Hulletilt of the University of Minnesota Hospitals and Minnesota Medical Foundation

Surgical Treatment l of Congenital Megacolon

It i Volume XXII Friday, December 22, 1950 Number 11

~-. __ .,_.__..- I MERRY CHRISTMAS HAPPY NEW YEAR

BULLETIN OF THE UNIVERSITY OF MINNESOTA HOSPITAIS and MINNESOTA MEDICAL FOUNDATION Volume XXII Friday, December 22, 1950 Number 11

INDEX PAGE I. THE SURGICAL TREATMENT OF IDIOPATHIC CONGENITAL MEGACOLON

(Hirschsprung's disease) ••• ...... , • • 164 - 181 \ DAVID STATE, M.D., Associate Professor, Department of ; Surgery; and.

WILLIAM ROGERS, M.D., Medical Fellow, Department of Surgery: University of Minnesota Hospitals

II. MEDICAL SCHOOL NEWS ...... , . . 182

III. CAIENDAR OF EVENTS .• ••• •••••.••••••••••• l8j - 187

Published weekly during the school year, October to June, inclusive.

Editor

George N. Aagaard, M.D.

Associate Editors Wallace D. Armstrong, M.D. Craig Borden, M.D. Erling S. Platou, M.D. Richard L. Varco, M.D. Howard L. Horns, M.D. W. Lane Williams, M.D. James L. Morrill, President, University of Minnesota Harold S. Diehl, Dean, The Medical School, University of Minnesota Ray M. Amberg, Director, University of Minnesota Hospitals O. H. Wangensteen, President, The Minnesota Medical Foundation Address communications to: Staff Bulletin, jjjO Powell Hall, University of Minnesota, Minneapolis 14, Minn. / MERRY CHRISTMAS HAPPY NEW lEAR 164 I I. THE SURGICAL TREATMENT OF IDIO .. life (pseud~megacolon). Although ac­ J PATH~NGENITAL MEGACOLO~ cepted by some, this classification met (Hirschsprung's disease) considerable opposition primarily 'be­ ) cause all cases of dilatation of the David state colon with marked obstipation were William Rogers called megacolon. In light of more re­ \ cent findings, it is important to differ­ J entiate true megacolon from the pseudo­ t Introduction megacolon for in the latter the patho­ , logical findings, treatment and prognosis f The striking clinical features, the are decidedly different. Much of the • unique pathological findings and the confusion regarding the results of I evasiveness of the etiological factors certain forms of treatment can be traced J have made Hirechsprung's disease a pro­ to this failure of differentiating be­ vocative and stimulating enigma. Many in­ tween true and pseudom.egacolon. vestigators in the past have tried to solve the mysteries of etiology and therapy Etiology 1 but without convincing success. Recently the observations of Whitehouse and Kernhanl The theories advanced to explain I and Neuhouser, Swenson and their co-workers2 Hirschsprung's disease fall into three have resulted in a better understanding of cat~30ries, f the pathogenesis of this disease and per­ mitted a more rational ,approach to treat­ Congenital. Hirschsprungl7 felt that ment. Beoause it is an infrequent disease the dilatation and hypertrophY of the (occurring once in every 10,000 births)3 colon was a congenital defect. Myal8 we felt that reporting our experiences with thought that the dilatation of the bowel seven patients treated surgically would be was oongenital in origin but the hyper­ worthwhile. trophy was secondary, while Fenwickl9 r\ '1 and Genersich20 held the reverse to be , Review of the Literature true, i. e., that hypertrophy was pri­ ) mary and the dilatation secondary. The According to Ruhrah,4 Billard5 in 1810 fact that the specific pathological ) was the first to report the autopsy find­ changes in the bowel have been noted in ings in a case of congenital megacolon. foetus and in the newborn add consider­ He described colonic sclerosis and dila­ able support to the congenital theory but /II tation in a six day old male. In 1867 the nature of the developmental defect Lewitt6 of Chicago reported the first case was never explained by these theories. from this country. A number of other authors, (Von Ammon,7 Barth,8 Peacock,9 Mechanical, Bartle22 thought that Gee,lO Bristow,ll Morri~,12 Futterer and patients with megacolon had an abnormal­ Middeldorf,13 Cheadle,l Guame15 and ly long mesasigmoid which predisposed to others,) reported cases but it remained torsion and obstruction of the bowel, for Hirschsprung16 to give the disease its Marfan23 felt the obstructing mechanism classical description at the meeting of was a kinking at the pelvic rectal the Berlin Congress for Children's Diseases junction. Perthes24 noted that water in 1886. Since the latter report,the introduced through the rectum would pass disease entity has been well recognized by out readily through a colostonw but the medical profession and numerous case fluid introduced into the colostomy reports have found their way into the would not be passed per rectum. He felt literature, that the phenomenon was best explained by postulating the presence of obstruct­ It was Hirschsprung, too, who in later ing the valves at the pelvirectal jun~­ case reports17 divided cases into two tion. Treves25 described rectal and groups: anal atresia as the basic defect while Concetti26 claimed that localized con­ (1) Those occurring in infancy (true genital aplasia of the muscular coats of megacolon), (2) Those occurring in adult the large intestine immediately above M:EImY CHRISTMAS HAPPY NEW YEAR 165 the rectum was the obstructing mechanism, larly the circular and longitudinal Critical evaluation of the above theories muscle layers. The mucosa frequently points to the fact that in congenital presents inflammatory changes and ,) megacolon no obturating obstructing mechan­ ulcerations. Attention has been focus­ ism other than fecal contents within the ed on the myenteric plexuses of the j lumen has been found. bowel and conflicting reports regarding the status of this structure have ap­ Neurogenic. In absence of any apparent peared in the literature. In 1901 ( obstructing mechanism to explain the Tatte133 demonstrated scanty ganglion changes in the bowel, many investigators cells in the enlarged colan at varying J have literally been forced to postulate levels, and felt that there was inter­ some type of deficiency of the nerve supply ference with peristalsis. In 1904 to the bowel as the basic defect in con­ Brentan034 stated that the "nerve ele­ f gential megacolon. ments-" in the large intestine were weak­ 1 ly developed but failed to specify Fenwick19 in 1900 thoUgh megacolon was Which portions of the intestine he meant. , due to reflex spasm of the internal anal In 1908 Finney35 showed that the gang­ "'~ sphincter. -Hurst2l felt that failure of lion cells in the enlarged colon were relaxation of the internal anal sphincter present in normal numbers and did not (achalasia) was the prime dUficulty, show any degenerativerch~nges. In 1920 while Pennat027 thought that a localized and 1924 dalla Valle3~&36a studied many paralysis of a bowgl segment was the basic sections of various portions of the problem. Hawkins2 in 1907 considered the large bowel with special reference to condition to be due to neuromuscular inco­ the nerve cells of the myenteric plexus­ ordination in one portion of the large es in two cases. He found that the bowe'l which prevented the normal peri­ ascending, transverse and descending stalticwave from passing through it and portions of the colon were enlarged but thus there was impedence to the passage of the sigmoid was of normal caliber in intestinal content beyond this abnormal both cases. The cells of the myenteric area. In 1926 Fraser29 described mal­ plexuses were normal in appearance and ! function of the colon in cases of con­ number in the cecum, ascending, trans­ genital megacolon associated with defective verse and descending colon but in more r relaxation of the internal sphincter due than 100 sections from the sigmoid colon , to abnormalities in the involuntary nervous no nerve cells could be found. t system. Wade and Roya130 in 1927 stated that the disease was due to an overactivity In 1927 and 1928 cameron37,38 report­ of the sympathetic nervous system and they ed two cases of congenital megacolon in performed lumbar sympathectomy with ap­ which he found no change in the myenter­ parent success. In that same year Martin ic plexuses of the distended and hyper­ and Burden31 clai:n:ed that "rectosigmoid trophied colon, but at the pelvic rectal I sphincterismus" due to derangement of the area where the colonic distention intrinsic nerve supply of the bowel caused stopped and where the bowel had a more a partial intestinal obstruction which normal diameter he noted that the gang­ resulted in enlargement of the bowel lion cells of the myenteric plexus were proximally. In 1930 Scott and Morton32 replaced by imflammatory cells. Cameron I demonstrated that evacuation of the en­ felt these changes were due to destruc­ larged colon followed spinal anesthesia tion of the ganglion cells by sOW8 un­ I and this was interpreted as demonstrating known agent. In 193439 and 1937 Etzal the overact1vity of the sympathetic ner­ studied a number of cases that had both· vous system. acquired megacolon and megaesophagus. He found disappearance of nerve cells Pathology and degenerative changes in the myenter­ ic plexuses in the terminal portions of In the enlarged segments of the colon the colon. there 1s a marked increase in the thick­ ness of all layers of the bowel, particu- In 1938 Robertson and Kernohan41 MERRY CHR ISTMAS HAPPY NEW YEAR 166 described changes in the myenteric plexus that the absence of motor ~ctivity and of the colon in one patient consisting of an increase in inhibition would result decrease in the size of the myenteric in a functional obstruction with second­ plexus with vacuolation and disappearance ary dilatation and hypertrophy of the of ganglion cells. proximal colon.

In 1940 Tiffin, Chandler and Fabcr42 Recently, Swenson and co-workers44 studied a case of congenital megacolon by means of colonic motility studies very carefully and found that ~here the using a multiple balloon technique have dilated bowel passed into normal calibered presented evidence supporting the con­ sigmoid there we~e for a distance of from tention that congenital megacolon is 5 to 7 em. no genglion cel18, but un­ due to malfunction of the rectum and usually abundant nerve fibers were present rectosigmoidal area that results in in Auerbach's plexus. Elsewhere the partial colonic obstruction. ganglion cells were normal both above and below the point where the norwBl sigmoid The weight of evidence thus appears colon and dilated bowel met. They postu­ to point to a basic defect in the myent­ lated that the primary disturbance was a eric plexus in the rectum, rectosigmoid localized interference with the passage and sigmoid colon which produces a of normal peristaltic waves across the functional obstruction with secondary sigmoid colon due to defective innervation. dilatation and hypertrophy of the This resulted in a functional partial ob­ bowel proximally. However, there are struction with secondary dilatation and a number of points which prevent hypertrophy in the proximal bowel. wholehearted acceptance of this theory, (1) The absence of the ganglion cells Whitehouse and Kernahan in 19484; of the myenteric plexus is not always published, in a most-complete fashion, seen in the narrowed rectosigmoid their findings in 11 cases of congenital area45 and the myenteric plexus may be megacolon and 5 cases of secondary mega­ absent from the dilated bowel as well: colon. The myenteri.c plexus was found to (2) The rectum, as visualized by barium be absent in the most distal part of the enema, appears to be normal in regards colon in all cases of congenital mega­ to size, shape, distensibility and con­ colon. In 80% of cases it was absent in tractibility. (;) If the changes in the "transitional region", i.e., the area the bowel proximal to the narrowed of beginning dilatation between rectUm and areas were secondary to obstruction sigmoid, and in 60% of the cases it was, alone one would expect the cecum, be­ in addition, absent in the lower part of cause it has the largest diameter of the sigmoid. In 20% of cases absence of all portions of the colon, to have the the myenteric plexus extended into the rrBXimum dilatation46 • In all of our upper sigmoid and lower descending colon. cases we have been able to show that Above this point, i.e., descending colon, the maximum dilatation 1s in the sig­ transverse colon and ascending colon the moid rather than the cecum and if one myenteric plexus appeared to be normal. obtains good roentgenograms of the colon In all cases of congenital megacolon there after thorough emptying one sees that were nerves present, when the myenteric the ascending and variable extents to I plexus was absent, which were not seen in the transverse portions of the colon the control cases. As a result of this are capable of active peristaltic con­ study the authors felt that the basic tractions while the dilated sigmoid cause of megacolon was the absence of para­ shows no peristaltic activity or con­ sympathetic innervation and a consequent traction whatsoever. It is our feeling increase in the action of the sympathetic that the basic defect of impaired or nervous system in parts of the colon where altered physiological activity does not the myenteric plexus was absent. Since involve the rectum and is not confined the parasympathetic nerve fibers are motor to the narrowed sigmoid alone but in­ to the gut and the sympathetic nerve fibers volves also the dilated sigmoid, des­ inhibitory, it seems reasonable to assume cending and variable extents of the MERRY CHRISTMAS HAPPY NEW YEAR 167 transverse portions of the colon. In sup­ structing congenital bands or dia-o port of this concept we point to the fact phragme of the ani-rectal area, anal that there is apparently a difference in stenosis, and spina bifida may give the the parasympathetic innervation of the as­ clinical picture of true congenital cending and right side of the transverse megacolon, but they do not represent colon as compared to the left side of the pathognon~nic roentgenographic changes transverse and sigmoid FSrts of the colon. as described above. As pointed out by The vagus supplies the former whereas the Neuhouser2 to visualize the narrowed sacral parasympathetics supply the rectosigmoid area only a small amount latter. (4) No good histological studies of barium should be injected while the of the central nervous system in these patient is being examined fluoroscopi­ cases have been done to rule out a lesion cally in an oblique position. If these in brain or spinal cord as the cause for instructions are not followed the this condition. bariumwll1 pass readily into the dila~ ed colon and obscure the narrowed recto­ Diagnosis: sigmoidal area.

All of our cases presented the typical We have noted no additional roentgen history that characterizes other reports findings of importance in our cases. on this condition; namely, obstinate con­ If sufficient barium is given to fill stipation and marked abdominal distention the colon proximal to the markedly from birth or early infancy. Vomiting dilated sigmoid it becomes apparent that was frequent and diarrhea alternated with although the cecum, ascending and vari­ the constipation. Poor nutrition, anor­ able extents of the transverse colon eXia. failure to gain weight, and grow are dIlated; they have not lost their in height; weakness" dyspnea and anemia haustral markings. After the barium is were also noted. On physical examination evacuated, the haustral markings and the marked abdominal distention was ac­ contractility of the right side of the centuated by the thin facies; prominent colon stands out in marked contrast to ribs, and "toothpick" arms and legs. The the dilated, contractless sigmoid colon. ,costal margins of our patients were wide­ As described below; we have utilized ly flared and large loops of bowel could this finding to determine the extent of readily be seen beneath the thin abdominal colonic resection in our cases. wall. The fecal filled redundant loops of colon were readily palpated and had a Treatment thick, doughy consistency. On rectal ex­ amination, one was imp'essed with the 1. Non-operative or medical treat­ absence of feces in the rectal ampulla. ment. Proctoscopic examination revealed a normal appearing empty rectum and no obstruction This form of therapy has been was met as the scope passed into a Widely built around special diets, laxative~ dilated loop of sigmoid colon containing and enemas. In this regard Friedell 7 large masses of feces. has shown that hot water enemas (l150F) are capable of assuring more effective After the large bowel was cleaned out evacuations of the colon. Hurst26 ad­ completely by repeated cleansing enemas, vocated using increasingly larger coni­ a barium enema stUdy revealed (1) a normal cal bougies to induce a better relaxa­ appearlng rectum (2) a narrow segment of tion of the internal sP~8ncter. rectosigmoid (3) a Widely dilated sigmoid Stebins, Scott &Morton have reported colon which usually o~scured the degree of temporary remissions after the use of dilatation of the remaining colon. These spinal anesthesia. findings are similar to those emphasized by Neuhouser2 and they must be present Numerous reports have also been before a diagnosis of true congenital mega­ written regarding the efficacy of colon can be made. Other conditions such certain drugs in this malady. Good re­ as pseudomegacolon or dolichocolon, idio­ sults have been reported follOWing the pathic constipation of childhood, ob- use of paras~athomimetic drugs such MERRY CERISTMAS HAPPY NEW 'YEAR 168

ae mecholyl bromide49 and Doryl50 for the treatment of congenital mego­ (carbamoyl choline chlorIde); but con- colon• . versely equally good results have been claimed for syntropan51 which is sympatho­ It is difficult to Avaluate the ef­ mimetic. ficacy of sympathectomy as a form of therapy for Hirschsprung's disease. There is no question that a small per­ The most thorough evaluation of this centage of cases may be handled effective­ problem has been made by Ross59 and ly using .medical treatment, and it should .Passler60 • In 29 cases studied by Ross, be tried on all patients. However, in relief was obtained in 21, improvement most instances medical therapy is neither occUlred in seven and the remaining pa­ effective nor practical. The mortality tient died three months after operation. attendin~ conservative treatment has also PassIer reviewed the literature and been rather high. Danziger52 reported found 117 cases of megacolon in which 75 per cent mortality, Schn~iderhohn59 sympathectomy was performed. He report­ 79 per cent and Ask-Upmark54 37 per cent ed relief was obtained in 38 cf the with conservative therapy. It should be cases and improvement was observed in added, however, that these mortality 64. The results were classified as a rates pertain to the pre-transfusion, and failure in 12 of the cases and three pre-antibiotic era and the mortality patients died. These results in the figures are undoubtedly lower now. Al­ main, are good but the follow-up in most though medical therapy may be successful casss was of short duration. The early it is rarely ideal for it entails untold enthusiasm for this procedure has waned hardship on both parent and child. No for it has become obvious with the one can blame a child or his parent look­ passage of time that recurrence of ing for relief from the disagreeable task symptoms is frequent and since the size of colonic lavage even though daily fecal of the bowel 1s not apparently altered, evacuations are produced thereby. We the dangers of volvulue remin. Grim.. have been impressed, too, with the person­ son6l points out, too, that sympathec­ ality and behavior problems that these tomy may d'ecrease or interrupt the im­ patients have presented even though their pulses over the pathways for visceral colons are being emptied successfully by pain which give early warning of im­ enemas. paction, pressure necrosis or volvulus. Another serious objection is that with Surgical TrA8tment both the Learmonth and Adson procedures, the male 1s rendered sterile because of Surgical procedures have been carried interference with the ejaculatory ap­ out either on the extrinsic nerve supply paratus. of the colon or directly on the large bowel itself. Surgical Procedures ~ the ~

Sympathect0!!IY The surgical treatment directed to­ wards the bowel itself has varied con­ In 1927 Wade and Royfe30 did the first siderably and includes the following: sympathectomy for congenital megacolon. , They did a lumbar ramisection. While Intestinal puncture, either through Learmonth and Rankin55 advised division the abdominal wall or after a laparo­ of the presacral nerve and inferior tomy has been tried in a considerable i mesenteric plexus, Judd and Adson56 felt number of cases. As can be anticipated, that bilateral lumbar sYm£athectomy was the results were very poor35. preferable. Later Adson5'( advocated infradiaphragmatic resection of the Exploratory laparotomy alone for pur­ splanchnic nerves, and removal of the poses of diagnosis or combined with the coeliac and upper two lumbar ganglion. milking of the dilated bowel of its De Takats and Biggs58 and Ladd & Gross50 intestinal contents has been attempted have also advocated lumbar 8~~athectomy on a number of occasions. 35 The only f MERRY CHRISTMAS HAPPY NEW YEAR 169 I purpose that exploratory celioto~ has the patient would soon develop control f served in this regard, is to establish the of the colostomy." The follow-up in diagnosis because the removal of the fecal this case also~ vas only of short dura­ material by milking has, of course, only tion. Finney3/ reported a case in resulted in temporary benefit. which he first performed a colostomy at the hepatic flexure followed in about Colotomy with the evacuation of the six months by a short circuiting opera­ contents of the bowel also has been done tion between the ascending portion of a number of times but although the im­ the colon and the sigmoid flexure with mediate results are satisfactory, the the dilated bowel lelf intact. Five patient has had a return of the symptoms months later the dilated portion was quite quickly.35 excised and to complete the mUltiple procedure the colostomy was closed at a Colostomy has been performed both as later date. The author stated the pa­ an emergency measure or to combat the tient made an excellent recovery from intestinal obstruction which so frequent­ this multiple stage procedure and was ly occurs with disease, as well as a gre­ apparently normal in every respect, ap­ liminary to a more radical operation. 2 prOXimately a year after the completion A few patients apparently have been left of the operation. with a permanent colostomy and have bene­ fited from this form of treatment. . Neugebauer73 also favored multiple Colop~~ation has been used by Krede163 stage resections (exteriorization of Franke and others, but the results did Bloch-Mikulicz) because it commanded the not justify its continued use. lowest mortality. Others who have ad­ vocated resections of the ~iant colon Colopexy has been tried a number of incl~de Terry,74 Fischer,7 Yeazell and times. Treves24 and Richardson65 reported Bell 6 and Anschutz76. The latter re­ failures but others have felt that satis­ ported a mortality rate of only 10% and factory results could be obtained by this in 20 cases he had obtained apparent means. cures in 16.

I Entero-anastomosis without resection Total removal of the colon has ~een , has been reported by Pfisterer67 and advised by Barrington-ward677 Mlr:zzi78 i others to have resulted in failgees only. and more recently, Grimaon 1 and co­ it The twg cases done by Lengemann and workers. In recent personal communica­ Franke 4 died soon after operation from tion to us, Grimson79 pointed out that I disruption of the anastomosis and peri­ he had done a complete colectomy with tonitis. iliosigmoidostomy in four patients. Two r of these patients have done very well , 23 Perthes made use of a procedure but he felt that the removal of the } similar to a pylorostomy for pyloric ob­ ileocecal valve offers a definite handi­ , struction. This operation was performed cap to the procedures and he is now in on the upper rectum but the results were favor of medical treatment for all cases. ) unsatisfactory. L£wen69 and Gant70 Ladd and Gross50 have reported their divided Houstonls folds with apparent experience with both local resection as f success•. Morris71 tried splitting the well as complete colectomy. Resection soft parts posteriorly after the modified of the transverse colon or sigmoid loop t! Kraske operation of the sacrum and was performed in ten patients with one ) evacuated the intestinal contents after death due to peritonitis. Five patients p introducing the arm into the bowel. were greatly improved and in satis­ , factory condition one, four, ten, eleven f 72 t Treves amputated almost all the and twelve years after operation. A large intestine, including the rectum, sixthepatient was apparently improved ) bringing the splenic flexure out of the for 14 years and then developed recur­ anus. He felt that good results were rences and involvement of other parts bf obtained but as he puts it, "he hoped that the colon. In one patient there was no MERRY CHRISTMAS HAPPY NEW YEAR 170

apparent improvement l in another only functionally deficient rectum and recto­ slight improvement, and the remaining pa­ sigmoid by means of an abdominal re­ tient died eight months after operation section of the narrowed distal segment of endocarditis. Complete colectomies and a portion of the contiguous dilated with anastomosis between the ileum and sigmoid segment with a "pull throughll the lower sigmoid were done in three pa­ of the proximal dilated segment and tients. Two of these died shortly after preservation of the internal anal operation from disruption of the in­ sphincter. Practically the entire rect­ testinal suture line. The third patient um is removed with the anastomosis be­ did well for one year but at that time ing made just above the internal sphinc­ he developed ulcerations in the sigmoidal ter from below. In 52 patients upon stump which perforated and produced a whom this operation has been performed fatal peritonitis. Because of the tragic there was one postoperative death and experiences Ladd and Gross feel that apparently complete cures were obtained total colectomy should not be done. in 51 patients. As early as three months postoperatively the colon appar­ In an excellent article Whitehouse, ently was essentially nor~~ by barium Bargen and Dixon80 have analyzed their enema examination. Bodian and his co­ results with segmental colectomy in pa­ workers reported 12 cases treated surgi­ tients with congenital megacolon. They cally by a slight modification of the performed resections of the colon with Swenson technique. In eleven cases good temporary double barrel colostomies which results were obtained although the fol­ were closed at varying times from a few low-up ranged from only one week to weeks to several months after the original three months. operation, when the patient had shown general improvement. They pointed out The thesis upon which Swenson and his that Where the colon was greatly dilated, co-workers have devised their operation they removed it down to the sigmoid colon is that the rectum and rectosigmoid are and brought the ileum out along side of abnormal. Because the operative pro­ the sigmoid. The continuity of the bowel cedure necessitates the removal of the was restored at a later date. They had rectum it brings up the problem of dam­ operated upon 29 patients with 7 deaths age to the nervi erigentes and thus im­ 1 or a mortality rate of 24 per cent. They pairment of penile erections. It is t were able to evaluate 16 cases from the well known that after a combined ab­ standpoint of follow-up for a period of dominal perineal resection with removal f from one to 32 years follOWing operations. of the rectum, the majority of male pa­ , Thirteen of the patients obtained excellent tients are impotent. The Swenson pro­ results, that is they were restored ap­ cedure does not entail as wide a removal f parently to good health and had bowel of peri-rectal tissues as in the co~­ , movements without the aid of laxatives or bined abdominal perineal resection and ·f enemas. Three patients had good results this fear of sterility may be unfounded, and were so classified because they had but in the young male the pelvis is either minute persistent fecal fistulae or narrow and consequently the nerves are they had to take some occasional laxative more vulnerable. Until sufficient time or enema. In six of the 16 cases, pro­ has elapsed to evaluate the problem of gressive or perhaps persistent dilatation damage to the nervi erigentes completely, of the remaining portion of the colon was it seems to us that other operative noted in three, a fecal fistula persisted procedures in which the rectum is left in two and in two cases proctoscopic ex­ undisturbed should be tried and evaluat­ amination disclosed postoperative con­ ed. striction of the sigmoid flexure. These results of course are, in view of the long The operative procedure which we have t follow-up, very significant. utilized in our cases is based on the altered physiological activity of the ) Yery recently Swenson and his co-work­ colon as deterttdned by means of roentgen­ I ers~l have practiced the removal of the ograms after the administration of a r It I MERRY CHRISTMAS HAPPY NEW YEAR 171 barium enema. We have tried unsuccess­ but there is a gradual transformation fully both on the unanesthetized and of the bowel in the left side of the anesthetized patient} to place multiple transverse colon so that although there ballooma in various se~ents of the colon is dilatation still the haustral mark­ in an effort to determine physiological ings and the longitudinal bands as well activity of the large bowel. We were as the thickness of the bowel appear not able to place our balloons satisfactor­ normal. ily in the patients before operation from below and we have had no patient with a Operative Procedures colostomy through which we could introduce the balloons as described by Swenson. In Since these patients have suffered one patient under spinal anesthesia} the many years of chronic ill-health their balloens were introduced per anum and nutritional status is impaired and placed in the colon under direct vision special attention has been directed to­ after opening the peritoneal cavity but wards getting the patient in the best the physiological activity of the bowel possible condition for operation. They was depressed and no good tracings were have received a high chloric diet with obtained. vitamin supplements and where indicated repeated whole blood and plasma trans­ By means of fluoroscopic examination fusions have been given to elevate the and roentgenograms after the administra­ plasma proteins. It is important to tion of the barium enema we have deter­ take as much time as necessary to clean / mined in all of our oases the follOWing out the colon completely preoperatively imPortant points: (1) The rectum is of and this may take many days. For three normal caliber and is oapable of dilata­ days prior to operation the patient ia tion and contraction. (2) There is a given aureomycin, 250 milligrams q.i.d. variable length of narrowing and spasm of orally to decrease the intestinal f the bowel beginning at the reotosigmoid bacterial flora. An intravenous in­ , Junotion and extending to the dilated Jection of 510 glucose in distilled water . , sigmoid colon. (3) There is a definite is started in an arm before operation I difference between the activity of the and since it haa been shown that a 1arg9 i right side of the colon including the number of these patients may have idio­ ascending and Tight side of the transverse pathic dilatation of the urinary portions of the colon as compared to the bladder all our patients have had an ft left side of the transverse, descending urethral catheter inserted immediately f ~ and sigmoid portions of the colon. Even after being anesthetized. For anes­ , where there is marked dilatation of the thesia we have utilized pentothal- ; right side of the colon after the barium curare solutions in all the cases ex­ 1 enemas has been evacuated good haustral cept one where spinal anesthesis sup­ markings and peristaltio waves oan be plemented with pentothal-curare solu­ t demonstrated roentgenographically. On the tion was used. Regarding the incision} I other hand we have not noted peristaltic we have utilized both a left hockey waves of the descending or sigmoid colon. stick (Rochnegg) or more recently} a At operation} we have also been able to left paramedian incision from the establish clearly that the rectum has a symphysis pubis well up into the epi­ , norrral diameter and that there is a gastrium. In our first two cases the definite narrowing at the rectosigmoid hockey stick incision was used because I Junction of variable length separating the we anticipated some difficulty mobiliz­ rectum from the markedly dilated sigmoid ing the splenic flexure but we noted in ) colon. The dilated and hypertrophied these and subsequent cases that the portions of the colon show oharaoteristic­ splenic flexure was very mobile and of­ ally an absence of the haustral markings fered no problem in mobilization. Where and absence o~ the norrrAl longitudinal the paramedian incision has been used ) muscular bands. In the cases that we have care has been taken to keep the rectus observed these changes have involved the muscle intact. sigmoid colon and the descending colon i 't. r I MERRY CHRISTMAS HAPPY NEW YEAR 172

Extent of Reseotion normal in patients with megacolon. In these patients the mid colic artery was We have determined the proximal extent clamped at its origin and after the col­ of reseotion in all cases preoperatively lateral circulat:lon was found to be by n:eans of roentgenograms. We have felt good the vessel was transected and tied. secure in utilizing for our anastomosis This resulted in the needed additional that segment of bowel which shows good length to do the anastomosis without haustral markings and peristaltic activi­ tension. No attempt has been made to ties. In six of cur cases this level of close off the bare areas made by re­ proximal transection has been in the moving the descending and sigmoid colons right half of the transverse oolon and and their respective mesenteries. One ., in the remaining one in the ascending gram of Streptomycin and 500,000 units .I colon just prOXimal to the hepatio flex­ of penicillin have been deposited ure. In all instances we have come proxi­ routinely Within the peritoneal cavity, mal to the most distal area of active at the level of anastomosis before peristalsis. We have done this purposely closure. A nasal tube has been left so as to avoid any error in utilizing into the stomach for decompression pur­ bowel of questionable peristaltic activUy. poses for approximately forty-eight The distal line of resection has been in hours after operation. Closure of the the upper reotum. The bowel between the abdominal wound in layers has been prOXimal and distal line of resection has carried out using interrupted 30 silk been removed with careful ligature of the (deknatal). Postoperatively these pa­ vessels in the mesentery. Definition of tients have received parenteral fluids, the normal rectal ampulla has been made dihydrostreptomycin and penicillin for in all instanoes without difficulty. We the first four days. Early ambulation have insisted upon as little dissection has been practised. The rectal tube has of the rectum as possible for two reasons, been partly removed on the third day and firstly, because of the possibility of completely Withdrawn on the fourth. The interference with the nervi erigentes and urinary catheter has been left in until secondly, a large space left between the the fourth day, then removed and re­ rectum and hollow of the sacrum pre­ inserted if the residual urine measures disposes to perirectal infection and leak­ more than 75 cc. age at the line of anastomosis. In the one patient in wham the space between the Results rectum and sacrum was opened widely, a leak of the anastomosis occurred and a Seven patients have been operated deviating colostomy became necessary. A upon in the manner described above. ; closed one layer type of anastomosis has Thel:'e have been no deaths. One patient been made using Wapgensteen's intestinal developed a leak at the line anastomosis , b5 anastomosis clampa • Interrupted 40 which necessitated a proximal deviating ) silk sutures inserted in the Lambert colostomy. The remaining six patients fashion have been used. Because of the have had uncomplicated postoperative good length of the rectal stump there have courses with excellent clinical results, j been no particular tecllnical difficulties having spontaneous daily bowel movements with the anastomoses. The level of without the aid of enemaa or cathartics. J anastomoses has been between 6 and 10 cm The period of follow-up ranges from 4 to from the anal skin. After the anastomosis 23 months. Postoperative barium enemas f has been completed a rubber catheter is have been obtained in five of these pa­ introduced from below and placed into the tients and show good peristaltic activi­ prOXimal colon for decompression purposes. ty and emptying of the residual colonic Great care has been taken to extra­ segment. There has been a marked im­ , peritonealize the anastomosis. In two provement in the general health, physi­ patients we have had difficulty in bring­ cal endurance and personality in all the ing down the transverse colon to the patients operated upon. In those pa­ rectum because the distance between the tients who are still in the growing upper abdomen and pelvis is greater than period there has been a rapid increase MERRY CHRISTMAS HAPPY NEW YEAR 173

in height ~d weight. The results to tion revealed no definite evidence of date in these patients both from the obstruction at the line of anastomosis standpoint of the patients' response as although there was some slight narrow­ well as the sinoere thankfulness of the ing here. A number of 30 French cathe­ parents who had the problem of taking ter, however, passed readily through care of them before operation have made the anastomosis into the dilated colon this operative procedure be a most grati­ proximalwards. A small portion of the fying one to the surgeon, seoond perhaps transverse colon taken at this time for only to the Ramstedt operation for histological examination showed hypertrophic pyloric stenosis. typical changes of Hirschsprung1s disease. Following this transverse co­ ~ Reports: lostomy the patient got along 'nicely and was readmitted on 9-28-48 for clos­ was first seen at the University ure of the colostomy. After closure of Hospitals in June 1945 at the age of 5 the colostomy the patient got along weeks. At that time he presented symptoms nj,cely until January 1949 when, at this suggesting intestinal obstruction and had time, he again developed vomiting and a laparotomy. A volvulUS was found and abdominal distention which could not be 10 inches of the sigmoid colon were re­ controlled by enemas. He was returned sected leaving a double-barrelled co­ to the hospital for examination on lostomy. The colostomy was closed in ap­ February 15, 1949 at which time marked prOXimately two weeks and the patient de­ abdominal distention with visable peri­ veloped marked abdominal distention. staltic waves were readily noted. The Exploration of the abdominal oavity was rectum, however, was empty to examina­ carried out again, approximately one week tion and the flat plate of the abdomen after closure of the colostomy at which showed marked distention of both large time the anastomosis was found to be and small bowels. He was taken to the patent but there was marked dilatation of operating room and a proctoscope was the bowel prOXimal to line of anastomosis. passed through the line of anastomosis No further resection or anastomosis was between the transverse colon and sigmoid done at this time and the patient was colon and following this rapid decom­ treated by means of repeated enemas, pression occurred. After active pre­ cathartics, etc. and then discharged in operative preparation, on March 3, 1949 September 1945 under reasonable good con­ the patient was again taken to the trol. He was re-admitted in October of operating room the narrowed recto-sig­ 1946 because of recurring bouts of ab­ moid region was removed and an anastomos­ dominal distention and intestinal obstruc­ is was made between the transverse colon tion and a laparotomy was carried out at and rectum at a distance of 7 em. from Which time a diagnosis of congenital the anal skin. Postoperatively, the pa­ megacolon was made and a transverse co­ tient did well and was discharged on lostomy was formed. Following this the March 27, seventeen days postoperatively patient improved considerably. He was at which time he was having three to four well until May 1946 at which time the co­ loose stools per day, regularly. He lostomy closed spontaneously and he again failed to keep his appointments in our developed intestinal obstruction. He was outpatient department and was not seen readmitted and the colostomy opened and again, until November 20, 1950 at which again his symptoms subsided. Because of time he was having two stools per day colostomy retraction and intestinal ob­ without any enemas and was very active struction, he was readmitted 6-27-47 at and appeared normal in every way. He which time the transverse colon was brought had gained 14 lbs. and had grown 7~ up on anterior abdominal wall over two inches since his operation. Examination glass rods placed through the mesacolon revealed the previous laparotomy scars with an effort to prevent retraction of but no evidence of distention. Un­ the colon. This time it was noted that fortunately it was not possible to ob­ the transverse colon was markedly thick­ tain a barium enema at that time. ened and dilated. Proctoscopic examina- MERRY CHRISTMAS HAPPY NEW YEAR 174 Comment of oathartics and for a period of time, he also received mecho1y1 without any This patient presented the rather prolonged relief, however. He was typical history of a patient with symptoms first seen by us for the consideration of intestinal obstruction beginning soon of surgery on 8-29-49 and although he after birth who was treated for a volvulUS was having daily evacuations, by means of the sigmoid without a definitive dia~ of enemas, he felt that he could no guosis of megacolon being made until some­ longer go to school because he was un­ time later. While an anastomosis had been able to handle the problem of self ad­ done between the transverse oolon and the ministration of enemas away from home. sigmoid and there was no definite evi­ He was admitted on 9-28-49 and physical dence of obstruction at the line of the examination revealed a rather marked anastomosis still whenever his colostomy abdominal distention and marked flaring was closed, the proximal bowel distended of the costal margin. Roentgenograms and he developed symptoms of intestinal of the large bowel revealed the typical obstruction with marked abdominal disten­ narrowed area in the region of the tion. At his last operative procedure distal sigmoid and also marked dilata­ the previous anastomosis was found to be tion of the prOXimal colon. After patent but there was a residual narrowed emptying, however, good peristaltic area of the recto-sigmoid apprOXimately waves in the region of the ascending 5 em. in length. This area was resected oolon were noted. After adequate pre­ and the transverse colon was brought operative preparation he was explored down to the rectum. This experience is on 9-29-49, at which time, the sigmoid similar to that noted by others who have colon was found to be tremendously anastomosed the transverse colon to what dilated and thickened. This process appears to be normal sigmoid. FollOWing extended to the proximal one-third of removal of the narrowed sigmoid area, al­ the transverse colon where a trans­ though the same proximal colon was utili­ formation from the abnormal to normal zed, still by anastomosing it to the texture of the bowel occurred. The nar­ rectum distal to the narrowed area, the rowed area of the rectosigmoid was about patient has apparently been cured of his 7 to 8 em. but distal to this the rect­ difficulty. The fact that he has had no al ampulla had a normal transverse intestinal obstruction and 1s having daily diameter. Reseotion of the colon dist­ bowel movements even tlfough the rectum al to the hepatic flexure down to the has been left behind would also sub­ rectal stump was carried out, anasto­ stantiate the contention that it is not mosis then made between the asoending necessary to remove the rectum as long as colon and the rectum, about 1 cm. from the narrowed sigmoid area is removed and the skin margin. Postoperatively he actively contracting bowel is brought down did very well and developed spontaneous and anastomosed to the residual rectal bowel movements which were at first stump. quite liquid but within a period of a month after operation they had become " a 21 year old while male who quite well formed. He was last seen on was admitted to the University Hospitals December 11, 1950, at which time he was 9-28-49 and discharged on 10-8-49. He having 2 to ; well formed stools per was first seen at the University Hospi­ day and had gained approximately 14 Ibs. tals in 1930 With the history of chronic since surgery. He has been able to go constipation and abdominal distention to school and also has part time employ­ since birth. Be was acutely ill at this ment handling both responsibilities time with a hiBb fever J vomiting and without difficulty. A roentgenogram of intestinal obstruction but was treated the bowel, after barium enema on successfully by means of hot water enemas December 11, 1950 showed excellent con­ administered by Dr. A. Freidel1 of our tractility and emptying of the residual pediatric staff. He was carried along colonic pouoh. reasonably well by means of medical therapy consisting of daily enemas, use 1 MERRY CHRISTMAS HAPPY NEW YEAR 175 Comment of the dilatation of the right side of 1 the colon, good peristaltic activity This patient was the oldest in our end haustral markings could be made out present group and although he had been in the ascending and right half of the getting along relatively well by the use transverse portions of the colon. On of daily enemas} he could not continue 10-26-49 laparotomy revealed a normal his schooling away from home because he rectum, measuring 6 em. in transverse was unable to arrange for self-admin­ diameter but beginning in the retro­ istered enemas. The involvement of the sigmoid area and extending 14 em. to 15 bowel as determined by means of roentgen­ cm. prOXimally was a narrow segment of ograms apparently extended to the proxi­ bowel with a diameter of approximately malone-third of the transverse colon but 2 cm. The colon proximal to this was in order to insure an actively contract­ markedly dilated and hypertrophied. ing colonic segment for the anastomosis The haustral markings of the external it was necessary to utilize the ascending surfaces were absent being replaced colon and to anastomose this to the with a continuous surface layer of rectum. His response, postoperatively, opaque material. These changes in the has been most gratifying and he is now bowel extended to the middle portion of able to continue his schooling and in the transverse colon, where the bowel addition is well enough to hold down a wall although somewhat thicker and more part time job as well. dilated than normal had well defined longitudinal muscle bands and haustra­ ., a sixteen year old, white male tions. The transition of the abnormal was admitted to the University Hospitals to normal external surfaces of the on 10-2;-49. This patient gave a history bowel corresponded rather closely to the of constipation since birth requiring area where the haustral pattern and enemas for daily evacuation. A diagnosis peristaltic activity appeared to be of congenital megacolon was made and at normal roentgenographically. Balloons the age of three (in 19;6) a lumbar were placed into the transverse colon, sympathectomy was done at Mayo Clinic. dilated sigmoid colon and the narrowed This was followed by relief for three rectosigmoid region. Although some weeks but. the original symptoms of con­ small peristaltic ~aves were obtained, stipation reappeared. He developed in­ still the interpretations of these testinal obstruction and generalized con­ tracings were difficult to evaluate. vulsions in June of 1940 and was treated The colon from the junction of the prox­ by means of intestinal decompression and imal 1/; and distal 2/3 of the trans­ vigorous use of enemas. He was placed on verse colon down to the rectal ampulla mecholyl but because of reactions and was resected and an anastomosis between because no spontaneous evacuation of the the transverse colon and the rect~. was bowel occurred the medication was dis­ made at approximately 9 cm. from the continued. By means of enemas it was anal skin margin. Postoperatively the possible to produce daily evacuation of patient did very nicely and was dis­ the bowel as well as to prevent any marked charged on the tenth postoperative day distention. However, because of the need having t~o or three soft well formed for these daily enemas the youngster stools spontaneously. He ~as followed could not participate actively in the in our outpatient department and on his usual social and athletic endeavors of his last visit one year after operation he companions of the same age group and he was having two stools of almost normal , had become rather moody and presented a size and consietency per day. He had I, behavior problem to his parents. X-ray gained almost 20 pounds in weight, had ~ examination of the large bowel revealed grown two inches, and no longer pre­ I considerable spasm of the sigmoid colon sented a behavior problem to his par­ with marked dilatations of the descending ente. Postoperative films taken six and transverse portions of the colon. months after surgery revealed good con­ There was also considerable elevation of tractility and evacuation powers of the both leaves of the diaphragm. In spite residual segment of the colon. MERRY CHRISTMAS HAPPY NEW YEAn 176

Comment constriction at the rectosigmoid junc­ tion with marked dilatation of the sig­ Fqllowing operation this 16 year old ~id, dencending and left side of the boy developed spontaneous bowel move­ transverse portion of the colon. Prox­ ? menta, gained 20 pounds in weight and 2 imal to this, however, the bowel was of inches in height within a period of A a sIUlller caliber and appeared to show { year. Because he could not participate good normal haustrations as well as in social and athletic activities with active peristaltic waves. On 1-10-50 his companions he was no longer the aeri­ the patient was operl\ted upon at which I ous behavior problem he had been to his time the dilated sigmoid, descending parents before operation. and lateral or distal one third of the transverse portions of the oolon along t was admitted to the University with the narrowed rectosigmoid were Hospitals on 1-3-50 and discharged on excised. The latter was 8 em. long. 1-24-50. This eleven year old white male The transverse colon was then brought had marked constipation and abdominal down and anastomosed te the rectum at distention since birth. He was first Been about 7 em. frem the anal Ir.A.rgin. Post­ at the University Hospitals at the age of operatively, the patient did nicely and tt~ee when a diagnosis of congenital mega­ began to have spontaneous semi-solid colon was mAde. He was place on ~edical stools on the fifth postoperative day. therapy consisting of 200 milligrams of He was discharged on the thirteenth mecholyl one-half hour aft~r breakfast, p0stoperative day with the wound well mineral oil by mouth nightly and mineral healed and having soft but formed stools oil enemas as needed for relief from three times per day. About ten days fecal and gaseous distention. By careful after his discharge from the hospital attention to details of this regimen the he failed to paas any stool and de­ your~sterls parents were able to prevent veloped abdominal distention. He was marked abdominal distention and to effect proctoscoped at that time and although daily evacuation. On several occasions, some narrowing was noted at the line of however, it was necessary to hospitalize anastomosis a number 30 French rectal him fer episodes of acute intestinal ob­ tube could be passed without difficulty. struction which were relieved by means of He was admitted to the hospital for vigorous use of enerr~s as well as the observation and the rectal tube which insertion of the rectal tubes. For al­ had been passed at proctoscopy was left most a year prior to his last admission inserted. He was given sitting up to the University Hospitals, however, the exercises to strengthen his a~dominal management of the gaseous distention had muscles and instructed to go to the become increasinglydifficult. It was bath room immediately after breakfast. necessary for him to l1e down once per He again started to have spontaneOl'B hour daily to expell the gas which dis­ bowel movements and after further ob- tended his abdomen. Also because of in­ servation for another week, during creasing distention his appetite had which he had almost normally formed become impaired. He had not been able to stools daily it was felt that it would go to school and it had been necessary to be safe to di~ehnrge the patient. Fol­ hospitalize him in his local community on lowing this discharge from the hospital, several occasions for evacuation of his he did very nicely having spontaneous bowels. Physical examination upon ad­ daily bowel movements of almost normal missi~n revealed a thin, pale, poorly de­ caliber without any further episodes of veloIed yeung white male, weighing 85 partial obstructions. Seven months pounds and 53 3/4 inches in weight. There after the operation at further check­ was marked flaring of the costal margins up it was noted that he had gained ap­ and great I'l.bdominal distention. Large prOXimately ten pounds in weight and l00ps of bowel could be readily seen ~e­ had grown six inches. X-ray of the neath the distended anterior abdominal large bowe~ showed active peristalsis wall. After thorough cleansing of the and good emptying of the residaul bo~el a roentgenogram revealed an area of colonic segIl}.ent. MERRY CBRISTMAS HAPPY NEW YEAR 177 Commep.t measuring only about 4 em. The urin­ ary bladder was markedly dilated as This 11 year old patient had a temp­ was the gallbladder. The stomach, orary but incomplete obstruction follow­ small bowel were, however, within nor­ ing surgery but after exercises to mal limits. The lateral one-half of strengthen the abdominal musculature and the transverse colon, descending and establishing a daily bowel evacuation sigmoid portions of the colon were re­ pattern he had no further difficulty. In moved and an anastomosis was then made seven months after operation he had gained between the transverse colon and the 20 pounds and grown 6 inches. rectum at 6 em. from the anal skin. During the dissection of the rectum a __ .) a two year old, white male was larger space than usual was opened be­ admitted to the University Hospitals on tween the hollow of the sacrum and the 3-27-50 and discharged on 5-3-50. The rectum. Although the anastomosis ap­ history given by the mother revealed that peared to be·a good one, there was the patient had never had a spontaneous difficulty inoobliterating the space bowel movement since birth and it was between the sacrum and the rectum and necessary to give him Roap suds and oil this was not accomplished completely. enemas every third day. Various laxa­ The anastomosis was extraperitonealized tives, such as, castor oil, "castoria." and the abdominal wall closed in routine and mineral oil had also been used but fashion. Postoperatively, the youngster without any great success. The mother had did well apart from the difficulty in also dilated the baby's anus with her voiding and it was necessary to leave finger daily at the advice of her doctor, the in-lying catheter for a period of a but this had not apparently produced any week. On about the fourth postoperative beneficial results. Examination on ad­ day he developed a spiking temperature mission revealed a pale, thin youngster ranging to 1040 F. which persisted daily with marked abdominal distention. Roen­ in spite of intensive antibiotic therapy. tgneograma of the abdomen revealed marked On 4-16-50 a small transverse incision gaseous distention of multiple intestinal was made behind the anus and by means loops. A barium enema done by the of a blunt dissection, the space be­ referring physician revealed the presence tween the rectum and the sacrum was of marked dilatation of the sigmoid colon entered and a large amount of pus was with a short narrowed rectosigmoid portion. obtained. This abscess was obviously The rectum appeared to be of normal due to a breakdown of the anastomosis. character and had good contractility. He After drainage, in order to deviate the I was given several blood transfusions, fecal stream, a colosto~ at the level preoperatively. During the course of one of the hepatic flexure was done. After of these transfusions the patient develop­ this procedure the temperature subsided 0 ed chills and a fever of 104 • All and the patient gradually improved. He cultures of the blood were negative and was discharged on 5-3-50 and was asked repeat cross-matching showed co~ati1itity to return in three months. At this time of the administered blood. The patient a barium enema showed no evidence of had a persistent fever for almost a week fistula so an attempt was made to close after transfusion. After the fever had the colosto~. Immediately following subsided the patient was operated upon the closure of the colosto~ the patient on 4-4-50 at Which time it was noted that developed a spiking temperature, ab­ the sigmoid and descending portion of the dominal distention and watery diarrhea. colon were remarked1y dilated with obliter­ A review of the x-ray plate which had ations of the haustral markings. The been interpreted as being negative for proximal portions of the transverse colon, a fistula, on re-examination showed a the ascending colon and the cecum were communication between the rectum and dilated but the haustral markings were the space posteriorly in the hollow of well-defined and the bowel was thin the sacrum. Consequently, it was neces­ walled. The narrowed area between the sary to re-open the colosto~ and the rectum and sigmoid was extremely short, patient was discharged on 8-31-50 with t f I MERRY CHRISTMAS HAPPY NEW YEAR 178 the colostomy draining nicely and his inchee and had gained three pounds temperature within normal limits. A re­ since discharge from the hospital three cent communication (12-9-50) from the months previously. He was having be­ patient's mother indicates that he is tween three and five semi-solid stoole getting along nicely; having spontaneous spontaneously. A bariurn enema on bowel movements per colostomy. We plan 11-16-50 revealed good contractility to admit him again in six months and and evacuation of the remaining portion check him once more, carefully, for evi­ of the colon and lower ileum. dence of fistula at the line of anasto­ mosis. If healing has occurred at the Comment: site, the colostomy will be closed. This patient had an uncomplicated COIDInent: postoperative course and has had an ex­ cellent result in that he is having This patient is the only one in our daily spontaneous bowel movements and series Who developed a leak at the.line has grown about 2~ inches in a period of anastomosis. The opening of the large of three months. space between the hollow of the sacrum and the rectum, we feel, is an important , A nine year old, white rrale. factor in the development of the fistula. was admitted to the University Hospitals In all our other cases wh have takeR care on 9-18-50 and discharged on 10-14-50. only to mobilize enough of the upper This patient gave a history of marked rectum to permit a ready anastomosis and constipation and inability to have we have had no disruptions of the line spontaneous stools without the use of of anastomosis. enemas since birth. He had failed to grow and gain in weight at a normal _ was admitted to the University rate, although his mental development Hospitals 7-26-50 and discharged on was good. Physical examination revealed 8-29-50. This five year old white male a small, thin, pale white boy about the had a history of marked abdominal dis­ size of a five year old, with ~arked tention and failure to have spontaneous abdominal distention, and flaring of the bowel movements since birth. He needed costal margin. Fecal filled masses daily enemas to produce bowel evacuation within loops of colon could be felt and to control abdominal distention. realily through the thin abdominal wall. Examination on admission revealed a well­ After adequate preoperative preparation developed somewhat pale young boy with the patient was operated upon on 10-5-50 markedly protuberant abdomen. Peri­ at which time a normal rectum and a nar­ sta~tic waves could be noted through the rowed segment of sigmoid 8 em. long were thin abdominal wall and fecal filled found. Proximal to this there was mark­ redundant loops of bowel could be readily ed dilatation and hypertrophy of the palpated. After adequate preoperative colon extending to about the middle por­ preparation the patient was operated upon tion of the transverse colon. At this on 8-15-50 at which time the colon distal site there was a rather sharp change to the Junction of the right 1/3 and left 2/3 from the dilated colon to almost normal of transverse colon to the upper level of appearing transverse colon and ascend­ the rectum was removed. An anastomosis ing colon. The left side of the colon was thp,n effected 1etween the transverse from the mid-transverse colon down to colon and the re.ctum at 8 em. from the the upper portion of the rectum, was anal skin. The narrowed area of the resected without diffiCUlty and an rectosigmoid areameasures approxiootely anastomosis was then roade between the 6 em. in length. Postoperatively the rectum and the transverse colon at ap­ patient did nicely and was nischarged on proximately 7 em. from the anal skin the fourteenth postoperative day having margin. Postoperatively the patient did two to three well-formed Roft stools per very nicely and was discharged on the day. At a postoperative visit on 11-15-50 ninth postoperative day having three it was noted the patient had grown 2~ soft but well-formed stools per day. MERRY CHRISTMAS HAPPY :NEW YEAR 179 His postoperative progress has continued IV. The above described operation to be good with spontaneous stools daily had been done on 7 patients without a and a definite improvement in his general death. Six patients have had excellent health, appetite and weight gain of ap­ res~ts postoperatively while the re­ proximately five pounds. Postoperative maining one developed a leak at the barium enema revealed excellent filling line of anastomosis necessitating a and emptying capacities of the residual proximal colostomy which up to the time colon segment. of this publication has not been closed.

Comment: V. The saving of the rectum is of importance, because it eliminated the This nine year old boy had the typical question of damage to the nervi erigen­ history and physical findings of con­ tea, which is a deterrent to whole­ genital megacolon. Following segmental hearted acceptance of those operative resection of the colon and anastomosis procedures in which the rectum is re­ of the mid-transverse colon to the rectum, moved. he has done nicely. Sunnnary and Conclusions: I. A review of the historical, etiological and pathological features of References true congenital idiopathic megacolon (Hirschsprung's disease) i.e., has been 1. Whitehouse, F. R. and Kernohan, presented. J. W. Arch. Int. Med. 82:75, '48. II. Careful x-ray studies of the colon 2. Swenson, 0., Neuhauser, E. B. D. in 7 patients with segmented megacolon and Pickett, L. K. reveal Pediatrics. 4:201, 149. 1. A normal rectum. 3. De Takats, G. and Biggs, A. D. 2. A narrowed segment of recto­ J. Pediatrics. 13:819, '38. sigmoid and sigmoid portions 4. Ruhrah, J. of the colon of variable Am. J. Dis. Children 49:763, '35. length. 5. Billard, F., Die Krankheiten, D., 3. Marked dilatation of the colon Neugeborenen, W. proxiw~l to the narrowed area. Sauglinge Weimar 37:331, 1829. 4. Active peristalsis and normal 6. Lewitt, G., haustration of ascending and Med. Journal of Chicago: 24:359, right side of the transverse 1867 colon. 7. Von Ammon, T. S. 5. Absence of peristaltic waves Die Angeborenen Chir, Krankheiten and haustration from the left d. Meneshen side of the transverse descend­ Atlas Tafel IX Berlin, 1842. ing and sigmoid portions of the 8. Barth, G. colon. Wagner's Archiv. d Heilk 11:119, 1870. . III. A one stage t::-ansabdominal opera­ 9. Peacock, P. tive procedure is described, in which the Trans. Path. Soc. 23:104, 1884. narrowed terminal segment of the sigmoid 10. Gee, A. and portions of the colon showing no St. Bartholomew Hosp. Reports peristalsis roentgenographically are re­ 22:19, 1884. moved. The residual part of the large 11. Bristowe, J. S. bowel which has good peristaltic activity Brit. Med. Journal 1:1085, is then anastomosed to the upper portions 1885. ) of the rectum at a distance 6 to 10 em. 12. Morris, R. l from the anal skin margins. Brit. Med. Journal 2:1211, 1886. f t MERRY CHRISTMAS HAPPY NEW YEAR 180 13. Futterer, G. and Midde1dort, G. 37. Cameron, J. A. M. Virchow's Arch. 106:555, 1886. Arch. Dis. Childhood 11:358, '27. 14. Cheadle, L. 38. Cameron, J. A. M. ,) Laneet 1:399, 1898. Arch. Dis. Childhood 3:210, '28. ¥ t 15. Guame, P. 39. Etzal, E. , Revue des Malad de l'Enfance 9:155, Ann. Fae. de Med. r.e Sao Paulo I 1886. 10:383, '34. ~ 16. Hirschsprung, H. 40. Etza1, E. I Jahrb. f. Kinderh. 27:1, 1887. Guy's Hosp. Rep. 17:158, '37. f 17. Hirschspring, H, 41. Robertson, H. E. Md Kernohan, r Berliner kline Wochensch. No. 44, J. W. ( 1899. Proc. Staff Meet. MAyo Clinic f 18. Mya, G, 13:123, '38. Sperimenta1e 48:215, 1894. 42. Tiffin, M. E., Chandler, L. R, j 19. Fenwick, W. S, and Faber. l Brit. M. J. 2:564, 1900. Am. J. Dis. Childhood 59:1071, '40. I 20. Genersich, B. Whitehouse, F. R. and Kernohan Jahr. t. Kinderheilk, 37:91, 1893. J. W. 21. Hurst, A. F. Arch. Int. Med. 82:75, '48. Guy's Hosp. Rep. 84:317, 1934. 44. Swenson, O. Rhein1ander, H. F. and 22. Bartle, H. J. Diamond, 1. Amer. J. M. Sc, 171:67, '26. New Eng. Journal Med. 24:551, '49, 23. Martan: 45. Ravltch, M. Rev. mens. de malde 1'enf. Surgery 28:382, '50. 13:153, 1895. 46. Wangeneteen, O. H. 24. Perthes, G. Intestinal Obstructions, Arch. of klint Chir. 77:1, '05. Charles C. Thomas, Baltimore, '42. 25. Treves, F •. 47. Friedel1, A. Intestinal Obstruction, Minnesota Medicine 21:175, '38. Wm. Wood & Co., New York, 1899. 48. Stabins, S. J. , Morton, J. J., 26.· Concetti, and Scott, W. J. M. Arch. f. kinderheHk. 27:319, 1899. Am. J. Surge 27:107, '35. 27. Pennat~, 49. Law. J. L. La C1inica Med, Ita1. 13, '02. Am. J. Dis. Childhood 60:262, '40. 28. Hawkins, H. P. 50. Ladd, W. E. and Gross, R. E. Brit. M. J. 1:477-483, '07. Abdominal Surgery of Infancy and 29. Fraser, J. Childhood, Brit. M. J. 1:359, '26. Philadelphia, W. ~. Saunders Co., 30. Wade, R. B. ~nd Royle, N. D. '41. M. J. Australia 1:137, '27. K1 ingrnan, W.O. 31. Martin, E. and Burden, U. G. J. Pediat. 13:805, ,,8. Ann. Surge 86:86" '27, Danziger, 32. Scott, W. J. M. and Morton, J. J. Quoted from De Takots, G. and C1in. Investigation 9:247, '30. Biggs, A. D. 33. Tatte1, K. J. Pediat. 13:81', '38. Wiener Clin. W~chensch 14:903, '01. 53. Schneiderlohn, 34. Brentano, A. Quoted from De Takots, G. and Verhandlg. d. Deutsch. Gesel1sch F. Biggs, A. D. Chir. 33:265, '04. J. Pediat. 13:819, '38. 35. Finney, J. Me T. 54. Ask-UpIllArk, E. Surg., Gynec. and Obst. 6:624, '08. Bietr. Z. Chir. 151:72, '30. 36. dalla Valle, A. 55. Rankin, F. W. and Learmonth, J. R. Pediatria 28:740, '20. Ann. Surge 92:710, '30. 36a. dalla Valle, A. 56. Judd, E. S. and Adson, A. W. Ped1atria 32:569, '20. Ann. Surge 88:478, '28. MERRY CHRISTMAS HAPPY NEW YEAR 181

57. Adson, A. W. 72. Trevee, F. It Surgery 1:859, '37. Lancet 1;276, 1898. 58. De Takots, G. and Biggs, A. D. 73. Neugebauer, F. Journal Pediat. 13:819, '38. Ergebn. de Chir w Orthop. 59. Ross, J. p. 7:598, '13. Brit. J. Surge 23:433, '35. 74. Terry, W. J. 60. Passler, H. W. J. A. M. A. 57:731, '11. Megacolon and Megacystitis, 75. Fischer, A. W. Entstehung, Erkennung and Behand1ung, Zentra1b1. f. Chir. 59:261, '32. Leipzig, '38, J. A. Barth. 76. Anschutz, W. 61. Gr1mson, K. S., Vandergrift, H. N. Zentralbl. f. Chir. 58:912, and Dratz, H. M. '31. Surge Gynec. and Obsta 80:164, '45. 77. Barrington-Ward, L. E. 62. Ito, J. Brit. J. Surg. 1:345, Jikwa Zasshi, '14. Tokyo, No. 80 '07. 78. Mirizzi, P. L. 63. Krede1, L. Arch. Surg. 13:837, '26. Zeitschr. f. klint Med. 53:9, '04. 79. Grimaon, K. S. 64. Franke F., Personal communication, Nov. 25, Verhend1. d. Deutsch. '50. Gese11sch f. Chir. 34:165, '05. 80. Whitehouse, F., Bargen, J. A. Richardson, and Dixon~C. A. Boston Med. and Surg. Journal 144: Gastroenterology 1:922, 155, '01. '43. 66. Yeaze1l, L. and Bell, H. G. 81. Swenson, 0. Surgery 13:941, '43. Surgery 28:371, '50. 67. Pfisterer, A. 82. Bodian, M., Stephens, F. D. Jahrb f. Kinderhei1k, 65:160, and Ward, B. C. H. '07. Lancet 1:19, '50. 68. Lengenmann, 83. Wangeneteen 0. H. Verhand1. d. Deutsch. Surge Gynec. and Obst. 72:257, Gese11sch f. Chir. 36:34, '07. '41. 69. Lawen," A. Munch med Wchnschr. 56:1510, '09. 70. Gant, S. G. Constipation, Obstipation and Intestinal Stasis. Philadelphia, W. B. Saunders Co., '16. 71. Morrie, Brit. Med. Journal 2:1211, 1886.

) ,( ~ .~ r MERRY CERISTMAS HAPPY NEW YEAR 182 J II. MEDICAL SCHOOL 1MlS . Coming Events January 4 - 6 Continuation Course in Geriatrics for Physicians January 22 - 26 Continuation Course in Ophthalmology for Specialists Jan. 29 - Feb. 10 Continuation Course in Clinical Neurology for General Physicians, Internists, and Pediatricians February 15 - 17 Continuation Course in Cardiovascular Diseases for General Physioians '* '* * Geriatrios Course vascular diseases. In addition to 78 hospital beds for in-patient care, Outstanding Visiting faculty members there will be a well-equipped Heart who will participate in a oontinuation Clinic to care for both pediatric and course in Geriatrics to be presented adult out-patients. January 4 - 6 include Dr. William Dock, New York University Medical Centerj Dr. Offices for physicians, nurses, Albert I. Lansing, Washington University social service workers, and administra­ School of Medioine, st. Louis, Missourij tive personnel will also be provided. Dr. Nathan W, Shook, National Heart In­ Research laboratories will afford an stitute, Baltimore, Maryland; Dr. Edward opportunity to further research in such J. Stieglitz, Washington, D. C., and important disorders as rheumatic fever, Dr. E. L. Tuohy, Duluth, Minnesota. congenital heart disease, hypertension, and arteriosclerosis. Both lay and professional people interested in the problema of geriatrics * '* '* are cordially invited to attend a dinner Faoulty ~ in the main ballroom of the Coffman Memorial Union on Friday, January 5. Dr. Wallace D. Armstrong will be Dr. Edward J. Stieglitz will speak on chairman of the conference on "Metabolic the subject, "Emotional Hazards of Sene­ Interrelation" to be held in New York scence." Mr. Gideon Seymour, Executive C1 ty on January 8 and 9. The oonference Director of the Minneapolis Star and is sponsored by the Josiah Macy, Jr. Tribune, will speak on the subject, "Can Foundation. our Aged be an Asset?" Dr. Ancel Keys, who will preside at the dinner, will Dr. Edmund B. Flink attended the also calIon Dr, Harold S. Diehl for a recent oonferenoe on ACTH held in Chi­ greeting from the University of Minnesota. cago under the sponsorship of the Husbands and wives are weloome. Tickets Armour Company. may be obtained at $2.00 per place by Dr. Wesley W. Spink reoently ad­ writing to Dr. G. N. Aagaard, ;;;0 dressed the Los Angeles Society of In­ Powell Hall. ternal Medicine. The subject which Dr. Spink presented was "Brucellosis: '**'* Diagnosis and Treatment." Progress Note Holiday'* Greeting* '* Latest word on the Variety Club Heart Hospital indicates that the dedication The editorial staff of the Bulletin will probably be held around March 20, express our earnest hope that this will 1951. The hospital, When completed, be truly a Merry Christmas and Happy will greatly expand the Medical School's New'Year for all Foundation mempers, facilities for patient care, research, students, alumni, faculty, and friends and teaching in the field of cardio- of our Medical School. t MERRY CHRISTMAS HAPPY NEW YEAR III. UNIVERSITY OF MINNESOTA MEDICAL SCHOOL I CALENDAR OF EVENTS Visitors Welcome December 24 - December 30, 1950 Sunday, December 24 University Hospitals 9:00 - 10:00 Surgery Grand Rounds; Station 22. 10:30 - Surgical Conference; Todd Amphitheater. Monday, December 25 (Holiday) TU6sdal, December 26 Medical School and Universitl Hospitals 9:00 - 9:50 Roentgenology Pediatric Conference; L. G. Rigler, I. McQuarrie and Staffs; Eustis Amphitheater, U. H. 9:00 - 12:00 Cardiovascular Rounds; Station 30, U. H. 12:30 - 1:20 Pathology Conference; Autopsies; J. R. Dawson and Staff; 102 I. A. 3:15 - 4:20 Gynecology Chart Conference; J. L. McKelvey and Staff; Station 54, U. H. 4:00 - 5:00 Pediatric Rounds on Wards; I. McQuarrie and Staff; U. H. Ancker Rospita1

8:00 - 9:00 Fracture Conference; AUditorium. 1:00 - 2:30 X-ray Surgery Conference; Auditorium. Minneapolis General !L0spita1 8:00 - 9:00. Pediatric Rounds; Dr. Adams; 4th Floor. 8:30 - Pediatric Allergy Rounds; Dr. Nelson; 4th Floor. 9:00 - 10:00 Pediatric Rounds; F. H. Top; 7th Floor. ~ , Veterans Administration Rospital

8:45 - Surgery Journal Club; Conference Room; Bldg. I. 8:30 - 10:20 Surgery Conference; Seminar Conference Room, Bldg. I. 9:00 - Infeotious Disease Rounds; W. RaIl. MERRY CHRISTMAS --- HAPPY NEW YEAR 184 1I f TU8sda;y., December 26 (Cont.) ;) Veterans Admdnistration Hospital (Cont.) 9:30 - Surgery-Pathology Conference; Conference Room, Bldg. I.

10:30 - 11:50 Surgical Pathological Conference; ~le Hay and E. T. Bell. 10:30 - Surgery Tumor Conference; Conference Room, Bldg. I. 1:00 - Chest Surgery Conference; J. Kinsella and Wm. Tucker; Conference Room, Bldg. I •. j 1:30 - Liver Rounds; Samuel Nesbitt. 2:00 - 2:50 Dermatology and Syphilology Conference; H. E. Michelson and Staff; Bldg. III. 3:30 - 4:20 Autopsy Conferenoe; E. T. Bell and Donald Gleason; Conference Room, ; Bldg. I. t Wednesday, December 27 Medical School ~ University Hospitals 8:00 - 8:50 Surgery Journal Club; O. H. Wangensteen and Staff; M-109, U. H. 8:00 - 9:00 Roentgenology-Surgical-Pathological Conference; Allen Judd and L. G. Rigler; Todd Amphitheater, U. H. 11:00 - 12:00 Pathology-Medioine-Surgery Conference; Surgery Case; O. H. Wangen­ steen, C. J. Watson and Staffs; Todd Amphitheater, U. H. 5:00 - 5:50 Urology-Pathological Conference; C. D. Creevy and Staff; Eustis Amphitheater. 5:00 - 7:00 Dermatology Clinical Seminar; Dining Room, U. H. 8:00 p.m. Dermatological Pathology Conference; Todd Amphitheater, U. H4 Ancker Hospital 8:30 - 9;30 Cllnico-Patho1ogical Conference; Auditorium. 3:30 - 4:30 Journal Club; Surgery Office. Minneapolis General HosRita1 9:00 - 10:00 Pediatric Rounds; Dr. Lowry; 5th Floor. 12:15 - Staff Meeting; Classroom, 4th Floor. 3:00 - 4:00 Pediatric Rounds; E. J. Huenekens; 4th Floor. MERRY CHRISTMAS HAPPY NEW YEAR 185

Wednesday, December 27 (Cont.) Veterans Administration Hospital

8:30 - 10:00 Orthopedic-Roentgenologic Conference; Edward T. Evans and Bernard OILo~llin; Conference Room, Bldg. I. 8:30 - 12:00 Neurology Rehabilitation and Case Conference; A. B. Baker. 11:00 - EKG Conference; Myocardial Infarct II; Reuben Berman; Conference Room; Bldg. I. 2:00 - 4:00 Infectious Disease Rounds; Main Conference Room, Bldg. I.

4:00 - 5:00 Infectious Disease Conference; W. Spink; Conference Room, Bldg. I. 7:00 p.m. Lectures in Basic Science of Orthopedics; Conference Room, Bldg. I.

Thursday, December 28

Medical School and University Hos~itals 9:00 - 9:50 Medicine Case Presentation; C. J. Watson and Staff; M-109, U. H. 10:00 - 11:50 Medicine Ward Rounds; C. J. Watson and Staff; E-22l, U. H. 11:00 - 12:00 Cancer Clinic; K. Stenstrom and A. Kremen; Todd Amphitheater, U. H. 4:30 - 5:20 Ophthalmology Ward Rounds; Erling W. Hanse~ and Staff; E-534, U. H. 7:30 - 9:30 Pediatrics Cardiology Conference and Journal Club; Review of Current Literature 1st hour and Review of Patients 2nd hour; 206 Temporary , West Hospital. Minneapolis General Hospital

8:00 - Pediatric Rounds; Forrest Adams; 4th Floor. 9:00 - 10:00 Pediatric Rounds; F. H. Top; 7th Floor. 10:00 - Pediatric Rounds; Adult Contagion. 11:00 - 12:00 Clinical Pathology Conference; Large Classroom. 11:30 - Pediatric Conference; Main Classroom. 1:00 - 2:00 EKG and X-ray Conference; Classroom, 4th Floor. 2:00 - EKG and X-ray Conference; Classroom, Station I.

Veterans Administration Hospital

8:00 - Surgery Ward Rounds; Lyle Hay and Staff.

9:15 - Surgery Grand Rounds; Conference Room; Bldg. I. \ MERRY CERISTMAS HAPPY NEW 'YEAR 186 I Thursday, December 28 (Cont.) Veterans Administration Hospital (Cont.)

11:00 - Surgery Roentgen Conference; Conference Room, Bldg. I. 1:00 - Chest Rounds; William Stead. Friday, December 29

~~dical School ~ University Hospitals 8:30 - 10:00 Neurology Grand Rounds; A. B. Baker and Staff; Station 50, U. H.

9:00 - 9:50 Medicine Grand Rounds;C. J. Watson and Staff; Todd Amphitheater, U. H.

11:00 - 11:50 Medioine Ward Rounds; C. J. Watson and Staff; E-22l, U. H. 10:30 - 11:50 Otolaryngology Case Studies; L. R. Boies and Staff; Out-Patient Department, U. H.

1:00 - 2:50 Neurosurgery-Roentgenology Conferenoe; W. T. Peyton, Harold O. Peterson and Staff; Todd Amphitheater, U. H.

2:00 - 3:00 Dermatology and Syphilology Conference; Presentation of Selected Cases of the Week; H. E. Michelson and Staff; W-3l2, U. H. 2:00 - 4:00 Physiology Conference; 214 Millard Hall.

3:00 - 5:00 Neuropathology Conference; F. Tichy; Todd Amphitheater, U. H. 4:00 - 5:00 Clinical Pathological Conference; A. B. Baker; Todd Amphitheater, U. H. 4:15 - 5:15 Electrocardiographic Conference; 106 Temp. Bldg., Hospital Court, U. H. Ancker Hospital

1:00 - 3:00 Pathology-Surgery Conference; Auditorium. Minneapolis General Hospital 9:00 10:00 Pediatric Rounds; Dr. Lowry; 5th Floor. 9:30 - Surgery-Pediatric Conference; O. S. Wyatt &T. C. Chisholm; 4th Floor. Veterans Administration Hospital 10:30 - 11:20 Medicine Grand Rounds; Conference Room, Bldg. I.

1:00 - Microscopic-Pathology Conference; E. T. Bell; Conference Room, Bldg. I.

1:30 - Chest Conference; Wm. Tucker and J. A. M;yers; Ward 62, Day Room. ) 3:00 - Renal Pathology; E. T. Bell; Conference Room, Bldg. I. :i' f t I MERRY CHRISTMAS HAPPY NEW YEAR

Saturday, December 30

Medical School ~ University Hospitals

7:45 - 8:50 Orthopedic X-ray Conference; Wallace H. Cole and Staff; M-I09, U. H.

9:00 - 9:50 Medicine Case Presentation; C. J. Watson and Staff; E-221, U. H. 9:00 - 10:30 Pediatric Grand Rounds; I. McQuarrie and Staff; Eustis Amphitheater, U. H. 9:15 - 10:00 Surgery-Roentgenology Conference; J. Friedman, O. H. Wangensteen and Staff; Todd Amphitheater, U. H. 10:00 - 11:30 Surgery Conference; O. H. Wangensteen and Staff; Todd Amphitheater, U. H. 10:00 - 11:50 Medicine Ward Rounds; C. J. Watson,and Staff; E-221, U. H. 10:00 - 12:50 Obstetrics and Gynecology Grand Rounds; J. L. McKelvey and Staff; Station 44, U. H. Ancker Hospital

8:30 - 9:30 Surgery Conference; Auditorium. Minneapolis General Hospital

8:00 - Pediatric Rounds; Forrest AdaIllS; 4th Floor. 9:00 - 10:00 Pediatric Rounds; F. H. Top; 7th Floor. 11:00 - 12:00 Pediatric Clinic; Charles May; Classroom, 4th Floor.

Veterans Administration Hospital

8:00 - Proctology Rounds; W. C. Bernstein and Staff; Bldg. III.

8:30 - Hematology Rounds; P. Hagen and E. F. Englund.