Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  In the American Wild West, William Halsted was once a cowboy among surgeons. He saved his own sister from bleeding to death while giving birth by administering his own blood to her and, at the age of twenty-nine, when he had only been a surgeon for a year, he performed one of the first gall-bladder operations in America – on his own mother. He was addicted to cocaine, and later to morphine. He sent his shirts to a laundry in Paris, officially because they washed them better but more likely to smuggle narcotics. When he wrote an article on the medical use of cocaine as a local anaesthetic, he was clearly under the influence of the drug at the time, as it started with an unintelligible sentence 118 words long. After meeting Theodor Kocher in Europe, he abandoned his life as a cowboy and became the founder of modern surgical training and surgical scientific research in the United States. He developed various operative methods, including an improved intestinal join, and established the basic principles of cancer surgery. Two operations bear his name, for breast cancer and for inguinal hernia. He devised the mosquito forceps which, like Kocher’s forceps, are used by every surgeon on the planet on a daily basis. And it was William Halsted who introduced rubber gloves into surgery. He died in 1922 after an operation on his gall bladder performed by his own students.

  * * *

  Following on from the problem of joining together two pieces of intestine, in the early twentieth century Alexis Carrel showed that blood vessels could be reconnected and the blood continue to flow through them unobstructed. That made operations on blood vessels possible, a precondition for the following revolution, transplantation surgery. In 1954, Joseph Murray performed the first successful kidney transplant, between identical twins, and thirteen years later, Christiaan Barnard completed the first heart transplant at the Groote Schuur Hospital in Cape Town. Lastly, in 1982, Michael Harrison performed an open operation on a foetus in the womb of a pregnant woman, proving that even an unborn child could tolerate an operation and develop further into a full-term foetus. The only structures that cannot (as yet) be repaired surgically are the spinal cord and the optic nerve. All other tissues in our bodies appear to be able to withstand an assault by a surgeon.

  27

  Anal Fistula

  La Grande Opération: King Louis XIV

  KING LOUIS XIV of France was intelligent and well spoken, an excellent dancer, sociable, self-confident and gallant, big, strong and athletic, and in the best of health. He loved horse-riding, hunting and waging war and was, in James Brown’s words, like a sex machine. The Sun King was married several times, had a series of long-term mistresses and countless brief amorous liaisons. He contracted gonorrhoea at the age of sixteen and one incensed husband whose wife had been sleeping with the king is said to have visited a brothel with the sole intent of giving the monarch syphilis – a goal he did not achieve.

  Louis XIV dominated the political arena in Europe in the second half of the seventeenth century. His role reached its high (or low) point in 1713 with the Treaty of Utrecht, when the old power relationships in Europe would disappear for good to make way for new ones. Since then, three language areas (French, German and English) have set the tone. The Netherlands and Spain could only bring up the rearguard. Louis reigned for seventy-two years. His will was law; ‘L’état, c’est moi’ he is reputed to have said – ‘I am the state’. He was an arch-conservative despot who was responsible for the deaths of hundreds of thousands of soldiers and dissidents. Yet he revolutionised music, architecture, literature and fine art, and surrounded himself with the great creative minds of the Baroque period. His influence apparently extended to a surprising branch of medicine: obstetrics. It is said that through his unpredictable whims Louis XIV literally turned the act of giving birth on its head, although it is doubtful whether that was his intention. At that time, women gave birth as nature intended, squatting on their haunches, so that gravity could give them a helping hand. But Louis could not see the arrival of his bastard child by his mistress Louise de La Vallière clearly enough. So Louise had to lie on her back with her legs open, to give the king a better view – better even than the poor woman herself. Although giving birth lying on your back is difficult and painful, it became fashionable. And women still give birth that way.

  He was an exceptional man, if only because he lived to be exceptionally old at a time when few people lived to be old. His son Louis, his grandson Louis and his great-grandson Louis all died before him. Louis XIV died in 1715, four days before his seventy-seventh birthday, of gangrene. His leg was mortified, most likely as a result of hardened arteries, the ageing disease atherosclerosis. Because his subjects mostly hardly even lived to be forty, the condition was probably unknown. You died before your arteries could go hard. Judging by their treatment the king’s physicians had no inkling of what to do about it. They bathed the blackened leg alternately in Burgundy wine and ass’s milk. His surgeon Maréchal advised amputation, but the king, tired of life and tired of ruling, refused. He spent his final weeks in terrible pain.

  The young Louis XIV had almost died at the age of nine; not so much from the smallpox he contracted, but from the bloodletting administered by his doctors and which had led him to lose consciousness. He did not recover until he recognised his favourite pet, a white pony, which had been dragged up the stairs to his bedside. After that, his health was closely monitored by his personal physicians, who recorded his physical state daily in a Journal de Santé. This record was kept faithfully for fifty-nine years, day in, day out, by his doctors Vallot, d’Aquin and Fagon successively. That is how we know that, while on a campaign in 1658, Louis had a fever for so long that it was feared he had malaria, that in all those years he took a bath on at least one occasion, that he was given an enema almost every week for constipation, was short-sighted, was troubled by dizziness and suffered from gout or osteoarthritis. At the age of twenty-five, he had measles and, later in life, was obese, got worms and complained repeatedly of stomach pains. Unfortunately, there is no record of the last four years of his life.

  Two other painful episodes for the Sun King are worth mentioning. Louis loved the sweet things in life not only figuratively, but also literally. Sugar was still relatively new in Europe and led to many rotten teeth, particularly among the nobility, who could afford sweet things. Louis had a mouth full of bad teeth and an arracheur des dents, a tooth-puller, was regularly summoned to the palace at Versailles to remove yet another royal molar. By the time he was forty, the king had almost no teeth left. This is clear to see in many portraits, on which his cheeks and mouth look like those of an old woman.

  On one occasion, things went seriously wrong. The tooth-puller not only had a rotten tooth in his pliers, but a piece of the king’s upper jaw, with part of his palate attached to it. What happened to the unfortunate dentist is unknown, but the king developed a severe infection and an abscess in the bone of his upper jaw. The rotten tooth itself could, of course, have caused the abscess. Then it is possible that a piece of infected bone could break loose along with the tooth. In that case, the dentist could do nothing about it. In any case, Louis was in a bad way and there were fears for his life. Several surgeons were summoned. They eventually broke the jaw open further to release the pus and seared the remainder of the cavity caused by the abscess with a branding iron – with the king sitting upright in a chair and without anaesthesia.

  One of them would have stood behind the king to hold his head firmly with both hands, perhaps by pressing it against the back of the chair, with the right hand on the forehead and the left on the lower jaw. In that way, he could also force the mouth open. A second surgeon would have stood to one side and pulled the top lip out of the way with both hands to ensure a good view of the upper jaw. A third would be at the fireplace, warming up the branding iron. From his perilous and constrained position, the king must have been frightened to death when he saw the red-hot iron approaching him. The heat in his mouth, the stinking smoke and the excruciating pain must have taken his breath away, but Louis bravely endured the orde
al and soon recovered. He was left, however, with a hole in his palate between his oral and nasal cavities. That caused soup and wine to pour out of his nose when he drank. When he was eating, he could be heard from out in the corridor.

  The king was in the habit of receiving his guests while sitting on his chaise percée, his commode. Consequently, during an audience or while consulting his advisers, Louis could be defecating in public. There was a junior noble at the court whose only task was to wipe the royal derrière. The king never did that himself. Whether it was because of these extraordinary toilet rituals, too much horse-riding, certain sexual preferences, the more than 2,000 documented colonic rinses and enemas his rectum had endured, or perhaps worms in his bowels is not clear but, on 15 January 1686, Louis developed a swelling near his anus. On 18 February, it proved to be an abscess, which burst on 2 May forming a fistula that, despite warm compresses and more enemas, refused to close up.

  The word fistula is Latin for tube, pipe or flute. An anal fistula is known as a perianal fistula, meaning a ‘fistula in the area of the anus’. It is essentially a small passage, a hollow tunnel, between the intestines and the skin, as though a small creature has gnawed its way out of the rectum to the outside. However it is not caused by small creatures but by bacteria.

  A perianal fistula always starts with a small wound in the mucus membrane of the rectum, on the inside of the anus. The countless bacteria in the faeces can cause the wound to become infected. The infection can then become an abscess and, as is the case with abscesses, pus will form and exert pressure on the surrounding area. Around the rectum, the tissues close to the bowel are much tougher than those further away. An abscess adjacent to the rectum therefore tends to move away from the bowel; it burrows through the softer tissues and eventually becomes an abscess below the skin.

  The more pus develops in the perianal abscess, the greater the pressure. The patient suffers severe pain and fever. That is what Louis must have experienced in March or April of that year. Eventually, the skin will come under such pressure that it bursts, releasing all its stinking pus. That happened to the king early in May. The pressure then recedes, the fever retreats and the pain stops, but the passage from the small wound in the rectal mucus membrane to the skin almost never heals up on its own, but leaves a persistent fistula.

  Why a perianal abscess leaves a tunnel that refuses to heal by itself is not entirely clear. Perhaps the large quantities of bacteria continually present in the rectum or the mucus permanently produced in the mucus membrane have something to do with it. A fistula can stay dormant for a long time, without causing any symptoms or discomfort, but the passage can fill with pus and form a new abscess at any time. That means that once you have suffered from a perianal abscess, there is a great chance of it recurring. In some cases, the tunnel in the fistula can become so wide that bowel gases and even faeces can be released through it, which can of course be troublesome because you have no control over it. That was probably what was causing the king so much discomfort, since a fistula does not necessarily generate many symptoms.

  It is important when treating a perianal fistula to distinguish between two types. If the internal wound is very low in the rectum, close to the anus, the fistula tunnel comes out below the anal sphincter. Imagine that you insert a thin rod through the tunnel, from the hole in the skin on the outside to the hole in the mucus membrane on the inside and then cut the tunnel open down to the rod, from one hole to the other. In that way, you open the tunnel up along its whole length, so that the two small wounds at each end of the fistula become one large ‘regular’ wound. That one open wound can then heal, because the fistula is no longer there. You leave the wound open rather than stitching it up, rinse it six times a day with plenty of water, and wait. After six weeks everything has healed up per secundam. This procedure is known as a fistulotomy (a cut of the fistula) or, more graphically, as the ‘lay-open’ technique. The rod used to find the fistula tunnel is called a probe, as it ‘probes’ its way through the fistula.

  If, however, the internal wound is higher up in the rectum, further inside when seen from the anus, the fistula tunnel can pass above the anal sphincter, or even through it. If you then perform a fistulotomy, you not only cut open the fistula, but also the anal sphincter. That of course has to be avoided as, if your anal sphincter is damaged, you cannot control your bowel movements.

  Louis XIV clearly had so much discomfort from his fistula a surgeon was eventually summoned to perform a fistulotomy. However, the surgeon, Charles-François Félix de Tassy, had never performed the operation before. He asked the king for six months to prepare and practised on seventy-five ‘regular’ patients before cutting open Louis’s fistula at seven o’clock in the morning of 18 November 1686. The monarch lay on his stomach in bed, with his legs spread wide and a cushion under his belly. Also present were his wife Madame de Maintenon, his son the Dauphin, his confessor Père François de la Chaise, his physician Antoine d’Aquin and his prime minister, the Marquis de Louvois, who held his hand.

  The surgeon had made two instruments for the operation, an enormous anal retractor and an ingenious, sickle-shaped knife – a scalpel with a semicircular probe on its end. That enabled him to probe and cut open the fistula tunnel with the same circular movement. He therefore combined the two tools required for a fistulotomy, the probe and the knife, in a single instrument. De Tassy first spread the king’s buttocks, which were substantial, as Louis was by no means thin. That enabled him to examine exactly where the external wound was located – how far from the anus, in front of or behind it, and to the left or right. He then inserted his finger into the royal aperture to feel the internal opening, if there was one to feel. So far, the king would have felt no pain, only discomfort and embarrassment. The surgeon would then have asked the patient to lie still while he inserted the retractor and slowly screwed it open. With a little luck and enough light, the internal opening in the rectum should now have been visible. The spectators may quite possibly have taken a look over the surgeon’s shoulders at this point.

  Now the surgeon had to warn the king that it was going to hurt, but that he had to lie still for a short while longer. De Tassy inserted his ‘fistula probe-cum-knife’ into the external opening and pushed it inwards, gently but firmly, until he came to the internal opening. That was painful. Everyone had drops of sweat on their foreheads, and hoped that it would not last too long. When de Tassy saw the probe come out of the internal opening, he knew that, as far as he was concerned at least, the hard part was over. But, for the unfortunate patient, the worst was yet to come. With a short, sharp yank, the surgeon pulled the knife through the fistula. The king figuratively clenched his teeth, but did not cry out. The fistula was cut open. De Tassy quickly removed the large retractor from the anus and stemmed the bleeding with a wad of bandages. The patient would have felt a small stream of blood flow down his legs, but that soon stopped, too.

  * * *

  Haemorrhoids

  A lot can go wrong in and around the anus. The branch of medicine that deals with such problems is known as proctology. Proctological surgery includes the treatment of perianal fistulas and abscesses, anal warts and tumours, anal fissures, prolapses, anal incontinence and haemorrhoids (piles). Haemorrhoids are varicose veins in the three veins of the anus. From the perspective of someone lying on their back with their legs pulled up, these three veins are located at five o’clock, seven o’clock and eleven o’clock, i.e. rear left, rear right and front right. Haemorrhoids mostly cause no problems at all, except for itching and a little loss of blood. But if the flow of blood through the varicose vein is obstructed, it can generate quite sudden and severe pain. This can occur, for example, after sitting on a plane for too long. Napoleon Bonaparte allegedly lost the Battle of Waterloo because of this problem. If the symptoms become chronic, a haemorrhoidectomy – surgical removal – may be necessary. They can also be tied with elastic bands (Barron ligation), shrunk by means of an injection (sclerotherapy), or seared usi
ng electrocoagulation. In the Middle Ages, this was done using a glowing copper staff stuck through a cold lead pipe placed on the pile. Newspapers play an important role in the development of haemorrhoids: if you take a newspaper, comic, smartphone or laptop with you to the toilet, the pressure in the veins of the anus will be too high for too long. So don’t sit there any longer than you need to!

  * * *

  Louis left his bed after a month and was back on his horse three months later. He was not ashamed of his anal problem. The whole of France knew about it and had shared their monarch’s anxiety in the weeks of waiting. Fortunately, the king survived, proving that the operation had been a success. Wearing bandages in one’s trousers even became the fashion for a short time at the court in Versailles, in imitation of the brave king. The fistulotomy became known as La Grande Opération or La Royale. The story goes that Félix de Tassy was asked by at least thirty courtiers to perform the same operation, but had to disappoint them, as none of them were actually suffering from a fistula. In January 1687, court composer Jean-Baptiste Lully performed the magnificent Te Deum in honour of the king’s recovery (that was when he hit his big toe with the conductor’s staff).

  Given the favourable outcome of the operation and that there was no mention later of the king suffering from incontinence, he must have been suffering from a ‘low’ fistula, meaning that his anal sphincter was probably spared. Félix de Tassy was fortunate in only having to perform a simple fistulotomy. But how are higher fistulas treated?

  Hippocrates already had a solution to that problem more than 2,000 years ago. He was the first to mention the seton method, using a simple thread, in the fifth century BC. The Greek physician described a probe of pliable tin with an eye, like that in a needle, at the trailing end. He passed a thread made of a few strands of flax with a horsehair wound around them through the eye. He first inserted his index finger into the patient’s anus and then the probe into the external opening of the fistula. He pushed the probe through the fistula tunnel until he felt it emerge into the rectum with his index finger. He then bent the probe, pulling it out through the anus. With the thread now passing through the fistula to the rectum and out again through the anus, the two ends were tied together.