A NEW OPERATION FOR HÆMORRHOIDS

519A DISCUSSION ON THE CRUET.

possess a short option for the purchase of a very desirablesite for the proposed additions. It would be most regrettableif the money was not forthcoming until the site had

been otherwise disposed of.

A DISCUSSION ON THE CRUET.

THE abolition of the cruet has been solemnly discussed.First salt is banned on the ground that it delays digestion orhas an unfavourable action akin to a mild poison and canfurther act as an emetic ; next pepper is convicted of anirritant effect on the gastric organs, as well as upon the

organs of secretion, and, besides, contains an alkaloid ;then vinegar may precipitate an attack of gout, while

its use to produce a colourless complexion is quoted as

evidence of its injurious effects ; mustard, like pepper,is an irritant also and its effects as a blister are not

forgotten, in addition to which it is a well-known emetic;lastly, olive oil is indigestible, coating food with oil and sopreventing the gastric juices from doing their beneficent

work. On the face of it we have here a series of serious

indictments which might tempt some to regard the very oldinstitution of the cruet as after all a great human error.

The acceptance of such a view betrays little knowledge.Each item of the cruet is of decided service in dietetics, andwe have something more than the argument that the use ofcondiments is merely instinctive to support this state-

ment. The classic experiments of Pawlow have shown

how important is the r6le of the condiments in diet,how it is they improve appetite and increase digestivepower. Mustard, pepper, and salt, used, of course, in

sensible amounts, assist the appetite, give a zest for food,and partly by reflex action as well as local action, stimulatethe flow of digestive juices and ensure healthy assimilation.Even vinegar is known to have a softening effect on toughfibres, and hence its use is justified in so many instances.Lastly, the use of oil in a salad is a sound physiological pro-cedure, for it supplies an aliment which is deficient in thesalad vegetable, while as a vehicle for the uniform distri-bution of food materials in the human organism it does

excellent service. The reasons for the existence of thecruet and of its continued use are, therefore, by no meansmerely empirical, the institution is physiologically justified.

A NEW OPERATION FOR HÆMORRHOIDS.

MANY are the operations which have been devised for theadical cure of haemorrhoids, and the enthusiasm with whicheach in turn is praised by one surgeon is only equalled by theopposition which it meets with from other operators. For

instance, Whitehead’s operation has been, and is still,regarded by some as the very perfection of methods for thethorough removal of the hæmorrhoidal tissue, but others look upon it as needlessly mutilating and extremely liable to

produce stricture. Similar opinions have been expressed inregard to ligature and to the clamp and cautery. The fact isthat with any one of these methods a surgeon practised in itsuse can obtain excellent results, and the failures occur almostentirely in the hands of those who have had but little expe-rience of the method. Success in most cases depends onattention to small points which are often not described in I,text-books, and are therefore liable to be neglected by those Iwho have not practised the special method to any greatextent. In a recent issue of THE LANCET appears an account

by Mr. Norman Porritt of Huddersfield of a new operationwhich he has devised and employed successfully forthe radical cure of haemorrhoids. It consists essentiallyin the crushing of the base of the pile with a pair of crushing forceps, such as those devised by Kocher and modified by Corner for the appendix. The

crushed pedicle is then covered in by drawing togetherthe surrounding mucous membrane by means of a purse-string suture. The operation is a modification of the removalof haemorrhoids by excision, the real difference being thatthe vessels of the haemorrhoids are crushed instead of beingtied. It does not appear that Mr. Norman Porritt has per-formed the operation in many cases, but we have no doubtthat it is capable of producing satisfactory results. In allthese operations, as in many others, the man who performsthe operation is much more important than the method hehappens to use. We should like to hear further on the

subject when there is the necessary material, for the numberof sufferers is very great.

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VAGINAL SUTURE IN RUPTURE OF THE UTERUS.

THE best method of dealing with a case of rupture of theuterus is always a most difficult question for the practitionerto decide. In many cases the question is decided for him,since the patient is not in a condition to stand operativeinterference and her rapid death renders treatment of anykind impossible. At the same time a certain number of

these cases recover without any treatment, and it would be

easy to quote figures from the monographs written on thesubject to prove the apparent efficacy of the different pro-cedures adopted. Undoubtedly the ideal treatment, if thepatient is in a condition to stand it, is the removal of the

child and placenta by abdominal section whenever theyhave passed into the peritoneal cavity, and the subsequentremoval of the uterus by complete hysterectomy. In

this way perfect control of the hæmorrhage and free

drainage through the vagina can be secured, andthis method has the further great advantage that a

source of possible septic trouble in the damaged uterus is

removed. The high mortality following this operation, how-ever, has led many surgeons to recommend less severe

measures. Of these the one most frequently adopted andthe most successful is the plan of plugging the tear withgauze, and so arresting the hæmorrhage and providing fordrainage. It is a noteworthy fact that in most of the casesthe haemorrhage, although no doubt severe at the time, soonceases spontaneously, and if the patient survives the imme-diate dangers of the accident she does not, as a rule, diefrom further haemorrhage. Gauze plugging therefore prob-ably acts rather as a drain than as a hæmostatic, and thismay be the explanation of the good results obtained in thesecases and the answer to the objection that any firm pluggingof the tear is virtually impossible, since there is no

means of making counter pressure, at any rate in com-

plete tears. Naturally enough, when the tear has been

readily accessible surgeons have made attempts to treat it

by suture as well as by plugging. Cases of this kind are tobe found in the literature and an interesting example is theone described by Mr. H. J. Paterson in this issue ofTHE LANCET. In his case the cervix and lower uterine

segment were torn through for a distance of four inches, andthere was as well a tear in the posterior vaginal fornix,through which a portion of the sigmoid flexure prolapsed intothe vagina. The tear extended into the left parametrium,but was complete. The tear in the uterus was sewn up suc-

cessfully with catgut sutures and the opening in the vaginalvault closed with a purse-string suture round a rubber

drainage-tube ; two large vessels which were bleeding werecontrolled by ligatures. Continuous proctolysis was carried outfor 60 hours after the operation, and the patient made a goodrecovery. Mr. Paterson thinks that the advocates of hysterec-tomy lay too much stress upon the difficulty of controllinghaemorrhage, but in this he hardly does them justice. A con-

siderable number of writers on this subject have pointed out

that after the first severe bleeding there is often but little more,