CHAPTER XXI . 2 Internal Hemorrhoids or Piles versus Rectal Mucous Sac, Recto-Anal Mucous Sac.

Before the history of medicine and surgery began, man suffered at his hinder parts as well as at other parts of his organism. Bodily ills are as old as the human race, and the flowing of blood from the “terhinder” was a signal of distress or of physical anarchy, of which the references to “emeroids” in the Bible and in other ancient writings bear witness. The “emeroid” doctors of Egypt, in the time of Moses, unquestionably regarded the distress caused by the “emeroids” as a disease. And it came to pass that every subsequent Moses that has written on the subject of hemorrhoids up to the present time has regarded piles as a disease. And they likewise, all of them without exception, believe the “disease” to be hereditary, as is certainly their information on the subject. This mental obsequiousness of the proctologists of our day is indeed quite a long-drawn-out compliment to the pile doctors of Egypt, since our proctologists still continue to diagnose piles as a disease and “to smite the smitten of emeroids.”

I have always respected the idea of ancestral worship and of reverence for the dead past, but at the same time I have felt that one should not be wholly oblivious to their egregious mistakes.

If Moses, Samuel, Herodotus, Hippocrates, Galen, and other illustrious men had said that “emeroids” is a symptom of a disease, what a blessing they would have conferred upon suffering humanity. The simple use of that one word would have been illuminating, and would have set the tide of attention for the proper diagnosis and treatment in the right direction. Possibly some one more bold than the servile brotherhood did see and say that it was a mere symptom, but, if so, his temerity was treated by “the wise ones” of that day as similar innovations are treated to-day, with a “Tut, tut, tut; pugh, pugh, pugh. We know better, and we refer you to the following chapters in Holy Writ and to the classical work of the great Medi Cusus on ‘Pilus Diseasicus.’ And besides, have you no respect for the superior clinical advantages we enjoy?”

Notwithstanding the bad odor in which I shall be held, I will nerve myself to claim that, when the ancients considered and called piles or hemorrhoids a disease, they made a very grave and palpable mistake, and that, having made this mistake, it was inevitable that numerous errors should follow logically in its train when they attempted to account for the etiology, character, and means of cure of this “disease.”

Pruritus ani is also called a disease, and a similar bedlam of reasons is offered as causes and means of cure, all of which accounts for the many, many pages of a book filled to overflowing by a “classical” author, with compilations of the redeeming gospel truths on this subject from prehistoric times till the present day, including his own commentary, guesses, interpretations, and surmises. Ignorant as he is of the nature of this symptom, the conjectures of his perfervid imagination are “to laugh.” The errors of one or more authors, endorsed by the mistakes of others, seemingly make a truth to minds that are vassals to authority, which accounts for much of the useless medical literature of to-day and for the mistakes of those that are misguided by it.

Considering the pathological condition, it would be better if we were to give a more definitive characterization to it than “piles” or “hemorrhoids.” In accordance with the distinctive exhibit contemplated, we should describe it as a rectal mucous sac, an ano-rectal mucous sac, or an ano-muco-cutaneous sac. These are more distinctive and suitable designations for these symptoms of chronic proctitis, inasmuch, by such designations, we call attention to the fact that they are simply constricted mucus3 channels and sacs, with engorged arteries and veins, formed by the serous exudation that accompanies inflammation.

If a recto-anal mucus channel, under one or more layers of the mucous membrane, becomes constricted or obstructed (they usually do), its epithelial wall will become sacculated, and then we have a rectal mucous sac, or an ano-rectal mucous sac, or an ano-muco-cutaneous sac, all of which may be present in the same case. The inflammatory exudation called serum distends and destroys fatty tissue, which makes space for its lodgment under the tissue that imprisons it, and at the same time there occurs more or less proliferation of the cells of the tissue involved in the severe inflammation. The internal sphincter muscle, by its contraction, aids in the undue retention of the mucus and blood above it, hence the so-called pile-bearing region—that is, the sacculated mucosa region. The serous exudation meets with obstruction along the anal canal and the mucosa is sacculated. When the integument around the anus offers obstruction to the flow of serum and blood, we find that muco-cutaneous sacs are formed around the anus. If the exudation occurs in the areolar space under the ano-rectal mucosa, it readily passes down into the areolar space under the integument around the anus, and thence to parts deep, devious, and far away, as described in Chapter III.

Channels, reservoirs, sacs, that would hold from one to eight or more ounces of fluid, no longer excite my wonder and amazement at the extensive and serious pathological condition of which they are exhibits, a pathological condition that occasions symptoms often diagnosed as sciatica, rheumatism, myalgia, caries of the coccyx, coxitis, prostatitis, pruritus ani, scroti, and vulvÆ, auto-intoxication, anemia, invalidism, etc.

Inasmuch as we have learned the cause of sacculated mucosa at the lower end of the rectum and over the anal canal and of the integument around it, we had better in future omit the following designations and distinctions, which are merely a ridiculous display of sciolism. Surely we can do without them, and ought to do so for the sake of truth and simplicity. With a sigh of relief let us in future ignore: Safety-valve piles, organized piles, itching piles, blind piles, bleeding piles, moon piles, cutaneous piles, thrombotic piles, external and internal pile tumors, venous piles, ulcerated piles, capillary piles, mixed hemorrhoids, arterial hemorrhoids, white hemorrhoids, acute hemorrhoids, chestnut hemorrhoids, chronic hemorrhoids, inflammatory hemorrhoids, hypertrophic hemorrhoids, atrophic hemorrhoids, Egyptian piles, Philistine itching hemorrhoids, etc.

Quite naturally such a variety of “diseases” called forth many sorts of surgical operations for their removal, of which the following are the ones most in vogue: Clamp and cautery, ligature, crushing electrolysis, excision, submucous ligation, the Whitehead operation, the Earle operation, the American operation, etc.

Forget them all, forget all of the senseless terms that are employed to describe a supposed variety of “disease” and all of the barbarous procedures for their banishment, and the banishment, alas! too frequently, of the wretched sufferer likewise.

Study carefully the varieties of chronic inflammation and the character and extent of the exudation in each case. By so doing you will ascertain the nature of the many varied symptoms of proctitis, of which the following are the most common: Sacculated mucosa and integument, submucous and sub­tegu­men­tary channels, reservoirs, pockets, fistula, pruritus ani, fissure- or ulcer-in-ano, con­sti­pa­tion, diarrhea, etc.

Proctitis may present a chronic, a subacute, or an acute stage, with an atrophic or hypertrophic condition, or a less marked structural change in the tissue. If proctitis were treated early in its inception, none of the above-mentioned symptoms would have occasion to develop. When mankind becomes properly enlightened on the subject of proctitis, due attention will be given to it long before so many annoying symptoms occur.

Ano-rectal mucous sacs, formed by the serous exudation into the connective tissue and stasis of the blood, are the slightest symptoms of proctitis, and by far the most easily removed.

Since we have found out what are the symptoms and what is the disease, it naturally follows that in treating a sacculated mucosa we should be governed by the character of the proctitis, whether it be in a chronic, subacute, or acute stage. If the inflammation be acute, no matter whether or not there is a general prolapse of the sacculated tissue, it may be well to delay the treatment for removal of one or more mucous sacs until we have in a degree overcome the acute inflammation by the use of a shallow sitz bath, Fig.23, and by the use of a soothing ointment and liquid remedy, to meet the depurant requirements of the case.

The removal of the chronic inflammation, in whatever state it may be found, should be a paramount feature of the treatment from the time a case comes under one’s care. The cure of the disease ought to be of more importance than the removal of a symptom or symptoms. Should there be bleeding from a mucous sac, or should there be prolapse of it, or both, immediate treatment will give relief at once, and the sufferer will think you have performed a miracle, especially if the annoyance has existed for many years.

After the immediately annoying mucous sacs are removed by the hypodermic method, a physician can doubly guard his reputation in the painless treatment of mucous sacs by delaying further treatment of those remaining sacs, which, if treated, might occasion special annoyance, till such a time as the general inflammatory condition is much improved; but in the interim he may treat the mucous sacs that are located above the sphincter muscles, and the granular and ulcerated regions.

For the almost universal success in the painless removal of mucous sacs, the operator should be in possession of all of his normal wits and senses, so that his judgment will be at its best when the following points present themselves:

What to treat.

When to treat it.

Where to treat it.

How much to treat of it.

The quantity of remedy to be injected—all of which require discretion and good technique.

By the hypodermic method of treating mucous sacs some escharotic is employed with the object of causing the absorption of the sacculated mucosa. The object to be accomplished ought to determine the proper strength of any escharotic used. Whatever will absorb the mucous membrane involved in the sac in the slowest and mildest manner is the best remedy or the best way to employ any of the tissue absorbers you might select. And another fact: the lower the per cent. employed the larger the quantity that may be used at a time, and this is desirable if the area of a sac be large and you wish to absorb the greater portion of it. A skillful operator will make sure to have the escharotic used cover just the amount of the mucous sac desired, and no more. Physicians that are not aware of the channeled and sacculated character of the mucosa in the case of “piles” or “hemorrhoids” are liable to introduce the escharotic into the base or the center of the mucous sac with the hypodermic needle; and in such an event the remedy often enters a cavity or a channel, or both, and naturally it finds its way along the channel to the integument at the anus, whence, as a consequence, a deep, ugly fissure-in-ano is in a short time to be reckoned with by the patient and the physician, because of the destruction of the epithelial wall of the channel. The patient thereupon is far from being in a good humor, and the physician wonders how the thing happened, and he feels like quitting practice altogether, and doubtless many have done so; and certainly every one should do so if such an error were to occur a second time.

The object we wish to accomplish is to absorb the wall of the sacculated mucosa. Therefore the remedy should be injected at the apex of the sac, in the epithelial layer, or slightly deeper, if the occasion demands it. The area of the sac and the thickness of its walls must be taken into con­sid­er­ation, and will suggest the amount of the escharotic to be used.

A proper speculum is very essential to the successful treatment of sacculated mucosa, and I know of none equal to that devised some thirty years ago by Dr. A.W. Brinkerhoff. The speculum is easy to introduce, and by drawing a slide the tissue is properly exposed or shut out to a nicety, exhibiting just the amount you wish to treat. In some cases there is a rather lengthy sacculated mucosa on the side, or on the anterior wall of the anorectal tube, and it is advisable to treat only the upper third or half, and at a subsequent visit or visits to treat the remainder, thus avoiding annoyance to the patient.

The paramount concern should be to avoid causing pain both during the treatment of a sacculated mucosa or its possible occurrence a few hours or days later. I have often remarked that when pain or soreness follows the treatment of a mucous sac the fault is in the application of the remedy, and not in the remedy itself. Now and then there may be conditions in which you will expect pain or soreness to follow the treatment, and you will prepare your patient with the necessary appliances and remedies to overcome it promptly. Where there are no possible means for avoiding the pain consequent upon a treatment, leave nothing undone to make it as slight as possible. All mucous sacs ought to be treated without any after-annoyance to the patient, and they can be if we only wait for the proper time to treat them.

I have not thus far considered the muco-cutaneous sacs around the anus, which are neither useful nor ornamental, and which often indicate the volcanic action of inflammation and the amount of mucous lava thrown out around the vent.

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