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Postoperative treatment. — General surgeons are divided in their method of controlling the stools after rectal operations. Many purge the patient, vendita di viagra online liquefy the feces, and keep him busy and miserable through his frequent visits to the toilet, while oth- ers administer an opiate and tie up the bowel for days, procedures to be condemned because the former insures continuous irrigation and favors infection through soiling the field with fluid feces and the latter leads to excruciating pain and tear- ing open of the wound when accumulated, dry, and nodular fecal masses are evacuated. The writer kpens his patients on a regular diet and does not order a laxative unless the stools are hard, when he prescribes mineral oil, fruit, or other 596 MEDICAL RKC(JRD. [Oct. 9, 1915 laxative in .small doses to soften but not liquefy them, for at one sitting semisolid feces are evacu- ated without pain or injury. The former practice of cauterizinij wounds nu longer obtains, and they are drained and not packed, pernicious procedures responsible for vendita di viagra online many un- healed sores and fecal incontinence. For cleansing wounds, the swab and cotton moistened in an anti- septic buy viagra online in south africa is substituted for copious irrigation, which leaves the buy viagra online in south africa rectum filled with the solution, which dribbles out, soils the dressings, and keeps the patient uncomfortable. When healing is tardy the wound is satisfactorily stimulated by placing a gauze pledget moistened in a buy viagra online in south africa silver nitrate 6 per cent., ichthyol 10 per cent, or balsam of Peru 20 per cent, solution in it, but when the tissues are irritable and rebel against stimulants methylene blue 10 per cent, is soothing and effective. Pain from topical applications can be minimized by eucaine or cocaine 10 per cent, applications, but all suffering can be prevented by injecting eucaine (ig per cent.) beneath the lesion before it is treated. Pruritus Ani. — Ball's operation for pruritus ani, having for its object the severing of nerves from the skin, is buy viagra online in south africa an elaborate procedure and leaves ex- tensive wounds to heal when infection occurs. The writer has vendita di viagra online modified this procedure so that buy viagra online in south africa it can be performed under local anesthesia in ten minutes and the patient need not remain in bed more than two or three days. External Thrombotic Hemorrlioids are anesthet- ized by injecting enough eucaine into the pile to turn it white, when it is transfixed with a sharp- pointed curved bistoury, slit open, the clot turned out, and the wound drained to prevent reformation of the tumor. Subsequent dressings consist in cleansing the wound and inserting gauze drains un- til healing is complete. External Cutaneous Hemorrhoids are quickly re- moved with knife or scissors after having been in- jected with eucaine, which induces complete anes- thesia within 20 seconds. Following excision the wounds are closed with catgut or permitted to heal by granulation which is preferable, since there is less danger from infection and postoperative pain is slight. Many operations have been suggested for the cure of internal hemorrhoids, but the following pro- cedures named in the order of their usefulness, viz. : ligature, clamp, and cautery and modified excision operations are the most dependable and less often followed by annoying and dangerous sequete. Ligature Operation. — The ligature operatif)n is generally used, reliable, is rarely followed by hemor- rhage or complications, and its technique is simple and can be carried out under local or general anes- thesia. Except when there is a special reason for administering gas or ether the writer always oper- ates under sterile water or eucaine (Vs per cent.) anesthesia. Hemorrhoids are brought into view by a small enema, suction pump, having the patient strain, everting the anus, tilting buy viagra online in south africa the fenestrated speculum as withdrawn, or by inserting cotton tam- pons and withdrawing them simultaneously- which extrudes the piles. The hemorrhoid is then injected with water or eucaine until white (which indicates complete anes- thesia) incised at the mucocutaneous juncture, ligatured, and removed with knife or scissors. Remaining tumors are similarly treated and the operation completed by pushing hemorrhoidal stumps above the sphincter. A thick wedge-shaped gauze pressure-pad is then placed over the anus and held in place by a strong T-binder to arrest and prevent bleeding. Hemorrhoids located high after having been in- jected through an opening in the speculum are brought downward into the field of operation with forceps. Formerly following ligature operations patients suffered considerably, and it often became necessary to catheterize them, but since the writer discarded large, heavy, harsh plaited silk for linen ligatures, severe postoperative pain and inability to void the urine have vendita di viagra online been rare complications because the sphincter and levator ani muscles are irritated less.