ENORMOUS OVAL HEMORRHOID ENCIRCLING THE ANUS; WHITEHEAD’S OPERATION; ENTIRE CURE, Read before the Section on Surgery of the College of Physicians of Philadelphia, 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 encircling the Anus; Whitehead’s Operation; Entire Cure. REV. DR. E., aged sixty, was brought to me at the Jefferson Hospital by Dr. J. T. Rugh, December 4, 1893. There is marked tuber- culosis and insanity in the family; he had enteric fever in youth and several attacks of dysentery ; has always been markedly constipated. He has had trouble with hemorrhoids and prolapse of the rectum for about thirty years. For the last twenty years it has been a serious disability, and for the last two years it has practically pre- vented his doing any work in his profession, or, in fact, work of any kind whatever. He has scarcely begun his service in the pulpit before protrusion of the mucous membrane and the 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 of his condition, not to have any operation done. He has lost large amounts of blood of late, and never 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, the outer margin being one enormous, oval hemor- rhoid about an inch and a quarter in diameter and surrounding the anal aperture as though it were a great oval piece of rope. The aperture of the oval is filled with the prolapsed and ulcerated raucous membrane. Operation, December p, iBpj.—I began the operation posteriorly by an incision, which finally encircled the entire anus, at about the middle of this marginal hemorrhoid. In doing so it was very curious to notice how the fibrous tissues, being put on the stretch, were divided, but the softer, dilated hemorrhoidal veins yielded before the sharp knife without being cut; the moment that there was an aperture, the dilated veins would form hernias of large size between the fibres. I first went directly towards the anal aperture until I recognized the sphincter muscle; then by a blunt dissection of the tissues I reached the mucous membrane on the inner border of the sphincter. Following this, two fingers were inserted into the calibre of the rectum, and the pile-bearing area seized between the thumb and palm. The moment I recognized the mucous membrane at one point, from that as a point of departure I proceeded with the blunt dissection, all the way around, with but little trouble. Only three ligatures were required, and the amount of blood lost was moderate,— nothing whatever of a severe character. The operation, which had looked most formidable before it was begun, was quickly performed with 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 skin pari passu with the cutting. When the opera- tion was finished the anus was little more than its normal size. After the operation the patient reacted well, without nausea. The wound was dressed with careful antiseptic precautions. His highest temperature was ioi° F., which was only reached once, on the third day, and again on the eighth day, in consequence of constipa- tion. With these exceptions, the temperature ran from 98.5° to ioo° F. He was perfectly comfortable almost from the moment when the operation was completed. On the third day his bowels were opened by an enema of sweet oil and citrate of magnesia by the mouth. Fie had but little control of the sphincter muscle. On the eighth day the stitches, which had begun to cut out, were removed. Union by first intention took place, excepting at two small points, where the mucous membrane and skin gaped a little. He was out of bed in two weeks, and went home in three weeks, per- fectly comfortable. The gaping points were not quite healed. He was directed for a year to keep the bowels in a soluble condition by means of enemata and laxatives, and whenever possible to have his bowels evacuated in a bed- pan in the recumbent position. His control over the sphincter had returned almost entirely by the time that he left the hospital. Remarks.—The case is quite exceptional, in my experience. . I have never before seen such an enormous pile encircling the anus,—four inches long and three wide. I confess that when I first saw him I was not a little in doubt as to what ought to be done. The re- suit has shown that the Whitehead operation was not only the best thing to do, but I think the only thing. Since he left the hospital I have heard from him repeatedly and always with the most favor- able report. Since the middle of January he has preached every Sunday, sometimes three sermons in a day, has done pastoral work, trav- elling as much as twenty miles, and at home splits 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. Therapeutic Gazette THE A MONTHLY JOURNAL General, Special, and Physiological Therapeutics. H. A. HARE, M.D., Professor of Therapeutics in the Jefferson Medical College. GENERAL THERAPEUTICS. Ophthalmic and Aural Thchapcutics. O. E. DE SCHWEINITZ, M.D.. Surgical **o Genito-urinary therapeutics, EDWARD MARTIN, M.D., EDITORIAL OFFICE, 222 South Fifteenth St.. Philadelphia, U.S.A, W" Subscriptions and communications relating to the business management should be addressed to the Publisher. GEORGE 8. DAVIS, DETROIT. MICH.. V.S.A., 714 PUbort Street, Philadelphia Pa. Published on the Fifteenth Day of Every Month. 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