been seen to follow where large areas of mucous membrane have been taken off in attempts to overcome prolapse of the rectum by this method. Inaccuracy and unfamiliarity with the principles and practice of this method are, in my opinion, the causes of most of the accidents following it. As to the time required in its performance and technique, these can be much improved by a little variation in detail. The operation which I have been requested to come to Texas and explain is a combination of suggestions derived from my surgical confreres. For some of them I do not know to whom to accord the credit. For instance, the fact that the mucous membrane of the rectum, together with its varicosities, can be peeled off from above downward much more easily than from below upward, was suggested to me many years ago, I think, by Dr. Parker, in the University of Pennsylvania. I afterwards heard it mentioned by Dr. Weir, but it was a fact quite familiar to me at that time. The operation, as I employ it, is as follows: The patient having been prepared as for all aseptic operations, should be placed in the lithotomy position, with the hips somewhat elevated. The two lateral hemorrhoids are caught upon either side of the posterior commissure of the rectum, and dragged down. An incision is made through the cutaneous border, and a blunt curved scissors carried upward between the mucous membrane and the muscular wall of the gut to the height of the internal sphincter. It is then worked laterally around the intestine, separating the mucous membrane from the muscular wall at this height, and from this point downward, either with the finger introduced through the wound, or by the aid of the scissors, the hemorrhoids are peeled out of their beds upon the muscular wall until the margin of the anus is reached. This being done upon either side, it is an easy matter to cut the cylinder thus loosened from its attachment in the muco-cutaneous border. There is usually very little bleeding at this point, and what is may be easily controlled by applying a clamp with a somewhat elongated bite circularly around the flap. The mucous membrane is then dragged down until healthy tissue is reached, and the first suture is applied upon one side of the posterior commissure, attaching the mucous membrane to the cutaneous border. Little by little the mucous cylinder is then amputated, sutures being placed as rapidly as the tissue is cut. These sutures serve not only to attach the mucous membrane, but also to control bleeding. I have been in the habit of dividing this suture into two portions in order to prevent puckering the rectum, as with a purse string. Recently, however, it has seemed to me better to divide it even into four portions, as occasionally the anus seemed a little more contracted than I would like. No ligatures and no twisting of the arteries (and no hemorrhage of any consequence), have ever been employed in this operation. Up to this period I have performed it upwards of two hundred and sixty times. In this number I have had one stricture at the site of the operation, and I have seen a stricture one year after the operation two inches above the field. This latter stricture I can in no way account for. For the first, however, there is an easy explanation. The house surgeon of the hospital, not having been present at the operation, supposed than an ordinary clamp and cautery operation had been done. Noticing a little more oozing than usual in this operation, and not wishing to be disturbed at night, he calmly proceeded to pack the rectum without introducing a speculum. As may be supposed, this packing with dry gauze tore the mucous membrane loose and carried it as a folded mucous cuff upward into the rectum. The result of this was considerable bleeding, the collapse of the patient, and I was called to him to examine for a concealed hemorrhage. The concealed hemorrhage was coming from the mucous membrane, which had been carried up in front of the gauze, and was in no wise compressed by it. The patient was reanesthetized, the bowel washed out, and the mucous membrane sewed back in position. It did not unite, however, infection having taken place, and an ugly stricture followed. The operation can hardly be credited with this stricture. The disinclination of my housesurgeon to be disturbed at night was undoubtedly responsible for it. In a general way, however, I do not believe that this operation should be undertaken by those who operate only now and then. It requires familiarity with the anatomy of the rectum. I have actu 19-Trans. ally seen the entire sphincter taken out in attempting it. It needs manual dexterity and good assistants to perform it satisfactorily. The length of time which it consumes in expert varies from nine to twenty minutes, never more than the latter, the average being about twelve minutes. The patient is dressed with a small drainage tube surrounded by gauze, and a rubber capsule is passed into the rectum and held there by a compress of soft gauze and a T-bandage. This is left in position for four days, and usually occasions no inconvenience. After this it may be removed, and at the end of five days the patient's bowels are opened either by enemata or mild laxatives. In seven days the parts are ordinarily found to be united in all of their extent, and the patient can be safely allowed to get out of bed and walk around his room. Frequently I have had patients leave the hospital at the end of the first week and go to their work without any inconvenience. There is no great advantage in this operation with regard to the amount of pain which the patient suffers over the clamp and cautery, but so far as the final healing of the parts is concerned, it certainly saves from two to four weeks over either the clamp or the ligature. In certain cases, in which there are isolated hemorrhoidal masses, I have recently adopted a modification of this method, which consists in the application of Earle's forceps to the hemorrhoids, and suturing over them. The hemorrhoid is grasped and dragged down just as for the cautery operation. In the fold attaching it to the gut above one feels for and finds the artery supplying the tumors. A needle threaded with plain sterilized catgut is passed underneath this artery and tied, thus controlling the blood supply of the hemorrhoid. The long end of the thread attached to the needle is not cut off. The Earle clamp is then applied beneath the hemorrhoidal forceps, the tumor is cut off above, and the suture is carried around and around, this clamp passing through two layers of the mucous membrane grasped by it until the entire wound is sutured. After the sutures are thus introduced, the clamp is loosened and withdrawn and the loops tightened, thus absolutely bring ing together the edges of mucous membrane and eradicating the hemorrhoidal growth. I have performed this operation something more than fifty times, and at first glance it appears the ideal procedure. In one case I have noticed great spasm of the sphincter and a fibrous band surrounding the rectum just below the point at which the artery was tied. Whether this accident is likely to occur in many of the cases, or whether it shall prove a permanent disability or discomfort to the patient, I am not prepared to say, but I cannot report or advocate this operation or any other without frankly stating all accidents and complications which I have seen occur, or which it appears to me may do so. Theoretically, this operation and the Whitehead method seem to cover the ground of hemorrhoids in an ideal way, but practically their technique involves a capacity in the surgeon which is not met in every hamlet, and each possesses potentialities for evil in inexperienced hands which cannot be ignored. On the whole, therefore, it is my practice to teach students who do not intend to make a specialty of rectal surgery, that it is their duty to avoid these operations and confine themselves to that simple, easy, safe and most efficient method, the clamp and cautery, in the operative treatment of hemorrhoids. PUERPERAL FEVERS—FROM A SURGEON'S STAND POINT. EMORY LANPHEAR, M. D., PH. D., LL. D., Chief Surgeon of the Woman's Hospital of the State of Missouri. In the modern hospital puerperal fever is now practically unknown; the once frightful mortality has been reduced to zero by the application of surgical principles to obstetric practice. From hospital experience we have learned (a) that normal labor and normal puerperium are attended by normal temperature; (b) that "autoinfection" is impossible or practically so; (c) that “milkfever" is a myth; (d) that any rise of temperature above 99 degrees F. generally means infection; and (e) that infection depends upon some fault of the doctor or nurse. Among country doctors and also in the work of city practitioners not thoroughly familiar with the aseptic technic, puerperal infections are still almost as common as in pre-antiseptic days; and with midwives the mortality is something appalling. This must continue until every accoucheur learns that the confined woman is a wounded woman, and treats her with the same attention to surgical cleanliness as if the peritoneum were to be opened. CAUSES OF HIGH MORTALITY. The persistence of puerperal infections in spite of the fact that we know them to be preventable may be ascribed to— I. Non-familiarity with the various causes; II. Inappreciation of the term "asepsis"; III. Gross carelessness; IV. Meddlesome interference with a natural process; |