— In the thrombotic variety the tumors should each be incised, the clot turned out, and some escharotic or packing applied to the inside of the pile to insure the clos ing of any rent in the vein. The patient should then be placed in bed to remain there for several hours to prevent the tumors filling up again.
The surgical treatment of the cuta neous variety differs somewhat from the one just referred to, in that the tumor is seized with a pair of catch-tooth for ceps and then snipped off with a pair of curved scissors, care being exercised not to remove any more of the skin than is absolutely necessary, lest too much con traction follow the operation. When there is considerable space between the edge of the skin and the mucous mem brane, it is best to unite them by catgut sutures. If the sphincter has been pre viously divulsed, little pain will follow the operation. When there is only one tumor and that small, it can be removed with comparatively little pain after an injection into it of a 6-per-cent. solution of cocaine. It does not make any differ ence, from an operative point of view, whether the pile is inflamed or not; it should be operated upon just as soon as the patient's consent is obtained.
Cases of stricture from operations for extreme hremorrhoids have been re ported, but they are rare and follow only where an excessive raw surface is left after removal of swelled tumors.
Cutaneous Haemorrhoid, or Hypertro phied Skin.—This variety consists of hypertrophied prolongations of the skin. Cutaneous piles are frequently a result of the other variety, a fold of skin being left after the clot has been out-turned or absorbed. They may be single or mul tiple, but usually retain the natural color of the skin, which has become thickened. They are much aggravated by improper diet, irregular habits, and uncleanliness.
Internal Hmnorrhoids.
Internal hemorrhoids are developed, in many respects, like the external va riety, and the causes which produce the one may also produce the other. In cases of long standing they remain outside the anus nearly all the time and frequently become ulcerated, causing much pain and bleeding. It is not uncommon to see both external and internal piles pres ent at the same time, thus necessitating a 001111)in:it ion operation to insure a good result. The internal variety is due to
certain changes which take place in the blood-vessels in and beneath the mucous membrane.
Symptoms.—Some patients have in ternal piles for years and suffer very little annoyance from them, while others suf fer greatly from the first. Frequently strong men and women become emaci ated and nervous from an apparently simple ease,—so much so that they are totally unable to attend to their ordinary duties. The most prominent symptom of this variety of piles is the bleeding, and from this fact they are frequently referred to as "bleeding-piles." The bleeding is usually preceded by the pro trusion of the tumors during the act of defecation, and may be slight or pro fuse. Sometimes the haemorrhages are sufficient to induce fainting. When the piles are not inflamed, the only incon venience is a sensation of heat and full ness; but when they become swelled or strangulated and the inflammation be comes active, the sphincter alternately contracts and relaxes on them, thus pro ducing most excruciating pain, which lasts until they slough off, have been operated on, or are relieved by palliative remedies. In cases of long-standing, the walls of the piles become tough and hypertrophied. The bleeding, in the vast majority of cases, is of a venous character.
Cripps believes that the spurting, in cases which appear to be arterial, is due to the blood being forced as a regur gitant stream through a rupture in the vein by the powerful abdominal muscles. In sonic instances, however, others have witnessed hemorrhages wherein the blood presented the appearance of that coming from an arterial twig.
Internal haemorrhoids may be divided into two classes, viz.: capillary and venous.
—The capillary tumors are rare, smaller than the venous, spongy in texture, are formed by the superficial vessels of the mucous membrane, and re semble strawberries. They may appear alone or be present with the venous va riety. They rarely protrude and scarcely ever give pain, but always bleed pro fusely.