Upon the third morning he may have an oil enema or a dose of castor oil, which is to be repeated each day to prevent scybake forming, as these are liable to interfere with the ligatures. The greatest care should be taken to keep the skin in the neighbourhood of the anus as clean as possible by douching with carbolic lotion, and dredging with Boracic Powder, or lubricating with Boracic Ointment. The ligatures may be expected to come away in about f o days, after which the patient may be permitted to sit up. Should there be much swelling of the parts or retention of urine, a hot sitz-bath may be administered, which will often prevent the necessity of catheterisation.
The operation of excision is carried out by seizing each pile separately with the forceps and cutting it off close to the mucous membrane, the lips of the incision in which are then to be sutured with catgut. The best operation is that devised by A. B. Mitchell, the description of which, written by himself for a former edition of the present work, is here repro duced. The mucous membrane is washed with a r in f ,000 Perchloride of Mercury solution: the sphincter is dilated. One of the piles is caught in a pair of forceps and pulled well down. A long narrow-bladed forceps (Kocher's artery forceps answers admirably) is then applied to the base of the pile, so as to include a vertical fold of mucous membrane i to 2 inches long. The pile having been pulled well into the grip of the forceps, the blades arc clamped and the projecting pile removed with scissors. A needle threaded with catgut is passed through the fold of mucous membrane just above the forceps, and the end of the catgut is firmly tied so as to include the artery running into the pile. The upper end being thus fixed a continuous suture is applied loosely around the blades of the forceps. The blades are then removed, and the suture rapidly tightened and secured at the lower end. Each pile is treated similarly, and when the operation, which takes from about 15 to 20 minutes, is completed, 4 to 6 vertical lines of sutures remain within the rectum. The operation is bloodless. No attempt is made to insure subsequent inaction of the bowels. The patient is up and about at the end of a week.
The clamp and cautery method is carried out after the same prelimi naries have been gone through as for the ligature operation. Each pile or separate Imumorrhoidal mass is seized with forceps and a clamp is applied to its base or pellicle; the pile is then cut off, and the cautery at a dull red heat is laid on the wounded surface, which is to be thoroughly scared before withdrawing the clamp. The after-treatment is identical
with that following ligature.
.1 crushing clamp is employed by some surgeons to do away with the necessity of the cautery. The base of the pile is squeezed or crushed in the clamp, and when this is forcibly screwed tight the pile is excised, and after a few minutes of this severe pressure the crusher is unfastened nail no hemorrhage follows.
Ball's method of operating combines several of the details of the ligature, excision and crushing operations. He transfixes the crushed pellicle with a stout ligature and tics each half tightly, bringing the ends of the ligature round so as to strangulate the entire pellicle, including the half already tied, after having secured for the ligature a subcutaneous hold on the revolutcd skin of the anal canal by a previous dissection.
Whitehead's operation consists in excision of the entire pile area by removing a ring of mucous membrane, including the luemorrnoids, the border of the excised wound being brought down and sutured to the anal margin. The danger of the operation when performed by unskilled hands lies in the liability to contraction of the anal aperture and to injury of the sphincter in the dissection process.
In the above operative procedures a complete relaxation of the sphincter is of primary importance, and Porter has shown that by the injection of 'hula:es Eucainc and Adrenalin solution previous to general anesthesia the greatest degree of patency may be obtained without permitting the chloroform or ether narcosis to be pushed to a high degree of insensibility. Some surgeons have operated under spinal anesthesia successfully.
Boas has introduced an operative method based upon the principles which often effect a natural cure in spontaneously prolapsed piles. The patient is made to strain forcibly, so as to cause prolapse of the hemor rhoidal masses, after which a Bier's suction apparatus is applied till a sufficient degree of (edema of the anal skin and tissues is produced as will prevent reduction. The prolapsed and strangulated mass is then allowed to shrivel, which process is usually completed in about a fortnight.