BIRTH O F COLOSTOMY
RIOOKE
THE BIRTH OF COLOSTOMY ANTHONY R. MOORE Melbourne
LAJOKING B A C K to the origins of colostomy, one is enriched by the intelligence and appropriateness of the thoughts of our surgical forefathers. There is much to be proud of in the way the men who developed this operation accepted the surgical challenge it involved. Rather than merely listing the dates and names of the surgeons who made these discoveries (which is the formal approach to medical history) a broader view of surgical history will be presented. In this an attempt is made to correlate the general ideas and customs of a society with both the discoveries which were being made in medicine at that time, and the literary form of the medical writing . The origin of colostomy took place in the latter part of the eighteenth century. This period of history saw the genesis of many social habits and convictions which have been carried forward into modern society. Let us concentrate on the period 1750 to 1825. The conceptual feasibility of colostomy came from three observations, some of which had Ileen noted since biblical times. The first was that colostoniy could occur following injury by a sword, a spear, or a shot. Those wounded could develop an opening through which intestinal contents were discharged. The second was the observation that Siamese twins joined at the umbilicus. who nevertheless could be separated, could survive with a facal fistula. Rut it was the third observation which was probably the most important pointer to the possibility of colostomy. Before the event of surgery for the treatment of strangulated hernia, the natural outcome of such a complication was either death of the patient, or a gradually developing necrosis over the lesion Address for reprints: Anthony R. Moore, Senior Lectnrer, Department of Surgery, University of 3lell)ourne, Royal Melbourne Hospital, Victoria 3050.
followed by the formation of a fistula discharging intestinal contents, usually in the groin. Although these facts were known, they passed unexploited, for the first suggestion of a deliberate performance of colostomy was made by LittrC in 1710. This was recorded by Fontanelle, historian to the Acadtmie Royale des Sciences, and has been translated by Tilson Dinnick (1935) in his classic paper on the origins and evolution of colostomy. Monsieur LittrC saw in the dead body of an infant of six days a maldevelopment of the rectum. The rectum was divided into two portions both closed and connected by only a few threads of tissue about an inch long. The upper portion of the closed bowel was filled with meconium. The lower portion w a s entirely empty. M. LittrC wishing to render his observations useful, imagined and proposed a very delicate operation in the case where one would recognize a similar confirmation. I t would be necessary to make an incision in the belly, open the two ends of the closed bowel, and stitch them together, or a t least bring the upper part of the bowel to the surface of the belly wall, where it would never close, but perform the function of an anus. Upon this slight suggestion a clever surgeon could imagine for himself details which we suppress. It often suffices to know in general that a thing may be possible and not to despair of it a t first sight.
Yet it was not until the latter half of the eighteenth century that colostomy had its operative birth. Before relating the two original reports in the papers describing the first development of colostomy, let us consider the cultural landscape of that time, for these elements of the age influenced both the mental approach of the surgeons and the character of the writing they left for posterity. The later part of the eighteenth century has been described as the Age of Reason. Religion was in relative decline, and both rational philosophy and the scientific approach to sub28 I
MOORE
BIRTH 01: COLOSTOMY
jects were fashionable. David Hume, arguably Britain’s greatest philosopher, produced his Treatise of Hunznn Nature about this time, and Tmnianuel Kant wrote his famous Critiques uf Pure Reason, of Practical Reason, and Of Judgment, in the last quarter of this century. Second, this was the age of detailed description, both in people’s personal lives, and in literature and science. It was the time when people kept diaries containing detailed accounts o f their day-to-day activities. I t was the period when the epistolary novel-the novel written as a series of letters-reached the height of its fame. And it was also the age when detailed biographies such as Boswell’s Life of Johnson were becoming popular. I n other words. many people were turning their attention to a detailed record of the events which occupied them. T h e surgical pioneers of colostomy were no exception. Next, one could say this was the age of questioning and of classification. T h e spirit of irreverence towards all dogmas and commonly held heliefs prevailed. This was the period in which John Hunter was making his great anatomical atid pathological discoveries. achievements which were mirrored by Lavoisier i n chemistry, 1,avater in physiognomy. and Cavendish in physics. Tt was also the period when the concept of iiitlivitlualisni was being sown. I t was man as an iiidividual in society who was seen to be the iiiost important oliject, rather than the preservation of the established social order, a seiitimeiit which motivates Thomas Paine’s f i c q lmok Tlir Rights of M a n . There was a tremendous feeling of expansion and adventure in the air, of man coin% forth to contest with the world. He accepted the challenge of geographical exploration. of political activism, and of philosophical excursion. This was the time o f the discovery of Australia, the American Revolution, and also what is probably the single most important social event of modern times. the French Revolution, an event which can he traced to the Romantic writiiigs of Rousseau i n the middle part of the eighteenth century. These five movemeiits. the age of reason, the age of detailed description and documentation. the age of critical questioning and classification. the rise of individualism, and the rise of social egalitarianism. are all impor-
tant in the consideration of the intellectual climate which gave rise to colostomy. That many of these movements were born in France is appropriate, for that country was the cradle of colostomy. T h e first two original descriptions of colostomy were both written by Frenchmen in French. They are superb examples of surgical prose, and though it is necessary to present only short extracts from them, these modifications have been done with great reverence and respect for the original texts. T h e first man who should be part of any surgeon’s pride in the history of colostomy is Pillore. In 1766 he wrote what is a masterpiece of clinical writing and surgical judgement. It expresses tremendous daring in the life of a man who was in practice as a humble country surgeon. H i s report passed unrecognized until it was discovered in his papers by his son. T h e following is an extract from Dinnick’s translation (1935).
282
AUST.N.Z. J. SURG., VOL.46 -No.
M. Morrell, a wine merchant and posting master . . . was in the course of the year 1766 taken with difficulty in going to stool. . . . as his difficulties increased daily, he was advised to make use of mercury (or quicksilver) in siifficientiy large doses, that by their mass they would overcome the obstacle in the bowel. The patient indeed took two pounds of quicksilver. I t was watched for every day but did not appear. T h e motions became totally suppressed and the belly increased in size from day to day. . . . in this state of affairs T was consulted. I first examined the rectum, thinking indeed it was there the obstruction would be found, helieving it was possibly formed bl- hardened o r incarcerated fzeces, as I have often seen t o happen; hut instead of this species of obstruction I found the upper part of the bowel fixed and scirrhous, forming a very laree turnour which totally obstructed the rectum. I tried to pass sounds and cannulz of all shapes and sizes, continuing my efforts for several days, but uselessly. I n this state-that is to say, the patient having passed nothing from the bowel for over a month, his belly enlarging inspite of h i s most austere diet-1 proposed to him that I should make him an artificial anus. He agreed with me and cited the case of a man in his village who for several years had had an artificial anus which ATature had provided following a strangulated hernia. I knew of this case, also another in a woman and from the same cause. I was then indeed determined t o perform the operation, but as the case was a very delicate one T first asked five or six of my colleagues to see the patient in consultation with me. No one was of my opinion and no one agreed with me. Rnt the patient, 3, AUKST, 1976
great sense, being present at our consultation, prayed my colleagues to show him any other means by which he might be saved. They answered they knew of none. “Very well”, he replied, “it is indeed imperative to operate since my illness is mortal and you know of no other means to save me.” Encouraged by so strong an argument I performed the operation in the presence of my confri.res, and oi six pensioned pupils who were with me a t the time. I chose the caecum as that part of the bowel most suited t o our need, as much by its situation as because it would furnish a reservoir, and by its continual and involuntary action would hasten the evacuation of the intestinal contents. A small plate furnished with a sponge in the shape of a large button and held by an elastic bandage was devised in place of a sphincter, so that the patient could a t all times voluntarily remove it when he felt the need, and, by means of a small cly~tc.r-, coultl from time to time cleanse out the reservoir. M y patient and I conferred together and thought of all these things before the operation. I then operated. . . . I made a transverse opening in the muscles and peritoneum almost to the same extent. T drew the caecum out as f a r as possible and without effort: there held by an assistant and myself, I opened it transversely and stitched it to the two lips of the wound by means of a thread on two needles which T passed from side t o side. . . . Fourteen or fifteen days had passed since, the operation and the patient reported vague signs in different parts of the belly. W e at first attributed it to gases shnt in the intestines, but the patient, uneasy, said always that the pains were due to the mercury and consequently continued to take such positions as might help it to come out. On the twentieth day, the belly, which had been very flat, became swollen and painful . inspite of all onr efforts the symptoms quickly angmented and the patient died on the twmtyeighth day after his operation. I performed the autopsy in the presence of the same surgeons, colleagues, and pupils. and found as follows: a man of
Their mental approach towards 3 clinical problem was limited by their ignorance of what was going on inside the diseased abdoinen. Imperforate anus was obvious, but causes of bowel obstruction inside the peritoneal cavity could not be diagnosed, so that the surgeon was left in a position of dealing with something which was a complete mystery. “Iliac passion” was the name given to this group of conditions. Although the surgeons of this time were hindered by these handicaps they were not thwarted. There was a very great feeling of frustration that people were dying from conditions which post-mortem examination revealed to be obviously mechanical problems. The second great name in the history of colostomy is Dnret, who left his memoir of colostomy in 1793. Duret was a modest navai surgeon. His case was one of imperforate anus. H e called in his surgical colleagues. and together they attempted a perineal exploration, which was unsuccessful. H e was then left in a position of deciding what to do, and describes the events in prose which captures his surgical intelligence, his humanity, and his good nature. This again is an extract from Dinnick’s translation (1935). I t was now four in the afternoou and the ii;fant appeared without resource. T h e vomiting, the extraordinary swelling of the belly, and the coldness of the lower limbs seemed signs of certain death. To my surprise, however, the next morning the child still lived. This decided me to call a second consultation, at which 1 proposed as a last resort, to prolong the life of the child, the performance of a laparotomy and the establishment of an artificial anus.
..
Pillore then gives details of the post-mortem findiiigs. Tt was obvious that the operation had heen ;I coniplete success, but the patient had tlevelo1)t.d a gangrenous segment of sniall bowel as a result of the qreat mass of mercury which h a t 1 draycetl the lmwel down into the lower par1 o f the pelvis. It i s very difficult for 11s to put ourselves i n the position of surgeons operating at this tinie. It was not only a period IOO years before anzsthetics and antisepsis. hut also-and I think this is of equal importance, and very difficult for ns to appreciate-there was the handicap of their conceptual position. . J.
SrJKc.,
46 - NO. 3.
AUGUST,
1976
Duret then describes his attempt to perform lumbar colostomy in order to avoid the dangers of intraperitoneal contaniination. This was umsuccessfnl hecause he recognized that t h e lateral portion of the colon in an infant is not extraperitoneal as in the adult, but that it has a mesocolon which renders it free and floating. H e continues: ;I
Those assembled after witnessing the previous operation, and after prolonging the discussion sufficiently to prove both its interest to humanity and to surgery, decided : That without some extraordinary intervenI. tion the death of the child was inevitable; That the axiom of Celsus, “that it is better 2. to employ a doubtful remedy than to condemn the patient in certain death”. here found its application.
283
BIKTH O F COLOSTOMY
MOORE
And finally, That the decisions of M. Hevin upon laparotomy were not transgressed by this operation, as the cause and course of the malady were as here, recognized I made an opening about an inch and an half long which served for me to introduce the index finger into the belly, with which I lifted and pulled out the sigmoid colon. In the fear that it would immediately fall back into the belly I stitched it by two waxed threads through the mesocolon. I then opened the colon longitudinally. Gas and meconium came out in abundance. When the bowel had emptied itself to a certain extent I applied a dressing. It was simple and was composed of a pierced compress. In the night between Sunday and Monday the baby slept well, the body heat reuurned, the vomiting ceased, and the child took the T h e day breast easily on several occasions. following the operation all who had witnessed the operation the evening before expressed themselves satisfied with the advantageous changes they perceived. The bandages which surrounded the child were filled with meconium, and his voice, which had previously hardly been distinguishable, was now heard lustily. On the third day, as things were going from better to better, I charged the parents to bring the child twice daily to the hospital. Citizen Massac, Chief of the Administration, and Citizen Coulon, Physician in Chief, were charged to provide the necessary dressings , , On the fifth day the threads which held the howel appeared useless so I removed them for they were already producing redness and irritation in the region of the artificial anus. On the sixth day about one inch of the internal coats of the bowel appeared through the opening giving the wound the appearance o f a chicken’s egg. I attempted to reduce the prolapse by passing a lead cannula into the fistula both to obstruct any further herniation and keep a free passage for the faxes, but the child’s cries made one defer this means . On the seventh day the child was so well 1)oth at the site of the operation and in exercise of his functions, that I judged him no longer in need of care or supervision by a person of art.
3.
...
.
. .
This is the first report of a successful colostomy.. and the hahe on whom it was performed lived to the age of 45. With Duret hegins the history of successful colostomy. Let 11s just look at the number of things he noted. First, he antedated other workers in the concept of a Iitmbar colostomy. Second, he made a very small incision. Third, he made the bowel secure hy a stitch in the mesocolon, in an attempt to prevent recession of the bowel. Fourth. he rioted the occurrence of prolapse of the stoma, and fifth. he used the artificial
anus as a channel €or the administration of a colonic washout. All of this was placed on record in the first report of a successful colostomy. There have been many others in the history of colostomy whose innovations showed great ingenuity, courage, and high ethical purpose. Cromar (I$%) has given an exhaustive and comprehensive review of this topic. Rather than repeat these descriptions of the technical and surgical aspects of colostomy, I should like to bring to mind a man called Daniel Pring. Pring was a surgeon in Bath, and in 1821 in his article on “Artificial Anus” he reflected on the human elements of a colostomy-of the mental stress and problems associated with it. Pring’s passage is intriguing, for its satirical vein can be traced directly to that tradition of social criticism in relation to Bath, which is expressed in the novels of such writers as Smollett, Fanny Burney, and Jane Austen. Smollett, who was himself a doctor, wrote the following passage in his novel Humphrey Clinker (1771). Y o u must know, I find nothing but disappointment a t Bath; which is so altered, that I can scarcely believe it is the same place that I frequented about thirty years ago The inconveniences which I over-looked in the high day of health, will naturally strike with exaggerated impression on the irritable nerves of an invalid, surprised by premature age, and shattered by long suffering-but, I believe, you will not deny, that this place, which nature and providence seem to have intended as a resource from distemper and disquiet, is become the very centre of racket and dissipation. Instead of that peace, tranquility, and ease, so necessary to those who labour under bad health, weak nerves, and irregular spirits ; here we have nothing but noise, tumult, and hurry . . . . All these absurdities arise from the general tide of luxury, which hath overspread the nation, and $wept all away, even the very dregs of people. Every upstart of fortune, harnessed in the trappings of the mode, presents himself at Bath, and is the very focus of observation.
. . .
Pritig’s passage alludes to this extravagance and irregularity. Bath at this time was a place where women of fashion and men of passion went to show themselves. Pring plays cleverly on this general atmosphere of immorality which surrounded Bath in his passage on colostomy : The eligibility of the operation is next to be considered on the second ground-namely, how far the prolongation of life is desirable upon such terms? On this point it may be remarked, that the great bulk of mankind consent to live AUST.N.Z. J. Suitc.,
46 - S o .
\70~.
3, AUGUST.1976
BOOK REVIEWS under much greater evils than the one in question. The evils alluded to are generally of a moral kind: and it would often be a charity to substitute for all these moral blemishes one qrand physical evil, as this operation will doubtlessly be considered, and which should engross all the propensity that there is in human beings to torment themselves. Perhaps the advantages oi an artificial anus may, never-the-less, not be accrjtted willingly tipon 10 speculative a recommendation : f o r the further satisfaction, then, of those who may have occasion for such a facility, it may be observed that the evil is not so great in reality a s it is in apprehension. By means of stays, made to fit accurately above the hips, with a pad on one side, and buckles and straps in front, the escape of faeces and the prolapsus of the intestine, may be effectually prevented. The bowels, by habit, will come to act pretty regularly once in 24 hours; and by habit, also, the attention to this part, which was at first disgusting, will become less repuI-
sive, although, I fear, it will still amount to rather more than an interesting amusement, even if the patient should enjoy the advantage of having nothing else to do. I a m of opinion, upon the whole, that an anus in the side is better than no anus at all: that, if life is desirable on other accounts, a convenience of this sort will not render it altogether intolerable.
One feels a little nostalgic when reading the works of men who lived in an age which. although scientifically less sophisticated, had a grace and a charm which still appeal to us all.
REFERENCES CROMAR,C. D. L. (1968), Dis. Colon Rect., I I : 423. DINNICK, T. (1935), Brit. J . Swg., 22: 142. PRING, D. (1821), The London Medical and Physical Journal, 45: log. SMOLLETT, T . G. ( I T ~ I ) ,Humphrey Clinker, letter of ?\pril 23.
BOOK REVIEWS C A R D I O V A S C U L A R S U R G E R Y , 1974: AMERICAN H E A R T ASSOCIATION M O N O G R A P H N U M B E R 45.
Edited by J O H N H I N E S KENNEDY, M.D., Netz York: American Heart, Assoc. Inc., 1975. 28 cm x 21 cm, 219 pages, illustrated. Price: not stated. THISis the latest in the series of annual similar jtu.blication.5, commencing in 1962, which have been brought out by the American Heart Association. This paperhack volume consists of 31 articles, originally published as a supplement to Volume j I of Circulation in August, 1975. The articles were selected from 60 papers which were presented a t the Annual Scientific Sessions of the Association in 1974, and these papers in turn were selected from 223 abstracts of papers accepted (but not all presented) a t that meeting. This volume, then, is meant to represent the quintessential scientific interests of American cardiovascular surgeons during 1974, and in this aim it largely succeeds. Much oi the practice of cardiovascular surgeons is now. Standardized and accepted as such by the profession. However, many areas remain controversial and are the subject of continuing research and clinical assessment. These are the areas which are concidered in this monograph. It is not surprising, therefore, that fully two-thirds of the articles relate to surgery for coronary artery disease. On the other hand, the 16% of the articles which touch on aspects of cardiopulmonary bypass are a reminder that this .-\-\usr. X.Z. J. SIJRG., VOL.46 - I\'o
3, .\U(:IJST,
1976
essential and seemingly standardized technique remains an area in which many fundamental questions, such as the optimal method of preserving myocardial viability and function, remain unsettled. That coronary artery bypass grafting is a valuable and reliable method of managing selected cases of obstructive coronary artery disease is a fundamental prior assumption of this volume. T h e exact indications for and expected long-term outlook of surgical intervention remain to be defined. Two articles, from Loyola University and the University of Miami respectively, provide further useful data which tend to confirm the view that surgery for left main coronary artery obstruction very appreciably improves the otherwise gloomy natural prognosis of this form of cormary disease. A number of other articles provide evidence that better myocardial perfusion. improved quality of life and long-term graft patency are the rule following operation in the great majority of patients with disabling symptoms, but while an improved prognosis is quite probable with other than left main stem coronary lesions, this conclusion has not been substantiated in a rigoroui statistical fashion from data currently available. I t is surprising that only one of the articles i n this monograph pertains to the surgical management of congenital heart disease. While it is true that surgical endeavour in this area comprises no more than 10% to 15% of all cardiac operations, it would be false to conclude that surgical innovations are no longer occurring in this field
-785
RIOOKE
THE BIRTH OF COLOSTOMY ANTHONY R. MOORE Melbourne
LAJOKING B A C K to the origins of colostomy, one is enriched by the intelligence and appropriateness of the thoughts of our surgical forefathers. There is much to be proud of in the way the men who developed this operation accepted the surgical challenge it involved. Rather than merely listing the dates and names of the surgeons who made these discoveries (which is the formal approach to medical history) a broader view of surgical history will be presented. In this an attempt is made to correlate the general ideas and customs of a society with both the discoveries which were being made in medicine at that time, and the literary form of the medical writing . The origin of colostomy took place in the latter part of the eighteenth century. This period of history saw the genesis of many social habits and convictions which have been carried forward into modern society. Let us concentrate on the period 1750 to 1825. The conceptual feasibility of colostomy came from three observations, some of which had Ileen noted since biblical times. The first was that colostoniy could occur following injury by a sword, a spear, or a shot. Those wounded could develop an opening through which intestinal contents were discharged. The second was the observation that Siamese twins joined at the umbilicus. who nevertheless could be separated, could survive with a facal fistula. Rut it was the third observation which was probably the most important pointer to the possibility of colostomy. Before the event of surgery for the treatment of strangulated hernia, the natural outcome of such a complication was either death of the patient, or a gradually developing necrosis over the lesion Address for reprints: Anthony R. Moore, Senior Lectnrer, Department of Surgery, University of 3lell)ourne, Royal Melbourne Hospital, Victoria 3050.
followed by the formation of a fistula discharging intestinal contents, usually in the groin. Although these facts were known, they passed unexploited, for the first suggestion of a deliberate performance of colostomy was made by LittrC in 1710. This was recorded by Fontanelle, historian to the Acadtmie Royale des Sciences, and has been translated by Tilson Dinnick (1935) in his classic paper on the origins and evolution of colostomy. Monsieur LittrC saw in the dead body of an infant of six days a maldevelopment of the rectum. The rectum was divided into two portions both closed and connected by only a few threads of tissue about an inch long. The upper portion of the closed bowel was filled with meconium. The lower portion w a s entirely empty. M. LittrC wishing to render his observations useful, imagined and proposed a very delicate operation in the case where one would recognize a similar confirmation. I t would be necessary to make an incision in the belly, open the two ends of the closed bowel, and stitch them together, or a t least bring the upper part of the bowel to the surface of the belly wall, where it would never close, but perform the function of an anus. Upon this slight suggestion a clever surgeon could imagine for himself details which we suppress. It often suffices to know in general that a thing may be possible and not to despair of it a t first sight.
Yet it was not until the latter half of the eighteenth century that colostomy had its operative birth. Before relating the two original reports in the papers describing the first development of colostomy, let us consider the cultural landscape of that time, for these elements of the age influenced both the mental approach of the surgeons and the character of the writing they left for posterity. The later part of the eighteenth century has been described as the Age of Reason. Religion was in relative decline, and both rational philosophy and the scientific approach to sub28 I
MOORE
BIRTH 01: COLOSTOMY
jects were fashionable. David Hume, arguably Britain’s greatest philosopher, produced his Treatise of Hunznn Nature about this time, and Tmnianuel Kant wrote his famous Critiques uf Pure Reason, of Practical Reason, and Of Judgment, in the last quarter of this century. Second, this was the age of detailed description, both in people’s personal lives, and in literature and science. It was the time when people kept diaries containing detailed accounts o f their day-to-day activities. I t was the period when the epistolary novel-the novel written as a series of letters-reached the height of its fame. And it was also the age when detailed biographies such as Boswell’s Life of Johnson were becoming popular. I n other words. many people were turning their attention to a detailed record of the events which occupied them. T h e surgical pioneers of colostomy were no exception. Next, one could say this was the age of questioning and of classification. T h e spirit of irreverence towards all dogmas and commonly held heliefs prevailed. This was the period in which John Hunter was making his great anatomical atid pathological discoveries. achievements which were mirrored by Lavoisier i n chemistry, 1,avater in physiognomy. and Cavendish in physics. Tt was also the period when the concept of iiitlivitlualisni was being sown. I t was man as an iiidividual in society who was seen to be the iiiost important oliject, rather than the preservation of the established social order, a seiitimeiit which motivates Thomas Paine’s f i c q lmok Tlir Rights of M a n . There was a tremendous feeling of expansion and adventure in the air, of man coin% forth to contest with the world. He accepted the challenge of geographical exploration. of political activism, and of philosophical excursion. This was the time o f the discovery of Australia, the American Revolution, and also what is probably the single most important social event of modern times. the French Revolution, an event which can he traced to the Romantic writiiigs of Rousseau i n the middle part of the eighteenth century. These five movemeiits. the age of reason, the age of detailed description and documentation. the age of critical questioning and classification. the rise of individualism, and the rise of social egalitarianism. are all impor-
tant in the consideration of the intellectual climate which gave rise to colostomy. That many of these movements were born in France is appropriate, for that country was the cradle of colostomy. T h e first two original descriptions of colostomy were both written by Frenchmen in French. They are superb examples of surgical prose, and though it is necessary to present only short extracts from them, these modifications have been done with great reverence and respect for the original texts. T h e first man who should be part of any surgeon’s pride in the history of colostomy is Pillore. In 1766 he wrote what is a masterpiece of clinical writing and surgical judgement. It expresses tremendous daring in the life of a man who was in practice as a humble country surgeon. H i s report passed unrecognized until it was discovered in his papers by his son. T h e following is an extract from Dinnick’s translation (1935).
282
AUST.N.Z. J. SURG., VOL.46 -No.
M. Morrell, a wine merchant and posting master . . . was in the course of the year 1766 taken with difficulty in going to stool. . . . as his difficulties increased daily, he was advised to make use of mercury (or quicksilver) in siifficientiy large doses, that by their mass they would overcome the obstacle in the bowel. The patient indeed took two pounds of quicksilver. I t was watched for every day but did not appear. T h e motions became totally suppressed and the belly increased in size from day to day. . . . in this state of affairs T was consulted. I first examined the rectum, thinking indeed it was there the obstruction would be found, helieving it was possibly formed bl- hardened o r incarcerated fzeces, as I have often seen t o happen; hut instead of this species of obstruction I found the upper part of the bowel fixed and scirrhous, forming a very laree turnour which totally obstructed the rectum. I tried to pass sounds and cannulz of all shapes and sizes, continuing my efforts for several days, but uselessly. I n this state-that is to say, the patient having passed nothing from the bowel for over a month, his belly enlarging inspite of h i s most austere diet-1 proposed to him that I should make him an artificial anus. He agreed with me and cited the case of a man in his village who for several years had had an artificial anus which ATature had provided following a strangulated hernia. I knew of this case, also another in a woman and from the same cause. I was then indeed determined t o perform the operation, but as the case was a very delicate one T first asked five or six of my colleagues to see the patient in consultation with me. No one was of my opinion and no one agreed with me. Rnt the patient, 3, AUKST, 1976
great sense, being present at our consultation, prayed my colleagues to show him any other means by which he might be saved. They answered they knew of none. “Very well”, he replied, “it is indeed imperative to operate since my illness is mortal and you know of no other means to save me.” Encouraged by so strong an argument I performed the operation in the presence of my confri.res, and oi six pensioned pupils who were with me a t the time. I chose the caecum as that part of the bowel most suited t o our need, as much by its situation as because it would furnish a reservoir, and by its continual and involuntary action would hasten the evacuation of the intestinal contents. A small plate furnished with a sponge in the shape of a large button and held by an elastic bandage was devised in place of a sphincter, so that the patient could a t all times voluntarily remove it when he felt the need, and, by means of a small cly~tc.r-, coultl from time to time cleanse out the reservoir. M y patient and I conferred together and thought of all these things before the operation. I then operated. . . . I made a transverse opening in the muscles and peritoneum almost to the same extent. T drew the caecum out as f a r as possible and without effort: there held by an assistant and myself, I opened it transversely and stitched it to the two lips of the wound by means of a thread on two needles which T passed from side t o side. . . . Fourteen or fifteen days had passed since, the operation and the patient reported vague signs in different parts of the belly. W e at first attributed it to gases shnt in the intestines, but the patient, uneasy, said always that the pains were due to the mercury and consequently continued to take such positions as might help it to come out. On the twentieth day, the belly, which had been very flat, became swollen and painful . inspite of all onr efforts the symptoms quickly angmented and the patient died on the twmtyeighth day after his operation. I performed the autopsy in the presence of the same surgeons, colleagues, and pupils. and found as follows: a man of
Their mental approach towards 3 clinical problem was limited by their ignorance of what was going on inside the diseased abdoinen. Imperforate anus was obvious, but causes of bowel obstruction inside the peritoneal cavity could not be diagnosed, so that the surgeon was left in a position of dealing with something which was a complete mystery. “Iliac passion” was the name given to this group of conditions. Although the surgeons of this time were hindered by these handicaps they were not thwarted. There was a very great feeling of frustration that people were dying from conditions which post-mortem examination revealed to be obviously mechanical problems. The second great name in the history of colostomy is Dnret, who left his memoir of colostomy in 1793. Duret was a modest navai surgeon. His case was one of imperforate anus. H e called in his surgical colleagues. and together they attempted a perineal exploration, which was unsuccessful. H e was then left in a position of deciding what to do, and describes the events in prose which captures his surgical intelligence, his humanity, and his good nature. This again is an extract from Dinnick’s translation (1935). I t was now four in the afternoou and the ii;fant appeared without resource. T h e vomiting, the extraordinary swelling of the belly, and the coldness of the lower limbs seemed signs of certain death. To my surprise, however, the next morning the child still lived. This decided me to call a second consultation, at which 1 proposed as a last resort, to prolong the life of the child, the performance of a laparotomy and the establishment of an artificial anus.
..
Pillore then gives details of the post-mortem findiiigs. Tt was obvious that the operation had heen ;I coniplete success, but the patient had tlevelo1)t.d a gangrenous segment of sniall bowel as a result of the qreat mass of mercury which h a t 1 draycetl the lmwel down into the lower par1 o f the pelvis. It i s very difficult for 11s to put ourselves i n the position of surgeons operating at this tinie. It was not only a period IOO years before anzsthetics and antisepsis. hut also-and I think this is of equal importance, and very difficult for ns to appreciate-there was the handicap of their conceptual position. . J.
SrJKc.,
46 - NO. 3.
AUGUST,
1976
Duret then describes his attempt to perform lumbar colostomy in order to avoid the dangers of intraperitoneal contaniination. This was umsuccessfnl hecause he recognized that t h e lateral portion of the colon in an infant is not extraperitoneal as in the adult, but that it has a mesocolon which renders it free and floating. H e continues: ;I
Those assembled after witnessing the previous operation, and after prolonging the discussion sufficiently to prove both its interest to humanity and to surgery, decided : That without some extraordinary intervenI. tion the death of the child was inevitable; That the axiom of Celsus, “that it is better 2. to employ a doubtful remedy than to condemn the patient in certain death”. here found its application.
283
BIKTH O F COLOSTOMY
MOORE
And finally, That the decisions of M. Hevin upon laparotomy were not transgressed by this operation, as the cause and course of the malady were as here, recognized I made an opening about an inch and an half long which served for me to introduce the index finger into the belly, with which I lifted and pulled out the sigmoid colon. In the fear that it would immediately fall back into the belly I stitched it by two waxed threads through the mesocolon. I then opened the colon longitudinally. Gas and meconium came out in abundance. When the bowel had emptied itself to a certain extent I applied a dressing. It was simple and was composed of a pierced compress. In the night between Sunday and Monday the baby slept well, the body heat reuurned, the vomiting ceased, and the child took the T h e day breast easily on several occasions. following the operation all who had witnessed the operation the evening before expressed themselves satisfied with the advantageous changes they perceived. The bandages which surrounded the child were filled with meconium, and his voice, which had previously hardly been distinguishable, was now heard lustily. On the third day, as things were going from better to better, I charged the parents to bring the child twice daily to the hospital. Citizen Massac, Chief of the Administration, and Citizen Coulon, Physician in Chief, were charged to provide the necessary dressings , , On the fifth day the threads which held the howel appeared useless so I removed them for they were already producing redness and irritation in the region of the artificial anus. On the sixth day about one inch of the internal coats of the bowel appeared through the opening giving the wound the appearance o f a chicken’s egg. I attempted to reduce the prolapse by passing a lead cannula into the fistula both to obstruct any further herniation and keep a free passage for the faxes, but the child’s cries made one defer this means . On the seventh day the child was so well 1)oth at the site of the operation and in exercise of his functions, that I judged him no longer in need of care or supervision by a person of art.
3.
...
.
. .
This is the first report of a successful colostomy.. and the hahe on whom it was performed lived to the age of 45. With Duret hegins the history of successful colostomy. Let 11s just look at the number of things he noted. First, he antedated other workers in the concept of a Iitmbar colostomy. Second, he made a very small incision. Third, he made the bowel secure hy a stitch in the mesocolon, in an attempt to prevent recession of the bowel. Fourth. he rioted the occurrence of prolapse of the stoma, and fifth. he used the artificial
anus as a channel €or the administration of a colonic washout. All of this was placed on record in the first report of a successful colostomy. There have been many others in the history of colostomy whose innovations showed great ingenuity, courage, and high ethical purpose. Cromar (I$%) has given an exhaustive and comprehensive review of this topic. Rather than repeat these descriptions of the technical and surgical aspects of colostomy, I should like to bring to mind a man called Daniel Pring. Pring was a surgeon in Bath, and in 1821 in his article on “Artificial Anus” he reflected on the human elements of a colostomy-of the mental stress and problems associated with it. Pring’s passage is intriguing, for its satirical vein can be traced directly to that tradition of social criticism in relation to Bath, which is expressed in the novels of such writers as Smollett, Fanny Burney, and Jane Austen. Smollett, who was himself a doctor, wrote the following passage in his novel Humphrey Clinker (1771). Y o u must know, I find nothing but disappointment a t Bath; which is so altered, that I can scarcely believe it is the same place that I frequented about thirty years ago The inconveniences which I over-looked in the high day of health, will naturally strike with exaggerated impression on the irritable nerves of an invalid, surprised by premature age, and shattered by long suffering-but, I believe, you will not deny, that this place, which nature and providence seem to have intended as a resource from distemper and disquiet, is become the very centre of racket and dissipation. Instead of that peace, tranquility, and ease, so necessary to those who labour under bad health, weak nerves, and irregular spirits ; here we have nothing but noise, tumult, and hurry . . . . All these absurdities arise from the general tide of luxury, which hath overspread the nation, and $wept all away, even the very dregs of people. Every upstart of fortune, harnessed in the trappings of the mode, presents himself at Bath, and is the very focus of observation.
. . .
Pritig’s passage alludes to this extravagance and irregularity. Bath at this time was a place where women of fashion and men of passion went to show themselves. Pring plays cleverly on this general atmosphere of immorality which surrounded Bath in his passage on colostomy : The eligibility of the operation is next to be considered on the second ground-namely, how far the prolongation of life is desirable upon such terms? On this point it may be remarked, that the great bulk of mankind consent to live AUST.N.Z. J. Suitc.,
46 - S o .
\70~.
3, AUGUST.1976
BOOK REVIEWS under much greater evils than the one in question. The evils alluded to are generally of a moral kind: and it would often be a charity to substitute for all these moral blemishes one qrand physical evil, as this operation will doubtlessly be considered, and which should engross all the propensity that there is in human beings to torment themselves. Perhaps the advantages oi an artificial anus may, never-the-less, not be accrjtted willingly tipon 10 speculative a recommendation : f o r the further satisfaction, then, of those who may have occasion for such a facility, it may be observed that the evil is not so great in reality a s it is in apprehension. By means of stays, made to fit accurately above the hips, with a pad on one side, and buckles and straps in front, the escape of faeces and the prolapsus of the intestine, may be effectually prevented. The bowels, by habit, will come to act pretty regularly once in 24 hours; and by habit, also, the attention to this part, which was at first disgusting, will become less repuI-
sive, although, I fear, it will still amount to rather more than an interesting amusement, even if the patient should enjoy the advantage of having nothing else to do. I a m of opinion, upon the whole, that an anus in the side is better than no anus at all: that, if life is desirable on other accounts, a convenience of this sort will not render it altogether intolerable.
One feels a little nostalgic when reading the works of men who lived in an age which. although scientifically less sophisticated, had a grace and a charm which still appeal to us all.
REFERENCES CROMAR,C. D. L. (1968), Dis. Colon Rect., I I : 423. DINNICK, T. (1935), Brit. J . Swg., 22: 142. PRING, D. (1821), The London Medical and Physical Journal, 45: log. SMOLLETT, T . G. ( I T ~ I ) ,Humphrey Clinker, letter of ?\pril 23.
BOOK REVIEWS C A R D I O V A S C U L A R S U R G E R Y , 1974: AMERICAN H E A R T ASSOCIATION M O N O G R A P H N U M B E R 45.
Edited by J O H N H I N E S KENNEDY, M.D., Netz York: American Heart, Assoc. Inc., 1975. 28 cm x 21 cm, 219 pages, illustrated. Price: not stated. THISis the latest in the series of annual similar jtu.blication.5, commencing in 1962, which have been brought out by the American Heart Association. This paperhack volume consists of 31 articles, originally published as a supplement to Volume j I of Circulation in August, 1975. The articles were selected from 60 papers which were presented a t the Annual Scientific Sessions of the Association in 1974, and these papers in turn were selected from 223 abstracts of papers accepted (but not all presented) a t that meeting. This volume, then, is meant to represent the quintessential scientific interests of American cardiovascular surgeons during 1974, and in this aim it largely succeeds. Much oi the practice of cardiovascular surgeons is now. Standardized and accepted as such by the profession. However, many areas remain controversial and are the subject of continuing research and clinical assessment. These are the areas which are concidered in this monograph. It is not surprising, therefore, that fully two-thirds of the articles relate to surgery for coronary artery disease. On the other hand, the 16% of the articles which touch on aspects of cardiopulmonary bypass are a reminder that this .-\-\usr. X.Z. J. SIJRG., VOL.46 - I\'o
3, .\U(:IJST,
1976
essential and seemingly standardized technique remains an area in which many fundamental questions, such as the optimal method of preserving myocardial viability and function, remain unsettled. That coronary artery bypass grafting is a valuable and reliable method of managing selected cases of obstructive coronary artery disease is a fundamental prior assumption of this volume. T h e exact indications for and expected long-term outlook of surgical intervention remain to be defined. Two articles, from Loyola University and the University of Miami respectively, provide further useful data which tend to confirm the view that surgery for left main coronary artery obstruction very appreciably improves the otherwise gloomy natural prognosis of this form of cormary disease. A number of other articles provide evidence that better myocardial perfusion. improved quality of life and long-term graft patency are the rule following operation in the great majority of patients with disabling symptoms, but while an improved prognosis is quite probable with other than left main stem coronary lesions, this conclusion has not been substantiated in a rigoroui statistical fashion from data currently available. I t is surprising that only one of the articles i n this monograph pertains to the surgical management of congenital heart disease. While it is true that surgical endeavour in this area comprises no more than 10% to 15% of all cardiac operations, it would be false to conclude that surgical innovations are no longer occurring in this field
-785
