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.
About the time the tumor is thrown off, between the third and fourth day, and sometimes later, before the healing surface becomes strong, or should the portal circulation become obstructed and the hemorrhoidal vessels congested, secondary hemorrhage may rarely occur. It is easily controlled by the use of Monsel’s Salt, to which a little morphia should be added, carried in a small piece of wet absorbent cotton, and held on the ruptured vessel by the end of the finger until the hemorrhage ceases. A few minutes will usually suffice. Knowing where you operated will be a guide to the place of application. The injection of a strong solution of tannic acid will be sufficient in mild cases. I have never known a secondary hemorrhage, following carbolic acid injection, amount to anything more than an easily controlled venous hemorrhage. Am inclined to think secondary hemorrhage is most likely to occur when a pile breaks down from a partial injection, leaving the vessels unprotected in places, or from an injection too deeply into the substance of the bowel; yet, I have seen all these conditions time and again without the least tendency to hemorrhage.
With a fifty per cent. solution of carbolic acid and the combination given, carbolic acid poison and embolus are entirely out of the question. The only danger of embolus lies in the too sparing use of a weak solution of carbolic acid, injected slowly into the unobstructed calibre of a coursing vein. While a strong solution quickly and generously applied would destroy the tissue and obliterate the vessel as effectually as the hot iron.
The extensive sloughing that I have heard of so much I have never experienced, and am not able to conceive of such an occurrence, except it be in a very low state of vitality; but can imagine how a pile would slough if a few drops of carbolic acid were deposited in the center, or deeply into its base, leaving the apex and greater portion of the growth with a free circulation. A weak solution taking effect in the interstices of the most tender part of a hemorrhoid, but not sufficiently strong to attack the more fibrous portion, would doubtless result in inflammation and slough. A pile with a thin delicate covering and internal structure can be cured by an injection of water, while those of a more tough and fibrous character would only be exasperated by such annoying treatment and behave in a bad manner.
In looking over the comments of Kelsey, Andrews and others regarding the injection of hemorrhoids, it appears quite evident that they have not given the subject scientific study. It would seem that representative men and authorities, after a knowledge of the brilliant results following the treatment in many cases, attended by accidents in others, would seek to know and try to obviate the cause or causes of these unexplained irregularities.
They never improved upon the method in its primitive and undeveloped state, but seemed willing to magnify and enlarge upon all the accidents and complications arising from and following the indiscriminate use of all sorts of injection compounds, in the hands of the ignorant and inexperienced, and in diverse and unfavorable conditions for treatment.
How about the old methods? Only a few months since my attention was attracted to a gentleman of prominence, in middle life, strong body and good habit, who had been operated upon for the removal of piles by ligature. He was seven months in recovering, during which time two fistulas developed. I do not mention this case as an isolated one, because we all know that excessive and prolonged pain, causing in some instances lock-jaw and death, retention of urine, sloughing and stricture by contraction of tissue, abscess, fissure, fistula, intractable ulceration, hemorrhage, immediate or secondary, great and lasting prostration and slow recoveries, saying nothing about the dangers of anæsthesia etc., are not uncommon when the old methods are practiced.
About the time that Kelsey, after having deposited five drops of a carbolic acid solution in the center of a large tumor, observed it looking dark, angry and inflamed from the intrusion of a foreign substance, would have been a fitting moment for a full dose of carbolic acid, of suitable strength and in sufficient quantity to pervade the entire structure and form a compact coagulum; strangulating the circulation, cauterizing the tissue and thereby checking the inflammatory action at once; then followed up by the liberal application of hot water and a sponge.
The method that I adopt and recommend for the removal of piles, not only does the work neater and cleaner than the more heroic measures in vogue, but robs the patient of the terrors of etherization, as well as the dreaded consequences incumbent upon and more or less inseparable from operations of violence, in a peculiarly organized and sensitive locality; and, as Dr. E. F. Hoyt, of New York, says: “There is not a hemorrhoidal case possible but what can be obliterated by this means; and I am at a loss to explain why so many cling to methods that carry so much havoc and suffering. If every college in the land would have this subject demonstrated by men of experience and learning, all other means would soon lose recognition.”
I shall not take up time and space in enumerating cases but will briefly mention three of quite recent date, and of more than common interest on account of some of the associated history given.
Manuel L., aged 39, capitalist, had arranged his business affairs and prepared for the possible results of a ligature operation. All being in readiness, he was placed on the operating table by a prominent surgeon, who, upon examination, found the hemorrhoids to look so formidable in appearance that he refused to proceed further, stating that the operation might prove fatal.
On his first visit to me, he was asked to use the commode and strain out the piles, which presented to view a large, continuous hemorrhoidal mass encircling nearly one-half the bowel on one side, with five distinct and typical tumors on the other, similar to Fig. 1. He was directed to lie on the operating chair with the large growth oil the upper side, and about 30 minims of the carbolic acid preparation was injected in three different places in the mass, the protrusion returned and the bowels constipated for four days; after which the bowels were moved by an enema of slippery elm water, when not a vestige of the growth could be seen, and no pain.
He put his hand back to push in the bowel, as he had been accustomed for the past eight years, and found it gone; whereupon he said if this had occurred in the day of miracles, he would think me Jesus Christ. One operation is all that is required for the remaining five tumors, and both piles and prolapsus are cured by two operations. In fact, the smaller tumors should have been taken first, when the opportunity to get at them was much better.
The only inconvenience suffered was from an effort to hold the bowels, and the after-pain, which lasted about 14 hours, but was not severe; during which time an opium suppository was introduced every two or three hours. He stated that he was just getting over an attack of La Grippe and had been purged pretty freely, consequently did not evacuate the bowels previous to operation, but advised a liquid diet for the first three days.
George P., aged 37, druggist, had a continuous hemorrhoidal mass occupying both sides of the bowel when protruded, being separated only by an anterior and a posterior commissure. Glaring fibrous bands seemed to bind down the enlargements in places, presenting anything but an inviting case. He also had an arterial hemorrhoid attached just above the verge, constantly hanging out and exciting the external sphincter; looked like and was about as large as a medium sized strawberry, irritable and eroded.
The history of the case and the extreme ungainly appearance of the protrusion induced me to have it photographed. It is approximately represented in Fig. 2, but does not show the fibrous bands. The patient was placed on the side opposite the larger mass, which was injected at four different points. The bowels were constipated for four days by the occasional introduction of an opium suppository and then moved by enema, when the man shed tears of joy on having no pain at stool and finding no protrusion on that side. The next operation took the other side, together with the strawberry, and the case discharged, cured of piles and prolapsus.
Both of these gentlemen had been told time and again that the carbolic treatment was ineffectual and dangerous. One ex-army surgeon and college professor said he would not attempt any of the heroic operations in the second case, as there was too much tissue involved; that he would only agree to treat it by making local applications twice a week.
And further, he would not promise any results inside of ten months, asking twenty dollars per month. He would not swerve from his opinion, and could not say that a permanent cure would then be effected.
Mrs. Jane D., nearly 80, afflicted many years, had consulted fifteen different physicians, all of whom refused anything more than temporary relief because of extreme age; having always been considered delicate, with cataract now forming in both eyes. Would be satisfied if she could live not more than two years after a cure.
The tumors were “old bronzed veterans,” tough and unyielding. One side was taken at each operation and although confined to the bed mostly for the first seven or eight days after operation, could get out and in at any time without assistance. Had no constitutional disturbance, never missed a meal and was able to get up and down stairs inside of eight days unattended.
The dead piles embraced in the coagula were much longer in separating from the bowel, and base of attachment longer in healing than in the average case. Hot water sponge compresses were used frequently, together with opium suppositories for the first 24 hours, then occasionally for the next three days; after which hot water irrigation and iodoform suppositories. Later bismuth, eucalyptol and oxide of zinc ointment. An occasional dose of sulphur and pot. bitart. was given and the bowels moved by flushing of the colon; which was resorted to but twice.
In this case the edges of the thickened, calloused mucous membrane of the bowel where it joined the hemorrhoids, appeared to be so cartilaginous in places, that I expected hard ridges would be left; but they all disappeared and softened down by the use of eucalyptol, buckthorn and stramonium ointment. At one point a small polypus sprang up, which withered from the injection of a few drops of pure carbolic acid, like a tender sprout, after being frozen, under a scorching sun.
The lady could not repress her feelings of emotion, in expressing gratitude for the services rendered, but gave way and freely cried. Although in rather poor circumstances, she did not think a charge of fifty dollars sufficient and afterwards returned, saying that she felt that she would not die happy unless I was better paid, and insisted upon my taking another “twenty.”
Do not operate during an attack of piles.
Operate with the tumor, or tumors, on the upper side.
Handle the parts with extreme gentleness and deliberation.
See all that can be seen and treat all that can be treated without the aid of a speculum.
Protect the under parts from excoriation by waste and overflow of medicine.
Evacuate the bowels previously and constipate for four days after operation on large growths, or when several small tumors are taken at one time.
Hot water sponge compresses, early, often and continuously, are indispensable and unequaled for the relief of a pain, swelling and soreness. To be effective it should be applied as hot as can be borne.
Wait until the soreness disappears before performing a second operation. This will require from one to two weeks, according to the extent of the first operation and the physical condition of the patient.
Take great pains and care to perform a neat operation. A certain amount of ingenuity and tact are required, which, unfortunately, all do not possess. If a bungling job be made, the bowel punctured, a pile injected on one side only and the surfaces excoriated, do not attribute an unnecessary amount of pain and suffering to the preparation used or the method employed.
As a general alterative and curative agent in many diseases, and particularly to relieve and prevent hemorrhoidal congestion in rectal troubles, sulphur in small doses, persisted in for some time, probably has no equal. The most convenient form for administration is a palatable tablet (Wyeth & Co.), containing 2½ grains, or 5 grains with 1 grain of cream of tartar. Reference to the learned articles on the physiological and therapeutical uses of sulphur, by Dr. John V. Shoemaker, published in the Dietetic Gazette, Sir Alfred B. Garrod in the Lancet, and in Ringer’s hand-book of therapeutics, will be amply repaid.
Fig. 10.—Position for operating, or making a rectal examination. Engraving kindly furnished by Sharp & Smith, who manufacture one of the best office and operating chairs combined, on the market. It works without “cranks,” “levers,” or “ratchets.” Upholstering is entirely protected during an operation.
It is unnecessary for a lady to disrobe herself for examination, or suffer immoderate exposure. A cloth cover should be used, when a lady patient is placed on the chair, the same as in gynæcological practice.