cure of hfemorrhoids without the use of general The Kelly sphincteroseopc is int roduced. A pledget of cotton an inch or so in length. mois tened with a 4-per-cent. cocaine solution, is introduced and the speculum with drawn. The speculum is, after a few minutes, reintroduced, the cotton re moved, the haemorrhoid brought into view. and superficially seared or plume tured by a small electrocautery knife. Some of the cotton is permitted to re main. After a week or so a second haemorrhoid is treated, and so on until a complete cure results. Davis (Annals of Surgery, June, 1002).
Ligature is pre-eminently the best for ordinary cases of piles, with one excep tion, namely: the clamp and cautery. The results that have followed both have proved that they are deserving of the highest praise and a detailed consider ation. The reader may choose the one he can perform with the most satisfactory results, with the assurance that a radical cure will be effected.
Surgeons differ as to the best method of applying the ligature. The majority, however, prefer the operation which was devised by the late Mr. Salmond and popularized by Allingham, Sr.
The patient, having been previously prepared by purgation, is placed on the right side of a hard couch in a good light and is completely anesthetized. The sphincter-muscle is then completely, but gently, dilated. This completed, the rectum for three inches is within easy reach, and no contraction of the sphinc ter takes place; so that all is clear like a map. The hmmorrhoids, one by one, are taken by the surgeon with a vulsellum, catch-tooth, or Pratt's "T" forceps, and drawn down. He then, with a pair of sharp scissors, separates the pile from its connection with the muscular and sub mucous tissues upon which it rests. The cut is to be made in the sulcus, or white mark, which is seen where the skin meets the mucous membrane, and this incision is to be carried up the bowel and parallel to it to such a distance that the pile is left connected by an isthmus of vessels and mucous membrane only. There is no danger in making this incision, be cause all the larger vessels come from above, running parallel with the bowel, just beneath the mucous membrane, and thus enter the upper part of the pile. A well-waxed, strong, thin, plaited silk ligature (Turner's, No. S) is now to be placed at the bottom of the deep groove made, and the assistant then draws the pile well out. The ligature is tied high up at the neck (see Fig. 1) of the tumor do not assist in the formation of the pile, being outside it. The silk should be so strong that the operator cannot break it by fair pulling. If the pile is very large,
a small portion may now be cut off, tak ing good care to leave sufficient stump beyond the ligature to guard against its slipping. When all the hemorrhoids are thus tied they should be returned within the sphincter. After this is done any superabundant skin which remains ap as tightly as possible. Great care must be exercised in tying the ligature. The operator should be equally careful to tie the second knot so that no slipping or giving way can take place. If it is advis able, tie a third knot, for the secret of the well-being of the patient depends greatly upon this tying,—a part of the operation by no means easy to effect. If this is done, all the large vessels in the piles must be included. The arteries in the cellular tissues around and outside the lower bowel are few and small, and parent may be cut off; but it should not be too freely excised, for fear of contrac tion when the wound heals. A pad of gauze is then placed over the anus; this is covered with a tight T-bandage, as it relieves pain most materially and pre vents any tendency to straining.
To secure a cure by the ligature it is not essential to follow in detail the va rious steps as just recorded. The lithot omy position, with the limbs well flexed on the abdomen and held in position by Clover's crutch, presents a better view of the parts after the sphincter has been divulsed. Sitting upon a high stool in front of the patient, the operator has the free use of his hands and can apply the ligature with more ease and in a shorter time than when the patient is placed on the side. After all of the piles have been ligated and those portions external to the ligature cut off, the stump should be placed within the bowel.
Patients suffer considerably for the first twenty-four hours because the sen sitive nerves have been included in the ligatures. The pain during the second and third days is frequently quite annoy ing, though in some cases it will be very slight. The lower part of the rectum presents a sensation of heat and fullness. Patients are often awakened after the operation by sudden contractions of the levator ani, and the strangulated stumps seem to act as foreign bodies, keeping up irritation. The ligatures will ordinarily slough off from the seventh to the ninth day, but now and then they have to be removed by the surgeon. This compli cation occurs more frequently than the friends of the ligature would have us be lieve, and in such cases increased pain and delayed healing are always notice able. The time required to remain in doors in such cases varies from three to six weeks.