Part 3

M. et Ft. Sup. No. xii.

The pain does not usually continue longer than from twelve to fourteen hours, unless aggravated by undue exercise, or other similar causes, being replaced by a feeling of soreness, which is sometimes reflected down the limb or up to the bladder.

The treatment after the operation should be markedly palliative: hot water sponge compresses, hot water sitz-baths, and hot poultices are great as long as pain and soreness are complained of, together with opium suppositories, pro re nata. If the extent of the operation requires constipation of the bowels, enemas should be dispensed with until after the expiration of four days. Then hot slippery elm water, flaxseed tea, or corn starch as prepared for stiffening clothes, may be used, as well as a soothing suppository:

℞ Bism. Subnit. Iodoformi ā ā ʒ i Opii Pulv. gr. v-x Ext. Bellad. gr. v Ol. Eucalypti gtt. vi Ol. Theobrom. ʒ iiss Ol. Olivæ gtt. x

M. et Ft. Sup. No. xii.

The oil of eucalyptus will almost completely disguise the odor of iodoform.

In old people who lack sufficient vitality to quickly heal a broken surface, coat with bismuth, bismuth and oxide of zinc ointment, oxide of zinc powder, reduced resin cerate, eucalyptol, etc.

Eucalyptol is a sovereign remedy to stimulate healthy granulatious, after a broken surface has lost its freshness or acquired some age, in the proportion of ½ dr. to 1 oz. oxide of zinc ointment, containing a small quantity of stramonium or opium and belladonna. Or, ½ dr. to 1 oz. vaseline with 1 dr. oxide of zinc.

Anything that excites and keeps up pain is hurtful. Severe, continuous and prolonged pain is an indication that the changes are not going on in a satisfactory manner. It should always be subdued as much as possible. Suppositories containing glycerine, castor oil, or anything productive of much pain, should be wholly discarded.

Temporary sympathetic paralysis of the bladder, or spasmodic stricture of the urethra may occur, being relieved by hip baths or the catheter; the latter is very seldom required. Enjoin as little straining as possible. Many of the worst cases, in otherwise healthy people, will speak of holding the bowels as being the greatest difficulty encountered during the entire course of treatment. A little flatus will sometimes produce an annoying titilation of the muscles. It has been suggested that a small tube be introduced at such times for relief.

A certain amount of moisture begins to exude the second day after operation, particularly noticeable from external hemorrhoids, and a peculiar smell when the coagulum is thrown off. This should not be interpreted as suppuration.

It would not be reasonable to suppose that all cases will behave alike. The local and constitutional disturbance will, of course, depend upon the size or surface of attachment of the tumor or tumors and the nervous and physical condition of the patient. It is best to require patients to lay up for a few days after operation on large hemorrhoids, or when more than one of small size are taken, even though they do not complain.

In people enjoying average health, with internal hemorrhoids located on both sides, take one side at a time, making two operations of the treatment. In a case like Figure 1, not an uncommon form, it will be better to operate on all the five smaller tumors first, while they are exposed and kept out by the aid of the large one on the opposite side. Should the large growth be taken first, it may be impossible for the patient to hold down the bowel sufficiently afterwards to operate on any one of the five small fellows, and a speculum will be called into use; this will prolong the treatment, as few will submit to the operation on and the manipulation of all five tumors through the slot of a speculum at one sitting. Small isolated piles can be treated singly, and the patients allowed to go about their business. It is these bad cases, where the patient knows the importance, prepares and lays up for treatment, that we should make as short work of as possible; those who have been great sufferers, and possibly the operation on one small tumor would so arouse the others that the suffering would be as much, if not more, than if all had been treated at the same time. Not unfrequently the piles on the opposite side, and left for a second operation, will set up the howl and cause more pain and suffering than the side treated; especially may you look for such alarm if you allow any of the injection compound to fall on their unprotected surface. A patient once observingly remarked that it must be a peculiar kind of medicine that caused pain when brought in contact with the outside of a pile, but none when applied to the interior.

As regards pain, it might be briefly stated that little can be done in the vicinity of the rectum, it matters not what strength of carbolic acid is used, or plan of treatment adopted, without causing more or less discomfort in all cases, amounting to actual pain and suffering for a brief period in others. Not at the time of operation, for that in itself is practically painless, but during the process of cure.

This cannot be wondered at, when considering the extreme sensibility of the parts and amount of tissue involved and actually removed by a radical operation. Yet it is no greater in the majority of instances and not as much in extremely irritable piles, as that caused by the periodical squirting in of a few drops of carbolic acid and water, extending over a period of weeks, and even months, that is neither safe, certain, or otherwise satisfactory; and often brings discredit upon a process which, if properly understood and rationally applied, has no approach to comparison in any other method of cure.

Some physicians fear to use anything stronger than a little carbolized water and glycerine, lest they produce carbolic acid poison, embolism or a slough. This is a mistake, the dangers they seek to avoid are coupled with such uncertain and illogical practice.

Dr. E. H. Dorland, Chicago, Ill., says: “When a compact coagulum is formed, and the muscular layer of the bowel is not touched by the styptic it is impossible to do harm, all the learned theory to the contrary, notwithstanding. A weak solution forms little globules in a tumor, and we can imagine one so small as to be carried into the circulation.”

To effect a radical cure, it is desirable to get rid of the tumor bodily, not by shrinking or contraction into a hard knot, or by inflammatory destruction, but by a separation of the spongy and vascular growth from the normal tissue of the body, the same as if dissected off root and branch. This is obtained by putting a sufficient quantity of the preparation recommended just where you want it, and such results will invariably follow. I have seen internal hemorrhoids, about the third day after operation, become so friable that they could be crumbled off similar to a piece of cheese. The preparation can be relied upon to extend just as far as you put it and no farther, and will remove as much of the tissue as permeated. It will extend farther, and permeate more readily the structure of a pile than the sound tissue, because the former is much more spongy and cellular, allowing the preparation to be easily forced and diffused throughout its integrity (Fig. 8). A pile, properly injected, should appear the next day after operation perfectly dead, as if boiled or cooked, and of a leaden color.

NEEDLE AND SYRINGE.

A gold or platinum pointed needle should be used, fitted with a screw to gauge the depth of insertion, and of sufficient caliber to allow the preparation to pass through freely. There are several makes admirably adapted to this purpose, Fig. 9. A common hypodermic would be utterly useless.

A common glass barrel, metal bound, hypodermic syringe is all that is needed. It should be provided with side handles. Draw the medicine into the syringe before screwing on the needle, force out the air and gauge the nut on the piston for about as many minims as thought will be required.

When a syringe is not kept in constant use the piston will dry out and stick to the barrel. This is remedied by setting the nut on the piston when laying the syringe away, so that the piston will not quite go to the bottom of the barrel. When it is desired to use the syringe, screw back the nut, say sixteenth of an inch, and take up the syringe with thumb on the piston handle and finger on the cap at the other end, and press together, thus freeing the piston.

A heavy, open face watch glass with a center facet is a good receptacle for the injection compound before drawing it up in the syringe.

ACCIDENTS

MARGINAL SWELLING AND ABSCESSES.

Marginal swellings and abscesses, appearing the third or fourth day after operation, are produced by excessive irritation. I have never seen them occur except when the patient disobeyed instructions and exercised inordinately. One instance, in a case of long standing, where the piles occupied both sides of the rectum between the sphincters, I operated on both sides and injected every tumor at one sitting, enjoining rest and quiet. He afterwards rode a long distance and walked a half mile, which caused an unusual amount of pain and soreness; not content with this he took a dose of castor oil, when a very painful marginal swelling occurred. Being a strong man up to this time he had used no palliative measures whatever, and only then informed me of his suffering. Hot water and a sponge soon eased the pain and a superficial abscess developed; it was slit up and a good recovery followed.

According to my observation and belief, piles situated just above the verge and in proximity to the network or plexus of nerves surrounding the anus, are more prone to cause a marginal swelling than others, particularly if improperly or two deeply injected, and an irritating quality of carbolic acid be used. It might also be stated that pain varies in intensity as it approaches the verge, one of the most acutely sensitive surfaces of the body. A small sensitive pile not larger than a salmon egg, situated within the grasp of the external sphincter, will keep up a titilation and contraction of the muscle sufficient to disturb and put ill at ease the entire animal economy.

A swelling or lump which often appears immediately after injection of piles of any considerable size just above the verge, is of no consequence and will subside within a few days. A similar swelling sometimes results from a severe attack of internal hemorrhoids, which some speak of as the developing of an external pile, but I do not see that such formations are anything more than marginal swellings, caused by the irritation above.