A system of practical medicine. By American authors. Vol. 2

by Unknown

⁴⁷ Surgery in the Pennsylvania Hospital, p. 210.

⁴⁸ Agnew's Surgery, vol. i. p. 445.

Those who suffer from prolapse of piles should avoid the habitual use of cushioned seats. They should assume a semi-erect posture during defecation, or, when this is attended with difficulty or inconvenience, they should contrive a portable water-closet seat by boring a hole an inch and a half in diameter through a piece of planed board, bevelling it so as to fit the person. These means will often prevent the extrusion of the tumors. After defecation the patient should rest for a little while in the recumbent attitude.

The careful touching of external piles with strong nitric acid is a mode of treatment that has been quite successful in the hands of some surgeons. The intolerable itching of these bodies can be allayed by touching them with tincture of aconite-root or with a concentrated tincture of prickly-ash bark. Freezing them with the ether spray allays the pain and itching for the time being, but these symptoms return with redoubled energy after the effect has subsided.

Should an attack of the external variety of piles not result in absorption, but leave an excrescence, painless but inconvenient, and liable at any time to become inflamed, excision would be in order. Divide the integument by an incision radiating from the anus, separate the skin from the tumor down to its base, and after seizing it with toothed forceps cut it off with scissors curved on the flat. Little flaps or tabs of skin remaining after piles may be snipped off with scissors. It is not well to operate upon external piles unless they obstinately resist all milder treatment. There are frequently venous enlargements containing blood-clot, and when this condition exists proceed as follows: Pinch up the little tumor between the thumb and finger of the left hand; transfix its base with a curved bistoury, and cut out; at the same time, by pressure with the thumb and finger, extrude the clot. Fill the bottom of the little sac with cotton wool, and the operation is complete. It is not necessary in these cases to wait until the inflammation subsides before operating.

The operative treatment of the internal variety may be by strangulation, by the cautery, by the écraseur, and by the use of caustics. The former of these is the safest and most convenient method, and the one usually employed in the Pennsylvania Hospital, and should be performed in the following manner: The lower bowel having been thoroughly evacuated and the patient etherized, the operator should gently but firmly stretch the sphincter. The patient should be placed upon the side, with the upper part of the body prone, the hips elevated, and the thighs flexed upon the abdomen. Transfix the largest tumor with a strong, long-handled tenaculum, cut through the skin at the base with a knife or scissors around its external half, and hand the hook to an assistant, instructing him to make gentle traction. Then encircle the mass with a stout cord if the mass is not too large, or pass a stout needle threaded with a double silk ligature, from without inward, deeply through the base of the pile, drawing it through the mucous membrane on the opposite side; cut loose the needle and tie tightly, so as to completely strangulate the included tissues on either side and leave the ends of the ligature long. Treat all the remaining tumors in a similar manner seriatim, and then with scissors cut away the strangulated bodies to within a safe distance of the ligatures, the ends of which are now to be cut off close. Place an opium suppository in the bowel, and the operation is complete.

When for any sufficiently good reason the patient will not bear the ordinary anæsthetics, it will become necessary to modify the operation as follows: The tumors having been well extruded by enema of warm water or by the efforts of the patient, bend him forward over a chair and direct an assistant to draw aside the buttocks. Then pass the double ligatures as before indicated, but refrain from tying until all the tumors are thus secured, as the operator will find it convenient to draw upon the ligatures to keep the mass of piles within view and working-distance. Then draw down each tumor, cut around its base, and tie as before; cut off the ends of the ligatures and the greater portion of each strangulated tumor, and return everything within the bowel, and follow with an opium suppository. In many cases Morton has used the nitrous oxide gas with the best results. The hook should then be withdrawn, and each knot should be drawn more firmly down prior to its reduplication. Following this procedure, if properly carried out, the tumors will change color, becoming blue, thus indicating complete strangulation.

The operation by the clamp and cautery is a good method when the hemorrhoidal tumors are small. The operation is that of Mr. Cusack of Dublin, and the clamp employed is that invented by Mr. H. Smith of London. This instrument is so well known that a detailed description of it would be unnecessary. In operating with it the tumor is to be drawn well out and the clamp applied close up to its attachment with the bowel. Strangulation is effected by means of the screw which runs through the shafts of the handles. This accomplished, the strangulated portion is cut off with scissors, which should leave a stump three-eighths of an inch long. To this stump apply the actual cautery at a dull red heat, touching its every portion, after which unscrew and remove the clamp and look for hemorrhage. Should any occur, touch the bleeding point with the hot iron. Confine the patient to bed for five or six days and give sufficient opium to confine the bowels. After this time has elapsed administer a dose of oil. Remember that but one pile should be clamped at one time. "The taking two piles into the clamp at once is sure to result in hemorrhage." Do not allow the cautery-iron to touch the clamp. After the operation return the parts within the sphincter and cut off any tabs of redundant integument with scissors.

The removal of internal piles by means of the écraseur was the favorite operation of Chassaignac, but it is a mode of procedure which is now regarded with disfavor by the best surgeons on account of the liability to hemorrhage, and from the fact that troublesome and injurious contractions of the anus have not infrequently followed its use. The employment of iron or copper wire instead of the usual chain has been recommended by those who prefer this mode of operation. The plan adopted by Chassaignac was to pedunculate the piles by tying a ligature around the base and drawing them down. The chain being then applied, the strangulation and crushing off was slowly accomplished by means of the lever of the instrument. It should take from twenty to twenty-five minutes' crushing to accomplish this object.

For the treatment of internal piles by caustics Houston of Dublin used strong nitric acid. A fenestrated speculum should be employed, and the acid should be applied with a piece of wood or with a glass brush, care being taken to limit its action to the tumors, the redundant liquid being mopped up with a swab of lint or prepared absorbent cotton. The entire surface should afterward be bathed in oil. The acid is relied upon to produce a granulating surface, by the healing of which and by the subsequent contraction a cure is sometimes achieved. At best, this plan of treatment has proved tedious and unsatisfactory.