The operation under consideration certainly deserves a place in rectal sur gery, but not so prominent a one as Mr. Whitehead grants it. It is not suited for the treatment of ordinary or even severe r cases, for two reasons: first, they can be cured by a less difficult operation; sec ond, complications frequently accom pany and undesirable results may follow the operation. The operation is indi cated in long-standing cases, accom panied by frequent hemorrhages, where there are no distinct pile-tumors, but where the veins of the entire rectal wall are engorged and extensively dilated from the external sphincter upward for two or three inches. When such a con dition is present nothing short of the removal of the entire disease area will effect a cure.
It is necessary to emphasize the danger of stricture following this operation; I have had 15 such cases come under my care within the past five years. Persons thus mutilated not only suffer from the constriction and ulceration, but in addi tion from an unbearable pruritus that is being irritated constantly by the dis charge. All these untoward conditions are the result of non-union and retrac tion of the mucous membrane.
Opinion of a large number of surgeons, both in this country and Europe, secured in regard to the disastrous results that are apt to follow Whitehead's operation. The replies include 200 cases, of which the following is a summary: Loss of the special sense by which the patient should be warned of a coming evacuation and enabled to prepare for it, S cases; in continence of flatus and faces, 23 cases; paralysis of the sphincter, 4 cases; chronic inflammation of the rectum, 1 case; failure of union of the wound by first intention, with retraction of the edges of the wound, forming a contract ing, tubular ulcer with stricture, 9 cases; other ulcers, 2 cases; irritable and pain ful anus, 12 cases; eversion of the mu cous membrane, 4 cases; neuralgia of the pelvis and inferior extremities, 2 cases; general neurasthenia. 1 case; fatal peritonitis, 1 case; non-fatal septic re sults, 5 cases; fistula in ano, 1 case; reported as having bad results without accurate description, 127 cases. Total, 200. Andrews (Columbus Med. Jour., No. 3, '95).
If, in the statistics given by Andrews, the names of the operators were men tioned, most of the disastrous results will be found to have followed the work of incompetent men. The writer's own results have been excellent in those cases in which he had done the Whitehead operation, slightly modified by himself. Marcy (Jour. Amer. Med. Assoc., Sept. 14, '9.5).
Whitehead's operation (complete re section) considered rather formidable, with loss of time, considerable hemor rhage, and danger of sepsis; Allingham's (ablation and ligation) excellent in most cases, but takes longer, involves a greater loss of blood, and is followed by more post-operative pain than the clamp and cautery. In recommending the latter
the necessity of stretching the sphincter, applying the clamp in the long axis of the bowel, and using the cautery at a dull-red heat emphasized. Parker Syms (N. Y. Med. Jour., Feb. 12, '98).
The method of excision as practiced at the Mikulicz clinic is productive of the best results. In the important points it is identical with Whitehead's opera tion. The preliminary preparation con sists in the administration of castor-oil three days before operation, and re stricted diet. On the evening before and on the morning of the day set for opera tion rectal irrigations with boric-acid so lutions are given, followed by tinctura opii, 10 to 15 drops. The lower third of the rectum is covered with a paste made of iodoform, and 3-per-cent. carbolic so lution. The technique differs from Whitehead's as follows: The sphincter is not stretched to the point of paralysis, the anus is merely dilated enough to bring the limorrhoids into plain view. HEM ostasis is solely accomplished by suture. No ligatures are used. The suture is made with catgut instead of silk. Blood is removed during the oper ation by a continuous irrigation with cold boric-acid solution. The use of sponges is interdicted. The line of su ture is dressed with a paste of iodoform spread on gauze. The bowels are moved for the first time on the tenth day, being kept costive by the administration of opiates. Phlebitis, thrombosis, and ul ceration contra-indicate this operation. Eighty-one cases thus operated upon from one to five years ago, have been followed with no recurrence. Reinbach (Beitriige zur klin. Chin, B. 23, H. 3).
Operation for hmmorrhoids to prevent the loss of mucous membrane that oc curs after most of them, and avoid con traction of the cicatrix. Opposite the base of the luemorrhoid, parallel with the muco-cutaneous junction, a curved in cision is made, and is carried upward on the same plane as Whitehead's opera tion. A second curved incision is made, forming an eclipse at the poles, of which an incision is carried upward, giving two rectangular flaps of mucous membrane: the hemorrhoidal mass is then ligated with catgut and removed, the flaps are then stitched, with a small piece of the catgut ligature left protruding to act as a drain. E. Eliot, Jr. (Med. News, Dee. 1, 1000).