As a rule, patients operated on by the ligature are able to be about from ten days to two weeks, although the ulcera tion may not be entirely healed. Many other operators have met with equally good success. This fact, coupled with the permanent cure which follows this operation, has won for it a very enviable reputation. At the same time there is one other operation—the following— that will be succeeded by just as good results, from which patients suffer much less, recover more quickly, and with as few bad results as follow the ligature, namely: the clamp-and-cautery opera tion.
Bloodless method for treating humor rhoids, each haemorrhoid being seized close to its base between the tips of the thumb, index, and middle It is put upon the stretch and twisted and finally so completely crushed that it is pulpified, and none of the investing tunics remain except the mucous mem brane and its understratum of fibrous tissue. Thirty-two cases treated success fully by this method. Manley (Boston Med. and Surg. Jour., Feb. I, '94).
Recovery followed all of the 269 cases treated in Dittel's service by Dittel's elastic ligature for hemorrhoidal nod ules.
Twelve days was the average time.
aniesthesia is used except Schleich's local infiltration. The curved polypus forceps are guided by a finger of the left hand inserted into the rectum. By turn ing the forceps ninety degrees the nod ule is brought up out of the anus, and with the surrounding mucosa is then ligated with an elastic cord stretched to its utmost. The nodules lose their vitality in eight to ten days and drop off, leaving a clean, granulating surface. The external anal skin must not be in cluded in the ligature. Editorial (Jour. Amer. Med. Assoc., Nov. 6, '97).
The el amp-a nd-eautery operation was originated by Mr. Cusack, of Dublin, and brought prominently before the pro fession in England by Mr. Henry Smith. In America it is a question which is the more popular, the clamp-and-cautery or the ligature, both having advocates of equal ability. I have previously indi cated my preference for the clamp-and cautery operation. At present there are at our command many admirable clamps, the very popular Paquelin cautery, and the cautery irons. By the aid of these the operation can be performed with rapidity; and, when used with care, it is not a barbarous procedure, as is often claimed, but a scientific surgical opera tion, whereby only the diseased tissue is removed. The pain which follows the
clamp-and-cautery operation is less than that of any other operation for piles.
There are four steps in the operation: I. The sphincter-muscle should be thor oughly divulsed in every direction (Fig.. 2). This will cause the piles to come quite prominently into view. Each in turn is seized with a vulsellum or catch tooth forceps and drawn well down. 2. The mucous membrane and skin should be severed and the pile dissected upward gated and a wedge-shaped compress placed over the anus and kept in place by a well-adjusted T-bandage.
When the piles are small or situated high up and cannot be drawn down and clamped, the narrow cautery-blade should be drawn once or twice across each pile; this will cause them to shrink up. The cautery may be applied, if used with discretion, to any dilated veins pres ent that might at some future time form piles.
This operation is preferable to the (Fig. 3). 3. The clamp should be ad justed firmly in the incision at the base of the tumor; that portion external to the clamp is then excised with a pair of scissors. 4. Every portion of the stump should be thoroughly cauterized with the cautery-point at a dull-red heat, after which the clamp should be loosened to see if bleeding occur (Fig. 4). If it does, the operator should readjust the clamp and cauterize all bleeding-points.
After all the piles have been removed in this way the rectum should be irri ligature; not because the cure is more effective, or the operation less difficult to perform, but because of the facts that the operation can be performed more quickly, with greater ease and accuracy, and the patient's suffering is less and re covery is several days earlier than after the ligature. When the ligature has been applied ordinarily it will not slough off before the eighth day; and, when it does, it leaves an ulcer with irregular edges, which not infrequently has a tendency to become chronic.
At best, patients are rarely able to be about the room before the tenth day, and frequently not for two weeks; while after the cautery method the ulcer will be clean and smooth shortly after the oper ation, and will be practically healed by the time the ligature has sloughed off. Patients can sit up on the third or fourth day, and it is a rare occurrence if they are detained from business more than a week.