ENORMOUS OVAL HEMORRHOIDENCIRCLING THE ANUS;

WHITEHEAD’S OPERATION;ENTIRE CURE,

Read before the Section on Surgery of the College of Physicians ofPhiladelphia , March 8, 1894.

BY

W. W. KEEN, M.D.,Professor of the Principles of Surgery and of Clinical Surgery in the

Jefferson Medical College.

REPRINTED FROM THE THERAPEUTIC GAZETTE, APRIL ib, iBq4 .

DETROIT, MICH.

GEORGE S. DAVIS, PUBLISHER.

1894.

Enormous Oval Hemorrhoid encirclingthe Anus; Whitehead’s Operation;

Entire Cure.

REV. DR. E., aged sixty, was brought to meat the Jefferson Hospital by Dr. J. T. Rugh,

December 4, 1893. There is marked tuber-culosis and insanity in the family; he had entericfever in youth and several attacks of dysentery ;

has always been markedly constipated. He hashad trouble with hemorrhoids and prolapse ofthe rectum for about thirty years. For the lasttwenty years it has been a serious disability, andfor the last two years it has practically pre-vented his doing any work in his profession,or, in fact, work of any kind whatever. Hehas scarcely begun his service in the pulpitbefore protrusion of the mucous membrane andthe hemorrhoids takes place, and his discom-fort is so great that he is unable to preach.Seven years ago he consulted the late Dr. Ag-new, who advised him, in view of the severity ofhis condition, not to have any operation done.He has lost large amounts of blood of late, andnever has a stool without the protrusion.

Status Prcßsens. —A well-nourished, large,heavy man. On examining the anus, it re-sembles more than anything else a large,

swollen vulva after delivery (Fig. i). It meas-ures four inches long by three inches wide, theouter margin being one enormous, oval hemor-rhoid about an inch and a quarter in diameterand surrounding the anal aperture as though itwere a great oval piece of rope. The apertureof the oval is filled with the prolapsed andulcerated raucous membrane.

Operation, December p, iBpj. —I began theoperation posteriorly by an incision, whichfinally encircled the entire anus, at about themiddle of this marginal hemorrhoid. In doingso it was very curious to notice how the fibroustissues, being put on the stretch, were divided,but the softer, dilated hemorrhoidal veinsyielded before the sharp knife without beingcut ; the moment that there was an aperture,the dilated veins would form hernias of largesize between the fibres.

I first went directly towards the anal apertureuntil I recognized the sphincter muscle; thenby a blunt dissection of the tissues I reachedthe mucous membrane on the inner border ofthe sphincter. Following this, two fingerswere inserted into the calibre of the rectum,and the pile-bearing area seized between thethumband palm. The moment I recognized themucous membrane at one point, from that as apoint of departure I proceeded with the bluntdissection, all the way around, with but littletrouble. Only three ligatures were required,and the amount of blood lost was moderate, —

nothing whatever of a severe character. Theoperation, which had looked most formidablebefore it was begun, was quickly performedwith comparative facility. The whole pile-bearing area was cut away, step by step, and

Fig. i.

Showing the oval hemorrhoid and the prolapsed raucous membrane in its centre.

Fig. 2.

Showing the result two months after operation.

the raucous membrane stitched to the skinpari passu with the cutting. When the opera-tion was finished the anus was little more thanits normal size.

After the operation the patient reacted well,without nausea. The wound was dressed withcareful antiseptic precautions. His highesttemperature was ioi° F., which was onlyreached once, on the third day, and again onthe eighth day, in consequence of constipa-tion. With these exceptions, the temperatureran from 98.5° to ioo° F. He was perfectlycomfortable almost from the moment when theoperation was completed. On the third dayhis bowels were opened by an enema of sweetoil and citrate of magnesia by the mouth. Fiehad but little control of the sphincter muscle.On the eighth day the stitches, which hadbegun to cut out, were removed. Union byfirst intention took place, excepting at twosmall points, where the mucous membrane andskin gaped a little. He was out of bed in twoweeks, and went home in three weeks, per-fectly comfortable. The gaping points werenot quite healed. He was directed for a yearto keep the bowels in a soluble condition bymeans of enemata and laxatives, and wheneverpossible to have his bowels evacuated in a bed-pan in the recumbent position. His controlover the sphincter had returned almost entirelyby the time that he left the hospital.

Remarks. —The case is quite exceptional, inmy experience. . I have never before seen suchan enormous pile encircling the anus,—fourinches long and three wide. I confess thatwhen I first saw him I was not a little indoubt as to what ought to be done. The re-

suit has shown that the Whitehead operationwas not only the best thing to do, but I thinkthe only thing.

Since he left the hospital I have heard fromhim repeatedly and always with the most favor-able report. Since the middle of January hehas preached every Sunday, sometimes threesermons in a day, has done pastoral work, trav-elling as much as twenty miles, and at homesplits kindling-wood, carries coal, shovels snow,and can walk several miles without any fatigue.The result leaves nothing to be desired.

JANUARY 16, 1893.

WHOLE SERIES. VOL. XVII. No. I. SERIES, VOL. IX.

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