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,[1] 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.
[1] 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.
Fig. 4.—External hemorrhoid before operation.
Fig. 5.—Three days after operation, with coagulum still attached by pedicle.
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]).
Fig. 6.—Three internal hemorrhoids before operation.
Fig. 7.—After a liberal injection into the middle tumor.
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 | |
| 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.