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aptitude, extensive general surgical training and the special skill resulting from the repetition of the operation hundreds of times would reduce the difficulties of the operation to a minimum and render it neither tedious nor bloody. It is not, however, what the operation would be in the hands of such an operator that is to be considered, but rather what it would be found to be by the operator of average experience and opportunities. My judgment is that in the hands of the latter operator, the operation in aggravated and extensive piles would be found to often justify the opinion of Kelsey, already referred to, that it is "naturally difficult, tedious and bloody." It ought to be ranked as a major operation. Especially ought it to be ventured upon with caution in the case of patients who are very weak and unfit to be subjected to a prolonged operation, or in whom, by reason of renal or pulmonary disease, prolonged anesthesia would be dangerous. The operation is one which appeals much more to the operative bent of the general surgeon than to that of the rectal specialist, and I am not surprised that by the latter class of practitioners it is almost universally condemned. To one, however, who is accustomed to dealing with vascular tissues, to whom the hæmostatic forceps and the ligature are ready and frequent servitors, to whom the preservation of cut surfaces from septic contamination is a thing of easy routine, to whom the coaptation of cut surfaces, subsequent primary union, the avoidance of tissue necrosis and limitation of suppuration are always eagerly sought for, to such the technical difficulties inherent in the ablation of hæmorrhoidal tumors after the method of Whitehead will seem trivial obstacles beside the ideal perfection of the results to be gained. My judgment is that the operation is based on sound surgical principles, and that it is a valuable and permanent addition to operative surgery. The frequency with which it will be resorted to will depend much on the individual surgeon; it will be more frequently employed by surgeons who are doing much general operative work, and I think that I can see in its results qualities that will cause it to be more and more frequently resorted to, as multiplied experience brings to the opera or increased skill.

Certain cautions, however, require to be noted before dismissing this subject. First, I can see how that an operator may readily so injure the sphincter that permanent fecal incontinence may result. It is by no means an easy thing to always recognize at once the muscular fibres of the sphincter in the first stage of the dissection. This will be the case more especially in the instances of aggravated disease, when the tumor is large and the sphincter flabby, and the additional preliminary stretching at the time of the operation has entirely relaxed it. Unless great care is taken to identify the structures exposed by the primary

incision, and to keep clearly to the inside of the muscle, the operator may find that he has included a part or the whole of it in the mass which he is enucleating; even though he may perceive his error before going very far, he may yet have divided important nerve fibres the section of which may entail permanent loss of power in the muscle. The first steps in the operation therefore, should be characterized by great care in the identification and avoidance of the sphincter; when the muscle has been clearly identified and drawn aside at a given point, the further enucleation may be done with expedition and without danger to it.

If

A second caution is to be observed from the side of the tumor. care is not taken to hug closely the surface of the muscle, and thus to keep outside the vascular tissue of the tumor proper, the process of enucleation will be less readily and speedily accomplished, and will be attended with an unnecessary amount of venous hæmorrhage. When, however, the sound tissues beyond the tumor have once been reached at any point, the further enucleation may be readily and safely accomplished by pursuing the enucleation circularly around the bowel from this point, and working downward to the anal margin. It is important also that the dissection shall be pushed upwards well beyond the diseased portion at all points, so that the final transverse section of the bowel when the tumor is cut away shall be made through healthy mucous membrane. If this precaution is not taken, the difficulties in obtaining final hemostasis will be much increased. No hesitation need be felt in advancing upwards with the dissection as far as may be necessary to find the healthy bowel, lest difficulty should be met with in bringing down the cut end of the bowel and suturing it to the skin. In the aggravated cases, now under consideration, there is always present much relaxation of the rectal walls above the tumor with tendency to prolapse, and considerable retrenchment of this relaxed membrane is of advantage to have coupled with the removal of the tumor proper in order to secure the most perfect result. On the other hand, none of the skin at the anal margin should be cut away however redundant it may seem to be at the time. When the suturing of the intestine to the skin has been completed the line of sutures will be at that time well outside the anus, but as time passes the rectal walls regain tonicity and retract upwards somewhat, the sphincters regain their power of contraction and close the anal orifice, drawing in the skin which has become adherent to the surface of the external muscle, until finally the suture line will be found to have disappeared within the anus, and a well marked integumentary funnel leading up to it will have been formed. In anticipation of this, therefore, no cutting away of integument should be done.

Another requisite for the most perfect result is that the retrenchment of the rectum shall be equal on all sides. In one of the earlier cases upon which I operated, after sufficient time had elapsed to bring about the definitive retraction and other changes described above, I found that upon one side the integument was not drawn up as far as on the other, but that on the contrary the mucous membrane here for a limited space remained drawn down below the margin of the sphincter, I had a veritable ectropion ani. This marred the perfection of the result. For a time, I was not able to explain the reason of this satisfactorily to myself, and naturally looked upon it as a result due in some way to the operation, or to some peculiarity of the patient. I have since learned that it was due to neither, but rather to a fault in the way this particular operation was done. In cutting away the diseased tissue, although I had gone through healthy tissue in every incision, I had nevertheless followed closely the line of demarcation between it and the diseased tissue, and inasmuch as the extent of the membrane involved in the disease had not been alike at all parts, I had cut away less on one side than on the other. Hence the lack of balance of the two sides, the unilateral superabundance of the mucous membrane, the ectropion. In one other case, operated before my attention had been awakened to this possible defect, I found a similar lack of balance to exist when my suturing was completed. I saw then at once the difficulty, and, without ado, proceeded to cut my sutures, and remove more of the mucous membrane where it was too abundant. The final result was perfect.

RECAPITULATION.

1. In the more aggravated forms of hæmorrhoidal disease the surgeon has to do with a veritable angeioma, sometimes involving the whole circumference of the anal end of the rectum.

2. The anatomical relations of this vascular tumor are such as to render possible its enucleation and ablation without special hazard to life, and without involving especially difficult operative procedures. This has been demonstrated on a large scale by Mr. Whitehead, of Manchester, England, and is corroborated by the experience of many other surgeons.

3. The method of excision and suture is inherently a more desirable operation than other methods involving strangulation of tissue, ulcerative and suppurative processes. It is not, however, so easy or so quick of performance, and demands a greater degree of technical skill and experience for its safe employment.

4. The best final results from the operation can only be obtained by avoiding injury to the sphincter muscle, or to its nerves; by the preservation of all the integument at the verge of the anus, and by the

even circular discission of the rectal mucous membrane above the growth.

CONCLUSION.

The operation of excision though, in the more aggravated cases of hæmorrhoidal tumors, often tedious and bloody, presents no difficulties not under the easy control of ordinary surgical skill; its results are superior to those obtainable by any other means; it is therefore an operation to be commended, and to be accepted as a permanent addition to the art of surgery.

DISCUSSION.

Dr. WIGHT.-Mr President, I have been very pleasantly impressed by the Doctor's able, and I could almost say, exhaustive paper. While I do not rise to criticise, for I am not competent to do that, and while I do not reject his principles, for I think that would be as incompetent for me to do as the other, at the same time I may be permitted to add something, not to this individual and particular operation, but to the treatment of cases just like these. To be brief as possible, first let me say that I believe there is a method of treatment which may not be quite so good, but which I think is nearly as good, as the one Dr. Pilcher has advocated. It is good enough, so far as I can see, in bringing about such results as are desired. With your permission, I will state the essential facts of my operation. Among the first cases I have treated, I operated upon some years ago a lady 76 years of age, who had suffered from this condition for over forty years, and I do not think I exaggerate when I say that the protrusion was fully as large or larger than any which Dr. Pilcher has presented. Not only was there this condition, but there were painful lacerations upon various parts of this protruded surface, and the patient was losing ground day by day, and week by week, and had been doing so for a long time; and as a last resort, I saw her with her family physician and advised an operation. Excision was out of the question under the circumstances, for the patient was in an exceedingly feeble condition, so I advised an operation which I am in the habit of doing, namely, ligation, as I believe in the proper application of the ligature we have the means to destroy the diseased part and control the hæmorrhage. The Doctor gave the anesthetic and the daughter of my patient assisted me in the ligation. I put on a row of ligatures around the most external part of the protrusion down to the cutaneous surface. Then I pulled the whole structure down and put on another row of ligatures above, and when I had finished I had on thirty-four ligatures. That case was one of the worst I have ever seen or operated upon, and the result could not have been any more desirable. The ligatures came away in a few

days, the pain was relieved, health and comfort were restored, and the patient is still living and is over 80 years of age. She very soon recovered her health and has not been in any trouble since.

While I do not condemn Dr. Pilcher's operation, it seems to me I ought not to approve it in a positive way. I am not going to condemn it or reject it, but on the other hand, I am not going to abandon a satisfactory method which I have employed for many years-the use of the ligature.

REPORT OF CASES OF HYDROCELE FOLLOWING OPERATIONS FOR RADICAL CURE OF VARICOCELE, STRICTURE OF URETHRA AND RECTAL

POLYRUS.

BY H. W. RAND, M.D.,

Read before the Brooklyn Surgical Society, March 20, 1890.

I have for sometime been much pleased with the results obtained by subcutaneous ligation of varicocele after the method described and advocated by Prof. Keyes. Of the entire number of cases upon which I have operated in this way, I have, unfortunately, kept no record, but can recall eleven. In nine of these no unpleasant result whatever was noted. In none has atrophy of the testicle increased after operation. In all atrophy was apparent, and in some cases marked, prior to operation. In several there was permanent increase in the size of the testicle. In two cases, however, hydrocele has followed and been apparently the direct result of the arrest of circulation through the veins.

As none of the authors who favor this operation speak of any such sequel, I deem these cases of sufficient interest to report.

CASE I. The first was a patient who had, a few months before, recovered from a sharp attack of gonorrhoea and 'was under treatment for a stricture of large calibre located in the deep urethra. He had an enormous varicocele of several years standing, with marked atrophy of the testicle. The enlarged veins were tied with a single silk ligature. No pain whatever was complained of after the operation, and there was only a moderate amount of swelling. The case progressed as usual for the first two weeks, the patient being up and around after the sixth day, wearing a suspensory bandage. During the third week the scrotum was noticed to increase in size, but with absolutely no pain. Three weeks after the operation it became evident that fluid was present in the tunica vaginalis. The swelling continuing to increase, a

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