The period of confinement after hemorrhoid operations varies with the method of operation from a few days to several weeks. An ordinary local anesthesia operation should n≪>t confine the patient to bed for more than a few hours or a few days at the most. The period of confinement after the clamp and cattery operation is from three to ten days, according to the judgment of the operator. According to the advocates of the ligature operation, the patient should be confined in bed for one or two weeks and kept in his room for two or three weeks longer, if necessary, until the ligatures cut through. The time necessary for the ligature to cut through varies from five days to five weeks and it is generally impossible to tell with any degree of certainty how long the patient will be confined after operation by the ligature method. If the patient be permitted to walk about before the ligature cuts through, there is danger of hemorrhage.

Secondary hemorrhage occurs more frequently from the ligature operation, but can be expected with any method of operative procedure in this region. The hemorrhage occurring after any of these operations has been so greatly exaggerated in description that many experienced operators are really afraid of it. Where bleeding is expected from complications during the operation, the introduction of a sup-depository containing three to five grains of witch-hazel or one to two grains of tannin acid, will usually control slight bleeding. When bleeding occurs after operation it may be controlled by packing the rectum. To do this effectively the rubber rectal tube, ordinarily inserted after a hemorrhoid operation, is wound around with a piece of gauze at about the middle of the tube, acting as a guard to prevent slipping. The tube is then put through a small opening in a square piece of gauze about the size of a gentleman's handkerchief. The gauze should not be allowed to slip past the guard on the tube. The tube is then pushed into the rectum so that the guard is above the internal sphincter. A firm packing is then introduced into the sort of pouch which it forms. Care should be taken to avoid bursting the rectum.

Allam has originated a conical sponge for this purpose, which is introduced into the ampul la of the rectum through a tube and then drawn down upon it by a cord which runs through its center.

The use of chloride of iron and other astringents are as a rule injurious and very irritating to the parts. Hot or cold water is best tried first for a few minutes and if not a success the Pennington tube will certainly give happier results. Should this not control the hemorrhage the patient should be anesthetized, the sphincter dilated and the blood vessels caught and tied. In the excision method the bleeding during the preliminary excision is always considerable, but secondary hemorrhage is practically unknown unless from some meddlesome interference.

Erysipelas infection occurs very seldom, but in the history of nearly all our old hospitals, death has been reported a few times from this cause. This form of infection is less likely to follow the clamp and cattery operation because the red heat of the iron not only kills the germ, but seals up the wound from further infection. Cree’s ointment is said to be almost a specific for erysipelas infection following a hemorrhoid operation.

Fig. 70. Control of bleeding by packing rectum with gauze, using Pennington tube.

Tetanus also follows hemorrhoid operations and in a number of cases reported where death was due to this disease, statistics show that in every instance the operation performed was the ligature method. No cases have been reported where tetanus followed the clamp and cattery or excision methods. Death from tetanus is almost a certainty after infection in these cases.

Abscesses and Fistula sometimes follow either of the methods in vogue for the surgical relief of hemorrhoids and are the result of infection brought about as a rule by traumatize in handling the parts or stretching the sphincters.

Stricture of the anal opening is probably more common following operations with the intention of removing all redundant tissue at the time of operation. One should recognize the fact that strangulated, swollen hemorrhoids are in part edemas and that when the irritating cause is removed or relief is given from the spasmodic contraction of the sphincters, the size and volume of the hemorrhoid mass will be greatly decreased. This is proven by the subsidence of the swelling between attacks of hemorrhoids as experienced by nearly all patients before they seek surgical aid. In the clamp and cattery operation stricture seldom results. Before removing these tumors it is well for the operator to form an idea as to the exact amount of redundant tissue which should be removed in order to bring about a normal condition, irrespective of the swollen and distorted appearance of the anal canal. This should be done while the patient is under the influence of a general anesthetic which causes a general relaxation of the body tissue. If operating under a local anesthetic the swelling produced by the hypodermic injection of the fluid is very likely to confuse one.

In the ligature operation stricture results from tying off too much or too large areas of mucous membrane. After the Whitehead operation, the stricture is likely to occur even under the most favorable conditions, as excision of the mucous membrane in its entirety and its union to a circular line in the skin can only form a circular cicatrix. This results in more or less of a stricture, dependent upon the amount of fibrous tissue formed beneath. Stricture may occur when the mucous membrane pouts above the line of union, forming a sort of roll on the wall of the anal canal. Ulceration and fissures at different portions of the anal canal are of common occurrence as the result of either the clamp and cattery or ligature operations but are easily healed within three to four weeks if the wound is kept clean with hot water, or peroxide of hydrogen. In conjunction with these aseptic some stimulating application in the form of twenty per cent. ichthyology solution, or balsam of Peru, introduced on a small piece of gauze into the anal canal every second or third day, will be found very efficacious.