The paramount concern should be to avoid causing pain both during the treatment of a sacculated mucosa or its possible occurrence a few hours or days later. I have often remarked that when pain or soreness follows the treatment of a mucous sac the fault is in the application of the remedy, and not in the remedy itself. Now and then there may be conditions in which you will expect pain or soreness to follow the treatment, and you will prepare your patient with the necessary appliances and remedies to overcome it promptly. Where there are no possible means for avoiding the pain consequent upon a treatment, leave nothing undone to make it as slight as possible. All mucous sacs ought to be treated without any after-annoyance to the patient, and they can be if we only wait for the proper time to treat them.
I have not thus far considered the muco-cutaneous sacs around the anus, which are neither useful nor ornamental, and which often indicate the volcanic action of inflammation and the amount of mucous lava thrown out around the vent.
CHAPTER XXII.
External and Thrombotic Piles versus Muco-Cutaneous Sacs and Thrombus.
The vent of a crater indicates the convulsive and destructive changes that have taken place within; and, very often, the vent of the gastro-enteric sewer gives like evidence of long, great, and severe destructive changes. The fire of inflammation has burned fiercely for many, many years, and serous lava has, from time to time, poured forth, leaving a searing, inflammatory path. As it was forced from the recto-anal crater, the acrid, burning mucus, that had been imprisoned, made subcutaneous streams, cavities, channels, sacs, etc. Its course is marked around the anus by peaks, crags, muco-skinny tabs, small and large bulging muco-cutaneous sacs, dilated anal veins in which clots of blood often form; light gray, brittle, shiny skin with small and large red and sore oases, thickly studded over the itching area, which the sufferer has scratched in the vain hope of appeasing the torture of pruritus ani, scroti, vulvæ; while cold drops of perspiration stand over his or her face and body, serving to indicate the physical and mental anguish inexpressible in words.
Muco-serous exudations under one or more layers of the recto-anal mucous membrane finds its way down to the integument around the anus, and being of a very irritating character, greatly increases the inflammatory process in the tissues it comes in contact with. Thus the increased inflammation and blood stasis and the augmented serum unite in hurrying the development of skinny tabs and the more or less capacious muco-cutaneous rugæ and sacs.
When the serous exudation takes place entirely under the recto-anal mucous membrane, there may be formed a large muco-cutaneous anal sac, especially on the right or left side of the anus, or the serum may pass under the integument about the anus with little or no anatomical change in the appearance of the skin at or about the anus. In the latter case, an experienced eye can detect sufficient evidence to diagnose the destructive changes wrought by the presence of serum in the connective tissue under the skin and ano-rectal mucous membrane.
The skin is not, as it should be, held fast by the connective tissue, but lies loose over the cavity; and a similar pathological condition exists under the mucous membrane of the anus, rectum, and sigmoid flexure, which circumstance might lead one, in some instances, to conclude that there was almost an entire separation of the mucous membrane from the areolar tissue, by the ridges, folds, large, pouched, prolapsed, sacculated regions of mucous membrane that has the appearance of having been simply carelessly laid over the muscular structure of the organs. When we observe such destructive changes by the invasion of serous exudation under the mucous membrane, we have every reason to expect periproctitis and perisigmoiditis, with the possibility of the formation of pus occurring with the usual consequences. So remarkable and serious are the excursions of the mucous currents into healthy neighboring tissue that we find a symptom of a disease vastly more annoying and serious than the disease itself. Is it any wonder we find stenosis (narrowing of the passage) of eight, ten, or more inches of the lower portion of the large intestine, which is usually diagnosed atony of the bowels? Surely, you must by this time appreciate the reason I made so strong an appeal for the twice daily use of the enema as a means of relief. You need the combination of many aids over a long period of time to effect a cure of proctitis, etc., and its numerous symptoms. Proctitis and colitis is a serious affliction, and should have your undivided attention with the hearty co-operation of the patient in effecting a cure. How foolish is the practice of removing one or two annoying symptoms (piles and fistula) and leaving the sufferer untreated, the disease itself and the other symptoms not so apparent at the time of the operation, and then dismiss the case as cured! Shame on such practice, in which ignorance and cupidity dominate! Humanity cries for a correct diagnosis and a humane treatment!