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Surgical treatment of hemorrhoids
SURGICAL TREATMENT JEROME M.
OF HEMORRHOIDS* LYNCH, M.D.
NEW YORK
S
treatment of hemorrhoids is not new. This operation has been routine for hundreds of years, but advances have been made in technique and in improved surgica1 principles. If we have not invented a new operation, we have at Ieast been so fortunate as to Iearn what to avoid. For some unknown reason a rough job seems to have had the right of way, whereas onIy the gentIest handling in this sensitive area shouId be aIIowed. Some of the archaic operative methods in vogue when I first became interested in recta1 work stiI1 survive. I admit I was myseIf responsibIe for a form of torture by the invention of a pIug, sufhcientIy Iarge to make anyone’s postoperative convaIescence a he11 on earth. With a powerfuI divuIsion of the sphincter before operation, and the use of this pIug afterwards, the operation was one never to be forgotten by the patient. They say the thumbscrew and the rack were pIayfu1 in comparison. I have done a11 I couId to counteract the misery I set forth, but it stiI1 seems to have a fascination for some operators, as news of it drifts back to me occasionaIIy. I wish now to go on record that I condemn the pIug I invented. The operation as practiced today, under IocaI anesthesia, is simpIe, effective and practicaIIy painIess, and the patient is not detained in the hospita1 for more than four or five days. I cannot too strongIy condemn the oId practice of divuIsing the sphincter. It is crude; often foIIowed by incontinence and invariabIy causes severe pain, hemorrhage into the muscIes, and often a certain amount of dysfunction. If the interna and externa1 sphincters are over-deveIoped or spastic, it is safer to cut them posteriorIy. URGICAL
If incontinence shouId resuIt a pIastic operation wiI1 remedy this misfortune, but there is no remedy if incontinence foIIows divuIsion. Hemorrhoids are so often associated with other pathoIogy that they shouId onIy be treated after a thorough proctoscopic examination satisfies the surgeon that there is no compIication. About one-third of patients suffering from cancer have had a hemorrhoida operation without this more serious condition being noted. This Iack of discernment aIso applies to infection of the coIon, diverticulitis, poIyposis, and interna hstula, which Dr. Kantor has mentioned. ProbabIy the infection was present before the operation and was not discovered. I can readiIy see the great importance of a thorough examination. The frequency of hemorrhoids is such that the Iayman imagines a11 rectal troubIes are hemorrhoids, and often the expIanation given by the patient is accepted without troubIe by the physician. Bush, in 1836, emphasized the fact that hemorrhoids were onIy too often associated with more serious iIIs. Ninety years Iater we give voice to the same warning. UncompIicated hemorrhoids give no symptoms except a vague feeIing of fuIIness, and indefinite discomfort with some Ioss of bfood. Severe bIeeding occasionaIIy occurs into the bowe1 but it is rare. On the other hand, repeated smaI1 hemorrhages resuIt in a secondary anemia which is brought to the patient’s attention by shortness of breath and genera1 weakness. Of importance are the secondary and deferred symptoms, such as digestive disturbances, Ioss of appetite and constipation. Mental depression is aImost aIways associated with pathoIogy in the ana in hemorrhoids. If region, particularly
* Read before the Section of Surgery, New York Academy 624
of Medicine,
February
6, 1931.
NEW
SERIES
Vol. XIV, No. 3
Lynch-Hemorrhoidectomy
these have existed for years with marked prolapse, Ioss of muscuIar tone is found, but one shouId be on guard not to confound this with a simiIar condition found in tabetics. Today’s operations are done nearIy entireIy under IocaI anesthesia. Some men prefer spina or generaI, but I Iike the IocaI anesthetic better. Forty-eight hours before, a cathartic is given. In the evening an enema is given. In the earIy days I preferred the cIamp and cautery to a11 other methods, but now I prefer the Iigature. Perhaps for the man who operates infrequentIy, the cIamp and cautery is safer. Surgeons have persona1 preferences, however, and by confining themseIves to one method deveIop better technique. I achieve good resuIts with Iigature. AI1 bIeeding points, either in the hemorrhoidectomy or any other operation, shouId be cIamped and tied and there is no fear of after-hemorrhages. The sphincter is cut posteriorIy, and the wound packed with a IittIe vaseIine gauze. This remains in unti1 after the boweIs have moved which is generaIIy forty-eight hours. My own practice is to give an enema of magnesium
REFERENCES
OF
I. ADSON, A. W., and BROWN, G. E. The treatment of Raynaud’s disease by resection of the upper thoracic and Iumbar sympathetic ganglia and trunks. Surg. Gynec. Obst., 48: 577-603, 1929. 2. WHITE, J. C. Diagnostic blocking of the sympathetic nerves to the extremities with procaine. J. A. M. A., 94: 1382, 1930. 3. MORTON, J. J., and SCOTT, W. J. Methods for estimating the degree of sympathetic vascoconstriction in periphera1 vascular diseases. New England J. Med., 204: 955-962, rg3r. 4. FLOTHOW, P. G. Surgery
of the sympathetic nervous system and chronic arthritis. Nortbwest Med., 29: 518, 1930.
5. LUNDY, J. S. Persona1 demonstration. 6. LABAT, G. Textbook on RegionaI Anesthesia PhiIa., Saunders, 1922. 7. S. Clin. North America, Pacific Coast Volume, 193 I. 8. FLOTHOW, P. G. Sympathetic aIcoholic injection * Continued
American
Journal of
Surgery
625
suIphate, I oz. to a pint of water at a temperature of 112’F., the next day foIIowed by a miId cathartic. The patient is then given an enema and the gauze removed. This shouId be done very gently. The wound must ,be irrigated after each movement. The patient is kept under observation without any additiona physica interference unti1 the wound is heaIed. The operation is practicaIIy devoid of pain. Even with the first movement, which is usuaIIy dreaded by the patient, he is agreeabIy disappointed. To summarize: in the past, hemorrhoidectomy was not aIone attended by pain and discomfort, but often by incontinence. Bad news traveIs fast and Ieaves a lasting impression. The dread of this operation which is stiI1 inherent in the minds of the genera1 pubIic may be founded upon the resuIts which attended the procedure as formerIy performed. I am frequentIy asked: “Is there any danger of Iosing contro1 if this operation is performed?” In the average surgeon’s practice there is at present very IittIe danger of this occurrence.
DR.
g.
IO.
I I. 12. 13.
14.
FLOTHOW* for reIief of arteriosclerotic pain and gangrene. Northwest Med., 30: 408-412, 1931. FLOTHOW, P. G. Surgery of the sympathetic nervous system. A report of fourteen sympathetic gangIionectomies. AM. J. SURG., IO: 8-18, 1930. MIXTER, W. J., and WHITE, J. C. Pain pathways in the sympathetic nervous svstem. Arch. Neural. @ Psycbiai., 25: 98-97, 1g;1. REICHERT. F. L. Personal communication. WHITE, J: C. Angina pectoris. Arch. Neural. @ Psycbiat., 22: 302-312, 1929. STERN, E. L., and SPIVACKE,C. A. The sympathetic component of the extrinsic nerve innervation of the lungs in status asthmaticus. Case report of blocking by aIcoho1 injections. J. Allernv. I_ I: 357-368, 1930. DANDY, W. E. Treatment of hemicrania by remova of the inferior cervica1 and first thoracic sympathetic gangIia. Jobns Hopkins Hosv. Bull.. ~8: 353-395,
from p. 604.
1931.
OF HEMORRHOIDS* LYNCH, M.D.
NEW YORK
S
treatment of hemorrhoids is not new. This operation has been routine for hundreds of years, but advances have been made in technique and in improved surgica1 principles. If we have not invented a new operation, we have at Ieast been so fortunate as to Iearn what to avoid. For some unknown reason a rough job seems to have had the right of way, whereas onIy the gentIest handling in this sensitive area shouId be aIIowed. Some of the archaic operative methods in vogue when I first became interested in recta1 work stiI1 survive. I admit I was myseIf responsibIe for a form of torture by the invention of a pIug, sufhcientIy Iarge to make anyone’s postoperative convaIescence a he11 on earth. With a powerfuI divuIsion of the sphincter before operation, and the use of this pIug afterwards, the operation was one never to be forgotten by the patient. They say the thumbscrew and the rack were pIayfu1 in comparison. I have done a11 I couId to counteract the misery I set forth, but it stiI1 seems to have a fascination for some operators, as news of it drifts back to me occasionaIIy. I wish now to go on record that I condemn the pIug I invented. The operation as practiced today, under IocaI anesthesia, is simpIe, effective and practicaIIy painIess, and the patient is not detained in the hospita1 for more than four or five days. I cannot too strongIy condemn the oId practice of divuIsing the sphincter. It is crude; often foIIowed by incontinence and invariabIy causes severe pain, hemorrhage into the muscIes, and often a certain amount of dysfunction. If the interna and externa1 sphincters are over-deveIoped or spastic, it is safer to cut them posteriorIy. URGICAL
If incontinence shouId resuIt a pIastic operation wiI1 remedy this misfortune, but there is no remedy if incontinence foIIows divuIsion. Hemorrhoids are so often associated with other pathoIogy that they shouId onIy be treated after a thorough proctoscopic examination satisfies the surgeon that there is no compIication. About one-third of patients suffering from cancer have had a hemorrhoida operation without this more serious condition being noted. This Iack of discernment aIso applies to infection of the coIon, diverticulitis, poIyposis, and interna hstula, which Dr. Kantor has mentioned. ProbabIy the infection was present before the operation and was not discovered. I can readiIy see the great importance of a thorough examination. The frequency of hemorrhoids is such that the Iayman imagines a11 rectal troubIes are hemorrhoids, and often the expIanation given by the patient is accepted without troubIe by the physician. Bush, in 1836, emphasized the fact that hemorrhoids were onIy too often associated with more serious iIIs. Ninety years Iater we give voice to the same warning. UncompIicated hemorrhoids give no symptoms except a vague feeIing of fuIIness, and indefinite discomfort with some Ioss of bfood. Severe bIeeding occasionaIIy occurs into the bowe1 but it is rare. On the other hand, repeated smaI1 hemorrhages resuIt in a secondary anemia which is brought to the patient’s attention by shortness of breath and genera1 weakness. Of importance are the secondary and deferred symptoms, such as digestive disturbances, Ioss of appetite and constipation. Mental depression is aImost aIways associated with pathoIogy in the ana in hemorrhoids. If region, particularly
* Read before the Section of Surgery, New York Academy 624
of Medicine,
February
6, 1931.
NEW
SERIES
Vol. XIV, No. 3
Lynch-Hemorrhoidectomy
these have existed for years with marked prolapse, Ioss of muscuIar tone is found, but one shouId be on guard not to confound this with a simiIar condition found in tabetics. Today’s operations are done nearIy entireIy under IocaI anesthesia. Some men prefer spina or generaI, but I Iike the IocaI anesthetic better. Forty-eight hours before, a cathartic is given. In the evening an enema is given. In the earIy days I preferred the cIamp and cautery to a11 other methods, but now I prefer the Iigature. Perhaps for the man who operates infrequentIy, the cIamp and cautery is safer. Surgeons have persona1 preferences, however, and by confining themseIves to one method deveIop better technique. I achieve good resuIts with Iigature. AI1 bIeeding points, either in the hemorrhoidectomy or any other operation, shouId be cIamped and tied and there is no fear of after-hemorrhages. The sphincter is cut posteriorIy, and the wound packed with a IittIe vaseIine gauze. This remains in unti1 after the boweIs have moved which is generaIIy forty-eight hours. My own practice is to give an enema of magnesium
REFERENCES
OF
I. ADSON, A. W., and BROWN, G. E. The treatment of Raynaud’s disease by resection of the upper thoracic and Iumbar sympathetic ganglia and trunks. Surg. Gynec. Obst., 48: 577-603, 1929. 2. WHITE, J. C. Diagnostic blocking of the sympathetic nerves to the extremities with procaine. J. A. M. A., 94: 1382, 1930. 3. MORTON, J. J., and SCOTT, W. J. Methods for estimating the degree of sympathetic vascoconstriction in periphera1 vascular diseases. New England J. Med., 204: 955-962, rg3r. 4. FLOTHOW, P. G. Surgery
of the sympathetic nervous system and chronic arthritis. Nortbwest Med., 29: 518, 1930.
5. LUNDY, J. S. Persona1 demonstration. 6. LABAT, G. Textbook on RegionaI Anesthesia PhiIa., Saunders, 1922. 7. S. Clin. North America, Pacific Coast Volume, 193 I. 8. FLOTHOW, P. G. Sympathetic aIcoholic injection * Continued
American
Journal of
Surgery
625
suIphate, I oz. to a pint of water at a temperature of 112’F., the next day foIIowed by a miId cathartic. The patient is then given an enema and the gauze removed. This shouId be done very gently. The wound must ,be irrigated after each movement. The patient is kept under observation without any additiona physica interference unti1 the wound is heaIed. The operation is practicaIIy devoid of pain. Even with the first movement, which is usuaIIy dreaded by the patient, he is agreeabIy disappointed. To summarize: in the past, hemorrhoidectomy was not aIone attended by pain and discomfort, but often by incontinence. Bad news traveIs fast and Ieaves a lasting impression. The dread of this operation which is stiI1 inherent in the minds of the genera1 pubIic may be founded upon the resuIts which attended the procedure as formerIy performed. I am frequentIy asked: “Is there any danger of Iosing contro1 if this operation is performed?” In the average surgeon’s practice there is at present very IittIe danger of this occurrence.
DR.
g.
IO.
I I. 12. 13.
14.
FLOTHOW* for reIief of arteriosclerotic pain and gangrene. Northwest Med., 30: 408-412, 1931. FLOTHOW, P. G. Surgery of the sympathetic nervous system. A report of fourteen sympathetic gangIionectomies. AM. J. SURG., IO: 8-18, 1930. MIXTER, W. J., and WHITE, J. C. Pain pathways in the sympathetic nervous svstem. Arch. Neural. @ Psycbiai., 25: 98-97, 1g;1. REICHERT. F. L. Personal communication. WHITE, J: C. Angina pectoris. Arch. Neural. @ Psycbiat., 22: 302-312, 1929. STERN, E. L., and SPIVACKE,C. A. The sympathetic component of the extrinsic nerve innervation of the lungs in status asthmaticus. Case report of blocking by aIcoho1 injections. J. Allernv. I_ I: 357-368, 1930. DANDY, W. E. Treatment of hemicrania by remova of the inferior cervica1 and first thoracic sympathetic gangIia. Jobns Hopkins Hosv. Bull.. ~8: 353-395,
from p. 604.
1931.