The applications are necessarily repeated two or three times at intervals of five days or a week. There is no necessity for local anesthesia when using nitric acid as it produces no pain in the mucous membrane. Care should be taken to avoid touching the margin of the anus with the acid, and before making the application the surrounding tissue should be smeared with Vaseline A suppository containing one-half grain of opium should be introduced to overcome the tenements following this procedure. Other eschatology used for this purpose are nitrate of silver, caustic potash, acid nitrate of mercury, arsenic paste, pyromaniac acid, and butter of antimony, but none of these are as good as the fuming nitric acid.

Carbolic Acid Treatment. The injection method has resolved itself almost entirely to the use of carbolic acid, with glycerin and some astringent drug. The active principle for the destruction of the hemorrhoid tissue is due to the carbolic acid contained in the mixture. The use of carbolic acid for the treatment of hemorrhoids is one that is almost entirely dependent upon the individual experience of different authorities.

Recommendations for its use are given with the greatest skepticism and warnings of dangerous and disagreeable complications. Before discussing the technique, the treatment should be clearly understood, as the method is generally condemned by the profession in England and America. The possibility of serious complications are so great that its use can hardly be recommended by a conscientious practitioner without due consideration. However, this condemnation should not altogether deter one from trying the method in selected cases and where the radical operation cannot be substituted for it.

The carbolic acid method should not be advised when the hemorrhoid is strangulated and cannot be pushed above the internal sphincter, or when highly inflamed, ulcerated, or when largely hypertrophied. It is only applicable to internal hemorrhoids when small and in a fairly healthy condition. The duration of the disease does not contraindicate the use of this method, when the tissue is fairly healthy.

The complications for which the operation is to be condemned and which sometimes follow, are: very great pain, and swelling, an extensive ulceration, abscesses followed by a fistula, inflammation of the veins (phlebitis), uremia and death from embolism.

In a successful operation the patient should not be confined to bed or detained from business longer than a few days. No cutting and no general anesthetic need be employed.

The amount of fluid to be injected is dependent upon the size of the tumor, and no general rule can be given as to the quantity to be used as each tumor may require ten minims (but no more), and the quantity must be graduated down from ten to two drops. The average amount necessary will be from four to six minims of the solution. A suppository of opium, belladonna and chloroform combination should be introduced the first two nights to prevent bowel evacuation and to relieve pain, and it is best that the bowels do not move for at least forty-eight hours; afterward, they are moved each day by a gentle laxative or cold water enema. This is practically all the after-treatment recommended by the average surgeon using the injection method. The inflammatory condition subsides and the swelling and bleeding usually ceases after the first day.

Sometimes there will be a prolapse of the injected homer-rhoid within twelve to twenty-four hours after the operation, therefore the patient should be warned against straining and the erect position avoided until this possibility is past. Should a prolapse of the injected hemorrhoid occur, the tumor should be replaced at once by gentle pressure or a soft sponge. Should strangulation and sloughing occur, the prolapsed hemorrhoid mass will usually protrude. Sloughing occurs as the result of carbolic injections, probably due to injecting the fluid too close to the surface of the tumor. Sepsis probably is the result of infection from some outside source, rather than from the fluid itself. The solution is not capable of producing pus as it is strongly antiseptic, but infection might be carried on the needle or syringe if they are not properly sterilized previously.

Morning before the operation a mild cathartic should be administered; a soapsuds enema should be given about one hour before the operation and the tumor washed off with a two thousand dichloride of mercury solution. The patient should be placed in the Sims's position and each tumor should be exposed separately. The parts should be thoroughly cleansed, and a fresh solution for each injection should be made. The syringe and needle should be thoroughly sterilized. The amount injected should be accurately gauged. Care should be exercised that no air is contained in the syringe prior to injection. The fluid should be injected slowly into the pile.

The amount to be injected will depend upon the size of the pile and vary from five to ten drops in each pile. The needle should be left within the pile until the mass turns white and care should be taken that the surrounding tissue is not injured as the needle is withdrawn. Pressure with the finger should be made to prevent the escape of the fluid. The hemorrhoids should be pushed above the internal sphincter after injection and the patient kept in the recumbent position for an hour or two after each operation. Only one hemorrhoid, or at the most two, should be treated at one time. The second injection should not be made sooner than five days after the first.

The following formula are used by different authorities for this work, and are quoted as given by them.

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