Part 2

TREATMENT.

It is quite common for those afflicted with piles to call for treatment while suffering from an attack, sometimes called the hemorrhoidal state. This is not a favorable time to operate. Reduce all local congestion and inflammation first, by palliative measures, such as hot water douches, injections into the rectum of equal parts of Fl. Ext. Hamamelis and Pinus Canadensis (dark) in a little water, or water and glycerine if the latter is not repelled by an irritated bowel. At the same time open up the portal circulation by the use of equal parts of sulphur and cream of tartar, a teaspoonful in syrup or mixed with sugar, once or twice a day for a few days, or any other suitable means to put the bowel and piles at rest. Often patients will know what will relieve them of this condition better than the physician, as what relieves one will sometimes aggravate another.

In all cases of large growths, whether the patient is in a comparative state of ease or not, a similar preparatory treatment before operation will shrinken the tumors and lessen the tendency to local congestion and pain. Sulphur should not be taken within two or three days of operation since it continues its action about that length of time after dosage; but the bowels should be sufficiently evacuated previously to enable them to be held for four days afterwards, by any agreeable cathartic, or by flushing of the colon. This will be unnecessary in the treatment of small growths.

The same course should be pursued to expose the tumors for operation, as was named under the head of examination. In some instances, where the tumors are not very large but exceedingly irritable (arterial), it might be quite difficult, even though the bowel be partially prolapsed, to expose them sufficiently for a good operation. In such event, paint the protrusion with a 5 per cent. solution of cocaine and allow the patient to sit, for a few moments, over a vessel containing a small quantity of steaming hot water. This will engorge the tumors, relax and materially aid in handling the parts.

As a precautionary measure in all operations by injection, to prevent the medicine from extending too deeply into the tissue of the gut by gravity, or the overflow from running down on the outside of the pile and over the bowel, let the patient lie on the side opposite to the tumor to be treated, so that the preparation will gravitate to the apex rather than its base of attachment.

Smear vaseline on the opposite side of the bowel and anus and over any piles that may show on that side, which, as the patient is now placed, are on the lower or under side and will catch any and all waste and overflow of medicine. As a further protection pack or hold absorbent cotton underneath the tumor being operated upon. If the tumor be small and partially obscured, the end of the finger may be held back of it to act as a counterforce while introducing the needle; or a double, slide tenaculum may be used to pull and hold it down for the same purpose, being careful not to remove the tenaculum when once applied until after the operation, as the least prick or scratch of a hemorrhoid will cause a free flow of blood and greatly hinder the sight when it is desirable to watch the action of the injection compound.

Should any portion of the injection compound fall on the muco-cutaneous surface, unless the latter be heavily coated with vaseline, or protected with cotton, it will excoriate and probably cause a great deal more pain and soreness than the operation itself. In operating through a speculum such risk is avoided by the sides and floor of the instrument, which afford a protection to the surrounding parts; that is, if the precaution regarding position when operating is duly observed, to wit: always operate with the tumor pendent, or with its attachment on the upper side.

FORMULA.

Make a glycerite of tannin in the proportion of 4 drachms (Squibb’s) tannic acid to 1 oz. (Price’s) glycerine. When the solution is complete, add 2 drachms each of (Squibb’s) salicylic acid and borax, putting in the salicylic acid first; stir over lamp, using a glass rod and porcelain dish, until dissolved, being careful not to burn. If any dirt or sediment be seen it had better be strained now through a piece of wet cheese cloth, while yet hot, into a two-ounce vial.

Select a No. 1 grade of carbolic acid, say Calvert’s, and barely liquify it by distilled water. Pour ½ ounce of the liquified carbolic acid in a clean graduate, and add ½ ounce of the glycerite of the salicylate of borax and tannin, previously made. Do not be sparing in giving the carbolic acid full measurement, if not a little in excess.

When the combination is effected with the acid, a floculent precipitate will occur, which should all clear up within two or three days, otherwise something will be found wrong either in the purity of the chemicals used or the manner of effecting the combination.

Too much importance cannot be attached to the purity of the ingredients entering into this preparation, as anything unnecessarily irritating should be scrupulously avoided. I have tried synthetic carbolic acid and found the odor of tar decidedly stronger, and believe it much more acrid and irritating than the commoner preparations. Neither can I see that anything is gained in using vegetable glycerine.

Inject from 3 to 30 minims, or more, according to the size of the tumor. There is no rule to regulate the quantity by count. The object is to inject a sufficient quantity to permeate the entire substance of the tumor, its texture being much more spongy than the surrounding tissue, and not extend beyond its base of attachment.

Here is where many make a mistake in the injection of hemorrhoids. Some are prone to use too much, even though the solutions be weak, and apply it too deeply, reaching to and destroying the muscular coat of the bowel, causing prolonged pain, deep sloughing, etc. While others use too little, which may act as a foreign body or local irritant, producing a central slough and a slow breaking down of the disturbed growth.

A tumor, properly injected, cannot inflame, because there is nothing to inflame, the circulation is stopped and thus it is as effectually strangulated as by a ligature, with the advantages of the immediate local anæsthetic, antiphlogistic, auterant and antiseptic properties of carbolic acid. The base of attachment heals, while the dead tissue, which is rendered non-inflammatory and antiseptic, disintegrates and is thrown off between the third and fourth day, a process that fortifies against secondary hemorrhage.

There is a medium ground to be taken, in regard to the quantity as well as the strength of carbolic acid to be used, with a little room for variation on either side; yet there must, in point of reasoning and fact, be a limit somewhere. If a little more should be used than is necessary to permeate the entire substance of the tumor, the result will not be disastrous, but may excite a little more local disturbance and pain. On the other hand, if a little less be used, the operation will be equally as effective and is probably the better side to err upon, provided the discrimination be not carried too far.

A similar dilemma confronts us respecting the strength. After trying the weaker solutions and watching their effects, I have concluded that the solution should contain not less than fifty per cent. of carbolic acid, combined with the glycerine of the salicylate of borax and tannin, the latter in such proportions as to produce an immediate astringent effect. Tannic acid not only keeps the carbolic acid within limits by its non-irritating astringent effect, but of itself combines with a certain portion of the albumen of the blood and other tissue, forming an insoluble albumenoid. The salicylic acid and borax, original with Dr. Q. A. Shuford, of Tyler, Texas, gives the preparation more consistency and seems to lessen the irritative properties of the carbolic acid.

Original.

A weak, thin, watery solution, aside from doing poor work, is much more liable to diffuse itself and be carried into the circulation like a hypodermic of morphia, than a solution sufficiently strong to act as a cauterant, destroying the tissue, forming a compact and an insoluble coagulum and strangulating the circulation at once.

A solution, weak or strong, when deposited to any depth beneath the surface, with live tissue and the circulation passing on all around it, will of necessity excite pain, inflammation and a slough, the same as a splinter in the flesh. The properties of carbolic acid being non-inflammatory in their nature, will often, where a small quantity is used diluted, produce an adhesive inflammation, an induration and a contraction in a tumor, by destroying the capillaries where applied.

It is always desirable, when operating on external hemorrhoids, to see that quite a goodly portion of the cutaneous surface, especially at the summit, is effected by the preparation applied inside the capsule; otherwise it will become inflamed in order to let out the interior coagulum, which I have often seen come out on the third day intact, and in one unbroken cystic-looking mass, Fig. 5. The same rule obtains regarding internal hemorrhoids, having thick, unyielding coats.

Puncture the tumor at the most accessible point, preferably with the needle, nearly parallel with, or at an acute angle to its base, carrying the point of the needle to about the center of the tumor, if it be globe shaped, or equi-distant from base to apex, if it be elongated, with the face or opening of the needle toward the apex. Be sure the needle is inserted beyond the proximal end of its opening, which is not always observable in treating small growths; but may be tested by forcing the piston of the syringe a little, and if the end is not sufficiently buried the medicine will show around it on the outside.

Inject the first few drops the same as you would a hypodermic of morphia, then slowly, drop by drop, watching its action by change of color on the surface of the pile. This change of color on the surface is quite marked with hemorrhoids of delicate covering, less so with those possessed of more tough and fibrous coats. Hold the needle in position a moment and if the quantity injected does not appear sufficient, turn the nut on the piston with which you have previously gauged approximately the quantity to be injected, back a few rounds and throw in more. Puncture large elongated tumors in two, three, or four places. The compound diffuses itself slowly and no doubt extends some farther than is always apparent at the time of operation. Withdraw the needle carefully; it may be necessary to force out a few drops of the preparation at the point of entrance, for the purpose of sealing up the puncture to prevent the escape of blood and medicine together, which, however, never amounts to much. If, after withdrawing the needle, some of the injection fluid runs out, unmixed with blood, take it up with absorbent cotton, since it indicates that the quantity at that particular part is superfluous. Now dry the surface of the tumor or tumors with absorbent cotton, smear with vaseline and return within the bowel.

A tumor properly injected immediately becomes hard. There are septa or compartments in elongated growths which do not permit the medicine to pass through readily, and if a soft section is noticed, it has not been penetrated, although will doubtless break down with the general mass. I have seen a liberal injection into the middle one of three tumors connected and arranged in a row, so cut into those on either side that a single reddened column like appeared afterwards on the extreme outside, (Figs. 6 and 7).

Large hemorrhoids must not be exposed too long after injection, since there is always more or less swelling produced around the tumor by the stoppage of circulation and the presence of a foreign body. Return the side not operated upon first, then the other, and if the tumor has considerable length, let it go in endwise. The patient can often return the protrusion with least pain.

A little practice will enable any one to see the simplicity of the entire procedure. If you should make a mistake when operating through a speculum, and land the whole charge into a fold or saggened portion of the bowel do not be alarmed, as it will only be a little more painful and longer in healing. Injection into internal hemorrhoids is not painful to any degree, therefore if the patient complains much you might suspect that you are invading the tissue of the bowel. With some, the injection into external hemorrhoids is quite painful at the first contact of medicine, but immediately thereafter subsides. Where the tumor is very sensitive, external or internal, precede by a hypodermic of from three to five minims of a five per cent. solution of cocaine. Introduce the needle point barely underneath the covering of the growth and force out one drop. This will anæsthetize enough to allow further penetration, when another drop can be thrown in. By this time you can approach the interior to a sufficient depth to inject from three to five drops more, and anæsthesia will be immediate and complete. There need be no fears from cocaine absorption, since the carbolic acid compound will catch and hold the cocaine all within the body of the tumor before it can be absorbed and enter the general circulation.

From one to two hours after operation, the carbolic acid looses its local anæsthetic effect and what I have called the after pain commences, caused by the presence of a foreign body acting on the peripheral nerve at a point where the line of demarkation forms. This pain varies in intensity with the sensibility of the patient and surface of attachment of the tumor or tumors. Some will not complain at all, saying the discomfort is not as great as the suffering from an attack of piles; while others will make considerable fuss, requiring an opium and belladonna suppository:

℞ Opii Pulv. Optim. gr. xii Ext. Bellad. gr. iv Ol. Theobrom. ʒ iii