THE

BROOKLYN MEDICAL JOURNAL

PUBLISHED MONTHLY BY THE MEDICAL SOCIETY OF THE COUNTY OF KINGS.

EDITORIAL COMMITTEE:

JOSEPH H. RAYMOND, M. D.,

ALEX. HUTCHINS, M. D.,

JOSEPH H. HUNT, M. D.,

GLENTWORTH R. BUTLER, M. D., FRED. D. BAILEY, M. D.

ON THE PATHOLOGY AND TREATMENT OF AGGRAVATED HÆMORRHOIDS.

BY LEWIS S. PILCHER, M. D.,

OF BROOKLYN,

Surgeon to the Methodist Episcopal Hospital.

Read before the Medical Society of the County of Kings, March 18th, 1890.

In this communication I desire to speak only of the more aggravated forms of hæmorrhoidal degeneration, cases in which a considerable portion, or the whole of the circumference of the anal portion of the rectum has become so diseased that a vascular tumor of considerable size has been formed. In these cases, the surgeon has to do no longer with a simple varicose condition of the hæmorrhoidal veins, nor with a fairly well defined and circumscribed polypoid hypertrophy of the vessels and submucous connective tissue, but with a true angeioma, which, although on its surface it may be more or less lobulated, in its deeper portion is formed by a continuous net-work of dilated vessels or cavernous spaces bound together by a varying amount of connective tissue.

The arterial supply of these tumors is very free; they are fed by the terminal twigs of the middle hemorrhoidal artery which descend to them almost vertically in the submucous coat of the rectum; these

arterioles display the same tendency to enlarge which is seen with vascular tumors in other parts of the body, and the result is that in the worse cases a dozen or more dilated arterioles of sufficient size to demand ligation may be met with by the surgeon in the course of an attempt to remove the tumor. The pulsation of these may often be felt beforehand by the finger introduced into the rectum above the growth. A certain quality of erectility is manifested by these tumors, in common with the more frequent and less aggravated hæmorrhoids, so that their bulk may vary considerably within certain limits according as they are more or less distended with blood.

These tumors always have a history of many years of development; not every case of neglected piles will develop into such a condition, but whenever this condition does develop there has preceded it a long history of piles that have become more and more aggravated with the lapse of years. In the six cases upon which this study is based, the patients were all in the prime of life, between 30 and 40 years of age, and in all but one their hæmorrhoidal troubles dated back to their early youth. This latter fact would indicate an original inherent developmental defect in the vascular network at the lower end of the rectum in each case as having been an important element in bringing about the ultimate extreme diseased condition. With one exception these patients were all persons of intelligence and education, careful of their persons, not given to excesses of any kind, and watchful to guard against anything which would tend to aggravate their condition; two were ladies of refinement and culture, two were clergymen, one was a printer and one was a laborer. These facts I mention simply from the corroboration which they give to the probability of the existence of a primary developmental defect as a predisposing cause of these extensive tumors.

Associated with the angeioma proper will always be found more or less oedema and relaxation of the adjacent mucous membrane which go to swell the bulk of the tumor and predispose to its ready eversion through the anus. The sphincters become chronically stretched and weakened, a circumstance which has both its advantages and disadvantages. It lessens the suffering caused by the eversion or coming down of the tumor, and makes its reposition more easy, but it also aggravates the infirmity of the patient since the tumor is no longer securely kept up after it is replaced, but quickly comes down when the patient stands for any length of time or makes any straining effort at the anus, or there is any abdominal pressure as in coughing or sneezing. This weakness of the sphincters must also be remembered in forming a prognosis as to the results of operations for the relief of these tumors, for a considerable lack of power upon the part of the

sphincters may still remain after the angeioma has been removed, causing some incontinence and favoring some prolapse of the rectum. The area of the rectal mucous membrane which is the subject of this angeiomatous degeneration does not extend upwards very far. From an inch to an inch a half will be found to be its usual limit. The tumor is a superficial one, involving only the mucous surface and the submucous connective tissue, so that it may be readily enucleated from the sphincters. This enucleation is not likely to be complicated by hæmorrhage, for the reason that both the afferent and efferent vessels enter or leave the tumor at its upper margin and are confined to the submucous connective tissue coat in which they run.

The size which these tumors may attain is considerable; in one of my cases the mass that was rolled out of the anus by the patient at the word of command was equal to that of a good sized apple, somewhat flattened. In its turgid state, darkly livid in hue, with a fissured lobulated surface covered by bloody mucus, it presented an appearance that might have easily excited fears that it was a malignant growth. The patient, worn out by years of suffering and dribbling hæmorrhage, presented a cachectic look that would have tallied well with such a diagnosis.

During the past eighteen months, six cases have claimed my care which properly came within the class of aggravated hæmorrhoids, or hæmorrhoidal angeiomata, which I have now so briefly and inadequately described. I submitted them all to excision after the method of Whitehead. It is to the merits of this operation in such cases that I desire very briefly to devote the remainder of this communication.

In the treatment of ordinary hæmorrhoids in the various degrees and conditions that they are met with, I have at times had occasion to resort to different devices, finding conditions that I believe are best controlled now by simple dilatation of the sphincters, now by injections of carbolic acid, now by the actual or potential cautery, now by the clamp and cautery, and now by the ligature. It is not infrequent that in the same case I resort at the same sitting to several of these measures. The only one of these methods that would commend itself to me as desirable to be used in removing the more aggravated hæmorrhoidal tumors now under discussion is possibly the clamp and cautery. The objection to the clamp and cautery is that it necessitates some subsequent sloughing and granulation, and in the extensive removal of tissue required in these cases might be followed by an undesirable amount of cicatricial contraction. Portions of the angeiomatous tissue would not be included in the clamp, and their subsequent obliteration by inflammatory fibrous hyperplasia would be uncertain.

The feasibility of removing hæmorrhoidal tumors en masse by the knife was first demonstrated on a large scale by Mr. Whitehead, of Manchester, England, who reported to the British Medical Association in August, 1886, that he had up to that time, beginning in 1876, operated in that manner upon more than three hundred patients without a death, a single instance of secondary hæmorrhage, or one case where any complication, such as ulceration, abscess, stricture or incontinence of fæces had occurred; and further, that, to the best of his knowledge, every patient had been completely and permanently cured. His method of operating included anesthesia, the lithotomy position, preliminary thorough stretching of the sphincters, division of the mucous membrane around the entire circumference of the bowel at its junction with the skin, exposure of the external sphincter, detachment of the pile-bearing membrane from the sphincters by scissors and fingers until healthy mucous membrane is reached, pulling down of the separated membrane and hæmorrhoids and cutting it away by cross incision, with suture of the free margin of the severed membrane, as fast as divided, to the free margin of the skin below, bleeding vessels being twisted as they were divided during the operation.

In January, 1887, Lange, of New York, reported a number of cases in which he had done a similar operation, the technique differing chiefly in that he inserted a row of buried catgut sutures between the base of the external flap and that of the separated mucous membrane, avoiding the sphincter and taking care not to penetrate into the rectum. These sutures occluded most of the vessels supplying the hæmorrhoidal region, lessening the trouble from hæmorrhage when the final ablation of the tumors was done. The pile-bearing portion was then cut away and the free margins of the severed mucous membrane and the skin were now sutured together. Lange speaks highly of the rapidity and completeness of the healing process and the comfort of the patient secured by his method of operating.

In 1888, and again in 1889, Marcy, of Boston, published papers claiming a long series of cases in which he had removed hæmorrhoids by excision with excellent results. His technique resembled that of Lange, differing chiefly in that he surrounded the separated pile-bearing membrane at its base by a line of deep, double continuous animal sutures applied after the manner of a shoemaker's stitch, with a needle pierced with an eye near its point. By drawing this line of sutures snfficiently close, but not close enough to produce necrosis of the enclosed parts, the blood vessels are occluded and there is no hemorrhage when the membrane is cut away.

Weir, of New York, has also reported a series of cases in which he has followed the method of Whitehead in excising hæmorrhoids, and gives preference to it, in suitable cases, over other methods.

On the other hand, Kelsey, of New York, has severely criticised the operation of Whitehead, pronouncing it "naturally difficult, tedious and bloody," and claiming that the results obtainable by the clamp and cautery were equally good, and obtainable by an operative procedure more simple and ready in its execution.

From my own experience, I have nothing new to add to the technique of the operation; I have worked on the lines laid down by Whitehead; the various steps of the operation I have found to be comparatively easy of execution, but taking much more time than the enthusiastic representations of the Manchester surgeon would have led me to expect. Some of this prolongation of the operation is due of course to the natural inexpertness of one who is new to the operation; some is due to the aggravated character of the cases with which I have had to do. Most of the time is used in securing hæmostasis, and to have to apply a ligature to twelve or more arterioles in a case has been my usual experience. There has been no special trouble or difficulty about any part of the work, it has been simply time-consuming. I have not tried the deep sutures of Lange, nor the buried shoemaker's stitch of Marcy. I shall, I think, test them in future cases with a view to their value in controlling bleeding and shortening the time required for the operation.

The results, however, have been all that the most enthusiastic partisan of the operation could have claimed for it. A perfectly healthy outlet to the rectum, as far as the mucous membrane is concerned, has been secured to all my patients. The contractile power of the sphincters in the worst cases, long weakened by constant distension, has, of course, demanded time for its restoration. In only one case, at the end of a year, is there still some lack of power in the sphincteric grip to wholly control the escape of gas or fluids, but in this case the improvement in the general condition of the parts, and the resulting comfort, is so great that the slight infirmity that still persists is regarded as insignificant.

The certainty, the absoluteness and the perfection of the cure are the points which have struck me as most clearly demonstrated in the few cases which I report. The procedure is an ideal one surgically inasmuch as it combines immediate and radical removal of all diseased tissue, with immediate closure of the wound and subsequent union by first intention. I cannot think however, that it can be called an operation easy of performance-I should say that it was an operation not to be lightly undertaken by one not accustomed to delicate operative manipulations, or without the presence of good assistants, good light, and appropriate instruments. Doubtless, as in the hands of the eminent surgeon who has introduced the operation, natural manipulative