QC}C 15, t921) BECTION OF PROCTOLOGt r TEz BRItTr 59 _qwj_ I59 f9211 L UMDICAL JOU.A 593 during this stage. Where this procedure lhas been carried out I lhave had no failures and no fatalities due to the anaesthetic. The absence of post-operative shock, vomiting, and pulmonary complications has been remarkable in all cases. Spinal anaesthesia has also distinct advantages over local anaesthesia in operating for strangulated herniae. It is in these cases often impossible to obtain satisfactory

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... estlhesia of the parietal peritoneum by local infiltration, and muclh pain and discomfort are thereby caused to the patient. Furthier, tlle pain experienced after operations performed under local anaesthesia is frequently a marked and disagreeable feature. I would tlherefore emplhasize the advantages of spinal anaesthesia for urgency operations in the aged. Where the patient's condition is so bad as almost to negative operation, spinal anaesthesia enables the operation to be safely undertaken. No preliminary preparation is necessary, and fluids cau be taken by the mouth during and imwediately after the operation is completed-a great gain to elderly patients. Shock, post-operative vomiting, and pulmonary complications are completely avoided. The extreme relaxation of the abdominal wall makes the handling of distended gut an easy matter in cases of intestinal obstruction. All tlese details are of equal importance to surgeon and patient alike, and tend appreciably to reduce the mortality for these operations. AT tlle Annual Meeting at Cambridge last year, when speaking on tile subject of the operative treatment of -cancer of the rectulm, I affirmed tllat there was no surgical subject on whicll surgeons differed so much or had varied their views so often. To-day, in discussing the operative treatment of haemorrhoids, I feel tllat we are dealing with a subject wllich is in the main stabilized, but I recognize tllat tllere are differences in practice in different schlools and details in the technique and aftertreatment whiclh miiay afford useful material for discussion. For the purpose of tlhis discussion I have prepared some fiaures based on a series of 1,000 consecutive cases treated at St. Mark's Hospital, and I am much indebted to Mr. Clement Chapman for the trouble lie has taken in ex--amining tlle records and preparing these figures. I think I cannot do better tllan go tllrouglh them and consider their bearing on the operative treatment of lhaemorrhoids. The first point to note is tllat, excluding external .haemorrhoids, which are in reality haematomata, only 560 -out of 904 cases of internal haemorrhoids-that is, 62 per cent.-required to be operated on as in-patients. It is possible thlat if more beds were available this figure miglht have been hjigher, but I do not think it would be appreciably so, because all cases considered to require operation go oni the waiting list, and very rarely fail to conme in whlen sent for-tllat is, tlley have not soughlt admission elsewlhere. In other words, it is possible to cutre some 40 per cent. of cases of piles proper witlhout operation. We are not concerned to-day with non-operative treatment. With regard to the cases of external haemorrhoids little need be said, for they are cured, and cured quickly, by incision and turning out the clot, or cutting off en bloc with or without a local anaesthetic. They have, in my opinion, little relationship to true piles, and are usually due to haemorrhages from the venous radicles of tthe inferior haemorrhoidals which occur as the result of straining at stool, and are of little consequence unless they become inflamed. The subject of the treatment of internal lhaemorrlhoids by injections is of some interest and one of tlle points which I hope will provide fruitful discussion. My personal experience of this treatment is limited to a small number of cases treated some years ago in the out-patient department at St. Mark's Hospital and to an occasional case injected in private. So far as the practice at St. Marlk's is concerned, you will see tllat only 49 cases out of 598 internal haemorrlloids were submitted to treatment by injection, and that the results were as follows: Cured 33, or 67 per cent.; improved 9; required operation 7, or 1 in 7. A perineal abscess followed in one case. It would appear from inquiries made at St. Mark's Hospital that tllere is a prevalent impression that this form of treatment is freely practised -there-an impression which may have arisen from an article having been written on the subject in the BRITISH MEDICAL JOURNAL by an advocate of tllis method who did temporary work at St. Mark's during the war. The method does not, however, find much favour with the assistant surgeons of the hospital at the present time. Without doubt carbolic iujections are most useful for and frequently cure the single bleeding pile, whiclh is a great inconvenience, and yet lhardly seems to justify an operation; sometimes by a single injection, but more often after three or four weekly injections. Treatment by injection, so far as experience at St. Mark's goes, is not satisfactory for multiple piles or for the intero-external variety. Failure to replace a thrombosing pile, if it prolapses after injection, may result in active inflammation, and though only one case of abscess occurred in 'the 49 under review, perianal and even iscliio-rectal abscess is well known to be a serious complication of this form of treatment, though probably due to faulty technique. No doubt, like all surgical methods, experience improves results, and it may be that we ought to give a more extended trial to this method, especially amongst those who can ill afford the time to lie up and do not enjoy the benefits of national insurance, out-of-work pay, and the like, and also for those who for some cause or another are unsuitable patients for an operation under an anaesthetic. The important factor to arrive at is the percentage of cases who, after treatment by injection, subsequently require operation. In the present series of 49, 7 were not cured by injection and required operation-that is, 14 per cent. The author of a recent article in the Practitioner, Mr. Eadie, a whole-hlearted advocate of injection; in preference to operation, gives injections two or three times a week, and finds that some nine applications are usually necessary for a cure. He goes on to say: " There appears to be a tendency for other veins of the anal canal to become varicose wlhen the supporting pressure of the piles is removed, and by seeing the patient from time to time we can inject these as these show in the speculum and before they give rise to symptoms. I therefore like to keep the patient under observation for a year, seeing him every two or three months." I think that this prolonged period of treatment must prove irksome to tlle patient, and it seems to me tllat twelve days or so in bed after a clamp and cautery opera. tion might prove not only more efficacious in the long run but more economical, both as regards time and money. It seems to me, lhowever, tllat treatment by injection is entitled to more consideration than it lhas met with in the past, and it is one of the points which I expect to hear freely discussed at this meeting. Tlle next point I wish to consider is the type of operation to be recommended and the special advantage and disadvantage of eaclh. You will see that in the series under consideration the ratio of the Wliitehead operation to ligature is about 1 in 60 and the clamp and cautery to ligature about 1 in 40. At the present time the clamp and cautery percentage is highier, because I believe I am more partial to this operation than either of my colleagues on the senior staff, and during a good part of tlle period involved in these statistics I was absent at the var. During 1920 there were 272 ligature operations, 23 clamp and cautery, 10 W\Tliteheadl, or about 1 in 27 Whlitehead to ligature, and 1 in 12 clamp and cautery to ligature. * Carbolic 10 parts. hamamehis 10, and water 80.