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: