CARTWRIGHT--THE 20. 21. 22.

23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41,

42. 43. 44. 45. 4S. 47. 48. 49. 50. 51.

MANAGEMENT

0F

Crozier, W. J . a n d Stier, T. J . B . : Temperature and frequency of c a r d i a c c o n t r a c t i o n s in e m b r y o s of limulus. Jour. Gem Physiol., 10:501-518, M a r c h 20, 1927. Dale, H . H . a n d F e l d b e r g , W . : T h e c h e m i c a l t r a n s m i t t e r of v a g u s effects to t h e s t o m a c h . Jour. Physiol., 81:320-334, J u n e 9, 1934. Dixon, W . E . : N i c o t i n , coniin, p l p e r i d i n , lupetidin, cytisin, lobelin, s p a r t e i n , g e l s e m i n . In: Heffter, A.: Handbuch der expcrimentellen Pharmakologie. Berlin, J u l i u s S p r i n g e r , Vol. 2, pt. 2, p p . 656-701, 1924. Elliott, T. R . : " T h e i n n e r v a t i o n of t h e b l a d d e r a n d u r e t h r a . ' " Jour. Physiol., 35:367-445, J u l y 2, 1907. Elliott, T . R. a n d B a r c l a y - S m i t h , E. : A n t i p e r i s t a l s i s a n d o t h e r m u s c u l a r a c t i v i t i e s of t h e colon. Jour. Physiol., 31:27~2-304. J u n e 30, 1904. Eugling, Max: U n t e r s u c h u n g e n fiber den p e r i p h e r e n T o n u s der Blutgef~,sse. Arch. ~. d. ges. Physiol., 121:275-297, 1908. Finkleman, B.: O n t h e n a t u r e o f i n h i b i t i o n in t h e i n t e s t i n e . Jour. Physiol., 70:145-157, S e p t . 18, 1930. Fleisch, A l f r e d : D e r V e r k f i r z u n g s r e f l e x des D a r m e s . Arch. f. d. ges. Physiol., 220:512-523, 1928. F r a n k e , F. E. a n d T h o m a s , J . E . : A n o t e on t h e m i n i m a l f a t a l dose o f n i c o t i n e f o r u n a n e s t h e t i z e d dogs. Prec. Soc. ExpeT. Biol. and Med., 29:1177-1179, J u n e , 1932. F r a n k e , F. E. a n d T h o m a s , J . E . : A s t u d y of t h e c a u s e of d e a t h in e x p e r i m e n t a l n i c o t i n e p o i s o n i n g in dogs. Jour. Pharmacol. and Exper. Therap., 48:199-208, J u n e , 1933. G a r r e y , W . E. : D y n a m i c s of n e r v e ceils. I. T h e t e m p e r a t u r e coefficient of t h e n e u r o g e n i c r h y t h m of t h e h e a r t of L i m u l u s polyphemus. Jour. Gen. Physiol., 3:41-48, Sept. 20, 1920. G a r r y , R. C . : T h e n e r v o u s control o f t h e caudal r e g i o n of t h e l a r g e bowel in t h e cat. Jour. Physiol., 77:422-431, M a r c h 15, 1933. G a s s e r , H . S. : P l e x u s - f r e e p r e p a r a t i o n s of t h e s m a l l i n t e s t i n e . A s t u d y of t h e i r r h y t h m i c i t y a n d of t h e i r r e s p o n s e to d r u g s . Jour. Pharmacol. and Exper. Therap., 27:395-410. J u n e , 1926. Gold, H a r r y a n d B r o w n , F r e d e r i c k : A c o n t r i b u t i o n to t h e p h a r m a c o l o g y o f nicotine. Jour. Pharmacol. and Ezper. Therap., 54:463-476, A u g . , 1935. Greenwood, M. : O n t h e a c t i o n o f n i c o t i n e u p o n c e r t a i n i n v e r t e b r a t e s . Jour. Physiol., 11:573-605, 1890. Gross, L o u i s a n d C l a r k , A . J . : T h e influence of o x y g e n s u p p l y on t h e r e s p o n s e of t h e isolated i n t e s t i n e to d r u g s . Jour. Physiol., 57:457-460, A u g . 16, 1923. Heinbecker, Peter: T h e p o t e n t i a l a n a l y s i s of a p a c e m a k e r m e c h a n i s m in L i m u l u s p o l y p h e m n s . A m . Jour. Physiol., 117:686700, Dec., 1936. H e i n b e c k e r , P e t e r a n d Bishop, G. H . : S t u d i e s on t h e e x t r i n s i c a n d i n t r i n s i c n e r v e m e c h a n i s m s of t h e h e a r t . A m . Jour. Physiol.. 114:212-223, Dec., 1935. H e n d e r s o n , V . E. : T h e m e c h a n i s m of i n t e s t i n a l p e r i s t a l s i s . A m . Jour. Physiol., 86:82-98, A u g . , 1928. H e n d r i c k s , M. D. a n d T h i e n e s , C. H . : A p h a r m a c o l o g i c a l s t u d y of t h e i n h i b i t o r y m e s e n t e r i c n e r v e s to t h e i n t e s t i n e . Prec. See. Exper. Biol. and Med., 2~ :993-994, J u n e . 1931. Hill, C a t h e r i n e J . : A c o n t r i b u t i o n to o u r k n o w l e d g e of t h e e n t e r i c plexuses. Phil. Tr. Roy. Soc., London. ( S e r i e s B ) , 215:355387, June 15, 1927. Himwich,H. E. and Fazikas. 5. F.: Effect of nicotine on oxidations in t h e b r a i n . A m . Jour. Physiol., 113:63-64, Sept., 1935. H o a g l a n d , H u d s o n : P a c e m a k e r s of h u m a n b r a i n w a v e s in n o r m a l s a n d in g e n e r a l p a r e t i c s . A m . Jour. Physiol., 116:604-615, A u g . , 1936. Ing, H. R.: T h e c u r a r i f o r m a c t i o n of o n i u m salts. Physiol. Rev., 16:527-544, Oct., 1936. I r w i n , D. A . : T h e a n a t o m y of A u e r b a c h ' s plexus. A m . Jour. Anat., 49:141-166, Sept., 1931. K i n g , C. E. a n d Arnold, L l o y d : T h e a c t i v i t i e s of t h e i n t e s t i n a l mucosal motor mechanism. A m . Jour. Physiol., 59:97-121, Feb., 1922. Klee, P h : P e r Einfluss d e r V a g u s r e i z u n g a u f den A b l a u f d e r Verdauungsbewegungen. Arch. f. d. ges. Physiol., 145:557-594, M a y 30, 1912. Kuntz, Albert and Thomas, J. E.: On t h e n a t u r e o f t h e r h y t h m i c c o n t r a c t i o n s in t h e s t o m a c h a n d i n t e s t i n e . Prec. See. E~per. Biol. and Med., 20:256-258, J a n . , 1923. Langley, J. N.: O n t h e n e r v e cell connection of t h e s p l a n c h n i c n e r v e fibres. Jour. Physiol., 20:223-246. A u g . 21, 1896. Langley, J. N.: On t h e s t i m u l a t i o n a n d p a r a l y s i s of nerve-cells and nerve-endings. P a r t I. Jonr. Physiol., 27:224-236, Oct. 16, 1991. L a n g l e y , J.. N . : C o n n e x i o n s o f t h e e n t e r i c n e r v e cells. Jour. Physiol., 5 6 : x x x i x , 1922. L a n g l e y , J.. N . a n d A n d e r s o n , H . K. : T h e i n n e r v a t i o n of t h e pelvic a n d a d j o i n i n g v i s c e r a . P a r t V. P o s i t i o n of t h e n e r v e

STRANGULATED

52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 6?. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80.

HEMORRHOIDS

425

cells on t h e c o u r s e of t h e e f f e r e n t n e r v e fibres. Jour. Physiol., 19:131-139, Dec. 30, 1895. L a n g l e y , J . N . a n d D i c k i n s o n , W . L . : P i t u r i a n d nicotine. Jour. Physiol., 11:265-306, 1890. L a n g l e y , J . N . a n d M a g n u s , R . : S o m e o b s e r v a t i o n s of t h e m o v e m e n t s of t h e i n t e s t i n e b e f o r e a n d a f t e r d e g e n e r a t i v e section o f t h e m e s e n t e r i c n e r v e s . Jour. Physiol., 33:34-51, Sept. 8, 1906. Lapicque, Marcene: A c t i o n de la n i c o t i n e s u r l'excltabilit~ et r i m b i b i t i o n du m u s c l e stri~. Compt. rend. Soc. de biol., 84:654656. A p r i l 16, 1921. L i n e g a r . C. R., Dille, J.. M. a n d K o p p a n y i , T h e o d o r e : A cont r i b u t i o n to t h e p h a r m a c o l o g y of p h y s o s t i g m i n e . Science, 82:497, Nov. 22, 1935. L o r e n t e de No. R. : F a c i l i t a t i o n o f m o t o n e u r o n e s . A m . Jour. Physiol.. 113:505-5~3, Nov. 1, 1935. Macht, D. I . : On t h e p h a r m a c o l o g y o f t h e u r e t e r . L Action of e p i n e p h r i n , e r g o t e x i n a n d o f nicotine. Jour. PharmacoL and Exper. Theram, 8:155-166, M a r c h . 1916. Magnus, R.: V e r s u c h e a m fiberlebenden d f i n n d a r m yon S~uget i e r e n . V. M i t t e i l u n g . W i r k u n g s w e i s e a n d A n g r i f f s p u n k t e i n i g e r Gifte am Katzendarm. Arch. I. d. ges. Physiol., 108:1-71, 1905. Mulinos, M. G. : G a s t r o - i n t e s t i n a l m o t o r r e s p o n s e to v a g u s s t i m u l a tion a f t e r nicotine. Prec. See. Exper. Biol. and Med., 26:4953, Oct., 1927. Never, H. E.: Die B e d e u t u n g d e r D e h n u n g a n d d e r R e z e p t i o n s o r g a n e ffir die R h e o k i n e t i k . Arch. f. d. ges. Physiol., 235:733736, 1935. Nell, Pierre: L e s y s t ~ m e n e r v e u x ent6rique. Essai d'analyse par ]a m 4 t h o d e ~ la n i c o t i n e de L a n g l e y . Arch. internat, de physiol., 30:.~17-492. J a n . 25, 1929. P a c i n i . A. J . a n d M c G u i g a n . H u g h : Detoxifieation o f n i c o t i n e by u l t r a v i o l e t rayu. Jour. Pharmacol. and Exper. Therap., 39:241-244, J u n e , 1930. P i - S u n e r , A. a n d R a v e n t o s , P i j o ~ n J . : S u r de blocage de la conductinn ~ervou~e p a r la nicotine. Compt. rend. Soc. de biol., 114:97-100, 1933. P u e s t o w , C. B . : S t u d i e s on t h e o r i g i n of t h e a n t o m a t i c i t y of t h e i n t e s t i n e : t h e a c t i o n o f c e r t a i n d r u g s on isolated i n t e s t i n a l t r a n s plants. A m . Jour. Physiol., 106:682-688, Dec., 1933. R a i f o r d , T h e o d o r e a n d Mulinos, M. G. : I n t e s t i n a l a c t i v i t y in t h e e x t e r i o r i z e d colon of t h e dog. A m . Jour. Physiol., 110:123-128, N o v . , 1934. R a i f o r d . T h e o d o r e a n d Mulinos. M. G . : T h e m y e n t e r i c reflex a s e x h i b i t e d by t h e e x t e r i o r i z e d colon of t h e dog. A m . Jour. Physiol., 110:129-136, N o v , 1934. Raventes, J.: A c t i o n de la n i c o t i n e s u r la conduction n e r v e u s e d a ~ s la p r e p a r a t i o n n e u r o - m u s c u l a i r e . Compt. rend. Soc. de blol.. 110:739-740. 1932. Raventos, J.: A c t i o n de la n i c o t i n e s u r les fibres s y m p a t h i q u e s pr~- et p o s t g a n g l i o n n a i r e s . Compt. rend. Soc. de blol., 116:11221124, 1934. R a v e n t e s , P i j o a n J'. : A c t i o n de la n i c o t i n e s u r les fibres n e r v e u s e s du v a g u e . I n f l u e n c e s u r ]a condnctibilit& Campt. rend. Soc. de biol., 114 :774-776, 1933. R e s e n b l u e t h , A. a n d C a n n o n , W . B . : T h e a d e q u a c y o f t h e chemical t h e o r y o f s m o o t h muscle e x c i t a t i o n . A m . ,four. Physiol., 116:414429. J u l y . 1936. Rosenblueth, A.. D a v i s . H . a n d R e m p c l , B. : Tile physiological s i g n i f i c a n c e of t h e electric r e s p o n s e s o f s m o o t h muscle. Am. Jour. Physiol., 116:387-407, J u l y , 1936. S c b a b a d a s c h , A r n o l d : I n t r a m n r a l e N e r v e n g e f l e c h t e des D a r m r o h r s . Ztschr. f. Zellforsch. u. miler. Anat.. l0:320-385, J.an., 1930. T h o m a s , J . E. a n d F r a n k e , F. E . : T h e site of t h e toxic a c t i o n o f nicotin on t h e r e s p i r a t o r y m e c h a n i s m . Jour. Pharmacol. and Exper. Therap., 34:111-135. Oct., 1928. T h o m a s , J . E. a n d K a n t , , A l b e r t : A study of the vago-enterlc r n o c h a n i s m by m e a n s o f nicotine. A m . Jour. Physiol., 76:698605, M a y , 1926. T h o m a s . J . E. a n d K u n t z , A l b e r t : A s t u d y of g a s t r o - i n t e s t i n a l m o t i l i t y in relation to t h e e n t e r i c n e r v o u s s y s t e m . A m . Jour. Physiol.. 76:606-626. May, 1926. T i e g s . O. W. : Studies on plain muscle. Australian Jour. Exper. Biol. and Med. Sc., 1:131-150, Dec. 15, 1924. T i e g s , O. W . : T h e n e r v e n e t o f plain muscle, a n d its relation to automatic rhythmic movements. Australian Jour. E x p e r . Biol. and Med. Sc.. 2:157-1c6. Sent. 16, 1925. Trendelenburg, Paul: Physiolo~ische u n d p h a r m a k o l o g i s c h e V e r s u c h e fiber die D f i n n d a r m p e r i s t a l t i k . Arch. f. exper. Path. u. Pharmakol., 81:56-129, Jjune, 1917. v a n Esveld. L. W . : V e r h a l t e n yon p l e x u s h a l t i g e n a n d p l e x u s freien Darmmuskelpr~iparaten. Arch. f. exper. Path. u. Phar~ukol., 134:347-386, 1928. W a k e b a m . Glen a n d T r a c y , G. P. : T h e effect o f u l t r a v i o l e t i r r a diation u p o n t h e t o x i c i t y of p u r e nicotine. Jour. Pharmaeol. and Exper. Therap.. 44:295-t298, Feb., 1932.

The Management of Strangulated Hemorrhoids By EMOR L. CARTWRIGHT, M.D., F.A.C.S. FORT WAYNE,

'THIS controversial subject is still the cause of lmuch debate, after these many years. Whether to operate early or to delay until the active inflammation has subsided is still as undecided, in some quarters, as ~ R e a d in e x t e n d e d f o r m b e f o r e t h e m e e t i n g of t h e A m e r i c a n logic Society, A t l a n t i c City, J u n e 7, 1937. S u b m i t t e d M a y 28, 1937.

Procto-

INDIANA

it was in William Allingham's time. The remark of N. J. Kilbourne (1) when discussing prolapsed, strangulated, gangrenous hemorrhoids that "Such cases are not usually operated on by competent proctoIogists in this stage" serves to show the attitude of some physicians. That such a view is not correct I

426

AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

have been able to determine by i n t e r r o g a t i n g the competent proctologists of the United States and Canada. DEFINITION The t e r m hemorrhoid means, of course, varicosities in the lower rectum, and not perianal hematomas. The various descriptive terms, such as prolapsed, thrombosed, strangulated, and g a n g r e n o u s hemorrhofds r e f e r merely to pathological changes and to changes in position of the lesion. The condition m a y or may not be accompanied by p e r i a n a l hematomas, and anal edema m a y be much or little. There is one common finding in s t r a n g u l a t e d hemorrhoids and t h a t is thrombosis of the a r t e r i e s , veins and capillaries making up the hemorrhoid. ETIOLOGY A N D P A T H O L O G Y It was f o r m e r l y thought t h a t thrombosed, prolapsing hemorrhoids were due to strangulation, produced by the sphincter muscles, but this idea is g r a d u a l l y giving way to the more tenable t h e o r y t h a t the resulting pathology is one of t r a u m a . The extrusion of a h a r d stool, or p e r h a p s severe d i a r r h e a , prolapses the hemorrhoids b r e a k i n g the intima, and thrombosis results. The n a t u r a l sequence then is edema, cellular infiltration, inflammation, ulceration and frequently gangrene. S t r a n g u l a t i o n does not enter into the picture at all, as noted by F. C. Smith (2). I n s e r t i n g the finger into the r e c t u m of one of these cases shows t h a t the sphincters themselves offer no resistance. W i t h this pathology in mind, it would appear to me t h a t it is j u s t as essential to excise this tissue at the earliest possible moment, as it is to excise a perianal hematoma at once, which l a t t e r procedure is universally accepted, I believe. Delay in i n s t i t u t i n g s u r g e r y serves to prolong the pain unnecessarily and increases the likelihood of sepsis. F E A R OF E M B O L I S M The danger of embolism is often mentioned, and this is no doubt a real d a n g e r when a crushing clamp is used, or when the anesthesia consists of local infiltration. In the f a t a l cases I have investigated the clamp and c a u t e r y or local infiltration was used. Clean s u r g e r y by p r o m p t excision of t h e masses, under a block anesthetic, e i t h e r spinal or caudal, or, if required, a general anesthetic, helps to avoid this d a n g e r and is a safe procedure to be followed in thrombosed hemorrhoids. Some vessels will require ligation, but this is easily accomplished when the hemorrhoids have been removed. An embolic death may follow a simple hemorrhoidectomy as well as a f t e r an operation on thrombosed piles, and the menace is not confined to proctology, as orthopedists and gynecologists will testify. F E A R OF L I V E R A B S C E S S A n o t h e r d a n g e r t h a t is given considerable thought is the likelihood of liver abscess, or a general blood s t r e a m infection, following s u r g e r y on thrombosed or gangrenous hemorrhoids. W. B. Gabriel (3) in his book has this to say,, "Septic internal piles should be t r e a t e d on palliative a~d antiseptic lines. When the piles a r e perfectly clean, a decision can be made as to what f u r t h e r t r e a t m e n t , if any, is required." Yet on page 30 of this same book, we find this sentence, "The process is almost i n v a r i a b l y well localized, and in spite of the theoretical dangers of septic pylephlebitis and portal pyaemia, I can recall only one death from a

sloughing haemorrhoid." This death in a p a t i e n t who was not operated upon shows us t h a t liver abscess may occur in the absence of hemorrhoidal s u r g e r y as well as following such surgery~. Necrosis, therefore, is no contra-indication to the removal of these hemorrhoids, provided it is done w i t h o u t clamps and without local infiltration. L o c k h a r t - M u m m e r y (4), with whom Gabriel was associated as an a s s i s t a n t for some time, w r i t e s in his most recent book, as follows: "I have always made it a practice to operate at once upon sloughing and s t r a n g u l a t e d piles, unless some other contra-indication existed. The result in all cases has been an immediate relief of p a i n ; and as a rule the p a t i e n t has been quite well a g a i n in a f o r t n i g h t or three weeks, and at the same time cured of his piles. If one waits until all sloughing and inflammation have subsided before doing the radical operation, the total t i m e before the p a t i e n t is well is n e a r e r five or six weeks." "I have never seen any ill-effects follow iramediate operation upon sloughing piles, and, on the other hand, I am sure t h a t the p a t i e n t is saved much trouble and pain by i m m e d i a t e operation." F E A R OF S T E N O S I S Still another reason given f o r delayed operation is the i n a b i l i t y to judge the amount of tissue it is necess a r y to remove. I t is a bit disconcerting to be conf r o n t e d with a p a t i e n t having large clumps of t h r o m bosed hemorrhoids p r o t r u d i n g f r o m the anal canal. My experience in these cases has been veryJ s a t i s f a c tory. The convalescent period has f r e q u e n t l y been s h o r t e r t h a n following an uncomplicated case. Experience, of course, is the guide one needs to reach a decision as to what sort of a plastic or r e p a i r operation is required in t h e case at hand. CASE R E P O R T A typical case report follows: F . R . S . , male, 51 years old, a packing house employee, was brought to the hospital by his doctor, with this history: Rectal bleeding and protrusion for at least twenty years. For the past few days piles have been out and he is unable to replace them. When the piles were first protruded, one was bleeding quite badly, and his doctor ligated it with black silk. I saw the patient at the hospital and found a lobulated mass as large as a small orange prolapsed from the rectum. The ligated pile was gangrenous and gave off the characteristic odor. The patient was suffering intense pain. He was sent to surgery immediately and under spinal anesthesia all thrombotic and gangrenous piles were excised. No clamps were used at any time. The bleeding vessels were ligated when necessary. He entered the hospital August 5, 1935, dismissd from the hospital August 9 and discharged from my care August 23. He had the largest collection of prolapsed, thrombosed hemorrhoids I have ever seen. I have recently obtained the views of the surgeons of the A m e r i c a n Proctologic Society concerning t h i s vexatious problem. Of 116 replies to my questionnaire 76 operate promptly upon acute s t r a n g u l a t e d hemorrhoids while 38 do not, and two follow no p r e d e t e r mined plan. It is i n t e r e s t i n g to note the t r e n d away f r o m the clamp and cautery', as shown by the choice of operation f r o m the 76 o p e r a t i n g early. Only eight chose the clamp and cautery, while 65 use some f o r m of a modified l i g a t u r e operation, and three had no p r e f e r ence. It would a p p e a r t h a t if t h e r e ever was a t i m e when the c!amp and cautery was especially dangerous it would be in the presence of thrombosis. Quite a

CARTWRIGHT--THE MANAGEMENT OF STRANGULATED HEMORRHOIDS

number of the surgeons volunteered the information that they n e v e r use the clamp and cautery. The choice of anesthesia assumes as great importance, from the standpoint of safety, as does the type of operation. There are 18 who use local infiltration, the big majority use block anesthesia, and a few general. I f the infiltration is made at a considerable distance away from the thrombosed area it may be a fairly safe method. I f not away from the area the procedure may be extremely dangerous. This view is held by a big majority of the surgeons as shown by their choice of block anesthesia. A few replies to the questionnaire follow: Dr. Louis J. Hirschman prefers the ligature operation with caudal anesthesia. He says: "Knowing that a blood clot forms an excellent medium for the culture of pyogenic organisms in this region thrombosis is an indication for immediate removal." "Knowing that strangulation means necrosis and even when hemorrhoid is reduced means recurrence, immediate removal is also mandatory." Dr. Curtice Rosser uses the ligature operation, always under a block (spinal or caudal) or general anesthesia, never under infiltration. He says: "I find

that it is always possible to discover normal tissue at the b a s e of the strangulated pile and if local injection of chemicals and t r a u m a to the pathologic tissue is avoided at operation, I believe there is less danger in the removal of the pathology than in awaiting further extension. I used the clamp and cautery for some years in this situation, but decided there was some danger of trauma with the clamp." Dr. F r a n k C. Yeomans uses the clamp and cautery operation and uses low spinal anesthesia with a small dose. He says: "My results in several such cases have been very satisfactory." In his book (5) we find the following: "When the sphincter is tight and the protrusion not replaced, thrombosis of the vessels and gangrene frequently ensue. Sloughing then occurs and spontaneous relief may be obtained, but at the expense of several weeks of needless pain, suffering and disability. Prolonged ulceration, abscess, or a fistula may be sequelae. Under these circumstances, when the situation is fully explained to the patient and there is no other contra-indication to operation, he will usually accept immediate operation, which is the proper procedure for strangulated, sloughing piles. Relief is immediate, the hemorrhoids are cured, and no complications, other than those encountered in a simple hemorrhoidectomy, ensue. To limit the possibility of infection, the clamp and cautery is the operation of choice." The 38 surgeons advising delay before instituting surgery in strangulated hemorrhoids gave as their reasons; fear of embolism, blood stream infection or liver abscess, and fear of stenosis if too much tissue is removed. They advocated various methods of palliation, chiefly rest and hot moist compresses.

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One of the most interesting discussions that I read on this subject was that of N. L. Blumental (6), Director, Surgical Division of Trekhgorny' Hospital, Moscow, U.S.S.R. He recounted the dangers of the conservative treatment of strangulated piles, and emphasized the likelihood of the condition not remaining localized, with embolism and pyemia imminent. He then decided to break away from the generations-old attitude of merely standing by while the nurse recorded exquisitely painful as well as dangerous defecations, the while applying hot water compresses. In a series of cases operated upon by excision, without clamps and without anal dilatation, under general anesthesia, his results were so good that he recorded them in a paper which should be read in its entirety. The important thing to remember is that we all want to get our patients well. However we should not close our minds to any advances in surgical therapy which tend to hasten this end. A procedure which brings about a worth-while reduction in human suffering, while at the same time eliminating the hazards of watchful expectancy, should be utilized. SUMMARY An attempt is made to bring order out of chaos in the therapy of strangulated hemorrhoids. Following a description of the condition, the etiology and pathology are taken up in turn. The alleged dangers of early operation are cited, and the reasons for these dangers are given. Quotations are taken from wellknown text books on proctology. A questionnaire was devised and submitted to members of the American Proctologic Society for their opinions on this vexing problem. These questionnaires were tabulated, and quotations made therefrom. One case history is given. CONCLUSIONS Strangulated, thrombosed, sloughing, and gangrenous hemorrhoids should be operated upon promptly. The danger of embolism or liver abscess is greater in those cases not operated upon, than it is in those cases operated upon under block anesthesia, without clamps, and without anal dilatation. The preponderance of opinion among the surgeons of the American Proctologic Society favors this procedure. REFERENCES 1. 2. 3. 4. 5.

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Kilbourne, N . J . : Local Anesthetics Producing P r o l o n g e d A n a l g e s i a : Elimination of Pain A f t e r Rectal Operations. S. G. O., 62:590, M a r c h , 1936. Smith, Frederick C.: T h r o m b o s i s of the Hemorrhoidal V e i n s . T h e Amer. Jour. of Surg., M a r c h , 1929. G~briel, W i l l i a m B. : T h e P r i n c i p l e s and Practice o f R e c t a l Surgery, p a g e 36, H . K. Lewis and Co., London, 1982. L o c k h a r t - M u m m e r y , ft. P. : D i s e a s e s of the Rectum and Colon and Their Surgical Treatment, p a g e 88, Second Edition. William W o o d a n d C o m p a n y , B a l t i m o r e , 1934. Yecmans, Frank C. : Proctology, a Treatise on the Malformations, Injuries and Diseases of the Rectum, A n u s and P e l v i c Colon, p a g e 155. D. Appleton and Company, N e w York and London. 1929. B l u m e n t a l , N . L. : S u r g i c a l T h e r a p y of Strangulated Hemorrhoids. Klln. Med., xi, 145-149 ( N o s . 3-4), 1933.