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THE REATMEN OF HEMORRHOID 191 THE REATMENT OF HEMORRHOID BY CLEROSINGPERIVENOUS INIECTIONS HISTOLOGICA EXAMINA TION RHEMORRHOIDSTREATE BY THESE INIECTIONS
TRAITEMENT DES HEMORROIDES PAR DES INIECTIONS SCLEROSANTES PERIVEINEUSES EXAMEN HISTOLOGIQUE HEMORROIDES TRAITRES PAR ES INIECTIONSὶ
Physiciam to the St. Antoine Hospital
THE reaiment of hemorrhoid by injections causing clerosis
is no in ood repute in France. It was condemne here, severat ears aso, by rst-clas surgeons hos influentialopinion is lam. Dis here rem mos difficultrias to attemptuoiulit current Settin s strongly. Is nevertheles Lattemptrihe ask it is hecause since these criticisms were directe against the method iis technique has evolved the processes have been modihed, and on theother hand again m persona experience miready extendins Verthree ear has prove to me that it,ouldie ron to foreso Systematicali a reaiment which. unde certain mell-defined conditions.
is the right thin in the right place. certaini domo intensio dra in parallelietween the reaiment by injections and the surgica methods ansas far a Lam concerned shalliso dissuade a patient rom ursica intervention insuch is his wish and in domo se any counter indication. ut it mustio befors ite stat, omin to ea or rejudice, some eopte refer toremat for ears it procidenti bieedinthemorrhoid rather hanbe operate upon and that other cannoti operatedipo for very good medica reasons, impede porta circulation, pathologica cardiac-arteria system, etc. . In these patient the low an Ver Progressive itherins of the emorrhoida masses, the unchesteinstreate separatet a chosen intervais, illiso have the ver realand ometimes Anserous dra back of the sudde suppression ofth hemorrhoida flow dra backs ometimes o considerable thathemorrhoid have, in ali languases been sive most laudato mameS:
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oeines δ' r. vena de oro sol ne Ader Zoolate, etc.... Finctily whenthe patients are to debilitate by repeate hemorrhases, netther the operation nor the anesthesia cani performed but the injectioncanae made without an delay. For a long time the oni substanc employed was carboli Glycerine, hic Mitchel brought ut in America bout fori years ago. The opposition hicli, have potnted out above was calle forthespeciali by this substance. ut ther medicament have been injected ergotine Euereth boilin sal water Lostonin iodoformedether, Beckὶ adrenalin Muian heroi quinine and urea hydrochloride
the three method most employed: carbolic glycerine. 96milcohol. and the doubie hydrochlorate os quininerand urea. The technique sed for the injections os carboli Glycerine varies ver much illi the authors some injeci a pure concentraled solution, other a solution very much diluted do it 12lta the quantityinjecte varies homone to went drops Some perform the per-ntion in ne Sittins other in successive Sittings. Some kee thepatient in bed. other alto 'hei patient to wal immediately after the injections This is ho Professor Roux of La Anne one of the Strongest advocates of this treaiment, operates Aster senerat anesthesia on most occasions follo ed by dilatationis the anus this author injecta one or two drops of the concentrate solution in the centre of thehemorrhoidal nodule andine staris the injectio Dom the shin without
The patient must res for two day after the operation. Since 890 Roux has no performe more than a doeten incise operations forhemorrhoids He has realed hundred os cases by injections os carbolic lycerine illi complete success, without an seriou miShBP. and without a relapse hen the patient takes the indispensabie pre- caution to avoid injur to the rectum. have no persona experience of this ind of reaiment, utrahappenesto examine severa patient trealed by Professor Roux and by one of his pupiis, and senerali specthing the result were very satisfactory I found a relapse in one of these patientS. Boas proposed in l9l5, to replace the injections os carboli glycer- in by injections of SN alcohol. his is the technique he recommends: Aster havins haved the periana region and made a localanesthesia wit injections os novocain and adrenalimat i , he applies for twent minutes o the anal region a Bier cup, o a to dra thehemorrhoid wel out he then injecis in each of the tumour aramali
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are reate in ne sitiins, an after in operatio the hemorrhoidsare pushed bac into the rectum. f the locat anesthesia is ood the patient oes no usuali fee any ain. The whole operation lasis two minutes Aster the injections the patient is putrio bed and remains
bed for 8 days. At that moment it is eas to laeti rectat examinatio that he hemorrhoid have change into a hard cord hichfinali completet disappears in a se weekS. trie the injections of 96 N alcohol twice in each of these cases the final result was excellent but the patients were in greatlain fortherarst two dctyS. The proces to hic Ι save the preference consist of injectinga ira solutioni doubie hydrochlorate os quinine an urea. I have used it regulari for the last three ear an have treate a great number of patienis, butra an only use for m statistics, 2 cases concernins patienis,hom I was able o follow closely. These injections are ni meant for interna hemorrhoids, whichmustae found with the anuscope, ithout an locat anesthesia Mytechnique has change sinceri besan thes injections. At irst Iinjected a few drops in the hemorrhoid themselves, and then Padded
Sub-mucous injections to the intravenous injections. For the last fixmon th have adopte the practice of sivin thes injections soletyin the Sub-mucous cellula tissue, at the base of the hemorrhoids. This staris a loca oedema, and later clerosis. hicli inder the venous circulation. I inject ac timera tori c.c. once a week 6 tol injections are senerali necessar to obtain a result Aaron os
obtained very good result without exceedini submucous injections. certain amount of preparation is indispensable the patient mustinke amenem three hoursiefore the injection, and introduce, Orn in and evenins durin the periodis reaiment, a bismut suppositor whicli adheres to the mucosa, and proiecis it to a certain eXtentisom the contactis oecat matters hesides in orde to avoid infection, it is necessar to take the greatest asepti precautions jus HS i ii ere a case of actua surgica intervention The emorrhoid
hicli is orae reate mus besainted with odine before and after the injection: the instruments and the liquid tot injecte must be
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the anal region The hemorrhoid themselves are nolmainful is theret an palmit is due to a fissure ordo an inflammator ovibrea whichmus firstrae allayed A preliminar treaimenti histi frequenc isthen very usefui. Besore proceedininwith a ne injection it is a wellio Ake Sure, by recta examination that the precedin injectio hasno test an painsul inflamed nodule . Durin the whole period of the reaiment the patient must folio the sua die of peopte suffering rom hemorrhoids no ine, no
The injections o no require either a nursin home o hospitat: the constitutem typica consultins urgery reaiment, a real ambulato areaiment. The patient Who has been injected must simplWremainsittin forine hou before resumin his usual work. In the large majorit os cases the injectio is absolutet painless, and this is easti understood a the quinine and urea solution has an analgesic action which lasis severat days the cases in hic the injection as ainsul are se . hen there is palmit is a therarsi injection hen the tissues are notoet anesthetized.
Truo os, hospital patient had violent ain immediatet after thei injection: the ceased during the course of the day. w others have twice had a listi difficulty in urinatins The injectio is Some- times follo ed the nex dano the day after by aclos of blood Oneosis patients who subsequently made a complete recovery lost more
painsul inflammato modules. whic occurredit the potnt of injection: wasince oblige to stomthe reaiment for eight days. another timela fifteen days These mishaps neve reached a potnt at whic thepatient had to sta inaedis required a special reaiment in no casehas it Been necessar to abando theumatinent Patients have them-selves asked for the resumption of the injections in the hospital&where, as every one knows, it is ather dissiculi to se the patient to return regulari to the utpatienis depariment, there is, o to Specth, nodefectionis resards the treaiment of hemorrhoids This cante explain-ed by the relies hichas due partinio the action of the medicamentinthe sensatio of heaviness, the pruritus and the ano-rectat discomfort. Four os, patienis,ho had received 10 injections starte againto bleed, ix, eight o te month later a ne series of injections had
i Mith M. Andre Cain Lobtaine a rapid succes inureatin the anal fissure with
injections o quinin and urea we intendri continuetur experimentS.
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to e siven hic this time, eem to have produce final resulis. One wonder whether, in these patienis, the first reaiment had been sufficiently intense, and is a se hemorrhoid had notheen test unireat ed But his cannoti said of two patients who suffered rom relapses sicand eighteen months later. Both had profuse hemorrhases hichnothin could stop. ne of them,lio a sent o mea Dr. videmnoit was the sister of a hemophiliac she hadio reat hemorrhoidaltumours, but a real sphincterial hemorrhasical rectitis whichiled overiis hole sursace injections ad been the ni treaiment hichmastere thes hemorrhages. She had been sive 20 injections and had est Paris si months past, completet cured. he has justwritte me to say that the hemorrhases have started again. The other patient also realed with great perseverance remaine in good condition foris ea an a half, and then sussere again from intense hemorrhages. Despite her aversion to Sursical treaiment Dr de Martet operate on her, an want ou to examine the histolosica stides whicli come rom his operation. The mode of actionis the injectionsis clearly to e see o the lide the produce a submucous and perivascular clerosis hic en loses the vesseis. This is the repor of the histologica examination: l. In the areas here injections have been recenti made, theconnective frame whicli unites the hemorrhoidal dilatations is oedematised the infiitrationis serofluid render the fibrilla structure of the connective issu apparent an sivescit a liair aspect But the veinsiliemselves are not modihed the areio thrombosed the are notsurroundedi an leucocyti infiitration thei endothelium is intact.2. here the injections areis old standing the proces of clerosis is more apparent. The ratio is inverted the connective tissu i exuberant. hile the lumen of the ein is maller. Some of the veins have notiost thei permeabili , and one noti eSthat heir alis are intaci thei endothelium unmodihed thei passagefree But his passas is progressivel narro ed Itiecomes maller, sinuous, irregular, and finalty it disappears Al that remain to markthe track of the vel is a cellula traii made findothelium and muscula celis of the Vein. At certai potnis these cellula traiis are ver abundant and standout against the homogeneous appearance of the connective tissue
hich old them This issu is essentiali forme of hunches of collagen extremel poor in celis A eatur of primary importanc is the absence of inflammator reactio and of lympho-plasmati infit-trates. we have not yet studied in delati the reaction of the elastic tissue
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in the course of this provoked scierosis It wouldie very interestingto know what happens to the elastic tissu proper of the hemorrhoidal
2. The proces is septi an non-inflammato . The connectivetissu reacts o contact illi the injecte Substance by an excessive Secretionis collagen substance. The clerosis is no the resultis aprevious multiplicationis fixed or migratin celis.
Out o m 52 patients. 6 had relapses of hemorrhages, and rhad thei hemorrhoida prolapsus hardi modihed o nolint all. It musino be conclude Domihi that ali the other patients are definitelycured a Some of them received their las injectio not more than laurmonilis aso But what caniniready be asserted is that without exceptio at the patienis,ho received injections experiences rea relis In orde to make it possibi to appreciate the resulis,hicli I obtainedwit the quinine and urea injections Lmus potnt out thatri did notsive injections to any and ver patient ho was sufferin Domhemorrhoids. veryone nows that hemorrhoida outhrealis canae cured by a se days diei and locat topica Every one of the patients I realed had atready had recourse to the usual treatments but without resulis. The were sufferin Do hemorrhases alarmin by theirabundane or thei recurrence or eis the had an hemorrhoidal prolapsus o even both, prolapsus and hemorrhages. The resulis in cases of prolapsus are ometim especiali favour
able and this hould notae los sish of hecause is e have means of Stoppin hemorrhases. e have no palliatives hic mill reat prolapsuS. I ma mentio as a favourabie case, the histor os a patient. 7 years old who was sent to me by Dr. Felix Ramond. Hesutared rom a prolapsus wit hemorrhases the prolapsus protrudingat each stool and whicha was obligesto push in again. his pro lapsu Sometimes came ut durins a walh. his man whom I realeda ea ansa hali aso has no more hemorrhases the prolapsus hichi ver muc reduced disappears by itfel aster a stool the patient tot me that he fel a different man after the rectiment. Ι,ill also mentio the caseis a patient of Dr. Raoult of Vernon, who had falle into suci a state os post-hemorrhasic anemia that I A calle in about three ear aso, orandiu is the hemorrhoids
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were not accompanted by cancer. I made, o the Spol, Mur injections and since then the patient has notaad an more hemorrhases. Dr. Raoult wrote 29th Ianuar l923: Themiarminthemorrhasessor,hich o were calle in have neve recurred: the patient hasno had any smaller aemorrhase either. It is naturali dissiculi to dra a comparison,ith themther methodso treaiment. do no spectk of salves, suppositorie or interncti me dicamenis hic the patient had ali use to a reat extent before
comin to se me. The result were certaini superior to those of
treate man patients h hadiso ha an relie Dom electricity. Ac mentioned above. I do ometimes sive a se electrica applica tionsae reci star the injectio trectiment. As resard the injections os carbolic glycerine and of alcohol. Lamlesto belleve that the are superior to the injections o quinine andurea hen the Roux and Boas method are used but these methodsconstitute rea surgical realmenis,hicli necessitate locat o seneralanesthesia a sta inaed and a Severe diet Bette resulis tha those indicate would perhaps e obtained i the quinine and urea injec
tions ere sive unde the Same conditions.
state above that the injectio method could notae compared with the surgica methods, hich count thousand of cures but the injections have no the fame indications a these methods. In casti sup the account of the surgical reaiment it must noti overtooked that in hemorrhoid it is very ainful a leas durin the 8 hours hic follow the operation. Relapses are notisXceptioncti and wΟrSestili, it may happen that the surgical intervention is followed by stric ture of the anus, or by incontinence afleast partiat liquids and enemas).Like many physicians Pliave seen examples of these miShapS, occurr- in no indee to ouns and inexperiene surgeons, hut eUen to urteadins urgeons Astros Ouenu says: The sursica treaiment of hemorrhoids entatis more dissiculties than wouldie belleve a first Sight It is no always simple it is even osten ci domo hesitate to
The reaiment of hemorroids by injections causins scierosis ix orthyos a place alonsside the surgical methods It has it precis indications, even is more limited han the incisive methods. The final resulis of the quinine and urea injections are perhaps inferior to those of the carbolicslycerine and SN alcollo injections. ut the have no the samedrawbacks They domo require generat anesthesia or locat anesthesia
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198 THE REATMENT OF HEMORRHOIDS
They do not require absolute rest in bed therare a typical ambulato treaiment an enabi the patient to follow the realmen and at thesam time atten to his bufiness. Is the do not always radicali cureth patient, it can a least e state that here is always a positive improvement besides the method is absolutelysainless, and performed
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TREMMENT OF HAEMORRHOID B INIECTION& 199 THETREAT MENTOTHAEMORRHOIDS BYSUBMUCOUS INIECTIONS OF CHEMICA H. GRAEME ANDERSON LONDON
Surseon to St. Mark' Hospital for diseases of the rectum consultins urseon to the Royal ai force senior assistant surgeon to the Belgrave Hospital
AT St. Mark' Hospital I have experimented with the followinschemicats carbolic acid, quinine and urea, iron perchloride, eruot lead acetate alcohol, an formalin There is no doubtthat carbolic acid is the est os ali, thous quinine and urea sives almos a good resulta The lalter hould e sed in Mandra per
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200 ACUTE LUMBAGO ACUTE LUMBAGO
SIR, - hos o us h have had personat experience of the
exquisite ain caused by an attack of acute lumbas oush tobe speciali fratefulcio r. H. S. Muttar, F. R. C. S., or his
it for ears, ut i ha no occurre to me torus it as r. Multarhasione. As resard the acute attach, Lam fur that it is due to the retention in the dorsat fascias and apo euroses of waste Substances, hi hexercise and other measures ould have prevente accumulatins In m persona experience the attac has comet when makins Some ordinarymovement in the proces of dressing or even by a coush. The feelingis asci somethin ha snappe o been tor at a potnt Somewhereabout the crest of the ilium and then the hac muscies sorint extraordinarii painsul an disablin spasm I doub this hein a protec live fixation ' it is more like the explosionis a munition dump. Thepat of the ear o whateve it is, is quitem tolerable assair it is theexquisite ain of the musci spasm, and the eas mith whicli it is induced. hic is so disabling. Eleven ear as Phad a very severe attach, an a soon asci was abierio moveri a trealed electricatly by a frien and colleaque The effect of the reaiment was entirelyto remove the pas element, althous the ain of the tor potntremained My ex attach euan in the second wee of this month. It was comparativel mil to besin illi, ut a sudde movementinduce the sna and the paralysin spasm. Iaad quinine urea hydrochloridem hand an sol a medicat frienda sive me an injectionwhicli containe 1 ramo the rus in c.cm. r. Souttar sed a per cent. Solution, and that is apparenti sussicient This injectionwas sive into the har massis contracted muscle, hic mas tender hendouched. In tes than an hou the spasm,as much relieved, and in quitem hori time the tendenc to disablin spasm a checked. There remained however, a secon tor spol further ut alon theilia crest, hic was causin a loca spasm, o Phad the injectionrepeatedin the followiniday, and wit an equalinsatisfactor result. am,ritin this letterin Sunday, and the injections ere sive on