Electric Treatment of Hemorrhoids
DEDICATION
ACKNOWLEDGMENTS
INTRODUCTION
HEMORRHOIDS
In General
Etiology
Four Basic Types
A Common Misdiagnosis
The Anoscopic Examination
UNDERSTANDING ELECTROMEDICAL CURRENTS
Basic Principles
General Biophysical Effects
GALVANIC ELECTROMEDICAL CURRENT
Basics
Specific Biophysical Effects of Negative and
Positive Galvanism
GALVANIC CURRENT ELECTROTHERAPY : HEMORRHOIDOLYSIS
Introduction
Effectiveness
History
Technique
Specific Biophysical Effects of Negative and
Positive Galvanism
Comparison Between Negative Galvanic Hemorrhoidolysis
and Sclerosing Solution
Electrode Construction
Disadvantages
Advantages
ALTERNATING ELECTROMEDICAL CURRENT
Basics
Waveform Analysis
ALTERNATING CURRENT ELECTROTHERAPY
Fulguration
Desiccation
Coagulation
Cutting
Diathermy
Cauterization
CONCLUSION
BIBLIOGRAPHY
COPYRIGHT
DEDICATION
To Linda, Kara, and Heather.
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ACKNOWLEDGMENTS
Sincere thanks and credit is gratefully extended to those authors to whom
reference has been made, and to those whose illustrations have been used
as a pattern for the original computerized line drawings. To the members
of the American Osteopathic College of Proctology who have lent their
contributions and support, I express my appreciation.
I am grateful to those who have patiently reviewed and
edited this manuscript. I am indebted to Dr. Shefrin who gave me my first
clinical exposure to the Electric Treatment of Hemorrhoids. I am particularly
indebted to Dr. Gear who allowed me access to his large medical library,
and to Dr. Cranford who sent me key articles from across the miles. If
not for their help, this manuscript would not have been possible.
RAS
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INTRODUCTION
There has never before been a comprehensive work published
on the electric treatment of hemorrhoids. For physicians interested in
office proctology, the timeless value of this work will be treasured.
The equipment needed for the electric treatment of hemorrhoids is commercially
available and relatively inexpensive. Now even the most inexperienced
clinician can understand, diagnose, and treat hemorrhoidal disease effectively;
without anesthesia, and without pain.
American physicians have treated hemorrhoids using electric
modalities for more than 100 years; using almost every conceivable electric
modality available. Advocates claim some methods to be more successful
than others, but results vary in the hands of the medical practitioner.
Varying factors include experience, duration, intensity of treatment,
and a clinician ability to selectively match a hemorrhoid with the electric
modality best suited.
In 1987, I became aware of several rectal clinics in this
country that specialized exclusively in the electric treatment of hemorrhoids.
Most of these rectal clinics had recently opened, but some had been in
business for over 30 years. Also in 1987, I became aware of several companies,
that were manufacturing and marketing electric medical equipment exclusively
for hemorrhoids. Recent activity of this kind in the area of electric
proctology has spurred a renewed interest by physicians, to treat hemorrhoids
electrically.
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HEMORRHOIDS
HEMORRHOIDS: IN GENERAL
Hemorrhoids affect about 80% of all Americans at some time in their lives.
"Hemorrhoids caused Napoleon to sit side-saddle, sent president Jimmy
Carter to the operating room, and benched baseball star George Brett during
the 1980 World Series. Over one half of all healthy people reporting for
physical examination have some degree of hemorrhoids."
Hemorrhoids are simply varicose veins located in and around
the rectal area. When they become inflamed, hemorrhoids can itch, bleed,
and cause pain. Unfortunately a hemorrhoidal condition tends to get worse
over the years. That is why safe, gentle, and effective treatment for
hemorrhoids is advocated as symptoms occur.
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HEMORRHOIDS: ETIOLOGY
Many everyday activities cause tension and pressure within the veins of
the body and rectum. This increased pressure can cause incompetency of
the one-way valves inside the hemorrhoidal veins, causing them to dilate.
Combine these varicose veins with hereditary and environmental factors,
predisposing or contributing factors, and a complicated hemorrhoidal condition
exists.
Hemorrhoids are so common that many doctors believe they
are a normal consequence of the strain from man walking erect. Erect posture,
a condition peculiar only to humans, can cause pressure and swelling in
the rectal veins. Hemorrhoids do not exist in other animals; only man
suffers from hemorrhoids. Prolonged sitting, standing, and walking, are
all activities humans do in a substantially erect posture.
Heredity, the quality of the hemorrhoidal veins genetically
derived from ones ancestors, may predispose an individual to developing
hemorrhoids. It is well known that hemorrhoids tend to run in families.
An improper diet may consist of spicy or low fiber foods.
A diet consisting of spicy foods, might taste good going down, but may
burn and pain the rectum at defecation. Some spices are not digested completely,
and the resulting residue may cause inflammation of the rectal veins as
it slowly accumulates in the stool. Where ever low fiber diets are in
vogue, such as in the United States, constipation reaches endemic proportions.
Constipation is a condition that results in straining
during bowel movements. "The major causative factor in the development
of hemorrhoids is straining while at the stool." Straining at the
stool, lifting, and rigorous exercise can cause increased pressure within
the rectal veins; causing hemorrhoids to form, by rupturing the one-way
valves inside the rectal veins.
Poor anal hygiene due to scratching and harsh wiping,
directly traumatizes the anorectal tissue, and induce hemorrhoid inflammation.
Irritating substances such as soap and scented toilet paper, act in a
similar manner. Patients frequently rub soap into their rectum to get
it clean. This is bad. As a rule of thumb, "If you wouldn't put in
your eye, don't put it your rectum." The rectum is a most sensitive
area.
Pregnancy and childbirth are a leading cause of hemorrhoids
in women. Childbirth causes the largest amount of swelling in hemorrhoids,
as the newborn infant passes through the vagina, parallel to the rectum.
Pregnancy causes an increase in rectal venous pressure, as the enlarged
uterus presses against a major abdominal vein (the Inferior Vena Cava).
This is because the Inferior Rectal (Hemorrhoidal) Vein and the Middle
Rectal (Hemorrhoidal) Vein both drain into the Internal Iliac Vein, which
drains into the Common Iliac Vein, which drains into the Inferior Vena
Cava.
When the Portal venous circulation is impaired, this can
also cause hemorrhoids. This is because the Superior Rectal (Hemorrhoidal)
Vein drains into the Inferior Mesenteric Vein, which drains into the Splenic
Vein, which drains into the Portal Vein. When the pressure in the Portal
vein rises, as in liver cirrhosis, or other causes of portal hypertension,
the circulation in the Superior Rectal (Hemorrhoidal) Vein may be reversed,
carrying portal blood through the Inferior Rectal (Hemorrhoidal) Veins.
The circulation in the Superior Rectal (Hemorrhoidal) Vein may be reversed
because of it's peculiar absence of the one-way valves, common in other
rectal veins. When this collateral venous circulation develops, owing
to an increased blood volume and pressure, internal and external hemorrhoids
occur.
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HEMORRHOIDS: FOUR BASIC TYPES
Noll describes in my opinion the physiology of hemorrhoid formation better
than anyone has done before, in his book PROCTO BASICS.
"Hemorrhoids are progressive in their development;
with time, trauma, and infection contributing to their development. All
types of hemorrhoids are progressive stages of internal hemorrhoids. The
mucosa of the rectum becomes detached from it's supportive structure above
the annulus hemorrhoidalis, and begins it's descent in sliding fashion
toward the anus. Enlargement of the veins behind the mucosa fills the
space formed by the descent of the mucosa. This is hemorrhoid disease.
When separation breaks through the anorectal muscle ring
and descends further, an external hemorrhoid has developed. The vessels
contained within an internal hemorrhoidal mass are those of the superior
hemorrhoidal plexus."
Hemorrhoids develop in various degrees: "First degree
hemorrhoids are short projections of hemorrhoidal tissue into the anal
canal. Second degree hemorrhoids prolapse with defecation but reduce spontaneously.
Third degree hemorrhoids prolapse with defecation but recede only by manual
reduction. Fourth degree hemorrhoids are permanently prolapsed and cannot
be reduced into the anal canal."
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HEMORRHOIDS: A COMMON MISDIAGNOSIS
Unfortunately, patients will assume they have "piles" or hemorrhoids
whenever there is any symptom in the rectal area. This is a misconception.
The diagnosis of hemorrhoids is frequently complicated by symptoms of
the following:
Cancer, fissure, fistula, pruritus, prolapse, strictures,
warts, and polyps. Other diseases of the colon and rectum are commonly
the cause of abdominal or anorectal pain, bleeding, diarrhea, and constipation.
"Too often the physician in general practice will
take the patient's complaint of hemorrhoids as the given truth, without
an examination, and give him some salve or medicine, not knowing what
the trouble is. The proctologist does not usually see proctologic cases
until others have failed to give the necessary relief."
The digital rectal examination is an important part of
the patient's history and physical examination; but not regarded as a
good examination for the detection of hemorrhoids alone. Most cases of
mild to moderate hemorrhoids will be missed by the physician performing
only a digital examination. Symptoms from the above mentioned diseases
can easily be misdiagnosed as hemorrhoids, if an anoscopic examination
is not performed.
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HEMORRHOIDS: THE ANOSCOPIC EXAMINATION
An anoscopic examination is mandatory, in any patient suspected of having
hemorrhoids. A proctosigmoidoscopy or colonoscopy may be strongly recommended,
depending on the history and or the severity of the patient's symptoms.
Unfortunately, not even the anoscopic examination is taught in most medical
schools today.
Physicians in general practice are strongly encouraged
to learn anoscopy. Just owning an anoscope does not make one qualified
to use it. The best selling anoscopes today are disposable round plastic
anoscopes, without a side-viewing slit. These items should be discarded
into the nearest trash barrel. Any physician using one of these today
does not know what he is doing. All anoscopes should have a side-viewing
slit, like that which is common to the Brinkerhoff, or Hinkle-James model
proctoscopes. Hemorrhoidal formation and rectal prolapse cannot be brought
properly into view, without a side-viewing slit.
Noll describes a proper technique for the proctologic
examination. He describes in detail, his way to use a proctoscope (anoscope).
"Digital examination should always precede instrumental
examination, to pave the way and to determine that no obstruction is present.
The well-lubricated anoscope is directed towards the
umbilicus, until the distal end is beyond the anorectal muscle ring. Then
meeting no resistance, the direction is changed to occupy the rectal ampulla.
The obturator or slide is then removed and the mucosa is noted for the
presence of blood, fecal debris, polyps (pedunculated or sessile), hypertrophied
papillae, or other masses. The mucosa is examined for ulcerations, varices,
parasites, factitial ulcers, and other inflammatory processes. The scope
is then maneuvered to bring any hemorrhoidal formation and excessive mucosal
prolapse into the side viewing slit, noting the position, extent of involvement,
flexibility, or fixation. Condyloma Accuminata may be noted, as well as
carcinoid. Pus at the posterior pectinate line may indicate a deep postanal
abscess. Fissure in Ano, anterior or posterior may be seen.
If the scope is removed and is to be reinserted, the
obturator or slide must be replaced before re-insertion and possibly re-lubrication,
to avoid possible trauma and pain."
Although a digital rectal exam is important in the diagnosis
of rectal disorders; in this authors opinion, a good anoscopic examination
is even more important. This is why only physicians trained in anoscopy,
should be called upon to confirm a diagnosis of hemorrhoids.
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UNDERSTANDING ELECTROMEDICAL
CURRENTS
ELECTROMEDICAL CURRENTS: BASIC
PRINCIPLES
"The transformation of the basic electrical energy into the different
therapeutic currents is best visualized by the smile of a water system.
Water can be applied either at high or low pressure, at a large rate of
flow or in a fine spray, running continuously or in abrupt squirts or
waves. Similarly the flow of electrons may be even, or be interrupted,
or reversed, frequently or infrequently, symmetrically or asymmetrically;
the rate at which the current is increased from zero to maximum may be
slow or rapid and it may remain at low tension or rise to very high tension."
"Unidirectional currents are those which flow in
one direction without reversal of polarity; the galvanic and the interrupted-galvanic
are examples unidirectional currents. Alternating currents are those which
reverse their direction of flow; this group includes the slow sinusoidal,
and high frequency electrosurgical currents."
"Galvanic current, also described as the direct or
constant current, is the basic and also the first known form of electrical
current." "The interrupted galvanic current, used in electrodiagnosis,
is usually produced by a mechanical device placed in a galvanic circuit
that interrupts the current flow at regular intervals." Constant
galvanic current can be manipulated to be made useful for electromedical
purposes.
"If a galvanic current passes through a rhythmically
varying resistance which at the same time periodically reverses the direction
of flow of the current, a reversing galvanic wave or slow sinusoidal wave
is produced. When a galvanic current treated in this way, consists of
rhythmical waves, each of which gradually increases in intensity and volume
from zero to maximum and without a pause decreases to zero and then repeats
the same process in the opposite direction; then it must also be classified
as an alternating current."
When a constant galvanic current is changed into a slow
sinusoidal wave, then alternating current electromedical principles come
into play. It has been established that slow sinusoidal current, a mainstay
in the treatment of paralysis, furnishes a stimulus of long duration to
both smooth and skeletal muscle fibers. The low frequency alternating
sinusoidal current used to treat paralysis differs significantly from
the high frequency fulgurating current used to treat superficial skin
lesions. High frequency current defined is, "an alternating current
having a frequency of interruption or change of direction sufficiently
high so that tetanic contractions are not set up when it is passed through
living contractile tissue."
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ELECTROMEDICAL CURRENTS: GENERAL BIOPHYSICAL
EFFECTS
"According to biophysical effects, electromedical currents can be
divided in two groups: 1) currents causing ionic changes in the tissues
and a minimum of thermal effects, 2) currents causing only thermal changes.
The galvanic and low frequency currents belong in the first group, high
frequency current in the second. "
This comparison chart between direct and high frequency
alternating current electricity will help the reader better to understand
the major electromedical differences. "The two principle primary
effects on living tissues are the ionic or chemical effect and the heating
or thermal effect. Generally speaking, ionic effects are exerted by the
galvanic and low frequency currents, while a primary heating effect is
exerted by high frequency currents."
Amperage is simply the volume of electric current; specifically
it is the volume expressed in amperes, a unit of electrical current in
the meter- kilogram-second system. Volt is simply the force of electricity;
specifically it is a unit of electric potential and electromotive force.
Specific biophysical effects of electromedical currents
will be discussed in detail, further in this treatise.
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GALVANIC ELECTROMEDICAL CURRENT
GALVANIC ELECTROMEDICAL CURRENT:
BASICS
Galvanism refers to the therapeutic uses of direct current electricity.
Galvanic current has polarity, having both a positive and a negative pole;
current flows continuously in one direction, having no alterations and
therefore no frequency; unlike high frequency alternating current.
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GALVANIC ELECTROMEDICAL CURRENT:
SPECIFIC BIOPHYSICAL EFFECTS OF NEGATIVE AND POSITIVE GALVANISM
"The human body may be considered from the viewpoint of electrotherapy
as a bag of skin holding a solution of common salt (Na+Cl-). When the
molecules of NaCl dissolve in water they dissociate into sodium ions (Na+)
bearing a positive charge and chlorine ions (Cl-) bearing a negative charge.
The flow of direct current through the salt solution causes these ions
to move in a definite direction, the sodium ions migrating towards the
negative pole (cathode) and the chlorine ions towards the positive pole
(anode), the process known as ion transfer or iontophoresis. When the
positively charged sodium ions arrive at the negative pole, and the negatively
charged chlorine ions at the positive pole, they loose their charge and
become free unelectrified atoms; these in turn cause a secondary chemical
reaction in the water and form caustic sodium hydroxide and liberate hydrogen
gas at the negative pole and form caustic hydrochloric acid and liberate
oxygen gas at the positive pole.
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"The alkaline and acid reaction of the poles of
galvanic current when increased to sufficient intensity will lead to the
destruction of tissue by coagulation of protein at the positive pole and
by liquefaction of protein at the negative pole. This is best illustrated
by bringing two wires from the terminal of a galvanic generator to a piece
of raw steak.
In this experiment, the intensity of each reaction varies
with the strength and relative density of the current at each pole. At
the positive pole, the wire becomes adherent to the meat, and the tissue
surrounding the wire hardens; due to coagulation of protein at the positive
pole. "Around the negative pole a white foam appears (hydrogen gas)
and the wire becomes loose, due to the liquefying action of sodium hydroxide
on the protein around the wire. This experiment demonstrates that the
positive pole of the galvanic current hardens tissue while the negative
pole softens it, provided that a current of sufficient intensity is applied
and bare metal electrodes are employed."
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GALVANIC CURRENT ELECTROTHERAPY:
HEMORRHOIDOLYSIS
HEMORRHOIDOLYSIS: INTRODUCTION
Therapeutic Galvanic treatment for hemorrhoids has recently become in
vogue for physicians. A great deal of money and advertising has been poured
into this technique to make it sound more attractive to the public. It
is frequently publicized, and sometimes incorrectly so, as a viable alternative
to a surgical hemorrhoidectomy. "It is partly due to the publics
perception that hemorrhoid surgery is undesirable, and partly to the failure
of the medical profession to avail themselves of simpler and less disabling
methods, that patients have been driven to seek so-called bloodless cures
by irregular practitioners."
The procedure takes about 10 minutes. A galvanic current
is painlessly introduced directly into the offending vein. The current,
negative or positive, causes a chemical or thermal reaction within tissue,
that either destroys and/or obliterates the hemorrhoid.
This method of treating hemorrhoids electrically has been
called by several names. It has been called the negative galvanic method,
named after a type of current that may be used. "Electrolysis"
by Stanton because it causes destruction of tissue, by passage of an electric
current . And the Keesey Procedure, named after Wilbur Keesey, who developed
this technique in the 1930's.
All the above names are descriptive, but only the term
hemorrhoidolysis is correct. Hemorrhoidolysis is defined as the dissolution
of hemorrhoids by chemical or electrical means. And that is exactly what
the procedure does. It dissolves hemorrhoids, by using an electric current
to cause a chemical reaction within the hemorrhoidal tissue.
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HEMORRHOIDOLYSIS: EFFECTIVENESS
"Probably no method for treating selected cases of hemorrhoids will
effect better results than those obtained by properly administered treatment
with galvanic current."
Keesey reports early success with the hemorrhoidolysis
procedure, having successfully treated cases that had been injected one
or more times futilely with a sclerosing agent. "The advantages of
this method are its simplicity, safety, and apparent permanency of cure.
It is a procedure requiring neither anesthesia nor hospitalization. There
are no unfavorable sequelae. In Keesey's own work, he never saw a severe
complication in over 700 individual treatments. He never encountered a
case of rectal stricture, or metastatic abscess, associated with this
procedure."
Dr. Norman performed a study on 42 patients using negative
galvanic hemorrhoidolysis, at Barton Memorial Hospital, S. Lake Tahoe,
California. 19 patients had grade 3 hemorrhoids. 20 patients had grade
4 hemorrhoids. And 3 patients had grades 1 & 2 hemorrhoids. The mean
number of treatments for the complete resolution of symptoms, was 2.65.
All patients were successfully treated (Ablation of all hemorrhoidal disease
without scar tissue), and symptom free at a mean duration of follow-up
(direct contact) of 18.2 months.
Ferris, a general practitioner in Riverton Wyoming, cooperated
in a retrospective study of 26 patients, whom he had performed the negative
galvanic hemorrhoidolysis procedure. The average patient who completed
the procedure had undergone 5.2 treatments. 24 out of 26 patients surveyed
(or 92%) reported a significant improvement of their hemorrhoidal symptoms.
Ferris states that hemorrhoidolysis is effective for only
grades one and two, and some grade 3 hemorrhoids. All but two patients
were satisfied with the procedure performed by Dr. Ferris. A patient who
described the procedure as painful, received a shock during her fourth
treatment. Another patient still suffered from hemorrhoidal symptoms after
the procedure, but at a reduced level.
Many grade 3 and 4 hemorrhoids present with extensive
involvement of the external hemorrhoidal venous plexus, and with severe
disruption of the anoderm (dermal tissue). In my opinion, hemorrhoids
of this type may be helped by the hemorrhoidolysis procedure; but certainly
not completely obliterated 100% of the time.
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HEMORRHOIDOLYSIS: HISTORY
Contrary to common belief, this electric galvanic method is not new, it
being first employed in 1867. We are surprised that more attention was
not given to the method described by Dr. Baker in a paper which he read
before the Milwaukee Medical Society in 1892; " Treatment of Hemorrhoids
by Electricity." Baker's work inspired its adoption in certain localities,
but many failures due to defective technique and unfamiliarity of its
chemical action migrated against it. We do not hear again of the treatment
until a Chicago physician in 1899 made an attempt to use the method but
failed.
The galvanic current with the electric needle or electrode
had been used by a number of physicians with the report that poor results
were being obtained. Ogden notes, "It is not the method which is
at fault but the mode of application and the lack of close attention to
details." A poorly designed electrode was undoubtedly the reason
for the failure on the part of early galvanic current experimenters to
successfully use that current for treatment of hemorrhoids.
In 1934, Dr. Wilbur Keesey published a treatise on the
"Obliteration of Hemorrhoids with negative Galvanism." In this
work, he describes the proper technique and equipment that should be used
for the hemorrhoidolysis procedure.
Hemorrhoidolysis had not been well accepted by the medical
community. "The time consumed in administering treatment and lack
of knowledge regarding methods of treatment were the chief reasons for
it's waning popularity. If galvanic current is used where only alternating
current is available, such as in the United States, then a rotary converter,
motor generator, or chemical storage battery is needed to supply the current.
Some physicians purchased electric galvanic generators they did not know
how to use, and discarded it without ever having learned how to use it."
One problem early operators had, was an inability to change the setting
of the generator while one hand was confined to holding the speculum and
the other the needle, requiring, therefore, the service of an assistant.
Today, with great improvements in galvanic equipment technology,
and medical instruction readily available, negative galvanic hemorrhoidolysis
has gained widespread acceptance. Over the years, improvements have been
made on electric galvanic generating equipment. In recent years, manufactures
have made available to physicians, government FDA approved hemorrhoidolysis
equipment.
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HEMORRHOIDOLYSIS: TECHNIQUE
The technique used today, paraphrased in this section, is adequately described
by Keesey. Except for some minor modifications by Ogden & Stanton,
the technique as it is described here, has changed little in over forty
years.
The average case needs no other preoperative measure then
evacuation of the bowels and a preparatory cleaning enema. Existing complications
are best treated preoperatively. Fissures, ulcers, perirectal abscesses,
or fistulae should be eradicated first. Proctitis and colitis commonly
associated with hemorrhoids should be treated first.
The speculum is gently inserted to its full length, well
above the dentate line, and the slide withdrawn until the uppermost hemorrhoid
comes into view. Slight rotation of the speculum while the patient strains
will expose the entire hemorrhoid. The needle electrode is now inserted
into the internal hemorrhoid. True hemorrhoidal tissue has no sensory
nerves, which fact enables the painless insertion of the needle.
Genuine hemorrhoid tissue is most often characterized
by the brilliant red color of the submucous tissue appearing through a
break or erosion in the mucous membrane. If the mucous membrane is intact
the tumor will have a dark violacious appearance. The needle should be
inserted wherever the bright red submucous tissue is observed. Normal
mucous membrane is characterized by its pale, pink, translucent appearance
and should never be touched with the electrode.
From the standpoint of pain and good end results, a successful
treatment demands that the needlepoint be in the lumen of the vein. The
patient is the best guide, for if he complains of burning pain the technique
is improper. Anesthesia should be avoided in all cases, because it deprives
us of this index. The current is now turned on very gradually, two to
three minutes being required to bring the current up 5 to 15 milliamperes,
according to the tolerance of the patient.
Ogden suggests that the hemorrhoid be injected with 1-%
novocaine, so that it stands out full and distinct. He feels that the
generation of hydrogen gas is much greater if the injection is employed.
He is careful to remind us however, that the injection of novocaine anesthetizes
the tissue and that as a result the patient will be incapable of guiding
or aiding you in determining whether you are introducing the electrode
into mucous membrane, and you will be compelled to rely on your anatomical
and pathological knowledge of the structure.
The needle electrode should always be inserted before
the current is turned on, and upon termination of treatment, the current
should always be slowly turned off before the electrode is withdrawn.
A violation of these rules will produce a sudden shock, which, of course
should be avoided. The maximum current tolerance is continued until a
change of color occurs in the tissue. At first, light colored bubbles
are seen under the mucosa which later changes into a dark red, and in
some instances nearly black, color. Treatment is terminated at this point,
the whole procedure lasting 10 to 12 minutes. The current is slowly turned
off and the needle withdrawn.
"In turning on the galvanic current, be sure to turn
it on slowly to avoid shock to your patient. The same rule is to be observed
when turning off the current. Do not remove the electrode from the hemorrhoid
until you have shut off the current." "If the patient complains
of discomfort or pain, it will be due to too rapid building up or reduction
of the current. Better results are obtained if the amperage is kept low
and the time of treatment correspondingly lengthened, as by not using
more than 10 milliamperes, but for a full 15 minutes."
If the hemorrhoid is large, one or two other insertions
are made one-fourth to one-half inch away from the first, and the process
is repeated. However, in all punctures subsequent to the first, the current
is continued for only five minutes, because discoloration appears much
sooner. The evidence of successful treatment is complete discoloration
of the entire hemorrhoidal mass, the number of insertions required for
each tumor depending on its size.
Not more than one hemorrhoid is treated at a seance to
avoid nervousness or fatigue of the patient. Transitory nervousness and
excitement may be controlled by general conversation during treatment.
Complaint of burning pain is significant, but other sensations are due
to pressure and require no attention. Treatments are given every third
day, the average case requiring about six treatments for complete obliteration
of all hemorrhoids.
Except for a peculiar feeling of fullness for about twelve
hours following treatment, there is no painful reaction. If a thorough
treatment has been given, the individual tumor will retract well within
the rectum and carry the loose, redundant folds of perianal integument
with it. This dynamic result never fails to impress the patient who has
suffered with protruding hemorrhoids for a long period.
The hemorrhoid undergoes a rapid change, the mucosa assuming
a normal condition in 7 to 10 days. If the hemorrhoid is then not completely
obliterated, insufficient current has been used. In such a case a second
treatment of shorter duration (5 minutes) should be given. At no time
does the patient have to be recumbent.
Following each treatment, a small quantity of Nupercaine®
ointment, one percent, is injected into the lumen of the rectum. No other
postoperative treatment is necessary, as the after effects are negligible.
Bleeding, pain, and protrusion usually cease after the first treatment;
all symptoms are promptly relieved.
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HEMORRHOIDOLYSIS: SPECIFIC
BIOPHYSICAL EFFECTS OF NEGATIVE AND POSITIVE GALVANISM
Authors of the hemorrhoidolysis procedure, evenly disagree about the type
of current that should be used. Bacon, Nesselrod, and Stanton, advocate
the steady passage of unidirectional current from a large pad, which is
the negative pole, to a small positive pole needle that is inserted into
the hemorrhoid. Whereas, both Ogden and Keesey advocate just the opposite,
dedicating the small needle electrode to be the negative pole.
Stanton is the only author I know, that claims to effectively
utilize both positive and negative galvanic currents. He states that,
"positive galvanism is best for treating hemorrhoids. In treating
growths other than hemorrhoids, the negative pole is used." Dr. Stanton
suggests that negative galvanic current is best used for the removal of
papillomas and removal of both sessile and pedunculated neoplastic growths.
When a positive galvanic technique is used, deterioration
of the needle electrode may occur. "Positive galvanism causes a steel
needle to disintegrate and causes discoloration of the tissue. In the
treatment of hemorrhoids, discoloration will, of course, make no difference.
Because of erosion of steel needles there is a danger of the tip eroding
and becoming lost in the tissue; therefore each steel needle is used but
once and discarded. To avoid erosion a gold (or platinum iridium) needle
is used; such needles do not disintegrate."
When a negative galvanic technique is used, the concern
is more for the production of hydrogen gas, than for the physiologic electro-thermal
properties listed above. "The galvanic current introduced into the
interior of the hemorrhoid and contacting with the water content of the
blood, generates hydrogen gas which destroys the organized structure and
capillary circulation of the hemorrhoid. This produces first, a liquefaction,
and then a hardening of the hemorrhoidal body."
Actual obliteration of the hemorrhoid is accomplished
by absorption, if it's small, as occurs in any simple contusion; or, if
a large, thin walled hemorrhoid is treated, it ruptures, causing a discharge
of thrombosed elements into the rectum. Following this there is contraction
of underlying tissue with hemostasis, absence of pain, and rapid healing
of the parts. Because the chemical action of negative galvanism is on
the liquid content of the mass instead of the tumor wall, it has one great
advantage over all other methods; that is, the resultant normal resiliency
of the mucous membrane after obliteration.
When applied to hemorrhoids, the negative pole produces
first a hydrolytic decomposition and then a contraction of the tissues.
In 1866, Althaus made microscopic observations of the changes in animal
structures due to the electrolytic action of the negative galvanic needle.
He found that the tissues were markedly contracted, and that there was
no inflammation, suppuration nor sloughing. When the current was applied
to the blood vessels they became changed into solid strings due to disintegration
of the blood and deposition of lamellated fibrin. Thus, it was determined
that the current could be safely and successfully applied to contract
and disintegrate tissue, and obliterate blood vessels for surgical purposes.
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HEMORRHOIDOLYSIS: COMPARISON
BETWEEN NEGATIVE GALVANIC HEMORRHOIDOLYSIS AND SCLEROSING SOLUTION
In the dog tissue experiment described here, Anderson observed microscopically
the differences in canine rectal tissue twelve hours after application
of: 1) negative galvanism at 15 ma. for 10 minutes, and: 2) injection
of 1-ml. of 5% phenol in oil.
Microscopic observation of canine rectal
tissue 12 hours after injection with sclerosing solution, reveals a contracted
distorted mucous membrane, which has lost it's elasticity, and presents
with a hardened "washboardy" appearance. There is a marked sclerosis
of the muscularis mucosa, contraction of Goblet cells and marked contraction
of surface membrane. Anderson concluded that these changes represent an
effort of the tissues to repair an injury.
Microscopic observation of canine rectal
tissue 12 hours after application of negative galvanic current, reveals
integrity of muscle fibers, with complete destruction of connective tissue
and vascular elements. Complete tissue disintegration is evidenced by
absence of nuclei. There is thickening of thrombosed capillary walls and
also of the intramuscular glands. The surface membrane maintains a smooth
appearance.
The rationale of the injection method is based on an inflammatory
sclerosing reaction. The negative galvanic current does not produce such
an inflammatory sclerosing effect because the chemical action is on the
liquid content of the mass instead of the hemorrhoidal wall. Advocates
of each technique claim their method to be the most effective.
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HEMORRHOIDOLYSIS: ELECTRODE
CONSTRUCTION
The active needle electrode is a most important factor, because it must
deliver the current to the interior of the hemorrhoid while preventing
escape of hydrogen from the tissue and allow clear visibility of the operative
field. "It must be carefully constructed with two objects in view.
The first of these is the sure delivery of the current to the interior
of the hemorrhoid; and second, the prevention of the escape of the electrically
generated hydrogen gases from the interior of the hemorrhoid. Undoubtedly
the lack of an electrode which would perform these two functions was the
reason for the failure on the part of early galvanic current experimenters
to successfully use that current for treatment of hemorrhoids."
Needle makers of early galvanic generating equipment,
used a glass bead at the base of the electrode needle. Today's galvanic
needle makers use a rubber or plastic seal tapered at the base of the
needle, in a manner to prevent escape of hydrogen gas. "This provides
a wider surface area to present to any possible apertures occurring between
the needle and the tissue, after insertion of the electrode. This surface
closes the apertures and prevents the escape of the hydrogen gas. Since
the electrode must under no circumstances pass through the hemorrhoid
and pierce the opposite side, electrodes tips today, are made short in
length."
The typical hemorrhoidolysis electrode used today, is
a set of twin parallel needles connected to a single handle. Both needles
are insulated up to the tip, are approximately 5 inches long by 1/8 in
diameter, and function in exactly the same manner. The reason for using
the double needle is that using two needles 3-mm inch apart will effect
a larger tissue area than will a single needle alone. Both needles function
as one, and are placed into the hemorrhoid simultaneously during treatment.
The use of a leather-covered copper electrode in combination
with a copper sulfate solution and galvanism, although acting to shrink
hemorrhoids, is slow and tedious work. Although this modality has value,
it is time-consuming and the results obtained are no better than those
obtained by other methods.
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HEMORRHOIDOLYSIS: DISADVANTAGES
1. External hemorrhoids cannot be treated with hemorrhoidolysis.
2. The comparative length of time required for each application
has been the subject of objectionable comment.
3. Complaint also has been made that due to exactness
of technique, the procedure was too tedious for the operator to steadily
support the needle.
4. This author has personally observed a single type 3
(right lateral) anorectal fistula develop, in a 34-year-old male patient
receiving negative galvanic hemorrhoidolysis treatments. This patient
did have any signs or symptoms of abscess on a prior proctologic examination.
It is uncertain however, whether or not negative galvanism was directly
responsible.
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HEMORRHOIDOLYSIS: ADVANTAGES
1. The hemorrhoidolysis procedure never causes more then a well-tolerated
discomfort to the patient.
2. Anesthesia is not required with hemorrhoidolysis, in
contrast with surgery.
3. Hemorrhage following hemorrhoidolysis rarely, if ever, occurs.
4. Infection following hemorrhoidolysis, rarely if ever
takes place. The method itself is self-sterilizing.
5. Sequelae and complications following hemorrhoidolysis
have not been reported in the literature.
6. Mortality following hemorrhoidolysis has never been
reported.
7. Recurrence after hemorrhoidolysis is uncommon, less
than 1%, in selected cases. Redundant mucosa becomes obliterated, although
normal mucous membrane retains its original elasticity and tonicity without
scar tissue formation.
8. There is no loss of time from work for the patient
receiving hemorrhoidolysis treatment.
9. Hemorrhoidolysis being an ambulatory office procedure,
is a self-evident economic advantage. The same applies to the avoidance
of expenses incident to hospitalization for surgery.
10. With hemorrhoidolysis there is no need for restriction
of diet, before, during, or after treatment, usually required with surgical
procedures.
11. Treatment of hemorrhoids by hemorrhoidolysis offers
a large field for qualified general practitioners. The majority of all
hemorrhoids are amenable to such treatment.
12. Hemorrhoidolysis is an effective and painless method
of obliteration. The technique is comparatively simple. Many patients
today demand ambulant treatment that should be accorded by ethical physicians.
13. The hemorrhoidolysis treatment for hemorrhoids is
not new, but its technique has been greatly developed on a scientific
basis.
14. No special preoperative or postoperative treatment
is required for this procedure.
15. Comparison of hemorrhoidolysis with other methods
of treatment proves it to be the method of choice because of physiological
end results, and the absence of serious complications.
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ALTERNATING ELECTROMEDICAL CURRENT
ALTERNATING ELECTROMEDICAL CURRENT:
BASICS
High frequency current is alternating current. It does not have polarity;
there are no positive and negative poles; the terminals of a high frequency
current are the same. "The regular service current supplied by an
electric service company is usually 60 cycles, alternating current, and
between 110 and 120 volts; 60 cycles means 120 alterations of polarity
per second. This rate is considered to be a low or slow frequency. This
slow rate of oscillation renders such current more lethal than therapeutic.
The shock from the make and break of the alterations of such current if
applied to the body would be intolerable and promptly fatal. Therapeutic
alternating currents are of high frequency, running upward from 100,000
alterations per second."
"The wave form of an alternative electrical current
refers to its visual appearance as shown on an oscillograph or an oscilloscope.
Reversing its direction of flow from several time to millions of times
per second, the current traces a wavy line which constitutes its wave
form." We will show you pictures of these waveforms whenever possible,
to help illustrate the principles of alternating current electrotherapy.
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ALTERNATING ELECTROMEDICAL CURRENT: WAVEFORM
ANALYSIS
The waveform analysis paraphrased in this section is adequately described
by Otto in his book "Principles of Minor Electrosurgery."
The earliest and simplest high-frequency alternating current
generators employed the principle of condenser discharge across a spark-
gap. This type of oscillator produces what is known as a damped wave form;
that is, with each condenser discharge a series of oscillations are set
up, the voltage peak of the first being highest and then each subsequent
oscillation of the series diminishing in voltage down to zero.
Each series of oscillations in this waveform picture is
called a wave train, and you will notice that there are distinct "no
voltage" separations between the wave trains.
A high-frequency current, of a highly damped
waveform, is ideal for coagulation, desiccation and fulguration. It produces
the most dependable hemostasis, the greatest precision and application,
with the surest results.
With the invention of the vacuum tube oscillator
by DeForest, a new high-frequency current different waveform was demonstrated.
The vacuum tube oscillator was capable of producing continuous wave oscillations
with equal voltage and without interruption.
This current, producing an undamped waveform on an oscilloscope,
produced an entirely new effect on tissue. When bi-terminal electrodes
of equal or near equal size are used, the current density is quite evenly
dispersed within the intervening tissue, with a corresponding temperature
rise adequate for medical diathermy, and without concentration sufficient
to cause cell destruction. The ability of medical diathermy to penetrate
heat deep into tissue has many therapeutic uses.
When the undamped waveform current is concentrated at
the active electrode; it cuts. When bi-terminal electrodes of greatly
different sizes are used, the current density is unevenly dispersed within
the intervening tissue, with a corresponding temperature rise adequate
for surgical diathermy, and with a concentration of heat at the active
electrode sufficient to cause cell destruction.
Concentrated at the active electrode, these continuous wave oscillations
produce such intense heat so very quickly, that the cells are volatilized
(exploded), producing a hole if the electrode is held stationary or an
incision if the electrode is moved. It is almost completely devoid of
dehydration or homeostatic effect and its usefulness is confined, therefore,
to cutting only in non-vascular areas. Surgical diathermy has not adapted
for use by modern surgeons, because it appears to have no advantage over
that of a scalpel.
Dr. Bovie the physicist succeeded in generating a moderately
damped oscillating current in which wave trains were placed closely enough
together for effective cutting, but with sufficient damping to retain
the desired dehydrating or hemostatic effect. It is this current, refined
over the years, which is still the typical cutting current of all Bovie
brand (and other electrosurgical) units.
From the foregoing it can, it is obvious that the two
distinct types of high-frequency currents are essential to successful
electric surgery. These are the currents provided by standard hospital
electrosurgical surgical units. They are: 1) the moderately damped waveform
current, and: 2) the highly damped waveform current. The four surgical
effects resulting from the use of these currents are:
1) Fulguration (electro-charring)
2) Desiccation (electrodesiccation)
3) Coagulation (electrocoagulation)
4) Cutting with hemostasis (electrosection)
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ALTERNATING CURRENT ELECTROTHERAPY
ALTERNATING CURRENT: FULGURATION
Mono-terminal application of high-frequency current is used in electrosurgery.
The current will flow from a pointed active electrode into the tissue
because the patient represents sufficient capacitance to attract the current
to "ground." If the electrode is held slightly away from the
tissue surface, the superficial dehydrating effect caused by the resulting
"sparking" is called fulguration.
· HIGH FREQUENCY ELECTRICAL CURRENT
· DESTRUCTION OF TISSUE BY ELECTRIC SPARKS
· MONOTERMINAL OR BITERMINAL NEEDLE ELECTRODE
Fulguration is commonly a mono-terminal technique with
the most superficial effect. Fulguration can also be a bi-terminal technique
for convenience for, and connection with, the application of electrocoagulation
to produce a somewhat what more penetrating dehydration.
"For proper fulguration technique, do not contact
the tissue. Hold the needle one or two millimeters away from the tissue,
allowing the current to spark to the surface being treated. When using
fulguration or desiccation techniques, applying more current then is necessary
will produce little more effect, because the surface will dehydrate and
carbonize quickly, electro-charring the tissue, forming an effect layer
of insulation against penetration of the current to the underlying structure."
Stewart states (p.246 Stewart) that fulguration, with
a short spark jump through the air, is used alone in the treatment of
small hemorrhoids.
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ALTERNATING CURRENT: DESICCATION
Desiccation is always a mono-terminal technique; that is, no indifferent
electrode plate is used. This of course, limits its effectiveness in elevated
or deep growths. For desiccation, the coagulating current of the electrosurgical
unit is used, with the needle held in contact with the tissue or the point
inserted.
· HIGH FREQUENCY ELECTRICAL CURRENT
· DEHYDRATION OF TISSUE
· MONOTERMINAL NEEDLE ELECTRODE
In treating external hemorrhoids Clark desiccates a line
across the hemorrhoid similar to the primary scalpel incision in the usual
technique. The needle is then inserted into the clot and the vein destroyed.
The hemorrhoid is then incised without hemorrhage and the clot curetted
out.
For the treatment of internal hemorrhoids, after sufficient
anesthesia is employed; each hemorrhoid is grasped by a forceps and clamped
at its base in the direction of muscle fibers, the needle is inserted
and the growth destroyed. "For the treatment of hemorrhoids with
electrodesiccation, the usual technique consists of applying a needle-point
electrode connected to the high-voltage terminal, either on the hemorrhoid
(desiccation) or at sparking distance from its surface (fulguration).
Subsequent drying, shrinkage, and sloughing occurs, depending on the strength
of the current and the depth of penetration, which in large hemorrhoids
must be considerable. Electrodesiccation should not be used in advanced
cases of hemorrhoids or those complicated by other ano-rectal pathology."
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ALTERNATING CURRENT: COAGULATION
The technique of electrocoagulation is always bi-terminal. An indifferent
plate or a special bi-terminal electrode is always used. Coagulation tends
to produce more necrosis of tissue then desiccation, and its destructive
effects are not as quickly limited by his own dehydration. This current
is often advantageous or necessary in the treatment of relatively large
or deep growths.
· HIGH FREQUENCY ELECTRICAL CURRENT
· COAGULATION OF TISSUE
· BITERMINAL NEEDLE ELECTRODE
The amount of coagulation around the electrode is dependant
upon: 1) The amount of current, and: 2) The length of time it is applied.
Of these two, the time is the more important factor. Contrary to what
one would expect, heavy current for a short time will not coagulate as
great amass of tissue as will lessor power over longer period of time.
This is because with a lower current, the tissues in contact
with the active electrode are not as rapidly dried out; thus permitting
the current to be applied longer and coagulation carried to a greater
depth. With a greater current, dehydration of the tissue occurs so fast
that a high resistance to current flow is introduced, thereby reducing
the current strength and limiting the depth in which coagulation can be
carried.
The coagulating needle has been in use for several decades,
and is widely used by those who claim to have certain secret methods which
are painless and which "dissolve" the hemorrhoid instead of
cutting it out. Electrocoagulation of hemorrhoids may be performed with
a single pointed electrode as the active electrode. Some authorities advocate
that the hemorrhoids be individually distended with a fluid solution,
before a series of coagulations are performed. In this procedure, plunge
the electrode into the depth of the hemorrhoid. The current is controlled
through a foot switch and its strength and duration determined by the
previous experience of the operator. The neophyte should experiment with
strips of meat beforehand. Obviously the depth of current penetration
is difficult to control.
"The technique of the bi-terminal clamp method consists
of freely and firmly grasping the pile along its basis parallel to the
bowel, just as in the usual clamp and cautery operation. The current is
controlled as described above, through the foot switch. Sufficient current
strength is used to coagulate the entire base of the pile. Theoretically
the desired degree of coagulation is determined by the tissue turning
to a light gray color; actually the tissue cannot be seen between the
jaws of the clamp. The portion of the pile above the clamp is excised.
Each of the hemorrhoids is removed in turn and a small piece of petrolatum
gauze inserted into the rectum. The skin should never be included in the
jaws of the clamp."
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ALTERNATING CURRENT: CUTTING
As explained under the section "Alternating Electrosurgical Currents,"
the waveforms of the cutting current are distinctly different from that
of the coagulating current. "Its effect is to explode the cells in
the path of the electrode with parting of the tissues. The heat of the
electrode also creates a shallow zone of dehydration on the severed edges,
which seals off the minute vessels and prevents vascular oozing from the
surfaces. The degree of hemostasis with the cut is directly proportional
to the depth of dehydration, and is variable with the speed of the cut,
thickness of the electrode edge, and the amount of power used." The
greatest amount of dehydration to the wound edges, with the greatest amount
of hemostasis to the cut; occurs when the electrode edge is thick, the
cut is slow, and the power is low.
· HIGH FREQUENCY ELECTRICAL CURRENT
· CUTTING OF TISSUE
· BITERMINAL NEEDLE ELECTRODE
Utilizing the cutting current, the electrosurgical instrument
is used to cut away and remove hemorrhoidal tissue. "According to
Gorsch, the cutting current has no place in the surgical treatment of
any type of hemorrhoid." As the scope of this monograph deals only
with the palliative treatment of hemorrhoids, the surgical removal of
hemorrhoids will not be further expounded.
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ALTERNATING CURRENT: DIATHERMY
In the treatment of hemorrhoids and other anorectal ailments, medical
diathermy has proved to be a useful tool. "Diathermy has afforded
considerable relief to those afflicted, with sometimes intractable cases
of anal neuralgia, sphincteralgia and coccygodynia, frequently associated
with hemorrhoids. It has also proved useful in aiding the decongestive
process of hemorrhoids following pregnancy."
The principle upon which medical diathermy works is as
follows: "Alternating current of sufficiently high frequency to avoid
nervous and muscular response can be passed through living tissue with
no effect other than the production of heat. This heat is produced as
a direct result of the resistance offered to the passage of the current.
For the treatment of hemorrhoids and other anorectal ailments
with medical diathermy, a rectal probe is inserted into the anal canal.
The rectal probe should be as large as a "small to medium" size
anal speculum. One of the bi-terminal electrodes is this probe, and the
other patient ground plate electrode is a flat pad covering a large surface
area of the body. "When bi-terminal electrodes of equal or near equal
size are used, the current density is quite evenly dispersed among the
intervening tissue." "An exceptionally high frequency current
is used, greater than 10 million cycles per second. A current flow, at
1000 to 1500 milliamperes, should be continued over a period of twenty
to thirty minutes, twice a week. Insulated electrodes may be preferable
when short wave diathermy is used."
In the 1940's, Diathermy was commonly used as a surgical cutting tool.
The principle of surgical diathermy works when one of the bi-terminal
electrodes is a small needle, and the other patient ground plate electrode
covers a larger surface area of the body. This uneven electrode size,
causes the current density to be concentrated at the tip of the needle,
and thus makes for an effective cutting tool.
Today, diathermy is no longer used as a cutting tool for
the electrosection of tissue. This is because the undamped waveform current,
is the only current available from a short wave surgical diathermy unit.
These high frequency waves, above 10 million cycles per second, as used
in surgical diathermy, are unsuited for electrosurgery surgery because
the energy is transferred to the operator through the electrode handle,
making it virtually impossible to attain an acceptable level of precise
power control.
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ALTERNATING CURRENT: CAUTERIZATION
The modern cautery is a device consisting of a wire like element (filament)
of high electrical resistance that becomes hot when a current is passed
through it. A silver, flattened (pencil like) tip, is fashioned over this
wire filament, for the sole purpose of conducting heat to the tissue.
This hot silver tip is used during electrosurgery to sear (cut) away tissue.
A rheostat controls the temperature.
"Heat cauterization in the treatment of hemorrhoids,
has been used since ancient times. Early medical writings describe a technique
of plunging heated instruments into protruding pile masses to destroy
them. Voillemeir in 1875 described a method of linear cauterization in
which the hot cautery was applied to the mucous membrane within the anus
in four areas - anterior, posterior, right, and left, but not directly
on the hemorrhoids themselves. Gant, as late as 1896, applied the cautery
directly to the dilated hemorrhoidal veins. The benefit derived from early
cauterization, was from the contraction of the cicatrix produced."
The electric cautery device has fallen out of favor in
recent years. One major problem with it was "burn out." The
length of life of its heating coil is as uncertain as in any other device
where a wire is maintained at incandescent temperature, be it lamp bulb,
toaster, or soldering iron.
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CONCLUSION
The "Electric Treatment of Hemorrhoids" is
a topic that covers a vast array of electrophysiology and technique. The
science of electricity is diverse, and it's application to Proctology
titanic.
Rarely do we see an evolution in medicine like that which
has taken place with the prevalent use of the electric modalities in the
treatment of proctologic conditions. Electric methods for treating hemorrhoids
have withstood the test of time, and are well documented. In recent times,
multinational proctology clinics been established, devoting themselves
exclusively to the treatment of hemorrhoids by electrical methods.
For physicians proficient at the proctologic examination,
the timeless value of this work will be treasured. The equipment needed
for the electric treatment of hemorrhoids is commercially available and
relatively inexpensive. For the first time ever assembled in a single
volume, is everything a clinician will need to know and understand about
hemorrhoids; including etiology, diagnosis, and the treatment of hemorrhoids
using most all known electrical modalities.
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BIBLIOGRAPHY
Bacon, Harry E. Essentials of Proctology. Philadelphia Pennsylvania:
J. B. Lippincott Company, 1943, p. 142.
Bernhard, Jerome J., Personal interview on electrosurgical techniques.
Phoenix, Arizona, January 4, 1988.
Buie, Louis A. Practical Proctology. Philadelphia Pennsylvania: W. B.
Saunders Company, 1938, p. 186.
Dorlands Illustrated Medical Dictionary. 26th ed. Philadelphia Pennsylvania:
W. B. Saunders Company, 1981
Electrical Hemorrhoidolysis. Wheatridge, Colorado: Hemcure Inc., [n.d.].
Gorsch, R. V. "Proctologic Conditions", Chapter 32, Kovacs,
Richard. Electrotherapy and light therapy. 5th ed. Philadelphia Pennsylvania:
Lea & Febiger, 1945, pp. 569-578.
"Help For Hemorrhoids?" Consumer Reports, Sept., 1986, pp.
578-580.
Hemcure Treatment Procedure. Wheatridge, Colorado: Hemcure Inc., [n.d.].
Holt, Robert Lawrence. Hemorrhoids: A Cure & Preventative. Laguna
Beach, CA.: California Health Publications, 1977, pp. 48-68.
Hemorrhoids? We Have Good News, a Cure Without Pain. Wheatridge, Colorado:
Hemcure Inc., [n.d.].
Keesey, Wilbur E. "Obliteration of Hemorrhoids with negative Galvanism,"
Archives of Physical Therapy, X-ray, and Radium, Sept. 1934; rpt. Chicago:
Cook County Hospital Physical Therapy Dept., [n.d.], pp. 533-540.
Kovacs, Richard. Electrotherapy and light therapy. 5th ed. Philadelphia
Pennsylvania: Lea & Febiger, 1945, pp. 66-186.
Muir, Wallace P. "The Post Cautery in Proctologic Surgery,"
Dover Street Clinic Review, May, 1941, pp. 83-86.
Nesselrod, J. Peerman. Proctology in General Practice. Philadelphia Pennsylvania:
W. B. Saunders Company, 1950, p. 80.
Noll, Carlton M. Procto-Basics. Medicus Publications: 40 Broken Arrow
Drive, Sedona Arizona 86336, 1978, pp. 45-50, 91-92.
Norman, Daniel. A., and others. "Management of Hemorrhoidal Disease:
An Effective, Safe, and Painless Outpatient Approach Utilizing D.C. Current."
Gastrointestinal Endoscopy, April, 1987. (mimeographed)
Norman, Daniel A., "Management of Hemorrhoidal Disease: An Effective,
Safe, and Painless Outpatient Approach.", Paper #43, Milford, Massachusetts:
Microvasive Inc., [n.d.].
Ogden, W. E. Hemorrhoid Treatment by Galvanism. Chicago: Reasearch Dept.
at H. G. Fischer & Co., Inc. Physical Therapy Headquarters, [n.d.].,
pp. 1-16. (mimeographed)
Operating and Service Manual 733 & 733A Hyfrecator. El Monte, California:
Birtcher Corporation, 1986, p. 38.
Otto, John F., comp. and ed. Principles of Minor Electrosurgery. The
Liebel-Flarsheim Co., 1957, pp. 6-11.
Schapiro, Kenneth. Retrospective Patient Interview Study: Patient response
to Electrical Hemorrhoidolysis. Wheatridge, Colorado: Hemcure Inc., 1986
Schrock, Theodure. "Diseases of the Anorectum," Gastrointestinal
Diseases, M. Slessinger M.D. and J. S. Fordtran M.D.,: Philadelphia Pennsylvania:
W. B. Saunders Company, 1983. (mimeographed)
Shefrin, David K. Treating Hemorrhoids and Associated Rectal Disorders
without a Hospital Surgical Operation. Phoenix, Arizona, [n.d.].
Shifrin, Dr. "Non-surgical Treatment of Hemorrhoids." Natural
Health Directory, 1987, pp. 6, 15.
Stanton, Frank D. Newer Concepts in Clinical Proctology. Clinton Massachusets:
The Colonial Press Inc., 1958, pp. 146-153.
Stewart, Harry Eaton. Physiotherapy Theory And Clinical Application.
Paul B. Hoeber, Inc., New York, N.Y., 1935, p. 246.
Ultroid the Complete Hemorrhoid Management System. Milford, Massachusetts:
Microvasive Inc., [n.d.].
Websters New Collegiate Dictionary, Springfield, MA.: G. & C. Merriam
Co., 1977, pp. 39, 1312.
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By: RICK A. SHACKET, D.O.
Department Of Surgery
Division of Proctology
Hillside Hospital
1940 El Cajon Blvd.
San Diego, CA. 92104
Copyright ©1989, By RICK A. SHACKET,
D.O.
All rights reserved. This book is protected by copyright.
No part of it may be duplicated or reproduced in any manner without the
written permission from the author.
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