A table to facilitate the computation of the solutions of cocaine, eucalypti quinine and urea hydrochloride has been appended and will be found very useful to the practitioner when called upon to perform local anesthetic operations in his office at a moment's notice. Very often patients become nervous when the preparation for the operation seems elaborate, so that any confusion or hesitation is best avoided. The instruments, solutions and the operating table should be prepared before the patient enters the room.

The Technique of the Operation as Performed Under General Anesthesia is as follows: The patient is given a dose of magnesium sulphate or a saline laxative the day before the operation, and placed upon a semi-solid diet. The morning of operation a high soapsuds or plain water enema should be administered about an hour before the operation, with a pint of simple water enema to clean out the rectum. Following this about four ounces of peroxide of hydrogen should be injected into the rectum for its antiseptic properties. On the day of operation the patient should not be allowed any form of nourishment.

The best method is to place the patient in the lithology position with the limbs well flexed and held with leg holders. The sphincter is then stretched and the hemorrhoids allowed to protrude. Each tumor is seized with the forceps, drawn down and the skin and mucous membrane divided at the subcutaneous junction. The incision is carried around the base on its sub mucous attachment and a strong silk ligature is thrown around its pedicab and tied tightly, as close to the rectal wall as possible. The portion of the pile external to the ligature is cut off, allowing sufficient stump to ensure the holding of the ligature. Each tumor is treated in like manner. A firm compress is placed over the parts, secured by a well-adjusted T-bandage and the patient placed in bed.

Very large hemorrhoids should be transfixed through the center, near the base, as suggested by Mathews' method, to make certain that the ligature does not slip after the tumor shrinks. In performing the ligature operation, it is of the most importance to tie the ligatures so securely that they do not slip and permit hemorrhage, and this is best secured by trans fixation The bleeding from the much-cutaneous incision is easily arrested by compression.

Ordinarily the ligature cuts through in from five to seven days, the exception is when the pile is hypertrophied and large. This complication occurs quite often with the ligature operation and is one of its drawbacks, as in some instances the ligature will not cut through within three weeks. When the ligature fails to cut its way through the entire stump, the remaining pedicab should be cut off with a scissors. Patients suffer considerably from pain during the first twenty-four hours, or the pain may last from three to four days. There may be heat and fullness in the anal canal and the patient is disturbed during the night by sudden twitching of the sphincter and spasmodic contractions of the elevator an, induced by the ligated stumps acting as foreign bodies.

The operation is open to the possibility of infection, although not seemingly any more so than the clamp and cattery procedure, when the clamped hemorrhoid separates, as so often occurs after the introduction of a suppository, the examining finger or the rubber tube.

The ligature operation certainly possesses equal merits with the clamp and cattery operation, and by many is considered better. This distinction should be made after an experience with both operations. The clamp and cattery operation can he performed as rapidly, is as free from hemorrhage or infection, and gives as good results as to permanent cure.

The After-treatment of these cases is of importance, for some unknown reason is entirely neglected, excepting when complications demand urgent treatment. It has been my practice to remove the tube on the second or third day, after the administration of a mild saline laxative; to wash off the wound with a mild antiseptic solution, or peroxide of hydrogen, and insert into the anal canal, with the aid of a probe, a small piece of gauze saturated with a twenty percent. solution of ichthyology in glycerin The ichthyology acts as a stimulant to the repair of the mucous membrane and also probably has the virtue of a mild antiseptic. The bowels are moved every second day by a saline laxative, or the administration of cascara, and the patient is kept in bed for ten days to two weeks. The diet is increased on the second or third day after the bowels have moved. Should there be a retention of urine following the operation, as is very often the case, the application of hot wet cloths to the anus will avoid the necessity of catheterize The patient should be instructed to keep the field of operation clean by the free use of warm water applied on a compress, particularly after the bowels have moved.

Whitehead Operation. The Whitehead operation or circular excision operation was first described by Mr. Walter Whitehead of England and consists of amputating the pile bearing circumference of the lower rectum. The operation has never become popular in either England or America excepting in exceptional cases where the ligature or clamp and cattery operation could not be substituted. The complications and sequel are so numerous and the operation so difficult, even under most favorable circumstances, that it is justly disapproved by most surgeons.

This operation resembles the so-called American Operation, which differs only in beginning the excision above, instead of below the pile-bearing area. The technique of both operations are of value as an additional knowledge when operating for some of the graver rectal diseases and for this reason is part of the knowledge necessary in the surgical treatment of rectal diseases.