Memoires sur L'enterotomie du gros intestin
Paris, 1856, pages 1-15
Observation on an operation to create an artificial anus, applied successfully by a new method, in the anal region of a newborn child, in a case of congenital absence of the rectum
Read at the Institute, in the meeting of November 2, 1835.
On September 8, I was awakened at midnight by an English lady who had been sent to me by Dr. Dubreuil, my friend. She handed me a letter from Mr. Deneux, to M. Blandin, who had not found him at home. In this letter, Mr. Deneux said "it's a newborn child that has an obstruction of the large intestines; the anus is well formed, the rectum communicates with the vagina, and the obstacle seems very high."
A one or two in the morning, I arrive at the home of MB, English, staying at the Rond-Point des Champs Elysees. I find Mr. Deneux who had delivered Mrs. B. of her baby. He said that the child was born on September 6 at four o'clock, and he was therefore thirty-three or thirty-four hours old, however he had not yet produced meconium.
The nurse told us that warm water injected through the anus came out of the vulva. This woman assured us she had found the urine-soaked diapers. The fact seemed doubtful to us.
This first child of a second marriage, though born at seven months, seemed well built and full of life, yet his belly was hard and pot-bellied, the anus and vulva were well formed. A flexible cannula, inserted through the anus, penetrated easily up to around 2 inches. Liquid injected into this orifice immediately issued from the vulva. A probe inserted into the vagina, through the vulva, easily met the cannula inserted through the anus.
We thought that the rectum was blocked at about two inches, and it communicated with the vagina; that is to say that we thought we recognized the existence of a rectovaginal fistula, in other words that dividing wall did not exist to a great extent.
During the exploration, which was long enough, the nurse was dipping her finger in sugar water, and gave it to the child to suck. After again carefully observed what I just said, our first concern was to advise the parents of the child. Our statement was to let them know that were only two ways to give vent to meconium, namely:
1 Through the anus or the natural way;
2 Through the abdomen.
It was easy for us to make them understand the danger of each operation, and their respective disadvantages. And we added that, if we succeed in finding the rectum through the vagina, there will necessarily be a communication between the intestine and the vaginal canal. Despite this statement, the parents immediately rejected the idea of the operation of Littre, and we thought it best to seek to restore natural orifices, even with the inconveniences of a fistula, rather than establishing a new one in the abdomen. It was then agreed that we would go in search of the interrupted rectum.
I proposed in this case to dilate the anus with a prepared sponge.
At four in the morning, a piece of sponge, 18 lines long, not as big as a finger, and attached at one end by a wire, was inserted into the anus and supported by a gauze square and a 'T' bandage. It was agreed that I would come at eight in the morning to place another sponge, longer and bigger, and that we would meet again at noon to carry out an operation if appropriate.
At eight o'clock, I removed the wet and swollen sponge, and it had strongly dilated the anus. I was able to introduce my little finger, with which I easily reached the vulva, but I was blocked above in a cul-de-sac. As it was doubtful that the child had urinated, I went in search of the urethra with a small straight probe of silver, without, however, finding the excretory duct. The little girl urinated abundantly, during my search, probably because I had stimulated the meatus with my probe. A new sponge, a little stronger than the first and slightly longer, was introduced into the anus where it remained firmly, as I said before.
At noon, according to our agreement, Mr. Denoux returned with me to discuss the course to take. I admitted Mr. Lebaudy, who had expressed a desire to attend, to the consultation.
After removing the sponge, which again strongly dilated the anus, I introduced my finger deeply through this orifice, without being able to discover anything other than the cul-de-sac of which I have already spoken. I was able to reach the vulva more easily with the tip of my finger. MM. Deneux Lebaudy and did the same.
We tried then to discover if we would not find the rectum distended with meconium, in order to perforate it.
The parents were warned that in the latter case, there would necessarily be a rectovaginal fistula. Unsatisified with our exploration, and although the child was already very tired, I decided to introduce the index finger into the anus. This new investigation does not find me at the top and a back pocket that I suspected must have been formed through the rectum. However, above and in front of the cul-de-sac which stopped my finger, I discovered a kind of fungal (?) narrowing, that I took to be the point where the intestine was narrowed or blocked.
To explain to M. Deneux and M. Lebaudy what I had just discovered, I said to them that the structure that I touched produced the same sensation as a withdrawn cervical matrix, softened, and the opening is very narrow. Each of these gentlemen unserstood what I had found, and Mr. Deneux said that he thought it might be the neck of the womb of the girl. A new exploration was made, and confirmed what had been thought Mr. Deneux. It was thenceforth established that there is a vagin into which opened the anus without a rectum, and the vulva and anus were linked in the vagina: there were, by a strange anomaly, two openings in the perineum instead of one, and both terminated in the vagina (1).
(1) This is the first time that this malformation is found: I have found no examples at least in the authors.
Having found that although we were dealing with an extraordinary malformation, which consisted in the absence of the rectum or part of the rectum, I decided to carefully explore the entire pelvis, through the walls of the vagina, again by introducing the index finger through the anus or the second opening of the vagina, and in order to go in search of the missing gut. After thoroughly exploring the the front, back and sides of the bony walls of the pelvis, I investigated with some difficulty, the bladder in front, the sacrum behind and the sacro-vertebral angle, which I explored thoroughly. I searched for the pocket that ought to form the rectum distended with meconium, by feeling the left side of the sacro-vertebral angle with the tip of the finger, through the posterior wall of the vagina, I felt a flattened body moving from under my finger when I moved it to some extent. I repeated several times the same maneuver, and I always felt the same sensation. Reflecting on this, I thought I was touching the object could be that the rectum. I communicated my discovery to my colleagues, who after doing the same research as me agreed with me.
Immediately, the diagnosis which had been so difficult until now, became clearer and more certain as to the facts already established, namely, that the vagina, larger than usual, seemed to occupy the pelvic cavity by itself, and that above and at the back, on the left side of the sacro-vertebral angle, was the end of imperforate rectum.
I felt relieved from that time, and as if freed from the difficulty presented by the surgical maneuver in such a delicate case, and I immediately thought to put into practice the operation that long since I meditated for similar cases (the absence of the rectum).
To facilitate understanding of the details you have just read, and those to follow, I show the parts as I suppose they were before practising my surgery. To draw an analogy as complete as possible between the subject of my observation and the attached figure, I represent the left half of a pelvis, taken from the corpse of a little girl who died a few days after her birth.
All the organs contained in the pelvis have been cut in half. I cut off a portion of the rectum to simulate the absence of this body, and I made a link between the vagina and anus.
The letters A and B indicate the anus and vulva, which were perfectly configured. These two openings communicated only with the vagina. The letter G indicates the end of the large intestine, ending in cul-de-sac below the sacro-vertebral angle, and which had no communication with the anus and vagina. In summary, the essential point to remember is that the anus communicated directly only with the vagina, and had no connection with the large intestine, from which it was separated by 2 inches, that is to say that the rectum was missing in all its extent.
Before starting the operation, we assured ourselves again that the membranous body that we felt under the finger was indeed the termination of the rectum. The elevation of the end of this intestine we appeared to be 2 inches above the skin of the perineum.
The procedure to be used was suggested to me by two failures I had experienced in similar cases, when operating together with my friend Dr. Troussel, two new-born children, in which the imperforate rectum also ended at 18 or lines 2 inches of the perineal skin. In both cases, I incised this part where the anus should be, I had dilated the wound with the prepared sponge, and finally I had perforated the rectum distended with meconium. The children became yellow and died within a few days.
I attributed their death to resorption of bile and meconium during a long journey through bloody tissue.
Unwilling to carry out the operation of Littre, I persisted in thinking that in such cases it was better to restore the natural way, but trying to avoid the inconveniences of resorption.
I thought then to attach the gut at the opening made in the skin, and to fix it there with stitches. A number of experiments on how best to establish artificial anuses in living animals, confirmed me in my fears about the dangers of resorption and the need to bring the gut sufficiently outside, to prevent infiltration and stercorous abscesses.
The proposed operation at first seemed very extraordinary, and was not at first well received.
Serious objections were raised; in particular the risk of hemorrhage, abscesses, etc.. And finally, I was told that if the intestine was twisted to a greater or lesser extent, it should be unwound, etc.
However, after discussing the value of each objection, I described the process again I intended to follow, and which was "to make an opening in front of the coccyx, behind the vaginal anus, to detach with the finger and the knife the posterior wall of the vagina, the coccyx and sacrum; to raise it to the cul-de-sac of the large intestine, to admit it through the vagina, and through the new passage, hold it with a hook; release it all around with the finger with the knife; draw it up to the opening of the skin, open it wide enough, allow the meconium to pass, and fix properly, using an interrupted suture, the opening of the intestine to that of the skin."
The operation was better appreciated and better received this time. We discussed it again; diagnosis and indications seemed so clear then, we thought that everything from the last review, seemed favourable for the bold operation I was proposing. From that moment, we were in complete agreement, the operation was decided upon, and opportunities were revealed to the relatives, who, knowing the unfortunate position of their child, were resigned to let us do whatever we deemed appropriate. We did not hide the dangers of this operation from them. However, I pointed out, contrary to what we said previously, that if we could re-establish a passage for the meconium, we would save not only the child but that there would be no recto-vaginal fistula.
During this period, the child had been placed in an emollient bath to soothe the irritation caused by this long and painful exploration, aimed at arriving at a decision.
Everything being prepared, a new exploration about the execution of the operation having been made, and the child being placed on a table, as to be cut, using a scalpel with a very short and convex blade on the edge, I made a transverse incision, 6 or 8 lines in extent, behind the vaginal anus; another incision, directed towards the coccyx, gave a T-shaped opening through which I introduced my finger, to give me a passage between the vagina and the sacrum and coccyx. I cut and tore the connective tissue that unites these parts; a probe placed in the vaginal anus warned me against perforation of the posterior wall of the vagina, this is how I penetrated at least 2 inches, and I found the end of the intestine. From that moment, the child pushed instinctively, and gave me a much better way to find through the vagina the termination of the rectum, which formed a kind of pocket. My colleagues were happy, like me, recognize that configuration.
I decided then to hold this pocket with a double hook; pulling towards me, I separated the intestine from adhesions that surrounded it, except on the side of the vagina, where I had to use the knife very carefully. This maneuver facilitated the movement of traction so that soon we saw the bottom of the intestinal pocket, and, to our delight we found that meconium was emerging on the sides of the double hook. So I pierced the cul-de-sac of the gut with a needle and double thread, and using this method and the hook, the gut was brought to the skin. An large enough opening was formed between the wire and the hook, and a large amount of meconium and gas came out. The operation time was so quick and satisfying for us and the assitants, that one of them hastened to inform the mother of this happy result. After cleaning the child, who was greatly relieved by the excretion, I finished the operation as follows.
Having ascertained that the intestinal opening was sufficient, I took the edges of this opening with torsion tongs. I handed these tongs to assistants who pulled on the intestine with prolonged traction until the attached portion passed the opening made in the skin.
I first made three stitches at each corner of the wound, but I noticed that the retraction exerted by the intestine made it go inside, and from that moment it was no longer at the level of the skin.
My experiments on living animals showed me that the essential condition for the establishment of an artificial anus, is for the mucous membrane of the intestine to be above the level of the skin, to prevent materials passing between it and the opening made in the tissue. So I carefully made six or eight stitches in the circumference of the bowel, which I developed in the shape of a tent.
During the operation, a little blood flowed. Immediately after, we made injections into the new rectum, and the child was placed in a sitz bath.
In the space of two or three hours after surgery, the small patient's linen was changed five or six times, and we found that meconium mixed with a considerable quantity of blood constantly seemed to emanate from the left corner of the wound. Several injections were made, in the artificial anus and vaginal anus. Poultices of linseed meal were applied to the wound. All the while, the little patient seemed to lose much of her strength, she turned pale, and her extremities cooled. Up till now she had been left in her crib. We returned her to her mother, who warmed her and soon restored her strength.
From 7 to 11 pm, her linen was changed several times, and she took a ten minute bath. At each change, the amount of meconium and blood decreased. Several times she was put to the breast, which she took badly at first, but soon she was able to suck strongly enough, and fell asleep. There was no appearance of fever, and twelve hours after surgery, there was no disturbance in the stitches. The injured parts remained red, but the inflammation but did not spread significantly.
On September 9, at 11 o'clock, there was a consultation in which we found:
1 That the child's general health was good;
2 That the excretion of feces was functioning well;
3 That there was no fever;
4 That the puffiness around the vaginal the anus was significantly decreased;
5 That the inflammatory redness that surrounded this part, and the anal surgery, had lost much of its intensity;
6 That the stitches were secure, there was every indication that the operation would be a success.
The next day we noted that the child had not soiled her diapers, and that there had been no excretion of urine. The little patient slept well, she continued to breastfeed all the times she was put to the breast, and she did not seem to be suffering at all.
On September 11, the wound and surrounding parts were found in satisfactory condition. The nutritive and excretory functions are accomplished perfectly; in a word, the child appears to be as good as if she was born without any malformation.
The stitches were cut from the tissue on the fifth to the tenth day; they fell out themselves or were cut.
The vaginal anus was shrunk and very narrowed, the artificial anus was a wide opening with a cracked edge, and the artificial rectum was retracted slightly. All around the opening, one felt that the surrounding cellular tissue formed an indurated circular ring; it is a kind of inflammatory shell that opposes the infiltration and absorption of the same.
Feceal material was coming out very easily. No accident developed.
After twelve days, the artificial anus began to shrink. The cracks were healed, and gave the artificial anus the puckered appearance of a natural anus.
As the shrinkage increased, I introduced tallow wicks, then wax candles and lastly candles of elastic gum that were less painful.
By carrying out this operation, I had intended to fill the gap left by the malformation, that is to say from the lower end of the large intestine to the skin. This method is based on the possibility of extending the end of the large intestine one or two inches. The inferior mesenteric artery alone is directly opposed to a graeter elongation, for by this maneuver, the S colon could easily provide a greater extension of this rectum defect. In doing so, I just did to the anal region what is done to the abdominal region, when establishing an artificial anus, that is to say one searches for the colon to bring it to the skin, with this difference only, that in one case, it is a loop of intestine that leads outside, while in the other, one takes the end of a kind of cul-de-sac formed by the pocket that ends the large intestine.
By this maneuver, I aimed to prevent bile and meconium from passing over surfaces devoid of mucous membrane, and consequently to prevent the destructive effects of resorption, which are as fatal as those of urine under such conditions, and especially when these fluids can remain, as in the pelvis.
Today November 2, that is to say fifty-five days after the operation, the little girl is in a perfect state of health; one would not suppose, seeing her, that she underwent such a serious operation . It is true that she had no fever, even in the early days. She is obviously as well developed as any other child her age and is even more advanced than her older sister had been at two months. She is fresh, cheerful, sensitive to music, she waves her little arms when she hears the sound of the piano. Her skin is perfectly white, which proves that there was not any resorption of bile.
This little girl performs all her functions very well, does not cry at night, and she seeks the breast when his mother is sleeping (1).
[(1) A few days after the operation, I found the little patient in a cradle far away from her mother's bed, she was cold and almost lifeless: I advised the mother to put her in the bed next to her to warm her. The child certainly would have died if I had not given that opinion in time, and I think I have saved many children in this way, by ensuring they were warmed by their mothers, for nature cannot do without this, even for humans. These little ones have not enough warmth in themselves to fight the cold outside, especially in a climate like ours.]
Defecation takes place as with other children; she has only an elastic plug a little less fat than your little finger always in the artificial anus,, which prevents the narrowing of this opening. She retains feces 24 and even 56 hours. Her older sister had similar constipation. When she cries, the plug is removed and the intestine empties often immediately. She is given an enema every 48 or 72 hours, and she evacuates every two or three days, according to her nurse. The mother, which is herself usually constipated, attributes this to a family disposition, rather than a result of the artificial anus, since her first daughter, who she she did not breastfeed, was absolutely the same (2).
[(2) Amussat showed us the little girl on November 17, we found all the details you have just read about the traces left by the operation, and especially on the perfect health of the patient. (Editor of the Gazette Medicale de Paris)]
Everything therefore convinces me that this is a cure as perfect as possible. I think I can expect the same outcomes as I would have expected of an anus established in the iliac fossa, and I even think this little girl will not experience the disadvantages faced by those who are afflicted with this revolting infirmity.
In any case, even though she cannot voluntarily retain feces, I do not suppose we could have remedied this inconvenience much more easily, when the artificial anus is established in the abdominal area. Although there is not yet, I believe, an example of children who have lived with an artificial anus in the anal region, in cases similar to the one I just mentioned I hope my little patient is now under conditions at least as favorable as if the anus had been established in the abdominal area. No doubt the artificial opening that I created lacks a sphincter, but the same drawback occurs by the process of Littre, and examples of removal of the rectum in which the patients could hold fecal matter, give me the hope that nature will do for this little creature she has done for adults and I think it will do even more. In any case, it seems to me that the lower end of the trunk is arranged, even without muscular apparatus, to obey the will to retain the material, while in the abdominal area nothing is established for this purpose.
The vaginal anus is a superfluous opening that seems to cause no problem. I do not think one should try to close this opening; I will only say that if the girl reached the age where she can become a mother, giving birth will require some attention from the obstetrician, when the perineum is distended.
Now consider if we had acted otherwise than I did. First, one might expect that the distention of the rectum would allow the making of a puncture through the vagina. This was the first idea that came to us, and that would come to any surgeon, but he might have to wait a few days; and even when one succeeded, there would have been a rectovaginal fistula. Moreover, the child would have died, most probably, because of the impossibility of dilating an opening so narrow and so deep. We could have done the operation of Littre, etc.; but I managed by a much better process. Let's see if we could have done better still.
Thinking at first to do better, one wonders if I should not have taken advantage of the well-configured anus which leads to the vagina, and is provided with its muscular apparatus.
I had this idea, but the fear of a rectovaginal fistula made me forgo the advantage that I could remove the sphincter by using it. It is true that there is now a more open, a vaginal anus, but I think it is better to have a superfluous opening than run the risk of having only the right number, because I might not have not be successful, and in this case the doubt justifies me again.
Considering such a case, perhaps another time I will try this development which I think is fortunate, and for the present, and future ... Besides, this is what I would do.
Splitting the vaginal anus back and side, and a portion of the posterior wall of the vagina; resect the mucosa around the sphincter, and bring the intestine to fix it there.
Now consider what the practitioners do in similar cases, that is to say where the rectum is missing to a greater or lesser extent. Make a hole in the intestine, or look for the colon in the side, these are the ways that surgery has used until now, and almost always without success.
In general, the well-motivated reluctance to carry out the operation of Littre is so great that, although the lives of some individuals have been saved by this method, almost all practitioners, however, prefer to establish the artificial route in the anal region; but the means are far insufficient. This brings only half-relief to nature, which needs to be greatly assisted. Also nearly all the children die a few days after incomplete operations that we practice daily in this region.
Some are content to dip a three-quarters, a lancet or knife in the wound, where they hope to meet with the rectum distended with meconium.
Others, more methodical, first make an exploratory incision, and do not make a puncture until after having explored the fluctuation of the intestine distended with meconium.
In both cases, even when we managed to open the intestine, besides the inconvenience of a shorter or longer path, the material must pass a non- mucosal surface and give rise to all problems of resorption.
Also note that, although there are many of these artificial anus operations in the anal area, in cases similar to the one I just mentioned, one cannot find, to my knowledge, a single proven success.
By contrast, among a very small number of artificial anus operations performed in the abdominal region, there are at least two or three successes.
At first you would be inclined to believe that the odds are more favorable for the operation of Littre than the one we practice in the anal region, but considering that this last operation is not at all similar to the first, we easily understand the difference in results.
The procedure that I use is only by analogy like that of Littre, and it can be compared, since in both, we will seek to bring the intestine at the opening of the skin. Note however that in my method, one is not necessarily interested in the peritoneum, while in the operation of Littre you open it twice; but in my method, which is, indeed, more difficult, the gut and neighboring parts suffer far greater traction.
Although malformations of the rectum are many, however, can be classified into five main divisions:
In the first, narrowed anus.
In the second, the anus is blocked by a membrane.
In the third, the rectum is more or less intercepted by a simple partition.
In the fourth, the anus is imperforate, and the rectum missing to a greater or lesser extent. According to the observations reported by the authors, these cases are the most numerous, and mine should be categorised in this class, because the abnormal vaginal anus is a superfluous opening.
In the fifth, rectum opens into another organ, the bladder, urethra or vagina, or other point of the pelvis, the sacrum, for example.
Let us discuss what to do in these different cases.
In the first, we must incise the anus, and expand as in adults, following a fissure of the anus.
In the second case, one must first make an opening in the center of the membrane, one must cut around, across the sphincter, then hold the opening dilated by a strong enough tent of lint.
In the third case, I think that after having dilated or split the anus at the back and side, we must dissect the mucosa, hold the rectum, excise the lower end which forms a sort of pocket, and fix this end to the sphincter or rather the skin. I feel justified in proposing this, because in the cases where we were content to puncture the septum, the children are dead.
In the fourth case, one must follow my procedure.
In the fifth case, after having given much thought, I was led to think that we should still use my method, unless the abnormal anus could not perform its functions. But in the case of opening to the bladder or urethra, we should lead it outside the posterior wall of the intestine, otherwise we run the risk of producing an effusion of urine, at least if we could not close the opening.
Direct experimentation on cadavers and living animals led me to put into practice the process I just described, which was successful. I think by this process we will get more success, not only in cases similar to mine, but in all those of a blockage of the rectum, except when the interruption occurs above the the pelvis, and these cases are extremely rare, I know only one or two mentioned by the authors.
From a unique case, one must not rush to draw general conclusions, I know; but here it is not just one more fact in favor of the power of surgery, for it is less the success which it must be considered that the opportunity to make in almost all cases what had not suspected or dared to do before the operation: in a word, it was demonstrated that one can do by the ordinary way that Littre proposed to the abdomen, and that A. Dubois, Desault, Duret and others have done.