1. Dilatation Of The Sphincters

Ver-neuil 1 was the first to recommend dilatation of the sphincters as a cure for piles. This treatment is based upon the idea that the spasm of the sphincter is thereby stopped, that the bowels act more freely and the pressure upon the venous blood-vessels is relieved. The dilatation of the sphincters may be accomplished gradually by introducing specula into the rectum, taking a larger size each time, which procedure occupies several weeks, or it may be done in one sitting (the so-called forcible dilatation). In the latter instance, however, chloroform narcosis is necessary. Complete dilatation is effected, according to Allingham, in the following way: The patient being fully under the influence of ether or chloroform, both thumbs must be inserted into the rectum, which is to be dilated gradually, first in the antero-posterior and afterward in the opposite direction. The amount of force used must be sufficient to overcome the spasm thoroughly. This manipulation must be continued until the sphincter muscles yield, as if reduced to a really pulpy condition. Care must be taken to act high enough up in the rectum so as to include the whole of the sphincter. The result is that the state of contraction is abolished and no spasm can occur.

In fact, for the time being, as in any other stretched muscle, paralysis results. With great gentleness the desired effect may be accomplished without tearing the mucous membrane. But some extravasation is usually noted around the anus for a few days. After this an opium suppository is kept in the rectum and the patient is placed in bed in a recumbent position. Dilatation of the sphincters may be recommended in the early stage of hemorrhoids, especially in cases combined with constipation; further in hemorrhoids during pregnancy or occurring in persons greatly debilitated by other grave diseases.

1 Verneuil: Gazette des hop., 1884, 1887.

2. Carbolic-Acid Injections

Pooley,1 Kelsey,2 Roux,3 and Lange 4 have recommended injections of carbolic acid into the piles in order to produce shrinking. This method is permissible only if the hemorrhoids are not inflamed. Proceed as follows: The piles are first thoroughly cleansed and dried, then covered with iodoform salve. In order to lessen the pains a few drops of a one-per-cent cocaine solution may first be used subcutaneously. Then three to five drops of either of the two following solutions are injected into the centre of each pile: (1) Carbolic acid 1, glycerin 3; (2) Carbolic acid 1, glycerin 3, distilled water 3. The injection is made with the common Pravaz syringe, but care must be taken that none of the solution drips from the needle, so as to avoid cauterizing the mucous membrane. Several piles can be treated at the same sitting. It is advisable, however, not to make the injections oftener than about once a week. This procedure if carefully done is not dangerous nor painful, and often effects shrinking or even disappearance of quite considerable hemorrhoidal nodules.

3. Cauterization With Fuming Nitric Acid

Houston,5 of Dublin, was the first to recommend cauterization of piles with fuming nitric acid. This may be done in the following manner: After thorough cleansing and drying of the anus and the surrounding parts, the entire area is covered with a thick layer of vaseline excepting the pile which is to be treated. The latter is then painted with nitric acid by means of a small stick of wood or a glass rod. Special care must be taken that the acid reaches no other spot. After the nodule has assumed a grayish-green color it is carefully dried, smeared with vaseline, and pushed back into the rectum. This method is best adapted for smaller nodules, especially if they have a wide base. Sometimes a second cauterization is necessary, which may be done after an interval of about five days or a week. Instead of nitric acid other cauterizing substances may be used, and Allingham has recommended concentrated carbolic acid as especially efficient for this purpose.

1 J. H. Pooley: "Injection of Carbolic Acid in Hemorrhoids." Toledo Med. and Surg. Journal. November, 1877. No. 11.

2 Charles B. Kelsey: The Treatment of Hemorrhoids." Medical Record, 1886, vol. ii., p. 141.

3 Roux: "Behandlung der Hamorrhoiden." Therap. Monatshefte, 1895, p. 124.

4 F. Lange: Centralblatt fur Chirurgie, 1887, No. 25. Beilage, p. 70. 5 Houston: Dublin Journal of Medicine, 1844.

4. Ligature

Cooper 1 recommended the ligature of hemorrhoids in order to cut them off from the circulation and thus destroy them. Salmon2 has improved this method by making an incision before applying the ligature. According to this writer, the operation is performed in the following manner: The patient is placed on the right side on a. hard couch and is completely anaesthetized. The sphincter muscles are then gently but completely dilated. The hemorrhoids, one by one, are then drawn down with a pronged hook fork; by means of sharp scissors the pile is separated from its connections with the muscular and submucous tissues upon which it rests. The cut is best made in the sulcus or white mark which is seen where the skin meets the mucous membrane. This incision is made in a direction parallel to the bowel and carried to such a distance that the pile is left connected by an isthmus of vessels and mucous membrane only. A well-waxed, strong, thin, aseptic silk ligature is now placed at the bottom of the deep groove which has been made, and the ligature is tied right at the neck of the tumor as tightly as possible. "When all the hemorrhoids have thus been ligated, they should be returned within the sphincter.

A small piece of absorbent cotton saturated with iodoform ointment is now placed into the bowel and a pad of cotton applied over the anus.

1 Cited from Alliugharn, loc. cit. 2 Ibid.