It is as a rule unwise to operate upon internal piles when in the state of acute inflammation.
Many attacks of external piles are due to extravasation of blood caused by rupture of the dilated vein during defecation, the thrombus so dis tending the tissues as to cause intense agonising pain. Here the surgeon can give instant relief by freely incising the skin over the inflamed vein and turning out the clot. Such cases, if left alone, spontaneously resolve themselves and the hmmorrhoid disappears, hut several days of severe suffering can be immediately cut short by one prompt incision.
Severe hamorrhage from internal piles is a clear indication for their removal, but in emergency the loss of blood must be stopped. Packing the rectum with ice or Puff Ball is advocated. Haemostatic injections as Hazeline, Perchloride of Iron, Tannin, Hydrastis, Alum, &c., have given way to Adrenalin Chloride, a small quantity of which diluted with 4 times as much water should be injected beyond the sphincter. The speculum may be introduced and the cleansed bleeding-point swabbed over with the undiluted solution, or the actual or electro-cautery at a dull red heat may be passed over its surface lightly in a linear manner; this latter procedure often effects a cure by forming an eschar under which the withered pile shrivels up.
linnals plan of treating all hemorrhoids is to employ a r in zo oint ment of Chrysarobin„ and others report favourably' of a i gr. suppository of the same with Belladonna and lodoform.
Surgical Treatment—The removal of the hemorrhoidal mass must be determined upon when palliative treatment has failed to relieve pain, prolapse and repeated hemorrhages. The method of injecting into each internal and protruded pile a few minims of a 20 per cent. solution of pure Carbolic Acid in glycerin and water is maintaining its reputation, and should be resorted to when for any special reason the usual cutting or ligaturing operation is contra-indicated; it effectually relieves pruritus. There is little to be said in favour of merely applying the cautery to the hemorrhagic mass with the view of destroying it—a procedure which is associated with much pain in the case of external hemorrhoids, and which is of little use in large internal piles. Electrolysis is practised by a few who employ an ionisation of a zinc solution by the unipolar method, but at best the results are only palliative.
External piles should he removed only by the scissors, a ligature never being resorted to save when necessary to tie a spouting vessel, but the skin around the pile must not be ligatured. A drop or two of Cocaine
solution may he injected into the base of each after thorough disinfection of the anal region, after which the piles are to be separately snipped off and the raw surface treated by lodoform under a pad of dry lint to which pressure is applied by a suitable bandage. ('arc should be taken not to remove any skin unnecessarily, lest the anal opening might become contracted in calibre, but all tags and redundant folds of skin containing remnants of former should be removed.
Internal piles may he removed by ligaturing, by excision, by the use of the clamp and cautery, or by crushing.
The patient should have a free purge given two days before—either castor oil or a saline, which should be repeated upon the day previous to the morning of the operation. Some surgeons give castor oil for the first purge, and follow it up by a saline, no solid food being administered after. Early on the morning of the operation the colon must be emptied by one or two large enemas. the patient has been fully anmsthe tised the surgeon inserts both his thlimb5 well inside the anus, and slowly dilates the sphincter without tearing it. The hemorrhoidal mass is then brought into view and within easy reach.
If the operation by ligature, which is the simplest and most easily performed, is selected the surgeon proceeds to seize each hemorrhoid separately with a pile forceps, and having snipped through with blunt nosed scissors the mucous membrane around its base, a stout silk ligature is tightly applied so as to thoroughly strangulate the mass, care being taken that the silk is buried in the sulcus or groove made by the scissors in order to prevent slipping. The pile is then cut off, but not too close to the ligature. Large hemorrhoids should be transfixed through the base by a sharp needle carrying a strong ligature in its eye, and the pedicle tied as tightly as possible before cutting off the distal portion of the pile. Small haemorrhoids may be ligatured without cutting away any tissue, but the mucous membrane must always be snipped through before the ligature is applied, otherwise the latter is certain to slip. Each pile having been separately treated in the above manner, and any external ones removed by the scissors, a Morphia Suppository may be slipped through the relaxed sphincter, and a dry antiseptic dressing applied under a T-bandage before the patient is carried to bed.