THE 
Cure of Hemorrhoids by Excision 
AND CLOSURE WITH THE BURIED ANIMAL SUTURE, 
HENRY O. MARCY, A.M., M.D., LL.D., 
OF BOSTON, U. S. A , 
Surgeon to the Private Hospital for Women, Cambridge; President of the Section 
of Gynecology, Ninth International Medical Congress; late President of the 
American Academy of Medicine; Member of the British Medical Associa- 
tion; Member of the Massachusetts Medical Society; Member of the 
Boston Gynecological Society; Fellow of the American Association 
of Obstetricians and Gynecologists; Corresponding Member 
of the Medico-Chirurgical Society of Bologna, Italy; late 
Surgeon, U. S. A., etc. 
Reprint From Annals of Surgery, November, 1889. THE CURE OF HAEMORRHOIDS BY EXCISION AND 
CLOSURE WITH THE BURIED ANIMAL 
SUTURE.1 
By HENRY O. MARCY, A.M., M.D., LL.D., 
OF BOSTON. 
THE recent discussion upon the surgical treatment of haem- 
orrhoids, published in the New York Medical Journal, 
evoked by a late paper of Mr. Whitehead, of Manchester, 
England, is both timely and interesting. 
The modifications of surgical procedure, based upon asep- 
tic measures, mark the present as the era of surgical revolu- 
tion, to which the surgery of the rectum should offer no ex- 
ception. 
Few of the minor surgical diseases cause so much suffering 
and present to the general practitioner such constant repetition 
of complaint, and in return for advice rendered, none are more 
appreciative and grateful than are the cured sufferers. 
The teachings of the text-books, with few exceptions, offer 
little improvement upon the methods of our fathers. The 
advocates of the ligature perhaps equal those who claim supe- 
rior advantage to be derived from the use of the clamp and 
cautery. Although, resulting from the use of either, a perma- 
nent cure is generally obtained, I am constrained to believe 
that both are radically defective and should be relegated to 
the history of surgery. While it may be conceded that the 
general practitioner is, in a measure, familiar with the patho- 
logical conditions pertaining to haemorrhoidal disease, it is 
well to keep ever in mind that the blood is carried directly to 
the part with the arterial impulse, through short branching ves- 
sels, and then in turn is received from the capillaries into an 
extraordinary net-work of veins which empty through the infe- 
lßead at the meeting of the New York Medical Association, New York, SeP 
tember 27, 1889, 2 
HE NR V 0. MAR CV. 
rior mesenteric into the portal system. These veins are en- 
tirely without valves. To this, in certain measure, has been 
attributed by various authors, from Boerhaave and Morgagni 
to the present time, as cause why quadrupeds are not sub- 
ject to haemorrhoidal disease. I take pleasure in calling at- 
tention to a recent most interesting and learned article upon 
this subject by Dr. Bodenhamer1. It seems, however, a just 
criticism that the weight of the venous column alone acts only 
in a very subordinate degree, as a predisposing cause, although 
manifestly an important factor, after the blood current be- 
comes greatly retarded in the oftentimes enormously dilated 
haemorrhoidal veins. Were the cause to be found in this pe- 
culiar distribution of the portal circulation, the upright posi- 
tion 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 haemorrhoidal plexus and lying 
almost entirely external to the sphincter muscle. Oftentimes, 
however, after the pathological condition has become well es- 
tablished the current through the ectasic vessel is so greatly re- 
tarded by the weight of the blood column in the erect posi- 
tion that most invalids learn to seek relief from change of pos- 
ture. 
Anatomists emphasize, in the normal condition, the large 
number of haemorrhoidal veins and their comparatively large 
size. 
In relation to the surrounding pelvic organs, they 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 sur- 
rounding parts, and their physiological function furnish, as it 
were, a predisposing cause of disease. To this very probably 
may be added individual structural weakness, as is often exhib- 
ited in persons with thin-walled veins of the lower extremi- 
ties. It has long been recognized that the varicosities of the 
haemorrhoidal vessels, which are probably wanting in the 
lower animals, are comparatively rare in the savage races, and 
I<<Are Quadrupeds Subject to Haemorrhoidal Disease?” New York Med. Jour. 
Jan. 12, 1889, p. 39. CURE OF HAEMORRHOIDS BY EXCISION. 
3 
become in a considerable ratio, a more and more constant fac- 
tor in the sedentary occupations pertaining to modern civiliza- 
tion. A great variety of pelvic diseases in the female, and the 
genito-urinary diseases in the male, complicated with constipa- 
tion, are in a large measure active causes. 
The rectum may be viewed as a convenient cess-pool 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 more or less 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 pres- 
sure. 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 large 
measure, off from the anal outlet. When the rectal contents 
remain sufficiently soft to produce everywhere equable pres- 
sure, the circulation is comparatively little disturbed, and de- 
fecation is accomplished with very little muscular strain. Let 
retention of the contents with absorption of the fluid portion 
go on until the molding process become" of difficulty, 
and the reverse is true. The over-loaded rectum produces 
pressure upon the venous return current, reflexive nervous irri- 
tation 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 re- 
sult of the venous congestion, and the irritated nerves contin- 
ually repeat the telegraphic messages of pain and suffering. 
Although the pathological conditions above described pro- 
duce by far the larger part of suffering ascribed to so-called 
“piles,” we must not forget that there are other diseased con- 
ditions which may be confounded with the above. Small 
fleshy masses about the verge of the anus, sometimes called 
condylomata, are of easy distinction. They have nothing what- 
ever to do with the hsemondioidal veins and are changes in the 
cellular structure of the skin, 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 suf- 
ficient frequency to be held in consideration. It is not unlike 4 
HE NR V 0. MARC Y. 
the villous growths of the bladder and other mucous surfaces. 
Its extraordinary vascularity commonly reveals its presence, 
because of haemorrhage, 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 suf- 
fering to be kept in mind. 
Mr. Whitehead, of Manchester, already referred to, very 
properly emphasizes the pathological conditions described 
above, and insists upon it that the extraordinary dilatation 
which the veins often undergo can be learned only by the dis- 
section of the living subject. My own attention was called to 
this many years ago in finding how very commonly the haem- 
orrhoidal veins were enormously dilated in the female who 
had suffered laceration of the perineum. 
However, where the laceration was complete, the ectasic 
vessels were wanting, although the mucous membrane of the 
rectum under these conditions is often seen as a soft, project- 
ing reddish tumor. From this it would seem safe to infer that 
the sphincter constriction, with the changes incident upon the 
retention of the rectal contents, acted as the cause of the 
dilated vessels rather than the superincumbent weight of the 
portal column of blood. 
When the venous plexus of haemorrhoidal vessels has be- 
come 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 
rounded protuberances and sometimes even into fungoid 
tumors of considerable size. Blood stasis often occurs pro- 
ducing induration, and suppuration may supervene. The 
veins sometimes rupture into the connective tissue and changes 
follow which result in tumors of various size, color and den- 
sity; so called external piles. 
The straining caused by defecation, or the gentle pressure 
of the finger from above downward, will frequently cause soft, 
bluish, exquisitely sensitive grape-like masses to protrude— 
internal piles. The mucous membrane covering these is fre- 
quently congested and abraded so that a more or less continu- 
ous haemorrhage ensues. CURE OF HAEMORRHOIDS B Y EXCISION. 
5 
The method for cure of haemorrhoids by the ligature, applied 
with slight modifications of detail, has been considered the 
safest, and most manageable procedure. The projecting 
tumors having been well drawn down are usually transfixed 
with a curved needle, armed with a double ligature, tied firmly 
in halves and a portion of the strangulated mass excised. In 
this way all the hsemorrhoidal tumors are ligated and the mass 
is returned within the sphincter. This was the favorite opera- 
tion of the late Dr. Van Buren of New York and his followers, 
and has at present, in Mr. Allingham, the famous English sur- 
geon, its most distinguished advocate. The use of the ligature 
applied to cause necrosis of tissue, and then allowed to remain 
in the wound, is open to the same general objections which 
have caused its abandonment for the constriction of the large 
vessels. Sloughing necessarily supervenes, which means 
always an infected wound, and exposes the patient to the same 
dangers, although perhaps less in degree, as infected wounds 
in any other part of the body. 
That this is not an hypothetical criticism there is abundant 
proof. The stoutest advocates of the ligature admit that ab- 
scesses, general septic poisoning, and other dangers, as secon- 
dary haemorrhages, are not wanting in the experience of the 
most careful and practiced surgeons. 
Were it necessary to adduce proof of the above statements, 
quotations could easily be given. Although these dangers are 
decidedly exceptional, making the operation a comparatively 
safe one, I cannot doubt the experience of many whom I am 
addressing could be added in corroboration of my personal 
testimony. Growing out of the dissatisfaction resulting from 
such experiences, the use of the clamp and cautery came into 
vogue and has been especially popularized by the distinguished 
surgeon, Mr. Henry Smith, of London. 
This procedure I early adopted in my own work, and en- 
thusiastically advocated its use for some years. Its advantage 
over the ligature lies chiefly in that the primary wound is asep- 
tic, while by the time the slough is ready for separation the 
subjacent tissues are fairly well protected by an abundant pro- 
liferation of granulating tissue. In my own experience the 
suffering produced by the burning, which is especially painful, 6 
HE NR V O. MAR C Y. 
if any of the external tissues are involved, renders it decidedly 
objectionable, while all wounds produced upon any of the tis- 
sues of the body by the cautery are invariably slow of repair. 
I am of the opinion that the results which I have ob- 
tained after the use of the cautery have been gen- 
erally more satisfactory than with the ligature. Haemorrhages 
are reported to have occurred secondarily, and it is claimed 
that contraction is much more common than after the use of 
the ligature. 
It may be accepted that the use of the cautery, except per- 
haps in certain conditions in uterine cancer, has been very 
generally relegated to the past. Even in cancer of the uterus 
it finds fewer advocates than formerly. Certainly bleeding 
can be controlled without its use, and it may be considered as 
questionable if deep burning is safer than the deep cutting of 
any tissue. 
Certain crushing instruments have been devised to be used 
either with or without the ligature for the purpose of produc- 
ing more rapid necrosis of the tissues involved. The advan- 
tage claimed for simple crushing instruments is the avoidance 
of haemorrhage, but on the other hand some operators report 
that haemorrhage has followed their use. Theoretically, crush- 
ing seems to me to offer very doubtful, if any, advantage over 
the use of the ligature, and as with the ligature must produce 
a septic wound. Therefore I discarded it without trial. 
There remains to be considered the cure of haemorrhoids by 
the chemical action of certain medicaments injected into the 
parts. Few of the modern methods of surgical procedure met 
the enthusiastic trial and received more speedy adoption than 
this, the so-called carbolic acid treatment of piles. It had 
much to warrant its acceptation; carbolic acid of itself was 
then believed to be the chief of antiseptics; rapidly coagulat- 
ing the blood and the albuminoids, there was little danger of 
poisoning from its absorption. Variously combined with mor- 
phia, cocaine, etc., little pain followed its use; patient and 
physician were alike enthusiastic. At present it appears, how- 
ever, that the general consensus of surgical opinion is that the 
result is, in large degree, disappointing. When the stronger 
preparations are used causing necrosis of tissue, no matter how CURE OF HAEMORRHOIDS B V EXCISION. 
7 
carefully injected, not seldom the tissues desirable to be re- 
moved fail to be acted upon, while those that should be re- 
tained are destroyed by the sloughing. The explanation is 
that the fluid introduced into the loose meshed connective tis- 
sue escapes beyond the extraneous part. When weaker prep- 
arations are used, even after many repetitions of the injections, 
the hsemorrhoidal vessels remain comparatively little changed. 
The method of cure by injection is also sometimes objection- 
able and even dangerous from secondary results. It is only 
recently that I have seen a young and otherwise healthy man 
rendered seriously ill with fever and general septic poisoning 
supervening upon the injection of haemorrhoids, at the hands 
of one of our most distinguished experts, where the connective 
tissue surrounding the anus remained for some days oedema- 
tons, reddened and painful. 
After this somewhat hasty but, I trust, judicial and dispas- 
sionate criticism of the above methods, it may be asked if any 
safer and better treatment can be offered for the cure of haem- 
orrhoids. There remains for us the discussion of Mr. White- 
head’s operation for cure by excision. This Ido not hesitate 
lo accept as a distinct step in advance of the methods previ - 
ously discussed. We have seen that the vessels are frequently 
so deformed as to fail entirely in the original purpose for which 
they were designed, and the end sought to be attained by all 
the previous methods is their destruction and removal. The 
real objection to dissection has been the fear of haemorrhage, 
and as a means to obviate this, both the ligature and clamp 
and cautery were devised. Mr, Whitehead has clearly shown 
us that his method of dissection is safe, that the haemorrhage 
is not excessive and a rapid cure results. It is certainly sci- 
entific in that, by a clean dissection, the parts desirable to eli- 
minate are removed. The free edges of the divided tissues 
are stitched together, followed usually by primary union. Mr, 
Whitehead’s method is best given in his own words1. “By the 
use of scissors and dissecting forceps the mucous membrane is 
divided at its juncture with the skin round the entire circum- 
ference of the bowel, every irregularity of the skin being care- 
YBrit. Med. Jour., Feb. 26, 1887. 8 
HENRY O. MARCY. 
fully followed. The external and the commencement of the 
internal sphincters are then exposed by a rapid dissection, and 
the mucous membrane and attached haemorrhoids, thus sepa- 
rated from the submucous bed on which they rested, are pulled 
bodily down, any individual points of resistance being snipped 
across, and the haemorrhoids brought below the skin. The 
mucous membrane above the haemorrhoids is now divided 
transversely in successive stages, and the free margin of the 
severed membrane above is attached, as soon as divided, to 
the free margin of the skin below by a suitable number of su- 
tures. The complete ring of pile-bearing mucous membrane 
is thus removed.” 
Mr. Whitehead very wisely emphasizes thoroughly paralyz- 
ing the sphincter by digital stretching. The bleeding vessels, 
which are small and easily seized, are immediately twisted 
upon division. The sutures are of carbolized silk and inter- 
rupted. 
The criticisms that followed the presentation of Mr. White- 
head’s paper, read at the meeting of the British Medical Asso- 
ciation in 1886, were for the most part favorable. 
Dr. Cousins emphasized the importance of the ring of liga- 
tures which he so carefully applied round the anus, as the real 
protection against haemorrhage. 
Dr. Kelsey, of New York,1 however, criticises Mr. White- 
head’s methed “as a naturally difficult, tedious and bloody 
operation,” and that no essential change has been made in the 
guiding principle. He claims that Mr, Whitehead does not 
give results in sufficient detail to enable us to judge of the 
points necessary for decision. Dr. Kelsey reports with much 
greater approval the experience of Dr. Weir in six cases of 
Whitehead’s operation. He admits that Weir’s experience 
shows results better than those obtained from the use of the 
ligature, but Dr. Kelsey, who seems never to have done White- 
head’s operation, expresses a distinctive preference for the 
.clamp and cautery. 
yViw York Med. Journ. Dec. 8, 1888, p. 626. CURE OF HAEMORRHOIDS BY EXCISION. 
9 
To these criticism Mr. Whitehead makes emphatic answer.1 
To the charge that his operation is “a difficult one, he says, 
that young surgeons have repeatedly assured him that they 
do not find the operation difficult, and that he is satisfied that 
it is an operation which can easily be performed by any sur- 
geon possessing average skill and intelligence. 
That it is tedious, he declares that “in an average case it can 
be completed in ten minutes. 
That it is bloody, he states “that it is never excessive, hemor- 
rhage, such as I meet with, may very well take a subordinate 
position to other and more important considerations involved 
in the operation.” Mr. Whitehead’s experience at the time of 
reading his paper, included 300 cases of operation, certainly 
sufficiently ample upon which to base deductions and which 
entitle his opinions as worthy of the highest consideration and 
respect. He clearly demonstrates that hitherto the profession 
have far too greatly feared the dangers of haemorrhage, seem- 
ingly the sole cause of objection to the dissection method. 
It does not seem hypercritical to take exception to Mr. White- 
head’s definition of the diseased condition, as a “pile bearing 
membrane” which he emphasizes should be removed. The de- 
formed ectasic hsemorrhoidal plexus is the important patholog- 
ical factor and the other changes which ensue are entirely 
secondary and comparatively unimportant. 
Supervening upon the operation the collateral circulation is 
speedily restored. The criticism that the minute venous radi- 
cles may be considered as rudimentary piles, although in a 
sense a quotation is scarely just to the author who plainly con- 
siders them as a part of the dilated plexus of vessels, already 
existing, only subordinated by the larger growths. These left 
behind all know are often a source of trouble. 
The conditions which pertained at the begining as the active 
cause of the disease may again reproduce disease but certainly 
rarely evinced by a large plexus of dilated veins appearing as 
hsemorrhoidal tumors. 
About ten years ago I operated upon two cases of prolapse 
of the rectum, by first, before resection, entirely encircling the 
operation for haemorrhoids, N. Y. Med. Jour. Feb. 23,1889. p 207. HENRY O. MARCY. 
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 to the case of the ring of the dilated hsemmor- 
rhoidal vessels before resection. For some years this method 
has entirely superceded ail others in my practice, and it has 
been repeatedly demonstrated to members of the profession 
with their distinct approval. The results of my experience in 
the use of the buried tendon suture in the cure of haemorrhoids, 
I incorporated in a paper read at the meeting of the American 
Medical Association in May, 1888, and afterward published1 in 
the Journal of the Association. 
On account of its simplicity, safety, and exceptional result, 
after abundant experience, I do not hesitate to offer my method 
to the profession as possessing distinct advantages in the treat- 
ment of this troublesome disease. Care must be taken pre- 
vious to the operation to have the large intestine thoroughly 
emptied by a cathartic and usually a large injection is given a 
few hours before operation. The patient is etherized, placed 
in the lithotomy position, the limbs supported by the Clover 
crutch, or some modification of it. The parts are thoroughly 
cleansed by a sublimate solution, as in other operations. The 
digital dilation of the sphincter is carefully made until the 
muscle is paralyzed. The rectum is then washed with the sub- 
limate solution, care being taken that none of it is allowed to 
remain. A considerable pledget of wool, into which iodoform 
has been freely dusted, is placed in the rectum. All the sub- 
sequent stages of the operation are carried on under irrigation 
with a mercuric solution. Along the line of the juncture ol 
the mucous membrane with the skin, either with a sharp knife, 
or with scissors, division is made from the central line poster- 
iorly from below upwards on both sides to the meridian line 
above. With a little care this division is made without injury 
to the plexus of vessels. The loose connective tissue fascia is 
easily separated by the finger, or a blunt instrument, quite 
deeply, cutting any connective tissue bands which may appear. 
The mucous membrane is separated from the plexus in a 
somewhat similar manner. 
iThe Surgical Advantage.® of the Buried Animal Suture. The Journal of the 
American Medical Association, July 21, 1888. CURE OF HAEMORRHOIDS B V EXCISION. 
11 
The deformed hsemorrhoidal plexus is thus separated from 
its surroundings except at its base. A needle with eye near 
the point is threaded with a tendon introduced posteriorly be- 
hind the mass, and withdrawn; again threaded with the extern- 
al end of the suture it is carried about one-third of an inch 
from its first introduction, unthreaded, threaded with the oppo- 
site end and withdrawn. This stitch resembles that taken by 
the shoemaker drawing the waxed end of his thread from 
opposite directions through the hole made with the awl. 
In this way the entire base is encircled by a line of 
deep, double, continuous sutures. As will be observed, 
this is the same stitch that I have used for many 
years in the co-aptation of the deep parts by the buried 
suture, as in the closure of the canal in hernia, in sewing off the 
pedicle of abdominal tumors, and in perineorraphy. The advant- 
age derived from this manner of sewing, is that an even contin- 
uous compression is secured from which it is impossible for 
any tissue to escape. The stitches are not drawn too closely 
since they are used to protect against haemorrhage, and not to 
produce necrosis of the enclosed parts. With scissors dissect 
away the haemorrhoidal plexus just above the line of sutures. 
The mucous membrane is now stitched by a continuous tendon 
suture to the line of division first made through the skin. This 
may be done either with the over and overstitch, or that which 
I have more recently learned to prefer, a running blind stitch 
taken from side to side from within outwards,which also buries 
the external line of sutures. In this way it will be observed 
that there are no stitches left in sight, that the divided edges 
are evenly and accurately approximated, restoring the parts to 
their normal condition. The wound is then carefully dried, 
dusted with iodoform and oftentimes still further protected by 
a thin layer of iodoform collodion. If properly done the oper- 
ation is aseptic and is followed by primary union. 
Were it requisite I could give a long series of cases with 
detailed results, also a series of photographs showing the dif- 
ferent stages of the operation and the processes of repair at 
different data. All this, however, seems superfluous. Almost 
without exception the patient is remarkably free from pain and 
the processes, of repair go on rapidly. 12 
HENRY 0. MARCY. 
When the operation is uncomplicated by any other, done at 
the same time, absolute restraint in bed is not necessary and 
micturition is usually voluntary and easy. Only one case has 
proved an exception and that unfortunately was a distinguished 
member of our profession. In this instance, I departed from 
the rule, which I believe should be absolute, and left a small 
portion of the plexus in front undissected, because it was com- 
paratively little changed. Elsewhere the ectasia was enormous. 
The anterior portion not included became cedematous, ex- 
quisitely sensitive, like an acutely swollen pile, caused reflexive 
vesical tenesmus, retention of the urine, prolonged catheteriza- 
tion and cystitis. This remaining portion had to be removed 
ultimately and the vesical conditions long remained trouble- 
some, although the healing of the wound was rapid and satis- 
factory. The cure of the haemorrhoids is complete and all the 
old sufferings and discomfort have disappeared. 
The case is instructive, as well as interesting, enforcing a 
surgical rule which the anatomy of the part teaches and which 
Mr. Whitehead very properly emphasizes, the careful removal 
of the whole hsemorrhoidal plexus. By whatever method at- 
tempted it is the failure to do this which gives failure in result, 
I do not remember ever to have dissected the parts, however 
seemingly irregular was the distension of the veins, without 
finding the whole plexus varicosed. The circulation through 
the veins, when once changed to cause dilatation, almost 
necessarily involves the whole plexus. 
Emphasis should be made in clinical instruction upon the 
early voluntary evacuation of the bladder, in the position 
easiest to accomplish it. The bowel may be safely moved the 
third or fourth day. Prolonged constipation resulting in hard- 
ened feces is to be avoided. 
In summarizing I think I may safely conclude: 
First.—That the ligation of tissues for the purpose of 
producing necrosis and the resultant septic decompo- 
sition should to-day be considered as unsurgical and unscien- 
tific, and should never be resorted to in any part of the body. 
Second.—The destruction of tissue by the actual cautery is 
productive of pain and suffering and is unwarranted, in that it 
is unnecessary, with the rarest of exceptions in surgery. The C URE OF HAEMORRHOIDS B Y EXCISION. 
13 
arguments in defense of its use would equally well apply to 
many other operations, where it has been universally aban- 
doned, as well as to haemorrhoids. That it is a relic of the 
barbarism of the past and should be relegated to history. 
Third.—The dissection and the removal of the haemorrhoidal 
plexus of diseased vessels is as rational and as scientific as the 
dissection and removal of diseased tissues elsewhere. The 
danger of haemorrhage from the excision of these structures 
is greatly exaggerated. Mr. Whitehead has shown in his 
abundant experience that they may be freely dissected with 
safety without special caution of control of the bleeding, and 
that his operation can only in a minor degree be called bloody. 
Fourth.—That by the method which I practice and advocate 
the operation can in no sense be considered a bloody one. It 
is simple and easy to do after a little experience. There is no 
arterial haemorrhage to be controlled. All the important ves- 
sels are secured before division by the continuous encircling 
sutures which serve a still further purpose of coapting and 
holding at rest the divided connective tissue. Necrosis of the 
parts is entirely avoided and with the care practiced in modern 
surgery the wound is maintained aseptic. The superficial tis- 
sues are accurately coapted so that not a single suture acts as 
foreign material. 
The advantages of closure with the animal sutures over the 
excision as practiced by Mr. Whitehead I think are: First, 
Constriction of blood vessels before division which certainly 
diminishes the loss of blood and ensures against secondary 
haemorrhage. Second, A much more accurate and easy mode 
of readjustment and closure of the parts. Third, Continuous 
animal sutures, which are buried and incorporated into the tis- 
sues, have a decided advantage over the interrupted silk suture 
which is ever to be considered as foreign and, if not removed, 
must be thrown off by suppuration. 
The advantages derived from the buried animal suture in 
other parts of the body are now generally accepted by the 
profession. 
Tendons taken from the freshly killed animal, properly pre- 
served and prepared, are greatly to be preferred, those from 
Cat-gut is often untrustworthy from inherent defects. HENRY 0 MARCY. 
the tail of the kangaroo proving superior to any others which 
I have been able to obtain. 
Measures for the permanent cure of hernia are based upon 
their use. All operative wounds made in healthy tissues with- 
out exception should be closed, layer by layer, with the buried 
animal suture, the skin itself not excepted, and when properly 
done drainage is no longer required and the wound can be at 
once made germ proof by hermetically sealing with iodoform 
collodion. To this rule amputations should prove no excep- 
tion. 
The use of the buried animal suture in its application to the 
cure of haemorrhoids, aseptically applied, is a logical deduc- 
tion from the Listerian teachings of a great fundamental truth 
formulated many years ago.