When an operation is necessary, that best suited for the case under advisement should be selected, no single operation being adaptable to all cases.
The general health of the patient should be looked into, and improved, if need be, by appropriate measures. The urine should be carefully examined to detect the presence of any kidney com plication. On the morning preceding the operation 2 teaspoonfuls of com pound licorice-powder should be given, and one hour previous to the same the surrounding parts should be cleansed, shaved, if necessary, and the rectum thor oughly washed out.
OPERATIONS.—Many operations, more or less valuable, have been devised for the relief of hemorrhoids. Dilatation of the sphincter has met with some success by French surgeons, who originated it.
Dilatation of the anus. In the first stage of haimorrhoids—that of inter mittence, where the attacks occur but three or four times a year and are ac companied by a slight burning sensation and pruritus of the anus, with a small flow of blood—gentle purgatives are ordered, applications of very warm water, enemata at the same tempera ture, and applications of plugs of cotton steeped in a 1-per-cent. solution of co caine. In the second stage, where the piles are procident and the rectal vari cose veins are very painful, forcible dila tation gives unvarying success. Before employing the speculum, local anes thesia of the parts is produced in the following manner: The patient being placed in the classical position on the side, with one leg extended, the other bent on the thigh and on the abdomen, an assistant exposes the anal region. The operator takes in a forceps a small plug of cotton, steeped in a 1-per-cent. solution of cocaine, and passes it into the rectum as high up as possible; this plug is followed by another a little larger, and yet a third and a fourth, increasing in size until he can insert one as large as a walnut. He then takes an ordinary Pravaz syringe filled with the same solution and inserts the needle into the perineum, half an inch from the anus, and injects slowly the contents, taking care to turn the needle in differ ent directions, and by this means one fourth of the circle limiting the rectal orifice is anmsthetized. The injection is
renewed in the second quarter, and so on until the circle is completed, each syringe containing '/, grain; it is thus that 1 grain of cocaine has been injected. But in order that the dilating process should be painless the sphincter must be ans thetized, and for this purpose the oper ator passes the index finger of the left hand into the rectum and plunges the needle through the skin up to the muscle, guiding it with the finger; he empties half of the syringe at that point and the remainder as he is withdraw ing it.
Twenty-six patients operated upon in this way without any accident. In the third stage, where the veins form a tur gescent mass, they should be removed with the bistoury, without dissection of the mucous membrane. Paul Reclus (La Semaine Med., Nov. 2S, '94).
Experience has shown, however, that dilatation offers only temporary relief. The crushing method of Mr. Herbert Allingham is occasionally used in Eng land, but rarely in this country.
And it may be said that of all the oper ations proposed, but four operations are entitled to consideration. They are: the injection, Whitehead's, ligature, and clamp and cautery.
Injection.—A few years ago the treat ment of piles by this method was quite in vogue, but specialists have practically discarded it. Experience has shown that the results are not permanent and that annoying complications frequently arise. This method is attractive to the laity because no knife is used; it is sometimes painless, and does not detain them from their business. This is true when a per fect result is obtained. On the other hand, when extensive inflammation and sloughing occurs they will suffer more pain and be detained longer than if a better and more radical operation had been made. It certainly is not the best operation for the average case of piles and is suited only for the small, distinct, pendulous piles situated above the grasp of the sphincter-muscle that bleed freely.