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Forty-nine patients with the Klippel-Trenaunay syndrome have been studied. Sixty-eight per cent have a superficial, embryological venous channel on the lateral aspect of the limb, 25 per cent have had one or more severe spontaneous haemorrhages from dilated varices and 22 per cent have suffered a venous thrombo-embolism. Twenty-nine per cent have had episodes of rectal bleeding or haematuria associated with pelvic angiomas. Foot volumetry (n = 31) showed that calf emptying was decreased in only five patients and only one of these had phlebographic evidence of deep venous obstruction, which conflicts with previous findings. The rate of calf refilling was increased in 81 per cent and phlebography demonstrated incompetent communicating veins in 45 per cent of patients. No patient had clinical evidence of an arteriovenous fistula, and arteriography (n = 22) and calf blood flow (n = 33) were normal, but lymphangiography (n = 14) showed lymphatic hypoplasia in 55 per cent of limbs. Eighty-eight operations have been performed on 38 patients but symptoms persist in 90 per cent. We suggest that surgery should be limited to the excision of localized symptomatic abnormalities and that the best form of control is provided by graduated compression stockings.

Internal Haemorrhoids-Clark et al. DiscussionDifficulties arise in the interpretation of the results of conservative treatment for internal haemorrhoids because of the frequent spontaneous remissions in symptoms that may occur in such cases, and also perhaps because of the fact that treatment by any method is often accompanied by simple advice on the avoidance of constipation, which might produce a slight amelioration in the condition. The number of patients so far treated in our trial does not allow of a full evaluation of all the factors, but all those in this series had had episodes of symptoms twice a year or more. A review at six months therefore seems reasonable to evaluate therapy ; and the random selection of patients into treatment groups minimizes errors of interpretation association with multifactorial analysis.Treatment by injection is generally painless and well tolerated by the patients. None of the complications which can arise from this treatment (Goligher, 1967) were encountered in these patients. On the other hand, treatment by ring ligation may be very uncomfortable, and was the reason for four patients refusing further treatment. Six other patients complained of some discomfort, often lasting for several days, and two patients lost time from work One of these patients developed painful groin glands two days after treatment. This disadvantage of treatment, however, was rewarded by a better objective endresult. The results from the present study indicate the need for further evaluation of the conservative treatment of this common condition. One hundred patients have now been admitted to the trial, and those treated are to be observed after six months and one year. These preliminary results, however, indicate that the conventional treatment by injections may not be as satisfactory as is generally supposed. The long-term results of treatment by the ring applicator are generally encouraging, though our experience shows that this treatment is usually a good deal more uncomfortable for the patients and is not well tolerated by all of them. If it is to be used it is important to keep well above the pectinate line with the ligation, and to prescribe analgesics such as pethidine 100 mg. for the first two or three nights after application of the ring. The rubber ring treatment is better confined to prolapsing piles alone; for firstdegree piles where bleeding is the main symptom injections with 5 % phenol in almond oil remain the treatment of choice. There seems to be no advantage in the use of almond oil alone. SummaryThe treatment of haemorrhoids by conservative methods has been examined. Injection therapy with the use of phenol in almond oil was effective in controlling bleeding, but with almond oil alone it was not. A comparison between the results of injection therapy and the technique of rubber ring ligation showed objectively better results after six months with ligations. However, ligation was sometimes followed by pain, and a few patients refused to continue with this form of treatment.These pre...

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