A Manual of the Operations of Surgery, page 279 by Joseph Bell
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(as sometimes happens) the tumour be of uniform thickness throughout, like a worm.
HÆMORRHOIDS OR PILES.--In the treatment of piles it is the differential diagnosis that is troublesome and occasionally difficult; the operative interference required is generally very simple, if the nature of the case be rightly determined.
External piles.--Operation.--The apex of the soft flabby excrescence should be seized by a pair of catch-forceps, and it should be cut off close to its base with a knife, or, what is better, a pair of curved scissors. Any little vessel which jets may then be secured. If, instead of numerous individual tumours, a ring of skin round the anus be involved, the whole of it should be shaved off, but not very close to its base, lest too great contraction of the anal orifice should ensue.
If the surgeon, after excising a pile or piles, will take the trouble to stitch up the wound with catgut, he will find the cure much more rapid and less painful than when this is omitted.
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 bowe