The Crushing Operation. The crushing operation is probably one of the oldest for the treatment of hemorrhoids. It was formerly the custom to seize the whole tumor with the powerful flat-jawed forceps and then crush it. leaving the pulp thus formed to slough away. This method, however, is now obsolete. The operation was introduced by Pol-lock of London, in 1880, and later used by Appalling, who substituted a screw crusher, which he advocates for the internal pile only. The pile is drawn through the crusher, which is then divided and the projecting portion is removed with a scissors. The crusher is allowed to remain on the tumor for about one-half minute and then taken off. Appalling advocates the use of the crusher only when the hemorrhoids are small and few in number. The operation is only applicable to cases one would select as favorable for the injection method and for that reason is not likely to be popular in this country. The method is particularly free from hemorrhage, a shorter period is required for recovery and the pain is less than when the ligature is used.

Strangulated Hemorrhoids. Probably the most frequent demand for relief by operation is due to the strangulation of the hemorrhoid mass. Strangulation occurs from either the prolapse of the hemorrhoid tissue or to an inflammatory condition, which causes an edema sufficient to extrude the hemorrhoids. Prolapse without irritation may result in strangulation after unusual straining, lifting, and inflammation. It may have its origin in a fissure, or be due to the bruise or abrasion of a hemorrhoid from a hard stool. Polyp or malignant tumors are frequently associated with strangulated hemorrhoids.

Dilatation of the sphincters with either the fingers or the common rectal dilator often gives relief in the simple form of strangulated hemorrhoids, as is proven by the sale of these dilators in the shops for the cure of hemorrhoids. Mild cases complicated by the presence of a fissure in anew, which is responsible for a certain amount of tenements, are also benefited by a mild degree of dilatation which may be classified as a palliative form of treatment. Strangulation occurs only with the internal and mixed varieties of hemorrhoids, as the external variety cannot be grasped within the sphincter.

When strangulation has gone so far as to become gangrenous the operation is considered by some as unnecessary and they permit the mass to slough off as would occur with prolapse of the rectum. This procedure is seemingly unnecessary as the tendency of the slough is to involve a large area of the mucous membrane and therefore is not definite in its outline. Subsequent healing must occur by slow granulation, the tissue is devitalized and much more subject to infection. The operation by the clamp and cattery can be performed in from fifteen to twenty minutes, the tissue is sealed by cauterization, the wound is definite in its area, and nature is assisted materially in its efforts at healing.

Hemorrhoids which have not become gangrenous, or when operation is postponed or inadvisable, are best treated by placing the patient in bed. with the hips elevated. Com-presses soaked in hot water or a twenty-five per cent. boor-triglyceride solution should be applied to the parts and a hot water bag laid over these to maintain the heat, which will encourage the circulation and prevent suffering.

Cold applications should not be used in these cases, as everything should be used to encourage a healthy circulation. During the period of strangulation, there is apt to be a rise in temperature of one to two degrees, accompanied by pain and distress, due to the prolapse or strangulation, and the patient is usually eager for surgical help to get relief.

Accidents and Complications which follow operation are pain, strangulate, dyslexia, hemorrhage, tetanus and erysipelas, varying with different individuals, with the operation, the method of anesthesia, the degree of operative interference and the place of operation. Local anesthesia sounds well to the average patient and is often the only method available for a certain class of people that fear the knife, but taking the subject broadly, local anesthesia is as uncertain in its relief from pain in rectal work as in other portions of the body. While one can do preliminary work and sometimes a complete operation, with only a reasonable amount of suffering, unexpected complications met with often give rise to considerable pain. Local anesthesia, therefore, should only be used in cases where one or two hemorrhoids are to be removed and the operation made as short as possible, so there will be little chance for drug poisoning and suffering.

The ligature operation gives more pain for a longer period than the clamp and cattery and, if we leave aside the consideration of other complications, it is altogether not so favorable an operation as the clamp and cattery Excision of the hemorrhoid mass (Whitehead operation) causes very great pain for a period of from eight to ten hours. After this, however, it subsides and practically ceases.

Opium or morphine are by far the best remedies to control the pain after hemorrhoid operations, and may be combined sometimes with bromide of soda for nervous individuals. Hot water compresses relieve pain and congestion and are advisably combined with the opium treatment in these cases. Orthonormal or pure chloroform or ten per cent. ointment of ichthyology applied before stools often relieves pain.

Strangulate and Dyslexia are most frequent complications with ligature operations, either under general or local antithesis In some instances it persists for from two days to a few weeks. Catheterize is sometimes necessary after the clamp and cattery and excision operations but not so frequently nor persistently as after the ligature. As a rule, the closer the rectum is packed the more likely we are to have this complication. The simplest relief from this difficulty is with the hot water compress applied directly to the held of operation. If properly and frequently applied this treatment seldom fails to relieve the sufferer. The knee-chest or the erect position seems to assist in emptying the bladder. If catheterize be necessary strict sepsis should he enforced to avoid infection of the bladder.