HEMORRHOIDS. B. F. BRITTAIN, M. D., JACKSONVILLE. Before speaking of internal piles I would remark that the proper treatment for external piles is to lay them open with the knife and turn out the clot or snip them off with scissors if they are in the form of tags of skin surrounding the anal region. All piles external to the sphincter ani, are external piles, all others are internal. There are a number of methods of treating internal piles, viz: dilating the sphincter ani muscle thoroughly, ligation, crushing, excision and injection of the pile tumor with carbolic acid. I shall address myself especially to the latter method. I shall attempt to show the carbolic acid treatment to be successful and as safe as other methods. A great many doctors are opposed to this method on account of the supposed danger of embolism. A majority of those who oppose the method, do it on theoretical grounds and not from observation. Bryant in the fourth edition of his Surgery, page 575, says the treatment of piles by their injection with carbolic acid has been freely used in America, and apparently with success. Dr. Edmund Andrews, of Chicago, has investigated over 3000 cases which were treated with carbolic acid, and while he prefers ligation, he says those treated with carbolic acid are cured rapidly the majority of them. Dr. John A. Wyeth, when discussing Dr. Will B. Davis' paper on the treatment of hemorrhoids, at the meeting of this Association in 1883, at Tyler, said that Dr. Andrews in analyzing the 3000 cases found that four had died, and five others had died, but the cause could not positively be traced to the acid injection. There were five cases of dangerous hemorrhage, and five that were not alarming. In twenty-three cases, there were sloughing, and there was abscesses in ten cases. Now as to the hemorrhage following the injection of carbolic acid let us compare it to some extent with the hemorrhage following ligation. Ligation is a safe operation, but I want to show that hemorrhage sometimes follows ligation. Allingham has operated with the ligature about 1800 times. He does not say how often hemorrhage, sloughing or ulceration occurred, but it must occur as often as it does in the carbolic treatment, perhaps oftener, or he would not devote nearly a whole page in the Encyclopedia of Surgery in advising how to treat hemorrhage that follows ligating a hemorrhoid. To show that he considered the hemorrhage very troublesome, if not dangerous, I will make a short extract from the article. After speaking of primary hemorrhage being a trivial matter, he says, "Secondary hemorrhage is of more serious import, and occurs generally in elderly people of broken down constitutions, or in those who have been free livers. As far as my experience goes, this hemorrhage is more venous than arterial, and occurs at or about the time of the separation of the ligatures. "I have found it utterly futile in cases of secondary hemorrhage to try and place a ligature around the vessel; it is usually the large veins or venous sinuses which are opened by sloughing or ulceration, and when the surgeon introduces a speculum and tries to find the source of bleeding, he can only see that the rectum is filled with blood." He then takes up a full half page in telling how to treat the hemorrhage. Dr. Stephen Smith, in his Operative Surgery, says: "The direct injection of carbolic acid is usually very successful and but little painful." Dr. Will B. Davis, in 1883, reported to this Association twentyfour cases of piles successfully treated with the carbolic acid injections. Dr. Q. A. Shuford, of Tyler, has treated successfully quite a number of cases without pain, and his patients being able to attend to their avocations without losing an hour's time. He has never seen any ill effects following the treatment. Dr. W. P. Agnew, of San Francisco, Cal., uses the carbolic acid injection, and always cures all his cases of piles. I make some extracts from Dr. Agnew's pamphlet: "Dr. Geo. F. Monroe in Medical Journal says, out of 2000 cases of hemorrhoids that I have successfully treated by the injection process, only two cases of extensive sloughing occurred, and these in syphilitic subjects. There were six cases of easily controlled secondary hemorrhage. Several cases suffered more than was agreeable when the tumor was not thoroughly injected. The treatment in my opinion is a safe one and yields excellent results." Dr. W. I. Kelley, of Cincinnati, O., in answer to the question, "Is there any danger of embolism in making injections into hemorrhoids, says: "I have made several thousand such injections, and emphatically say no." Sometimes a large vein is seen in a hemorrhoid, and if such exists, by no means stick a needle in it (the vein) as that might produce embolism." Dr. L. Haynes, of Los Angeles, Cal., says, "I have frequently made Allingham's ligature operation. It is easy and effectual, but followed by great pain and retention of urine, lasting in some cases seven days. One of my cases died from lock-jaw, and a similar result followed in a case in the Episcopal hospital of Philadelphia." Having endeavored to show that the treatment of hemorrhoids by injecting them with carbolic acid is both comparatively safe and successful, I come now to the practical part, how to do it, and how to prepare the acid. Dr. Stephen Smith uses the acid pure, or diluted with thirty parts of olive oil or glycerine. He uses no speculum, but directs patient to strain over a vessel of hot water and thus cause the pile to protrude. He then injects 2 or 3 drops of the acid of full strength, or enough of the diluted to get as much as 2 or 3 drops of the acid. Dr. Will B. Davis prefers the acid alone, or merely diluted with water. He seems to use no speculum but injects the pile when This it is out beyond the sphincter. He injects the pile gradually till it turns whitish, injecting every one to be found, at once. cures by disintegration. Dr. Shuford, of Tyler, prefers the acid prepared as follows: He uses a speculum to bring the pile into view and a hypodermic syringe with a needle four inches long. He injects from 5 to 10 drops of the mixture. These doses like Stephen Smith's cause the pile to shrivel in 4 to 6 days without any pain or inconvenience. He does not inject more than two tumors at once. Dr. Agnew makes a glycerole of tannin, double the officinal strength, and while hot adds refined borax and salicylic acid each 3ii. He uses a speculum to bring pile into view except when piles are large and easily extruded; also a syringe with long needle. He makes a good suggestion; that is to cause the patient to lie on the side opposite the pile to be injected, and he introduces the needle nearly parallel with the base of the pile and as far as the center. He now injects the mixture gradually and watches for the white spots to appear, which will spread over the pile. The acid gravitates away from the muscular coat of the bowel and towards the mucous coat of the apex of the tumor. He pays no regard to the number of drops used, but continues to inject slowly, till the tumor turns whitish. This cures by disintegration in 4 to 6 days. There is another precaution it would be well to observe. Sometimes a pile is double, so to speak, and in that case, inject both halves, for, if one is destroyed without the other, hemorrhage might follow. I have been using the acid treatment in my own practice only about one year, having treated about 20 cases. I have used the mild treatment generally, but sometimes approached the heroic. With me, the injection of only 2 or 3 drops into a tumor has too |