Eucalypti may be used in the same strength as cocaine, but has the advantage of not being so poisonous. Ethyl chloride has been advocated by the inexperienced for rectal operations, but if one once tries to anesthetize the rectal mucosa with the solution, the experience will be sufficient to demonstrate the extreme sensitiveness of the membrane to the freezing process and another trial will not be ventured. Quinine and urea hydrochloride has become a favorite combination for rectal local anesthesia and is deserving of the most complimentary position in the category of drugs for that purpose. It has proved most satisfactory as to anesthesia and to its non-toxic effects. The only drawback to its superiority over cocaine and eucalypti is that one must wait for five and sometimes ten minutes, before complete anesthesia is certain.

When the complete anesthesia of the part has supervened, the area of sensitiveness is much greater and more widespread than with cocaine, in my experience. Cocaine anesthesia is not as lasting in its effects as quinine and urea hydrochloride, the latter being almost certain to cover seven or eight hours. This is a great advantage when we consider that it outlasts the nervous shock attendant upon these operations.

It is well to bear in mind that local anesthesia in the operative treatment of rectal diseases is dependent largely upon the dexterity of the surgeon in properly infiltrating the mass to be treated, so that the patient will not resist the necessary manipulation of the surrounding tissue. Often the pulling and handling of the adjacent parts during the local anesthetic operations will excite fear and a lack of confidence in the operator, which in turn may produce so much nervousness in the patient as to make them struggle when the ligature is tied. Undoubtedly tying the ligature is the test of local anesthesia. The cocaine solution should never contain more than one-quarter grain in its total volume and a solution of one to five hundred is to be recommended as sufficient and safe, in preference to the stronger solutions. This weak solution of cocaine will do quite as well, if properly introduced, and leave no doubt as to its possible poisonous effect.

Fig 63. Stonewalling method of ligation within a sulfurs cut about the base of the hemorrhoid.

As a preliminary step toward the attainment of success with any of the infiltrating solutions used for producing local anesthesia, the correct diagnosis of the existing pathological condition under consideration should be of paramount miimportance When one attempts to operate upon a fistulous tract which is tortuous and subdivided into several penetrating branches extending beyond the area which has been anesthetized, the incomplete freedom from sensation in the distant tract results in pain and resistance on the part of the patient, which is often humiliating to the operator, to say the least. Under such circumstances it is far better to thoroughly understand the limits of work to be accomplished and to strictly confine our efforts within the region previously prepared for it.

When a certain diagnosis cannot be made before beginning operations on fistula, a general anesthetic should be recommended to permit thorough examination of the parts. In some instances, when the intention of the operator is to partially incise a long fistulous tract and he has purposely omitted complete anesthetization of it, exception to this advice may be judiciously taken. The following procedure is in favor among some practitioners. They anesthetize and incise a small portion of the tract on different days, until the entire course of the fistula is opened. This is both tedious and uncertain, but is acceptable to some persons who are timid and care little for the time it takes to relieve the condition.

In some cases hemorrhoids may exhibit all the symptoms commonly associated with the disease, such as protrusion at stool, bleeding, pain and tenements, but they may exist only as the result of one or two eroded hemorrhoids which act as an irritant to the sensitive anal canal, producing expulsion of the others.

If forced to operate under local anesthesia to afford relief to these cases, one should select for removal the hemorrhoids which seem to produce the greatest amount of annoyance to the patient. The results, after the removal of these offending hemorrhoids, are very frequently most gratifying to the patient and surgeon and warrant the careful inspection of the affected hemorrhoid area in an effort to select, if possible, a pile which is responsible for the trouble and remove it under local anesthesia.

Infiltration of the anew-rectal region is advocated by different operators in degrees varying with their personal experience and the amount of hemorrhoid tissue to be removed. Where more than two hemorrhoids are to be the subject of this form of anesthesia, the entire anal ring and the rectal mucous membrane involved should be infiltrated.

However,care and judgment should be exercised as to the quantity of the infiltrating solution injected, particularly when the ligature operation is done without much bleeding or leakage. When sufficient fluid is injected to choke off the local blood supply from pressure, one may find later either a localized area of dead mucous membrane, or have the entire lower rectal mucous membrane slough. No attempt to produce pressure anesthesia over the entire anal region should be made by infiltration.

Sterile Water Anesthesia seems to act only by virtue of the pressure produced in firm, unyielding tissue, and is probably the initial anesthesia brought about with any hypodermic injection. Such anesthesia is very transitional and is confined only to the area which resists infiltration. Soft healthy or broken-down ulcerated tissues do not hold the water injection well enough to produce anesthesia, but hypertrophied, tough and unyielding hemorrhoids, which have existed for years, are often ideal for simple water anesthesia. In my experience not more than two hemorrhoids should be operated upon at one time under this form of anesthesia, for the traumatize to the surrounding tissue causes considerable pain.