One important feature which should always be practised is thorough dilatation of the sphincter, not only for reasons above described, but because of the facility with which the surgeon then exposes the diseased tissues. Any distinct tumor or series of them may, for instance, be seized, isolated, and dissected out, either by an elliptical incision of the mucosa or by a more blunt dissection with scissors. The base, or pedicle, if sufficiently large to justify it, may be ligated before the incision is completed, after which catgut sutures may be used to close the opening in the mucosa. When the tumor is small the suture may be made to include the bleeding points so that even a ligature is not required. A more radical method of extending this same principle to the entire pile-bearing area, especially when prolapsed, or to so much of it as is affected, is the so-called Whitehead’s operation of excision, which practically consists in trimming off a ring of exposed mucosa, with its clusters of enlarged and more or less pendulous veins. This ring extends from the mucocutaneous border, at the verge of the anus, to a point perhaps 1¹⁄₂ inches above, the intent being to separate the mucosa and the tumors from the fibers of the sphincter, which can be practically effected in such a way that sphincter control is not lost. Hemorrhage will be free for a few moments, but is always within control. Larger vessels which spurt may be twisted or tied, while oozing surfaces are included within the row of catgut sutures, which is later placed in such a way as to unite the divided mucous tube with the skin border at the anus. The operation is, in effect, an annular excision of the lining of the rectum, and as such proves satisfactory. There is about it this temporary disadvantage that the pile-bearing area thus removed is also the sensitive area, and that for a few weeks, at least until nerve communications have been reëstablished, there is a lack of peculiar or normal sensibility about the parts which is annoying, and may perhaps lead to some incontinence, but this soon passes away. The measure is the most satisfactory of all for well-marked cases of hemorrhoids associated with more or less ulceration and prolapse.
An occasional dilatation, scattered here and there around the lower end of the rectum, perhaps with a mild degree of ulceration, is usually very satisfactorily treated by a method which it must be confessed would be rarely used on the exterior of the body, and yet which proves quite serviceable here, namely, the actual cautery. The consequences of its application are obliteration of the vein, cicatricial contraction of the overstretched tissues and eventual relief.
Fig. 593
Multiple polypi of rectum. (Potherat.)
Other methods of operation include the use of the clamp and cautery for removal of considerable masses, a method ordinarily less satisfactory than excision, and the use of the ligature, with or without incision of the mucosa at the base of the tumor, it being thus cauterized and expected to separate by sloughing, an uncertain procedure. None of these methods, nor others not worth mentioning, compare with the newer methods of excision.
Much has been recently written concerning the advantage of local anesthesia in doing these operations. This seems to have been advocated largely for effect, although external tumors can be treated by cocaine applications or by the ordinary injections of cocaine or one of its substitutes. It is claimed that the infiltration of the surrounding tissues with normal salt solution affords an effective local anesthetic. Mere local anesthesia is not sufficient for thorough work upon parts not easily visible, and the actual stretching of the sphincter is half the battle in dealing with these conditions. This cannot be thoroughly accomplished without general anesthesia. Consequently for any well-marked hemorrhoidal condition chloroform offers decidedly the preferable method, not alone from considerations of comfort, but from the standpoint of permitting more thorough and effective work to be done.
After these operations it is advisable to place within the grasp of the anus a stiff rubber tube wrapped with gauze. It permits the escape of flatus without distress to the patient, and it effects a better coaptation of surfaces recently united by suture than would otherwise be secured. Such a tube may be left in situ for from six to thirty-six hours.
TUMORS OF THE RECTUM.
The rectum is the frequent site, more especially in children, of polypoid degenerations similar to those seen in the nose. In consequence there are formed the so-called rectal polypi, which, in origin, consistence, and course correspond to the common nasal polypi. Such a pedunculated tumor may attain considerable size, especially when solitary, while, on the other hand, the mucosa may be studded with small pedunculated growths, giving the appearance represented in [Fig. 593].