Internal piles.—Incision is extremely dangerous, from the vascularity of the parts, and their being so inaccessible from their position within the sphincter ani. Hence ligature is safer and equally effectual. The patient should be directed to sit over hot water, and strain till the whole of his piles are fairly protruded. The surgeon should then transfix the base of each separately with a curved needle bearing a strong double thread. The needle being cut off, the threads should be very firmly tied, each isolating its own half of the pile. The tying should be exceedingly tight, so as to cause instant and complete strangulation and death of the tumours. All the piles should be tied at the same sitting. If the piles are very small they may be secured without transfixion in a single noose after being seized by a hook or forceps. There is greater risk of the noose slipping than when the base has been transfixed.
The strangulated masses must then be returned into the bowel, and the patient kept in bed or on a sofa till the ligatures separate, which is generally not till the fourth or fifth day. A certain amount of urinary irritation, showing itself sometimes in strangury, sometimes in complete retention, occasionally follows this operation.
Mr. Smith of King's College, and many other surgeons, treat internal piles by means of an ivory clamp to hold them tight, while they are burned off by the actual cautery or the thermo-cautery at a low red heat. They claim that pyæmia more rarely follows this mode.
There are certain cases in which the lower inch or two of the rectum are found red and congested, and in which every stool is followed by the loss of a certain quantity of florid arterial blood, and yet no distinct hæmorrhoidal tumour is to be seen. In such cases the ligature is not applicable, and relief is obtained by the application of pure nitric acid, or other potential caustics to the bleeding surface, as recommended by Houston, Lee, Smith, Ashton, and others. These cases are comparatively rare, and whenever they can be applied, the ligature is much simpler, safer, and more certain.
Venous piles.—When a sudden effusion of blood has occurred into one of the varicose veins or sinuses of a congested anus, an oval or rounded tumour is felt, very tense, shining, and painful. To slit it freely up with an abscess lancet, and evert the clot inside, at once relieves all the symptoms.
CHAPTER XIII.
TENOTOMY.
For convenience' sake I group under this one head certain operations used for the relief of distortion, in which muscles or tendons are divided subcutaneously. Since the discovery of the principle by Delpech, and the application of it by Stromeyer, Dieffenbach, Little, and countless successors, it has been used for very many cases for which it is totally inapplicable, e.g. for the division of the muscles of the back in spinal curvature. Still there remain several deformities for the relief of which subcutaneous tenotomy is a most important remedy; chief among these are Wry Neck and Club-foot.