WHAT WAS WRONG WITH WHITEHEAD’S WORK?

AN APPRAISAL OF HIS RECTAL OPERATION

CHEL~EA EATON, M.D.

Attending Proctologist, Peralta and BerkeIey blospitals
OAKLAND, CALIFORNIA

ALTER WHITEHEAD,” a sur- head’s theory was good. The reasonabIe-

W geon of Manchester,
on November
EngIand, said
IS, 1882, “During
ness of the idea was proved by the fact
that his coIIeagues and foIIowers tried
the past five years I have been excising hem- repeatedly to foIIow his supposed pIan.
orrhoida1 tumors according to a pIan which Some succeeded, more faiIed; but among
I beIieve to be more in harmony with sur- those that succeeded are men who are con-
gical principles than the operations in sidered to be pre-eminent today. We might
genera1 use, and I have abandoned those consider the statement of Dr. Frank
pyrotechnic aids and cumbersome appIi- Yeomans which shows no enthusiasm for
antes; etc.” H e goes on to reIate the the operation, but which admits that:
method which he has used in the surgica1 “Since, by this method (Whitehead
treatment of more than three hundred method) the entire cuff of hemorrhoida
fifty cases of severe, massive, hemorrhoida mucosa is removed, it appeaIs strongIy to
prolapse which he designates as “the cases the surgeon on theoretica grounds, not
where the bIood equilibrium is destroyed onIy as radica1, but as the operation’ of
and can no Ionger be cared for by the physi- choice.“2
cian.” After stressing pre- and postopera- In addition to the.manifest sincerity of
tive care, he describes the amputative purpose and the Iogic of the plan, there is
operation whereby the entire hemorrhoidal one point that is probabIy overIooked by
mass is freeIy and compIeteIy dissected to many of the present generation: the “per-
the “upper Iim;t of the hemorrhoids,” sona equation.” It seems that in the oId
after which the cut edge of the overIying days when they Iacked many of our modern
mucosa is sutured to the “denuded verge.“l advantages of diagnostic and therapeutic
ProbabIy no articIe in medica Iiterature aids, persona1 ski11 Ioomed Iarger as a
has caused more discussion, or more mis- requisite than it does today. When men
understanding, or has received more abu- couId not Iook through a fluoroscope at
sive epithets than what is commonIy lung or stomach, they had to compensate
supposed to be the expIanation of the by deveIoping and refining their sense of
“ Whitehead Operation.” The fact that touch and hearing. It is quite IikeIy that
this torrent of invective has flowed steadily they couId Iisten better with their stetho-
for three-quarters of a century and shows scopes than we can because they had no
no sign of abating makes one wonder other aids. And it is aIso quite IikeIy that
whether, after aI1, there wasn’t something surgeons of those days, incIuding Walter
good about it. Where there are clouds of Whitehead, attained great manual dex-
besmirching smoke there must be some terity and surgical judgment. The mere
briIIiant fire. fact that Mr. Whitehead excised 139 can-
Indeed, no one can deny that White- cerous tongues with reduced mortaIity,
shouId vouchsafe his integrity and testify
* Walter Whitehead, F.R.C.S., Ed.; F.R.S. Edin.; to his skiI1.”
Surgeon to the Manchester Royal Infirmary, England;
Past President of the British MedicaI Association; Pro- Indeed, it seems quite pIausibIe that
fessor of Clinical Surgery, Victoria University, England. this great surgeon was quite sincere and
83
 American Journal of Surgery Eaton--Whitehead’s Work

truthfu1 in his report of 350 cures by his pectinate Iine (mucocutaneous junction)
amputative‘ method for advanced hemor- the tissues have been cut in a circuIar
rhoids.’ There is undoubted truth in the manner at or near the anaI verge and when
opinion of one author who states: the mucosa of the rectum has beensutured
“I think that Whitehead’s favorabIe to this margin, it has become exposed
report is probabIy attributabIe to the fact externaIIy.”
that he did not perform the operation as it In his thorough, conscientious manner,
is popuIarIy done today. He probabIy did this authority goes on to eIaborate why
the operatron correctIy. Those who at- the confusion has arisen:
tempt to do it according to his description “Another expression which is often
very IikeIy do it incorrectIy.“4 used synonymousIy with the term pectinate
Thus, a new compIexion is given to the line is HiIton’s ‘white Iine.’ If HiIton’s own
matter. There is doubt about the descrip- statement is to be examined, it wiI1 be
tion of the so-called “Whitehead opera- found that the Iine to which he referred
tion.” The man’s integrity should carry is synonymous with the intersphincteric
some weight; the principIes of the operation Iine instead and his description alone is
are in accord with the cardina1 principIes of sufficient to convince the reader that he
surgery, * his surgica1 ski11 was great. And was confused . . . . “;
now, in addition we have something eIse to If the reader has not aIready abandoned
think about. this articIe as a result of being confused by
Whitehead performed his operation cor- the discussion of confusion, he wiI1 be con-
rectIy and obtained uniformIy good resuIts; vinced of three things: First, that if
others misinterpreted his description and modern proctologists cannot agree on
got faiIures. Disgust, censure, and invec- terminoIogy, what chance did Whitehead
tive foIlowed, the uItimate in abuse being have of describing his procedure with
voiced by one who attained some notice precision? Second, the reader wiI1 see that
‘and some accIaim by coining the term, there is a pIethora qf euphoneous, ambigu-
“ Whitehead deformity.” ous, and often meaningless terms (muco-
Now why shouId the faiIure to attain cutaneous line, anorectal juncture, white
Whitehead’s success be attributed to mis- Iine of Hilton, etc.) Third, he wiI1 suspect
interpretation of Whitehead’s directions? that the surgica1 anat0m.v of the anorectum
Again Iet me quote from an authority repre- is vague and wonder if there are reaIIy any
senting an institution that has handled true surgical landmarks upon which the
more than 30,000 recta1 cases: surgeon can depend for orientation and
“It shouId be said, in justice to White- guidance.
head, that the very prevalent ectropion of Now the story can be told. Now, we know
recta1 mucosa seen foIIowing his operation where and how to find the proper level
is due to no fauIt of his. Had his instruc- at which to amputate a proIapsing hem&-
tions been understood and foIlowed prop-
rhoida mass and subsequently estabIish
erIy, no such deformity wouId have
closure. The “denuded verge” of White-
developed. For h e expIicitIy stated that
head takes in too much territory, gives a
after the amputation has been completed,
leeway of interpretation that invites
the mucous membrane of the rectum was
sutured to ‘the free skin margin’ which trouble. Whitehead’s good results were
remained after the circuIar incision had due to his surgical ski11 and intuition
been made at the mucocutaneous juncture. because the true surgica1 Iandmarks that
The troubIe has arisen as a resuIt of a afforded the determination of the “line or
faulty conception of anorectal anatomy IeveI” in question were not revealed until
and instead of making the circular incision fifty years after Whitehead’s death. Our
at the beginning of the operation, at the present knowledge of the true surgical land-
NEW SERIES VOL.LXX, No. I Eaton-Whitehead’s Work American Journalol Surgery 85

marks of anorectal musculature developed between two easiIy paIpated Iandmarks :

after 1936. the intermuscuIar groove and the puborec-
That was when Levy produced proof taIis muscIe which separates the rectal
that the conjoined IongitudinaI mu&e ampuIIa from the ana cana1.“:
interwove with the divisions of the sphinc- Now, to answer the question as to what
ter to form a web.6 He started something. was wrong with Whitehead’s work: The
Prior to that the surgeon was Jaboring answer is that nothing was wrong with the
under the deIusion that the sphincters work of Whitehead himseIf. The “wrong”
were stacked in a vertica1 Iine like a stack was done to the name of this great surgeon
of doughnuts, a concept as useless as it by the Iess skiIJfu1 ones who were unwilling
was faIse. to take the bIame for their own mistakes or
The “web concept,” on the other hand, mishaps. There is no more justice in dub-
shows how, why, and where Iandmarks are bing a recurrent inguina1 hernia after repair
formed and what forms them. And in a “Bassini deformity” than in caIIing the
addition, one can readiIy see how the “ectropion of recta1 mucosa” folIowing an
branched tubuIar gIands at the base of the improper amputative hermorrhoidectomy a
ana crypts penetrate the meshes of the “ Whitehead deformity.”
web to various depths and, according to
REFERENCES
their depth of penetration, produce a
I. WHITEHEAD, WALTER: Surgical treatment of hemor-
variety of clinical manifestations. This is to rhoids. Brit. M. J., I: 148-150, 1882.
say that when the ‘true arrangement of 2. YEOMANS, F. Proctology. P. 166. New York, 1929.
the anore&aI muscuIature is visuaIized, D. Appleton & Co.
3. POWERS, D’ARcY. Whitehead’s operations. &if. J.
most of the recta1 surgeon’s probIems are Surg., v I 2: 625-629,
automaticaIIy soIved. He sees the mechan- ‘6 RANKIN, BARGER and BUIE. The CoIon, Rectum,
ism of pathoIysis; he has precise orienta- and Anus. P. 656. PhiIadeIphia, 1932. W. B.
Saunders Co.
tion and guidance by tangible Iandmarks. BUIE, L. A. Practical ProctoIogy. Pp. 51 and 203.
5.
Furthermore, he sees where the “ Iine or PhiIadeIphia, 1937. W. B. Saunders Co.
JeveI” is to be established in the amputa- 6. LEVY, EDWARD. Anorectal musculature. Am. J.
Surg., 34: 141, 1936.
tive operation for proIapsing hemorrhoids. EATON, CHELSEA. Proctologic postulates from an
7.
“The ‘Ievel’ should be estabIished midway anatomic standpoint. Am. J. Surg., 58: 64, 1942.