Complications which follow the Whitehead Operation. The complications and objections as enumerated by various operators are that it takes considerable time and dexterity; there is a copious bleeding; uncertainty of primary union; danger of stricture; and there is a possibility of incontinence owing to the removal of the sensory nerves of the pectin These complications sometimes result from the operation with the ligature or clamp and cattery, but are most often associated with the Whitehead operation.

The Technique of the Whitehead Operation is as follows, under a general anesthesia: The sphincters are thoroughly dilated so that the hemorrhoids and redundant mucous membrane project from the anal orifice. The mucous membrane is incised at its junction with the skin and around the entire circumference of the anal margin. Care is taken to follow the irregularities of the skin all around. The external sphincter and lower portions of the internal sphincter are then exposed by dissection with the blunt end of a scissors or the handle of a knife, then the mucous membrane, with the attached hemorrhoids, is pulled down and brought below the skin margin. The rectal mucous membrane above the hem.-hemorrhoids is then divided transversely and sewed to the free margin of the skin below. This excision of the pile-bearing mucous membrane should be done in successive stages, each portion being sewed to the skin progressively and continued around the entire anal margin. The blood vessels should be tied or better twisted when divided. During the excision of the mucous membrane care should be exercised not to remove too much superfluous skin, or skin tabs, as these tabs when left in sit, contract and eventually cause no further inconvenience.

Earle's Modification of Whitehead's operations is the application of a specially constructed clamp forceps which is applied transversely to the axis of the rectum, which clamps while cutting and sewing the tissue. The operation may be performed under local anesthesia by introducing the hypodermic needle at the anterior and posterior median commissary and infiltrating under the mucous membrane, but the operation is best done under a general anesthesia. The clamp may be applied parallel with the long axis of the rectum instead of transversely, in the judgment of the operator and dependent upon the size of the anal orifice. The sphincters are well dilated so as to bring the hemorrhoids well into view and an incision is made through the mucous membrane at the center of the anal orifice, posterior, sufficiently deep to allow Earle's clamp forceps to be applied at right angles to the long axis of the rectum.

The forceps should include the mucous membrane to be removed in that segment. Care should be taken to include in the forceps more of the mucous membrane than the skin. The tissue outside of the grasp of the forceps is now cut away and a continuous suture is begun at the lower end of the wound and passed around and around until the ends of the forceps is reached. The forceps are then withdrawn and the suture drawn taut. The skin and mucous membrane is brought into position with a few stitches, begun from within and passed outward. Each hemorrhoid and all the redundant tissue is dealt with in a similar manner. Hemorrhage is controlled by the running suture, and cut surfaces are protected from infection during the operation by being held with the forceps until they are drawn together permanently. Medium chromite catgut is the best future for this purpose. Pain should be prevented first by hypodermics of morphine, afterward by acetaminophen and cu-dine sulphate. The wound should be dressed four or five times during the first day, after irrigating with a solution of carbolic acid, one part to forty of water. The bowels should be moved on the fourth day. The patient should be allowed to get out of bed from the seventh to tenth day.

Earle recommends the use of Ebb’s curved scissors to excise the tumors, and as in the Whitehead operation, large plain catgut is the best suturing material. Earle's operation is desirable in cases presenting one or two peculated hemorrhoids and relaxed sphincters, as in selected cases, which can be operated upon in the orifice under the influence of cocaine. There is some trouble in drawing the sutures taut after introduction and Earle has added to his forceps a small hook, over which each loop of the suture is thrown until all are placed in position. Each suture can be accurately and surely tightened without dragging too much upon the wound. This operation is attractive from the surgical standpoint, but is not nearly as simple as the ligature, or clamp and cattery operation, and has the objection that there is sometimes a failure of primary union, a greater destruction of the sensation at the lower end of the rectum, and the production of a circular stricture at the point of operation. It is probably a safe operation in the hands of the expert, but is not to be recommended for the general practitioner excepting in selected cases.

After-treatment. The parts are washed off with a solution of dichloride of mercury (i-loco) and a compress of sterile gauze is applied with firm pressure from a T-bandage. Later dress and wash with the same solution of dichloride of mercury, which should be repeated several times daily. The external incision should not be drawn together by sutures, as the edges of the wound will coat themselves by subsequent granulation

Tittle’s Modification of the Whitehead Operation consists of a plan for the easy detachment of the mucous membrane and uniting such by section, after removing the hemorrhoid mass, which is of considerable help in the matter of saving time and loss of blood while operating. The technique as described by Cuttle is as follows: