THE 
SURGICAL TREATMENT 
OF 
HEMORRHOIDS 
BY 
EXCISION AND CLOSURE WITH THE BURIED 
ANIMAL SUTURE 
BY 
HENRY O. MARCY, A.M., M.D., LL.D. 
OF BOSTON, U. S. A. 
Surgeon to the Cambridge Hospital for Women ; late President of the American 
Medical Association ; President of the Section of Gynecology, Ninth Interna- 
tional Medical Congress ; late President of the American Academy of 
Medicine; Member of the British Medical Association; Mem- 
ber of the Massachusetts Medical Society ; Member of 
the Boston Gynecological Society ; Correspond- 
ing Member of the Medico-Chirurgical 
Society of Bologna, Italy; late .*■ *'' ' 
Surgeon XJ. S. A., etc. /V&N 
[Reprinted from the American Journal of Obstetrics, Vol. XXXII, No. 6.] 
NEWYORK 
WILLIAM WOOD & COMPANY 
1895 THE SURGICAL TREATMENT OF HEMORRHOIDS 
BY 
EXCISION AND CLOSUKE WITH THE BUEIED 
ANIMAL SUTUKE. 
In the evolution of. modern surgery it is an interesting study 
to observe the gradual and almost complete elimination of 
methods in surgical procedure which, at not a remote period, 
were considered indispensable and final. 
Thus we note the relegation of the cautery, accompanied by 
the condemnation of the barbarous methods under the sway 
of which, at an earlier period, every variety of wounds were 
treated. 
The use of the ligature for the constriction of structures, to 
cause their necrosis and elimination by suppuration, has been 
abandoned as equally unsurgical and unscientific. The last 
stronghold in which these methods have found refuge is their 
fundamental entrenchment in the rear of the column; and it 
is almost only in the treatment of hemorrhoids that any of the 
surgeons of the present are found still clinging to these pro- 
cedures of the fathers. 
It is in the conscientious belief that other and better measures 
should be substituted, here as elsewhere, for the cure of one 
o the most common and troublesome of the diseases usuall 
classed as belonging to minor surgery, that I offer this contri- 
bution. 
The causation of the ectasic condition of the hemorrhoidal 
veins is an interesting study, especially so since in no other part 
of the body do we find similar conditions or results. 
It is important to remember that the arteries in the lower 
portion of the rectum descend vertically in parallel lines toward 
the anal aperture in the connective tissue between the mucous 4 
MARCY I SURGICAL TREATMENT OF HEMORRHOIDS BY 
membrane and the muscles. The subdivision is by short branch- 
ing vessels, and the blood is received through the capillaries into 
an extraordinary network of veins which empty through the 
inferior mesenteric into the portal system. These veins are 
entirely without valves. The absence of valves has been ad- 
duced as evidence that in the earlier period of the develop- 
mental series man did not maintain the upright posture, and 
many authors, from Morgagni and Boerhaave to the present, 
have found in this evidence why quadrupeds are not subject to 
hemorrhoidal diseases. It seems, however, a just criticism that 
the weight of the venous column alone acts only in a very sub- 
ordinate degree as predisposing cause, although manifestly an 
important factor after the blood current becomes greatly re- 
tarded in the oftentimes enormously dilated hemorrhoidal veins. 
Were the cause to be found in this peculiar disposition of the 
portal circulation, the upright position of man would make this 
condition the rule rather than the exception, and it would be 
indeed extraordinary to find the varicosities limited to the 
hemorrhoidal plexus and lying almost entirely external to the 
sphincter muscle. Oftentimes, however, after the pathological 
Condition has become well established, the current through the 
ectasic vessel is so greatly retarded by the weight of the ‘blood 
column in the erect position that most invalids learn to seek 
relief from change of posture. 
In the relation to the surrounding pelvic organs the hemor- 
rhoidal vessels occupy a dependent position, and their only 
support is derived from a loose network of connective tissue. 
It is apparent that the anatomy of these thin-walled vessels 
their relation to the surrounding parts, and their physiological 
function furnish, as it were, a predisposing cause of disease. 
To this very probably may be added individual structural weak- 
ness, as is often exhibited in persons with thin-walled veins of 
the lower extremities. 
It has long been recognized that the varicosities of the hem- 
orrhoidal vessels, which are wanting in the lower animals, are 
comparatively rare in the savage races, and become in a con- 
siderable ratio a more and more constant factor in the sedentary 
occupations pertaining to modern civilization. A great variety 
of pelvic diseases in the female, and the genito urinary diseases 
in, the male, complicated with constipation, are in a large mea- 
sure active causes. EXCISION AND CLOSURE WITH BURIED ANIMAL SUTURE. 
The rectum may be viewed as a convenient cesspool for the 
more or less constant reception of the waste and worn-out debris 
of the alimentary canal, which is ever poured into it in a semi- 
fluid state. The curves of the lower bowel, from the sigmoid 
flexure downward, are an evident design, in part at least, to 
vary the support of the weight of the column, and are admirably 
adapted to deflect and equalize the pressure. To still further 
aid, that portion grasped by the sphincter ani is firmly held in 
the levator loop, and by it is carried upward and forward, thus 
taking the weight of the mass in a large measure off from the 
anal outlet. 
When the rectal contents remain sufficiently soft to produce 
everywhere equable pressure, the circulation is comparatively 
little disturbed and defecation is accomplished with very little 
muscular effort. Let retention of the contents, with absorption 
of the fluid portion, go on until the moulding process becomes one 
of difficulty, and the reverse is true. The overloaded rectum pro- 
duces pressure upon the venous return current, reflexive nervous 
irritation supervenes, a hyperesthetic state follows with increased 
tension of the sphincter ani; pari passu a cellular infiltration 
goes on in the loose connective tissue of the parts, as the result 
of the venous congestion, and the irritated nerves continually 
repeat the telegraphic messages of pain and suffering. 
Although the pathological conditions above described produce 
by far the larger part of suffering ascribed to so-called L' piles,” 
we must not forget that there are other diseased conditions 
which may be confounded with the above symptoms. Small, 
fleshy masses about the verge of the anus, sometimes called con- 
dylomata, without reference to cause, are of easy distinction. 
These have nothing whatever to do with the hemorrhoidal veins, 
and are changes in the cellular structure of the skin and sub- 
jacent parts or mucous membrane, and may be the result of 
friction or erosion arising from a variety of causes. 
The so-called villous tumor of the rectum is of sufficient 
frequency to be held in consideration. It is not unlike the 
villous growths of the bladder and other mucous surfaces. Its 
extraordinary vascularity commonly reveals its presence because 
of hemorrhage, and, unless differentiated, it will be diagnosticated 
as a bleeding pile. The soft, mucous polyp of the rectum is an 
adenoid structure of close relationship to the villous growth and 
is sufficiently often the cause of suffering to be kept in mind. 6 
MAKCY : SURGICAL TREATMENT OF HEMORRHOIDS BY 
The dilatation of the hemorrhoidal plexus is usually under- 
estimated as ordinarily examined. When the sphincter has 
been dilated under ether it will often be found that a rosette of 
vessels extrudes the size of a small tomato. 
Laceration of the perineum in the female is very commonly 
accompanied by such enlargement of the vessels, caused by the 
rectocele and defective function of the pelvic organs. When 
the laceration of the parts has included the sphincter the ectasic 
vessels are wanting, although the mucous membrane of the 
lower part of the rectum under these conditions is often seen as 
a soft, projecting, reddish tumor. From this may be drawn the 
inference that the sphincter constriction, with the changes inci- 
dent upon the retention of the rectal contents, acts as the cause 
of the dilated vessels, rather than the superincumbent weight of 
the portal column of blood. 
When the venous plexus of vessels has become pronouncedly 
varicosed they have as a covering the lax submucous tissue of 
the rectum close to the anus, and, when put on tension, are 
protruded as a ring of transverse rugae round the anal aperture. 
Certain of the rugae are developed into roundish protuberances 
and sometimes into tumors of considerable size. 
Upon the introduction of the ligature for the arrest of arterial 
hemorrhage by Ambrose Pare there arose a wide application of 
this important surgical innovation. Nothing seemed more natu- 
ral than that it should find one of its most valuable uses in the 
treatment for the cure of hemorrhoids. 
From the above description of the causes and pathology of 
hemorrhoidal tumors it might not seem difficult to determine 
when these conditions become amenable to surgical treatment. 
Perhaps a more accurate definition might be given as follows : 
When the blood equilibrium in the hemorrhoidal vessels has 
become so changed that the vessels themselves are ectasic, and 
the blood current so impeded that, in part at least, stasis has oc- 
curred, the surrounding connective tissue become edematous, 
the nutrition thus impaired causes nerve irritation, difficult 
defecation, with more or less marked resulting disturbance of 
nerve reflexes. Such conditions, as a rule, do not tend to spon- 
taneous recovery, and the patient is doomed to a greater or less 
degree of invalidism. 
The presenting masses are readily exposed, and few pro- 
cedures are easier than their ligation. In this we find abundant EXCISION AND CLOSUEE WITH BUEIED ANIMAL SUTUKE. 
7 
reason why the practice of ligation lias continued until the 
present. The criticism of this method that it is unsnrgical is 
found in that, while it includes in a blind way a considerable 
portion of the dilated vessels, it also compresses and destroys 
tissues important for preservation—to wit, namely, the sur- 
rounding integuments, mucous membrane, nerves, etc. It also 
leaves of necessity a very considerable portion of the hemor- 
rhoidal plexus of veins, which too commonly reappear after ope- 
ration, reproducing pathological conditions with their attendant 
suffering not unlike the primary affection. These are grave 
criticisms, to which may be added that which has caused the 
abandonment of the ligature, similarly applied, in every other 
part of the body—namely, the necrosis of the portion included, 
attended by a necessary local, infective, and suppurative pro- 
cess. At the best this is followed by a comparatively slow and 
painful convalescence, and all are aware that resultant septic 
conditions may pertain dangerous to the life of the individual. 
This operation has been variously modified in order to avoid 
these objections. In the attempt to maintain an aseptic condi- 
tion of the lower bowel, constant disinfection by the use of iodo- 
form, submucous ligatures, etc., has been employed. 
The only other method which the recent work presented to 
the profession under the assuming title of the “ American Sys- 
tem of Surgery ” has deemed worthy of serious discussion, is 
the destruction of the hemorrhoidal masses by means of the 
clamp and cautery. This is advocated as an advantage over the 
ligature from the fact that the destruction of the tissue included 
by the clamp is immediate and complete, that it controls hemor- 
rhage equally as the ligature, and that septic processes are less 
likely to supervene. 
The objections to the cautery are well founded—namely, that 
the resulting processes of repair, as after the use of the ligature, 
must be secondary and cicatricial. The period of convalescence 
is painful, and the suffering immediately following the operation 
is of the same exquisite type as is experienced from burns in 
any part of the body. As by the ligature, tissues are necessa- 
rily destroyed which should be preserved, and considerable por- 
tions of the hemorrhoidal plexus, invariably more or less dis- 
eased, are not removed. 
For a number of years I was an enthusiastic advocate of the 
clamp and cautery, since it gives a primary wound which is 8 
MARCY : SURGICAL TREATMENT OF HEMORRHOIDS BY 
aseptic, while by the time the slough is ready for separation the 
subjacent tissues are in a measure protected by the proliferating, 
granulating tissue. My results were more satisfactory than by 
the use of the ligature, although secondary hemorrhages have 
been reported and troublesome cicatricial contraction has been 
occasionally observed. 
It is worthy of our consideration to review briefly the advan- 
tages of the once common practice, and still occasionally used, 
resulting from the injection of certain medicaments into the 
parts. Carbolic acid was the most often used, since it is in 
itself an antiseptic, it coagulates rapidly the blood and albu- 
minoids, so that there is little danger of poisoning from its ab- 
sorption. Variously combined with morphine, cocaine, etc., the 
injection is accompanied with little suffering. By the use of 
weak solutions, even after many repetitions of the injections, 
the hemorrhoidal vessels remain comparatively little changed, 
and, if strong carbolic acid is used, necrosis supervenes which 
unfortunately is limited with great difficulty to the pathological 
structures, owing to the dissemination of the acid into the loose 
connective tissue. 
My friend Dr. H. D. Didarna, of Syracuse, N. Y., ingeniously 
modified this operation with manifest advantage by first includ- 
ing the parts to be operated upon with a provisional ligature. 
It is now quite ten years since the method of Mr. Walter 
Whitehead, of Manchester, England, for the surgical treatment 
of hemorrhoids, was brought to my attention. It seemed to me 
to possess very marked advantages over any procedure hither- 
to recommended, and I adopted it with most satisfactory re- 
sults, From that time to the present it has been more severely 
criticised than most other procedures, and often inaccurately 
described. I presume to recall the most important factors of this 
operation ; 
“ The bowel having been well emptied on the previous day, 
the rectum cleansed, and the sphincter dilated, it is easy to ob- 
serve the line of demarcation between the skin and mucous 
membrane. Upon this line the section is made until the hemor- 
rhoidal veins are freed from their connective-tissue attachment. 
These are divided into segments, each segment seized by ring: 
compression forceps, and the dissection continued upward in 
the cellular plane to the highest limit of the hemorrhoidal 
growths. Opposite to this the mucous membrane is divided EXCISION AND CLOSURE WITH BURIED ANIMAL SUTURE. 
9 
transversely, leaving the hemorrhoids simply attached by a loose 
cellular tissue, and the vessels proceeding from above and sup- 
plying the mass below.” , . . “ The hemorrhoids are then 
twisted and removed, the divided surface of the mucous mem- 
brane is drawn down and attached by several fine silk sutures to 
the denuded border at the verge of the anus.” . . . “A contin- 
gency that will at once suggest itself to the minds of those who 
read this description is the risk of stricture likely to follow the 
cicatrix resulting from this plan of operation. I may mention 
that, however, wherever it is feasible, with strict regard to 
removing every evidence of any hemorrhoidal growth, I invari- 
ably leave longitudinal strips of mucous membrane continuous 
with the skin ; but in severe cases, requiring the removal of 
the entire circumference, I have no fear of the bowel being in- 
conveniently contracted when raucous membrane alone is sacri- 
ficed, and believe that undue contractions only take place when 
annular cicatrix is formed at the expense of integument. I 
have taken great pains to ascertain that this fear is groundless, 
and I have watched most of my cases for a sufficient length of 
time to relieve ray mind from any further anxiety on this 
point; at the same time I fully realize that the progress of such 
contractions is slow.” 1 
In a further contribution2 Mr. Whitehead emphasizes the 
advantages of the operation described in his previous contribu- 
tion, and the criticisms which followed its discussion were for 
the most part favorable. 
Dr. Kelsey,3 of New York, criticised Mr. Whitehead’s method 
“ as a naturally difficult, tedious, and bloody operation,” and 
that no essential change had been made in the guiding princi- 
ple. At that time Dr. Kelsey appeared never to have per- 
formed the Whitehead operation and expressed a distinct pre- 
ference for the clamp and cautery. I have recently been 
informed that he has discarded the cautery and at present be- 
lieves in the use of the ligature. 
Mr, Whitehead4 made emphatic answer to Dr. Kelsey’s 
paper. To the charge that his operation is difficult, Mr. White- 
-1 “ The Surgical Treatment of Hemorrhoids,” British Medical Journal, Feb- 
ruary 4th, 1882. 
2 British Medical Journal, February 26th, 1887. 
3 New York Medical Journal, December Bth, 1888. 
4 New York Medical Journal, February 23d, 1889  MAK'CY : SURGICAL TREATMENT OF HEMORRHOIDS BY 
head replies “ that young surgeons have repeatedly assured him 
that they do not find the operation difficult, and that he is satis- 
fied that it is an operation which can easily be performed by 
any surgeon possessing average shill and intelligence ” ; that it 
is tedious, he declares “ that in an average case it can be com- 
pleted in ten minutes” ; that it is bloody, he states “that it is 
never excessive; hemorrhage such as I meet with may well 
take a subordinate position to other and more important con- 
siderations involved in the operation.” 1 
Mr. Whitehead’s experience at this date included three hun- 
dred cases of operation—certainly sufficiently ample from which 
to make deductions, and which entitle his opinions as worthy 
of the highest consideration and respect. 
It is more than fifteen years since I operated upon two cases 
of prolapsed rectum by first, before resection, entirely encircling 
the prolapsed parts with a row of continuous, double, tendon 
sutures. From the good result obtained in these I was led to 
apply the same method in suturing the ring of dilated hem- 
orrhoidal vessels before resection. Since, this method has en- 
tirely superseded all others in my practice, and it has been 
demonstrated by operating in the presence of many surgeons, 
always with distinct approval. My first publication upon the 
subject is found in the Journal of the American Medical Asso- 
July 21st, 1888.1 
Although I am distinctly indebted to Mr. Whitehead for his 
most valuable paper, I cannot but think my method of suturing 
and closure is worthy of consideration and adoption. For this 
reason I may be pardoned, for the guidance of those less experi- 
enced, in presenting the same somewhat in detail. 
It is important that the alimentary canal receive attention 
for a day or two prior to the operation ; that the lower bowel be 
carefully emptied by a cathartic the day previous and the morn- 
ing of the operation; that the rectum be cleansed by a large 
enema, the diet for a few days having been restricted chiefly 
to fluids. The patient, having been etherized, is retained in the 
lithotomy position by means of the Clover crutch, and the parts 
are protected by the inflated rubber irrigation pad. It is of the 
first importance slowly and carefully to paralyze the sphincter 
by a thorough dilatation of it. The lower segment of the rec- 
-1 “ The Cure of Hemorrhoids by Excision and the Closure with the Buried 
Animal Suture,” Annals of Surgery, November, 1889 EXCISION AND CLOSURE WITH BURIED ANIMAL SUTURE. 
11 
turn is then carefully cleansed by irrigating with a solution of 
bichloride of mercury (1:2000), followed by sterilized water. 
A loose wool pad of fist size, into which iodoform has been 
freely incorporated, is now introduced into the rectum, leaving 
a string for its withdrawal. Under a good light it is easy to 
follow the line of demarcation between the skin and mucous 
membrane. It will be found usually that the hemorrhoidal 
tumor is of much larger dimension than was previously sup- 
posed, and that it lies easily everted upon the external border of 
the sphincter muscle. 
With a pair of sharp-pointed, curved scissors or knife, the 
parts being steadied by two: fingers in the rectum, it is easy to 
follow the line of demarcation and divide, from behind forward, 
upaa either side, to the anterior median line. It will generally 
be found that the loose connective tissue is easily separated, 
with very little bleeding, until the external border of the 
sphincter is clearly brought into view. This is usually the up- 
per border of the hemorrhoidal plexus, and, if it extends higher, 
the dilated vessels are easily traced to their bases, generally by 
pressure of the scissors or some blunt instrument. The base is 
encircled with a double line of continuous tendon sutures, so 
taken as not to penetrate through the mucous membrane. The 
vessels are now divided at the base, and so much of the mucous 
membrane as is not diseased dissected free before division. 
Lastly the mucous membrane is divided transversely, and the 
entire ring of hemorrhoidal vessels is thus removed. It will 
now be observed that the external fibres of the sphincter are 
uncovered, lying at the base of two shallow circular flaps. 
These are approximated by a single continuous tendon suture, 
the stitches taken just within the divided edges, parallel to the 
flaps, each succeeding stitch entering directly opposite the 
emergence of the previous stitch. Tension upon this coaptates 
the parts without puckering, covers the sphincter, and leaves 
only a comparatively slight wound of unclosed structures. A 
second row of suturing, taken just within these divided edges, 
in the same way, by tension upon the suture, completely ap- 
proximates the skin and mucous membrane and buries it en- 
tirely from vision. The line of union is covered with a seal of 
iodoform-collodion, reinforced with a few fibres of cotton, and 
the operation is complete. 
It may be done much more rapidly than this description 12 
MAROY : SURGICAL TREATMENT OF HEMORRHOIDS BY 
would seem to imply, ten minutes being often ample for the 
operation. It is comparatively bloodless, because the vessels 
are occluded before division. It is important that the sphincter 
be completely paralyzed, since this muscle should be for some 
days without functional activity in order to lessen pain and pro- 
mote rapid union. The wool tampon had better be removed 
about the third day. It is well to adjust a small pledget of 
cotton or gauze as an anchor to the distal end of the string, 
since occasionally the wool pad may be drawn up the bowel. 
The advantages of this method of operation are apparent*. 
By the dissection as practised by Mr. Whitehead, only the dis- 
eased structures are removed and the remaining parts are left in 
an nndevitalized, clean condition. This is in accord with the 
rules of surgery which apply almost without exception to other 
parts of the body, and it seems an anomaly that this portion of 
the body should be beyond the pale of modern surgical pro- 
cedure. Although all surgeons are well aware that wounds of 
the anal outlet are liable to infection, yet the experience is 
abundant to demonstrate that the majority of such wounds can 
be wade and maintained aseptic, undergoing, as elsewhere, pri- 
mary union. 
When primary union is secured the recovery is, as elsewhere, 
rapid and the suffering is minimized. The lower bowel is in 
a large measure protected by the iodoform wool. The wound 
having been made and maintained aseptic during the dissection 
and closure of the parts, the protection from the collodion seal 
is ample for a short period. This must be kept under obser- 
vation much more closely than when used for the protection of 
wounds through cutaneous surfaces. It is surprising to note 
the rapid cell proliferation which ensues in an aseptic wound at 
rest, thereby protecting the in jured tissues. Two or three days 
place such a wound almost beyond danger. To this end, as 
also to prevent suffering, it is of the first importance to paralyze 
completely the sphincter ani with the minimum of injury. 
As might be inferred, the results obtained, when the opera- 
tion has been thus properly executed, are not alone excellent, 
but are much superior to those following the use of the clamp 
and cautery or the ligature. Primary union always minimises 
cicatricial structures. Even when suppuration ensues after a 
clean dissection, the tissues are on this account so much the less 
devitalized that they are better able to resist the invasion of EXCISION AND CLOSURE WITH BURIED ANIMAL SUTURE. 
13 
bacteria, and the vessels have been occluded by the sutures so 
that hemorrhage does not occur. 
It is six years since ray last publication upon this subject, and 
my own large experience during this period more than justifies 
all that I then wrote in favor of this modification of the opera- 
tion presented to the profession by Mr. Whitehead. 
I consider it so simple and effectual that I am in the frequent 
habit of adding this operation to the list of the operations for 
the restoration of the pelvic structures in woman, where hemor- 
rhoids are such a frequent complication—e.g., curetting, repair 
of the cervix, colporrhaphy, perineal reconstruction, all at a 
single sitting. 
Cases vary in severity, and in like manner do the conditions of 
ease and rapidity of repair and restoration of function. The 
nervous refiexes, which enter so often as a prominent factor 
into the suffering caused by hemorrhoids, are often slow to dis- 
appear as after other operations. “ Remove the cause of the 
irritation and trust that the irritation will disappear” is an old 
maxim accredited to Dr. Watson, the author of the u Practice 
of Medicine ” so familiar to our earlier days, given by him as 
advice in a celebrated consultation to Sir Benjamin Brodie. 
This paper has been written because of a review recently 
published 1 of the Whitehead operation by my friend Dr. E. 
Andrews, of Chicago. It is very evident that Dr. Andrews has 
been prompted to do this because of the wretched results which 
he has had under observation, the outcome of work performed 
b}r ignorant pretenders styled by him “certain persons calling 
themselves orificial surgeons/’ It is, however, but charitable 
to believe that, in his zeal to protest against such infamous 
imposition, the good doctor has failed to discriminate between 
these practices and the skilful performance of a well-advised 
surgical operation. Indeed, I greatly fear that he has never 
investigated the subject in a true judicial spirit, and it is very 
probable that he has never attempted the dissection and ex- 
cision of the greatly enlarged and deformed hemorrhoidal 
plexus of vessels. Certainly he misinterprets Mr. Whitehead 
and greatly exaggerates the extent of the operation in his ac- 
companying illustrations* Done as depicted, what he calls “a 
thorough Whitehead ” would result “in great and irreparable 
mischief.” 
1 Fort Wayne Medical Magazine, July, 1895. 14 
MAROY : SURGICAL TREATMENT OF HEMORRHOIDS BY 
The object of surgery is to save and not to destroy ; to remove 
pathological, not healthy structures ; and this is the very end and 
purpose of the dissection method, in marked contrast with the 
operations still so generally advocated, where,iindiscriminately 
the presenting masses are destroyed by ligature or cautery. 
In the earlier part of this paper I have emphasized the active 
part which the sphincter takes in producing the ectasic condition 
of the vessels, and given quotations from Mr, Whitehead’s pub- 
lished articles to show the proper limit of the advised dissection.. 
It is easy to determine the upper limit of the parts to be 
removed. 
After the complete dilatation of the sphincter the ectasic 
plexus of vessels lies really external and presents as a rosette of 
greater or less size, with the line of the skin marking the outer 
border of the tumor. Only the redundant mucous membrane is- 
removed, which has become as truly pathological as the vessels 
themselves. 
“ The important tactile organs connected with the special 
rectal sense” are properly never removed. The mucous mem- 
brane is never to be pulled down by force, nor in any instance 
should there be the slightest reason why, from tension, the 
stitches taken by my method should give way. 
The last objection made by Dr. Andrews is the danger from 
septic infection, which, he admits, uin Whitehead’s method is 
not very great, but is something.” 
The great advances made in modern surgery are in large part 
the ability to secure primary union in coaptated aseptic struc- 
tures. These methods have caused the condemnation and aban- 
donment of constricting by the ligature vitalized structures for 
the purpose of necrosis, and the use of the cautery, where follows 
of necessity the slow healing of an open wound. It would 
indeed be strange if the anal structures were the only excep- 
tion. 
Dr. Andrews is to be commended for his extensive research 
after disasters. Statistics have their value, often very great 
value, but it may be remarked that they serve an especially use- 
ful purpose to bolster up a preconceived premise. 
Let us briefly analyze Dr. Andrews’ table. Gathered from 
correspondence, he finds two hundred*and one cases where ill 
results have followed the so-called Whitehead operation. The 
methods employed under this designation are not described; EXCISION AND CLOSURE WITH BURIED ANIMAL SUTURE. 
15 
even the names of the operators are not given. The number 
of operations is omitted; no percentages are possible, and any 
analysis must be very unsatisfactory. 
Dr. Andrews, however, states that, if the Whitehead operation 
is thoroughly performed, the whole tactile mechanism is swept 
away and nearly all tactile special sense is removed. Thus, 
according to Dr, Andrews’ definition, these bad operations have 
been very imperfectly performed, since in less than four per 
cent of his defective cases has this result been observed. 
Another ill effect which it is claimed must result from this 
dissection is the loss of the reflex mechanism and consequent 
incontinence of feces. This is by far the most serious charge, 
and the number of cases reported is twenty-seven. But is it not 
far more likely that this has resulted from some injury to the 
sphincter? Certainly it is not properly involved in a correct 
dissection of the parts, and has never occurred in my experience. 
Nine cases of stricture are reported, a result which ought to 
follow as the rule if thoroughly done as described—according 
to Dr. Andrews’ reverse order of reading, ninety-five per cent of 
failures because stricture did not supervene. According to his 
own conclusions sixty per cent of the entire list is of little value 
because without accurate description. Most of the operators 
quoted as opposing the dissection method have never performed 
the operation. 
What we really need is the evidence which alone can come 
from honest, judicial, capable surgeons who have carefully dis- 
sected and removed only thepathological structures with aseptic 
primary closure. These witnesses, giving an analysis of their 
experience, would furnish evidence of a crucial character. 
It is now futile for those who have never operated to condemn 
this method as unsurgical and unscientific, unless, indeed, they 
can exhibit bad results of cases operated upon by men of acknowl- 
edged ability and in strict adherence to the detailed description 
of the method. 
My own experience in this operation extends over a period of 
twelve years of practice, with a large list of cases and of every 
variety. A statistical table at this writing is impossible, but I 
am assured that the operation, as I have performed it, is so ex- 
ceptionally satisfactory in results that I heartily commend it to 
the favorable consideration of all surgeons. I have never seen a 
case where the patient seemed to approach the danger line. The 16 
MAKCY : SURGICAL TREATMENT OF HEMORRHOIDS. 
subsequent suffering is very much less than by other methods, 
the recovery more rapid, and the results far more satisfactory. 
I commend to Dr. Andrews, as a surgeon of national repute, 
that he give this method a fair trial, with the assurance that at 
some subsequent period we shall have a reversal of his present 
verdict upon an operation of great importance to an army of 
daily sufferers. 
180 Commonwealth avenue.