rectal compIaints have hemorrhoids and that at least a quarter of the Iatter require operation. TAKING
THE
PAIN
OUT
OF
HEMORRHOIDECTOMY
In cases in which a hemorrhoidectomy the patient accepts it more is necessary, readily if he can be assured that it wiII not require etherization, that postoperative pain has been practically ehminated, that the stay in the hospita1 is at Ieast one-half what it was twenty years ago and that absence from work wiII probabIy not be longer than two weeks. However, there is no miracIe in this removal of pain, dis-
sible, of using accepted improvements in technic and of paying attention to details. The foIIowing is a Iist of the more progressive and usefu1 measures in the order of their importance : (I) A posterior sphincterotomy or “pectenotomy”; (2) use of oi1 anesthesia; (3) a11 sutures above area of sensation ; (4) cIean cut, systematic (5) successfu1 pre- and intrasurgery; operative narcosis; (6) regiona1, spina and caudal anesthesia; (7) inteIIigent postoperative dressings; (8) prevention of compIications, and (9) management of the postoperative stoo1. Posterior Sphincterotomy. One of the most important, recent advances in proctoIogy is the posterior sphincterotomy and
NEW SERIES VOL. LXII,
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3
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our experience has proved it to be a very necessary addition to a hemorrhoidectomy. As the Iiterature covering this operation
American
Journal ol Surgery
portion of the external sphincter Iatter location, each stroke being by the Ieft index hnger. (Fig.
303
at the guided 7.) The
t Intact
Peripnal
Ill useulature.
Poster’rov
Sphimcterotohy.
FIG. 6. Diagrams ihustrating what is severed as the result of a posterior sphincterotomy. A, the perineal muscles; B, the Ievator ani; c, the superhcia1 and deep portions of the external sphincter; D, the subcutaneous portion of the external sphincter; E, Minor’s triangle or the posterior triangular space; F, the coccyx; G, the glutei. The posterior sphincterotomy simpIy incises the subcutaneous portion of the extcrna1 sphincter (n) and also further separates, somewhat, the two legs of the superficial portion of the external sphincter (c) as they go off at a tangent to form Rlinor’s triangle (e) and become attached to the coccyx (F).
is not extensive, we wiI1 describe it in some detai1. The most superficia1 portion of the external sphincter, calIed the subcutaneous sphincter ani, is that portion which is feIt first by the finger upon entering the anus. It is this muscIe which goes into spasm folIowing infection or trauma in this region. Previously, this spasm was overcome by so diIating or stretching the muscIe that it became paraIyzed temporariIy but today such a resuIt is more effectiveIy and safely obtained by means of incising it either at the posterior commissure (Figs. 6, 7 and 8) or in one of the anteroIatera1 quadrants. We prefer the former Iocation. The left index finger is introduced into the anus up to the IeveI of the intersphincteric septum which is that depression existing between the interna and the external sphincters but detected best in the region of the posterior commissure. The scaIpe1 then incises, by successive strokes, the skin and this subcutaneous
interna sphincter and the major portion of the externa1 sphincter are in no way affected as the incision is carried down onIy to the dista1 tip of the interna sphincter and passes backward between the two tangentia1 Iegs of the superficia1 portion of the externa1 sphincter. (Fig. 6.) Following incision of the muscIe, the overIying skin edges are cut back somewhat on each side in order to prevent too rapid reapposition. Th e severed muscIe unites again within a week or ten days and re-epitheIiaIization takes pIace in from two to six weeks depending upon the amount of skin removed, the depth of the incision and heaIing powers of the patient. Sometimes cevitamic acid is needed. We cannot emphasize too strongIy the advantages of such a posterior sphincterotomy in a hemorrhoidectomy. It may be done as a first step whenever exposure is dificuIt to obtain, as obtains in some cases in which the anus is abnormaIIy long and the interna hemorrhoids are far up inside.
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But it shouId aIways be done either prior to or after the hemorrhoidectomy for the foIIowing reasons : It prevents the onset
DECEMBER, ,943
premature formation of such a band foIIowing the hemorrhoidectomy. Oil Anesthesia. Another important re-
FIG. 7.
FIG. g.
FIG. 8.
FIG. IO.
FIG. 7. Doing a posterior sphincterotomy. FIG. 8. Finish of the posterior sphincterotomy. FIG. g. Before operation. FIG. IO. Three weeks after operation.
of any postoperative spasm as mentioned above; it prevents edema from forming in the strips of ana skin Ieft between the excised hemorrhoids (Fig. IO) ; it opens up the anus so that a pressure dressing can be appIied and maintained where needed most, thereby eIiminating the necessity for intra-ana drains, packs, “ whistIe tubes,” etc. ; and finaIIy it quite def?niteIy prevents stricture formation in two ways: first, by so Iaying the anus open that no faIse apposition occurs across from one raw area to another prior to epitheIiaIization, and second, it severs any pre-existing fibrous pecten bandgTIO and prevents the
cent advance in proctoIogy is the use of a IocaI anesthetic in oi1. When this was first introduced by GabrieI” it was greeted with much approva1 but soon feI1 into disfavor foIIowing the occurrence of sIoughs and abscesses. However, the current soIutions now in use and their proper empIoyment have been so perfected that the latter are rarities. PersonaIIy, we have used between 400 and 500 ampuIes of a certain oi1 anesthetic* with onIy one compIication, an abscess out in the buttock which more probabIy was caused by infection carried there by the needle. We are certain that * Proctocaine. Columbus Pharmacal Company.
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SERIES VOL. LXII,
No. 3
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the use of such an anesthetic not onIy enhances the regiona and bIock anesthesia and the sphincter reIaxation during the operation but it aIso definiteIy reduces postoperative pain, discomfort, tension and diffIcuIty with bowe1 movements for at Ieast five days. But to obtain these benefits and to avoid complications, the proper technic of injection is required. The syringe used shouId be a dry one, the needle a No. Ig gauge, and the site of injection shouId be resteriIized. OnIy one or two needIe hoIes are necessary about an inch behind the anus. One cc. of oil is injected, from this Iocation into each of five different pIaces : into the sphincters on both sides of the anus, into the sphincters and Ievator ani behind the anus and out into both buttocks as described Iater in the description for injecting novocaine. (Fig. 5.) No oil is pIaced superficiaIIy beneath the skin. After withdrawa of the needIe, the whoIe area is massaged we11 to prevent unavoidabIe pooIing. In many patients an onset of symptoms occurs five or six days postoperativeIy which is an indication that the oi1 anesthesia had been operating previousIy. These patients shouId be given codeine for a day or two. Place Sutures in Non-sensitive Area. A suture producing tension within the area of sensation at the anus is a constant source of pain for severa days, especiaIIy upon motion of the gIutea1 and back musthe dissection of the cIes. Therefore, externaI hemorrhoid shouId be carried up to and beyond the mucocutaneous (pectinate) Iine so that the suture transfixing the pedicIe wiII be above any area of sensation. Active bIeeders shouId be transfixed, of course, but such transfixations do not seem to have the same disabIing effect as do pedicIes cIamped and tied too Iow. In the usua1 hemorrhoidectomy technic, the cIosure of the anus brings the skin edges together as much as is desired so that any stay or approximating sutures are unnecessary. If the Bacon method” is used, it wiI1 be seen that the approximating sutures pIace no tension on the skin edges.
American
Journal
of Surgery
305
Clean-cut Surgery. By cIean cut surgery, we mean the carefu1 excision of a11 so-caIIed cowIs, skin tabs, tits of skin, etc., on the edges of the incision as they have a tendency to become edematous and Iater persist in the form of skin tabs. This appIies to any and a11 methods of performing a hemorrhoidectomy. We herewith present no preference for any one technic other than that it be simpIe, aIIow pIenty of drainage and produce no tension on the anal skin. Preoperative Narcosis. The secret of a successfu1 preoperative narcosis is the use of smaI1 doses of severa synergistic drugs at the proper time. There are many variations but the foIIowing is an exampIe which has most patients nearIy asIeep on arrival at the operating room and in sIumber by the time the IocaI anesthesia has been injected : DiIaudid gr. pi2 or morphine gr. fC and ScopoIomine gr. fi50-$$00 S.C. I hour before operation SeconaI or nembuta1 gr. 1% p.o. $5 hour before operation We Iike diIaudid because it seems to cause Iess postoperative nausea than does morphine. The proper timing is important as has been made pIain by Leigh.” The opiates seem to require at Ieast an hour to produce their anaIgesic effects whiIe the short acting barbiturates require onIy onehaIf an hour. In our experience, one-haIf the dosage of a11 these drugs shouId be given to those over sixty, to the frai1 and debiIitated and to those having had cardiac decompensation. Anesthesia. One of the authors (G. A.) prefers spina anesthesia. This can be given in a smaI1 dose to produce onIy a “saddIe” area of anesthesia. It gives exceIIent reIaxation and exposure. Hirschman13 recommends a cauda1 anesthesia but we have found the waiting period, before the novoto be irritating. However, Caine “takes,” the same resuIts can be had with regional and bIock anesthesia if the proper technic is used. (E. T. W.) From 30 to 50 cc. of 2 per cent novocaine with adrenaIin is
306
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AngeIo-Hemorrhoids
required. We have had no one “feeI” the adrenalin and its incIusion is very necessary to prevent any aIIergic or toxic reaction from too rapid absorption of the novocaine. We wish to repeat this admonition: Never inject novocaine, without adrenaIin in it, into the tissues about the anus as the bIood suppIy is so great that it can be taken up too quickIy. The injection must be made systematicaIIyunder the peri-ana skin, into the sphincters and out into the buttocks. A three-inch needIe (No. 20 gauge) is quickIy inserted through the skin about an inch behind the anus in the posterior commissure and from this one position IO to 20 cc. of novocaine are injected beneath the perianal skin nearIy a11 the way around the anus. A little may have to be injected anteriorIy through other needIe hoIes. Injecting beneath the skin does not aboIish the Iandmarks. SecondIy, 5 to IO cc. are injected into the sphincters IateraI to the anus first on one side of the anus and then on the other side (Fig. 5) and aIso deepIy into the sphincters and the Ievator ani behind the anus. FinaIIy, 5 to IO cc. are fanned out into each buttock to anesthetize the sacra1 nerves which emerge from beneath the gIutea1 muscIes, thereby producing a bIock anesthesia. (Fig. 5.) The Ieft index finger in the rectum guides the introduction of the needIe into these various Iocations. Postoperative Dressings. The postoperative dressings are necessary 0nIy to prevent oozing as a11 major bIeeding points are supposedIy tied off as mentioned in a preceding paragraph. The posterior sphincterotomy aIIows pressure by means of dressings to be appIied right up to the interna sphincter and in many cases even up to the Iocation of the Iigated pedicIes. This pressure is heId in pIace by adhesive, not by a T binder. No rubber drains of any kind are needed. Prevention of Complications. The comphcations of a hemorrhoidectomy incIude postoperative bIeeding, urinary retention, infection and stricture. Postoperative
DECEMBER. ,943
bIeeding can be controIIed by adequate care of bIeeding points and transfixations during operation and by giving an ampuIe of vitamin K routineIy prior to operation in order to overcome any decrease of thrombin production caused by the administration of the barbiturates.14 The problem of postoperative catheterization is a serious one in recta1 work. The nervous inter-reIationship between the anus and the urinary bladder causes pain and spasm of the anus to throw the urinary sphincter into spasm and paralyzes the detrusor muscIe. Theoretically, the better the sacra1 nerves in the buttock are anesthetized by oi1 anesthesia, the Iess the urinary nervous system wiI1 be disturbed and, of course, aI1 of our pain and spasm preventing measures heIp. NevertheIess, retention stiI1 occurs. However, we have had considerabIe success in reducing this by using an ampuIe of doryI15 prior to catheterization. Woodruff et aI.“j have suggested instiIIing an ounce of 0.5 per cent aqueous mercurochrome into the bIadder at the time of operation to stimuIate the detrusor muscIe. We have used this routineIy in a11 of our recent cases done under spinal anesthesia with a definite decrease in the need of catheterization. However, in our cases in which IocaI anesthesia is used, mercurochrome is not instiIIed at the time of operation because catheterization at that time is as bad as it is eight hours Iater. However, when the Iatter is necessary we promptly start a urinary antiseptic. As the resuIt of Ieaving the wounds open and as the resuIt of the earIy institution of the hot sitz bath (second day after operation) we see practicaIIy no infection. Stricture is prevented in three ways: (I) by care during the operation to Ieave two or three paraIIe1 strips of skin and mucous membrane running up from the peri-anum into the rectum; (2) by the use of the posterior sphincterotomy and, (3) by frequent postoperative digita examinations and the breaking down of faIse appositions.
NEW
Whitney,
SERIES VOL. LXII, No. 3
AngeIo-Hemorrhoids
Postoperative Stool. The postoperative stoo1 is had forty-eight hours after operation by means of an oil retention enema foIlowed in an hour by a saIine enema (foIIowed by a hot sitz bath). Mineral oiI (s ounce nightIy) is started even before operation and continued until healing is had. This much oil will not leak and does soften the stool. MEASURING
PROGRESS
Progress in the management orrhoidectomy can be gauged
DAVS
of the hemby examina-
TABLE II* OF HOSPlTALlZATION OF NINETY-SIX
HOSPITAL THE
SERVlCE YEARS
1$,21-1942
FOURTY-FIVE AS
Cambridge
1$&Z-192$,
30 cases 10.7
CAMBRIDGE
HEMORRHOIDECTOMIES AS
SERVICE
OUTLINED
HospitaI
IN
DURING
COMPARED
CASES THE
WITH
HANDLED TEXT
I
Service
Our Service
1926-1935, 36 cases
‘936-1942. 30 cases
‘941-1942, 45 cases
8.3
7.7
4.4
* If we may cite the above figures as a criterion, the ordinary hospita1 service hemorrhoidectomy was requiring, roughly, an average of eleven days’ hospitalization some twenty years ago and less than eight days now. As a result of the various measures outlined in the text, our service cases are confined an average of Iess than five days.
tion of TabIe II which shows how the length of stay in the Cambridge Hospitai of ordinary service hemorrhoidectomies has decreased during the past twenty years from 10.7 days in the early Igzo’s to 7.7 days in the earIy 1940’s. However, when the preventive measures, which we have outlined, are consistentIy applied, as has been done in our service cases during rg4 I to 1942, the Iength of the hospita1 stay has been reduced to 4.4 days which is nearIy one-haIf that of the cases at the Cambridge Hospital. SUMMARY
Much progress has been made in the treatment of hemorrhoids during the past few years and, yet, there is stiI1 a surprising
Americxn
Journal
of Surgery
307
amount of confusion with reference to the subject among the medica profession. A review is made of the anatomy, physioIogy and pathoIogica1 conditions of the anus and their effect on the genesis of the various types of hemorrhoids. Selection of the proper form of therapy is discussed. SimpIe, interna hemorrhoids are injected; frank doubIe hemorrhoids are excised. A review of 1,056 consecutive recta1 cases admitted to the Boston Dispensary and the Cambridge HospitaI was made in order to ascertain the percentage having double hemorrhoids and therefore needing operation. Of the 1,056 patients, 615 or 58 per cent had hemorrhoids in one form or another. Of the 615 hemorrhoids, 161 were of the doubIe variety. This is 26 per cent of the total number of hemorrhoids or 15 per cent of the tota number of 1,056 patients with recta1 complaints. It is concluded, therefore, that approximateIy 58 per cent of a11 patients with recta1 complaints have hemorrhoids and that at Ieast a quarter of the Iatter require operation. When a hemorrhoidectomy is indicated, the Iayman accepts it more readiIy when he can be assured that the dreaded postoperative pain, discomfort and disability of the past has been practicahy eliminated. The Iatter has been accompIished, not as the resuIt of some new operation, but mainIy as the resuIt of using those advances made recently in proctoIogy which are applicable to a hemorrhoidectomy. These are to be found both in the field of technic and in our newer knowIedge of the anatomy of the anus. They incIude the posterior sphincterotomy, the use of an oil anesthesia, careful surgery with the main transfixing sutures above the area of sensation, prevention of postoperative complications and intelligent management of the first stoo1. REFERENCES I.
ROBERTS, S. M., and WILSON, P. D. ReIaxation of pelvic joints in pregnancy. Surf., Gynec. fl Obst., 58: 595-613. 1934.
ABRAMSON,
D.,
308
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Angelo-Hemorrhoids
2. GORSCH, R. V. Perineopelvic Anatomy. P. 78. New York. Tilghman Co. 3. MORGAN, C. N. Hemorrhoids. Brit. M. J., 4077: 399, 1939; 4078: 459, 1939. 4. BACON, H. E. and WOLFE, F. D. The injection treatment of hemorrhoids. Illinois M. J., 8 I : 202, ‘942. J. GABRIEL, \V. B. Treatment of hemorrhoids. hit. M. J., 2: 1266, 1939. 6. CORBETT, J. J. Offrce treatment of hemorrhoids. Am. J. Surg., 50: 641, 1940. 7. ROSSER, CURTICE. The rational management of hemorrhofds. Texas State J. Med., 34: 484, 1938. 8. WHITNEY, E. T. and KEANE, J. F. PerianaI cryptic tabs. New England J. Med., 22 I : 303-306, 1939. 9. ABEL, A. L. The pecten: the pecten band: pectenosis and pectenotomy. .!xncef, I : 7 14-7 I 8, 1932. IO. WHITNEY, E. T. Fissure-in-ano. Am. J. Surg., 59: 9-17.
‘943.
DECEMBER, ,943
I I. GABRIEL, W. B. The treatment of pruritis-ani and anal canal fissure. &if. M. J., 2: 1070, 1929. and postoperative 12. LEIGH, M. D. Preoperative medication. Canad. M. A. J., 47: 150-152, 1942. 13. HIRSCHMAN,L. J. The technic of a simpIe and effective hemorrhoidectomy. J. Kansas M. Sot., 43: 45-48, 1942. 14. FITZGERALD, J. E. and WEBSTER, AUGUSTA. Obstetric significance of barbiturates and vitamin K. J. A. M. A., 119: 1082-1085, 1942. 15. SHULZE, E. Zur BehandIung der Harnver haItung im R’ochenbelt und nach gynakologischen operationen. Miincben. med. Wcbnscbr., 82: 1358, 1935. 16. WOODRUFF, J. D. and TELINDE, R. W. The postoperative care of the urinary hIadder. J. A. M. A., 1’3: ‘45, 1939. 17. BACON, H. E. Anorectal operative procedures with special reference to the avoidance of pain. J. A. M. A., I 16: 363-366, 1941.
Correction: In the article, “Carcinoma of the Tip of the Tongue,” by Dr. Fink and Dr. Garb, which appeared in our October 1943 issue, the authors wish to draw the readers’ attention to an error they made on page 141. The sentence, “Ochsner and DeBakey reported a series of 3,047 coIlected cases of primary carcinoma of the tongue . . . ” shouId have read, “3,047 coIIected cases of primary carcinoma of the lung.”