highly delicate surface of the newly-made canal from the irri-
tating effects of the excretions, giving it, to some extent, that
protection which a mucous surface affords ; it also, perhaps
better than any other, preserves the continuity between the
opened end of the rectum and the external parts, for the free
passage of the faaces. The fulfilment of these indications is
absolutely essential to the success of the operation.

After the hollow instrument has been used for some time,
or until complete cicatrization has taken place, it may be laid
aside, and the finger, or the wax or elastic bougie occasionally
passed, in order to preserve the passage patulous.

9. The Liability to Coarctation. To prevent coarctation or
obliteration of the newly-formed canal, constitutes the most
difficult, troublesome, and serious part of the after treatment
of this, the ordinary method of operating, and a great obstacle
to the success of the operation, especially in all instances in
which the blind sac of the rectum has been found at consid-
erable depth from the external surface. Mr. Benjamin Bell
especially directs attention to this diflaculty in the two cases
upon which he successfully operated. [ Vide Cases XXX—
XXXI.^ Mr. Miller, of Methven, has recorded an interestinir
case of this character, in which the tendency to the closure
of the newly-formed opening was so great, that he was com-
pelled to repeat the operation ten times before the little pa-



THE THIRD SPKCIE3 OF MALFOKMATIOls'. lOO

tient was eight mouths okL [Vide Case CXXXVII?\ An-
other simihir and interesthig case is rehited by Mr. Francis
McEvoy. \yid6 Case XXXI V?[ M. Velpeau says, '-The
last portion of the intestine can never be reestablished but in
a ver}^ imperfect manner. It is a listula which we substitute
in place of the natural tube. The species of mucous surface
which ultimately becomes developed, can but very feebly
represent the tunics of the anus. Though the system be inca-
pable of entirely closing up stercoral fistulas, it has a constant
tendency to diminish them, so that they soon become nothing
more than mere ducts for the passage of fluid matters. The
absence of the sphincter, especially, is a fatal bar to success.
When this is the case, it would be extremely probable that
the anus w^hicli had been artificially reestablished would be
one of the most difficult to keep open." {Op. cit. p. 1090.)

Some surgical writers declare, however, that if the opera-
tion is properly performed — that is, if the incisions are suffi-
ciently extensive, no contraction or disposition to obliteration
of the artificial canal will take place, and consequently no
difficulty will be experienced in keeping it pervious. Among
those authors may be named the celebrated French surgeon
Dionis. {Cows d'' Operations de Chirurgie. Edit. IV. me.
par La Faye. tome I. p. 391. Paris : 1740.) And also Mr.
Malyn, a late English surgeon and writer, who says — '' Great
stress is laid by some authorities on keeping a plug in the
anus, to prevent the reunion of the sides of the wound. This
misht be of some service if the incisions were so slight as
only to serve for present exigencies ; as then the remainder
of the cure must be effected by dilatation. But when the
operation has been properly performed, there is no occasion
for a plug, inasmuch as the cut having passed across the
direction of the muscular fibres, they will retract and drag
the faces of the incision away from each other, so that if the
object were to reunite them, it would be most difficult to ac-
complish." {Cyclopaedia of Practical Surgery. By W. B.



110 THE THIRD SPECIES OF MALFOEMATIOX.

Costello, 2L D. Vol. I. Article^ AnxLS. p. 3-i3. London :
1841.)

It appears to me, however, that such an operation as Mr.
Malyn here recommends would completely destroy the power
of the sphincter ani muscles, if they existed, and ever after
occasion incontinence of faeces, an infirmity which might not
be preferable to death.

10. The Objections of M. Amussat. Twenty-five years ago
the celebrated JVI. Amussat, whose highly improved method, it
will be observed, I have in part recommended and adopted,
discarded the ordinary operation in these cases, in conse*
quence of what he conceived to be the insurmountable difii-
culties that always attend it. He declared most positively,
that the ordinary method by simply incising down upon the
rectum, when the blind sac of this organ laid deep, was en-
tirely inefficient, and ultimately attended with uniform fail-
ure. This he attempted to establish and maintain in a
remarkably able paper, which was read before the Academy
of Sciences on the second day of ]S"ovember, 1835, styled —
" Histoire d'une Operation d? Anus artijiciel 2>'''':i'i^^ue cweo
succes par un nouveau Precede^ dans un cas d^ Absence con-
geniale de VAnus / suivie de quelqnes reflexions su?' les Obtu-
rations du Rectum.'''' {Gazette Medicate de Paris. Ifovetn-
bre 28, 1835.)

It appears that M. Amussat was first led to reject the
ordinary operation, from the circumstance of his having per-
formed it unsuccessfully upon two cases, in each of which the
rectum terminated between one and a half and two inches
from the cutaneous surface of the perinseum. The operation,
he says, was performed in the ordinary manner, by simply
cutting down on the rectum, but both infants died jaundiced
in a few days, which event he attributed to the absoi-ption of
the bile and the meconium, consequent upon their coming in
contact with a wound of such considerable extent. That M.



THE THIRD SPECIES OF MALFOliMATION. Ill

Aniussat, however, lias considerably exaggerated the imper-
fections, difficulties and failures of the ordinary method, will
be sufficiently obvious when we take into consideration the
success which has attended it in numerous instances ; some of
them, it will be observed, were of a most discouraging char-
acter, the operation having been performed under the most
unfavorable and embarrassing circumstances. lie has in thus
imputing uniform failure heretofore to this operation, done
injustice to the several able and distinguished surgeons who
have in several instances performed it so successfully.

The main objection that ]\^. Amussat urges against the op-
eration, and the one which led him to reject it altogether, is,
that the bile and the meconium are liable to be absorbed by
the fresh surfaces of the wound made by the operation, and
thus cause jaundice, or mortal degeneration of the blood. It
was to this circumstance alone he attributed the loss of his
two cases, already alluded to. M. Amussat, however, failed
to verify this positive declaration of his, by 2^ jpost-mortem ex-
amination of the biliary organs of his two unfortunate cases.
I do not believe that the icteroid appearance of these cases
had anything whatever to do with his operation — that this
appearance of the skin was not caused by absorption of the
bile and the meconium, in the manner he imagined. They
doubtless would have died jaundiced had he not performed
the operation, for it is a notorious fact that by far the largest
number of such cases have this yellow tinge of the skin, inde-
pendently of any operation. Nearly all such cases, unless
completely relieved by the operation, die jaundiced ; the jaun-
dice, however, is neither the result of the absorbtion of the
bile and the meconium by the wound, nor is it the immediate
cause of death. The operation, if timely and judiciously per-
formed, instead of inducing jaundice, is the first step towards
removing it, if it already exists, and of preventing it, if it does
not exist. The icteroid tinge of the skin in these instances
may be the result of the too long retention of the meconium



112 THE THIRD SPECIES OF MALFORMATION.

in the intestines, or it may be tlie result of inflammation of
tlie umbilical vein, or of the biliary ducts ; indeed, this icter-
itious appearance is a phenomenon not unusual in infants of
from two to three days old, even when no malformation at all
exists, doubtless consequent upon a temporary excess of the
colorino; matter of the bile in the serum of the blood, for I
have myself often observed in the new-born the whole surface
of the body, as well as the tunica conjunctiva, to acquire a
yellow hue, more or less intense, the result of a slight or a
severe acute hepatitis w^hich obstructs the circulation of the
bile and causes its passage intq the blood. About one-third
of all infants born, are more or less affected with icterus. The
main objection of M. Amussat, to the ordinary operation uj^oii
this ground has, therefore, in my opinion, no foundation in
truth. His objections, however, to the operation, on account
of the liability to closure of the newly made passage, to infil-
tration and the formation of stercoral abscesses in the vicinity
of the artificial anus, are much more plausible, for these acci-
dents sometimes certainly occur, and they are serious obsta-
cles to the success of the ordinary operation.

11. The Method of M. Amussat. The chief feature, or pecu-
liarity of the method of M. Amussat, is the application to the
anus of the principles and the practice which Dietfenbach ap-
plies to the lips, in cases of narrowing and closure of the
mouth. {Traits sur Vart de restaurer lea defformites de la
face, par deplacement. Montpellier : 1842. Atlas.)

I have already shown at the commencement of this section,
that M Amussat advises the blind end of the rectum when
found, to be detached from its adhesions for the purpose of
bringing it down even with the external opening made by the
incision, and there attaching its mucous membrane by sut-
ures to the lips of skin formed by the edges of the cutaneous
wound. It will thus be seen that the object of M. Amussat's
method is to supply the whole track of the artificial canu'.



TIIK TIIIKD SPECIES OF M^y.FORMATION. 113

with the luitunil tissues, wliich in these cases is the sreat
desideratum, these tissues being already prepared and
adapted to the exercise of" tlie functions Avliich tliey are
designed, and will be called upon to perform.

It must be admitted that M. Amussat's modification of tlie
ordinary proceeding is in several respects a most decided and
most admirable improvement — that it is highly ingenious and
deservedly meritorous ; but it also must be admitted, how-
ever, that it cannot be universally adopted ; that it is by no
means void of danger, for by depressing the rectum too much,
serious if not fatal consequences might be the result ; and
that it is not, in every case, as essentially necessary'- to success
as he intimates. It will doubtless succeed well in all cases
in which the cul-de-sac of the rectum does not lie deep, and
having no adhesions, floats loosely in the pelvic cavity, as it
does in some instances ; or when it can easily be separated
from its adhesions, or these themselves are capable of being
stretched, so that it can be drawn down without much force
or difficulty to its external position in the perinseum. It is
however, on the contrary, impracticable when there is consid-
erable deficiency of the rectum, the very cases in which it
would be the most essential. The great difficulty in such
cases is elongating the rectum sufficiently. In order, how-
ever, to obviate this difficulty, M. Amussat advises that the
artificial anus be established in the coccvofeal, instead of the
perinEeal region, in as much as the blind end of the rectum,
lying nearer the former than the latter, would consequently
have a shorter distance to traverse in reaching the surface,
by being drawn directly backward, than by being pulled
downwards to the natural situation of the anus. He there-
fore advises the external incision to be made immediately
anterior to the coccyx, or to the left of this bone. He even
advises the excision of the os coccygis, if necessary to gain
room ; having himself on one occasion for this purpose,

removed the extremity of this booe in a case of this kind.
8



Hi THE THIKD SPECIES OF MALFORMATION.

The child, however, died a few days afterwards. [ Vide Case
CXLIV.]

It will be observed that M. Amussat, unlike M. Roux de
Brignoles, in this respect, attaches no importance whatever
to securing for the benefit of the artificial anns, the sphincter
muscles, by bringing down the end of the rectum into imme-
diate contact with them ; but on the contrary deprecates any
attempt of the kind. For the purpose of making his favorite
method sufhciently elastic to extend to all cases in which the
end of the rectum can be reached, he would sacrifice both
the natural situation of the anus, and the sphincter ani mus-
cles. But to discard these invaluable adjuncts, on this
•account merely, when they could be preserved by the ordi-
nary method, or by that of M. Roux, would be a great error
which should itself be discarded ; for without these it is
impossible to establish the complete function of the artificial
anus. The practice of M. Amussat, however, corresponds
with his theory on this subject, which is that the interior
outlet of the body is disposed in such a manner, indepen-
dently of its muscular apparatus, as to favor voluntary reten-
tion of the faeces ; consequently that the power of retaining
and controling the discharge of the faeces does not solely
depend, upon the sphincter muscles, for patients have been
known to retain control over the alvine evacuations, after the
excision of the inferior extremity of the rectum. He tliere-
fore comes to the conclusion that the same power will exist
after his operation for artificial anus in the coccygeal I'egion,
and hence he imagines there is no necessity for the sphincter
muscles. In this it will be seen he differs but little in opin-
ion from Mr. O'Beirne. {JVew Views of the Process of Defe-
cation. Dublin , 1833.)

It was the dutv of M. Amussat, however, to have estab-
lished his theory by undoubted facts, before drawing such
conclusions from it. This he never did, and until he does,
whether the operation is performed by the ordinar}-^ method.



THE THIRD SPECIES OF MALFOUMATION. 115

or by Ills own, tlie iiutural Bituiitiuii ot" the uiius in the periii-
seal region should be selected, and the sphincter muscles, if
they exist, should always, if possible, be secured, so that the
power of retaining the faeces by the artificial anus would
without doubt fail to be preserved.

The first case upon which M. Amerssat executed his inval-
uable operation, was a very complicated and difficult one ;
and as it is highly interesting and most fully illustrates his pecu-
liar method, I have produced it entire. [ Vide Case XLII.\

12. The Ojyeration of M. Amussat, performed hy others. Mr.
Waters of Parsonstown, England, records a case of imperfor-
ate anus and rectum, in which in 1.842 he performed a similar
operation to that performed by M. Ainussat seven years pre-
vious, (1835.) Complete success attended this operation. It
is said that Mr. Waters was not at all aware of the method of
M. Amussat when he performed this operation, but was led to
adopt the plan he followed, solely by his own reflections
upon the case. This may all be true, and it may afi'ord
another example that good surgeons every where think alike
and come to the same conclusions. One thing however is
certain, that the operation of M. Amussat was notorious for
seven years in France, previous to that performed by Mr. Wat-
ers, and that the Channel only divided the two surgeons. I
have presented Mr. Waters' case in full. [ Vide Case XLIII.]

Mr. W. G. Smith of Vauxhall-Walk, London, in 1846,
adopted in part the method of M. Amussat, in a very extra-
ordinary case. Complete success was the result of the oper-
ation. [^Vide Case XL IV.]

Mr. West says that he was a witness to the great advanta-
ges of M. Amussat's method in a little boy upon whom Mr.
Shaw operated successfully a few years since at the Middle-
sex Hospital. {Lectures on the Diseases of Infancy and
Childhood. Led. XXXI. p. 377. Phil. 1854.)



110 THE THIKD SPECIES OF ISIALFORMATION.

Dr. Hermann Friedberg, of Berlin, in a late and very able
essay on Artiiicial Anus, higlilj extols the method of M-
Amnssat, which he has more or less improved and faithfully
carried out. He successfully operated on a grave and very
interesting case by this method, somewhat modified by him-
self, and as this case fully illustrates his method of operating,
I have presented it in detail, translated from the French,
having been unable to procure a German copy of his work.
[Vide CaseXZVIL]

Mr. Redfern Davies, of Birmingham, England, also highly
approves of the method of M. Amussat, and proposes a modi-
fication of it. His remarks on the subject are practical and
certainly deserve attention. He did not, however, adopt his
own suggestions in a case of imperforate anus and rectum
upon which he operated. [ Vide Case Lll?^ The considera-
tions, however, which influenced him not to do so in this
case appear obvious enough. " The reasons," says he, " that
induced me, at the time when the rectum was opened, to
forgo even the attempt to bring it down were— that I deemed
the distance, two and a quarter inches, at which it was
situated from the external opening, to be so great as to
preclude the possibility of so doing. Bound down as the
rectum is by its foldof peritonseum, the meso-rectum, I feared
to encounter the almost certain dangers of peritonitis, or
pelvic cellulitis, which must inevitably be the probable
consequence of the laceration of its connective tissues, to
permit of its descent for such a distance. Besides, at such a
depth, how great an uncertainty there must be as to what
the forceps might seize hold of." And again, he says : —

" With all due deference to the opinions of others, and in
hopes that it will receive whatever of attention it may merit
in their hands, I beg to lay before the opinion of my moi-e
experienced professional brethren the following modification
in the operative interference usually adopted in these cases,



THE TIIIliD SPECIES OF MAI.FOKMATIOX. 117

wliicli T li;i(l intended, had the patient survived a sufficient
length of time, to carry into clFect. As far as can be judged
by the evidence of the published cases, death is the conse-
quence of different causes, according as the rectum is, or is
not, brought to the opening of the wound. If it is, death
ensues from the injuries inflicted, by so doing. If it is not,
death ensues, but secondarily, iu consequence of the difficulty
to defecation being only partially removed. I would propose,
therefore, to combine these two procedes, and endeavor to
obtain, by extending the operative measures over a consider-
able time, immunity from the evils of both : viz., supposing,
in the first instance, that an opening had been made (as was
done) into the rectum, nature being relieved, had not other
influences intervened, the child would have lived pro tern. ;
but then comes into consideration the subsequent difficulty in
passing the stool, owing to a gradual narrowing of the passage.
All this is said to be due to the mucous membrane not beiuo-
continuous with the outlet.

To remedy this, therefore, when the parts have recovered
from the efiects of the first operation, introduce a pair of
forceps, and, seizing hold of the lips of the opening into the
rectum, endeavor to bring it down, not by one vigorous and
decisive holding on by the forceps, and by main force
bringing the gut to the external orifice, but by gently and
repeatedly soliciting its descent, introducing the forceps at
certain intervals, and gradually endeavoring to accomplish
the end. If the rectum can be so moved from its position,
and be brought lower down in the pelvis (and so by repeated
attempts it has been proved) by one forcible extension, and
even that sometimes crowned by success, how much more
liively is it that success should attend the proceeding, when,
by the almost imperceptible tractions made upon it, the great
causes of failure, viz., peritonitis and pelvic cellulitis, would
be removed, owing to the small amount of disturbance that



lis THE THIRD SPECIES OF MALFORMATION.

â– would take place in the soft parts. Although, as far as I am
aware, this procede by successive stages has never before
been broached in any writings on the subject, the idea was
taken from a case reported in the " Lancet," vol. i. p. 493,
1S46, [ Vide, Case XLIY^ in which an incision was made into
the perineum for a distance of three inches, and on the second
day an attempt was made, by gently pulling, to draw down
the gut, which was not, however, fastened to the external
opening. One month afterwards the child was doing well.

I am fully aware that there is a vast deal of essential
diflference between this procede and the one I advocate :
nevertheless, accomplishing the end by successive stages, is
in this case shadowed out, and will, I trust, assume a definite
status in surgery." {Ediiiburgh Medical Journal, March,
1S5S. m. XXXIILp. 811.)

Although M. Amussat, in his very able and highly inter-
esting and practical paper already alluded to, laid down his
beautiful process for the establishment of an artificial anus in
the perineeum, and demonstrated its practicability and com-
plete success in the very first case upon which he executed
it ; yet strange, passing strange, he never afterwards in other
cases pursued this method to its consequences, but in place of
it, adopted and practiced colotomy. He thus seemed to have
designed and built a most beautiful superstructure, merely to
gaze upon it for a moment, and then to demolish it.

13. The Operation hy Puncture. Perinseal puncture was the
earliest method of operating in cases of congenital closure of
the anus or the rectum, and is still recommended and per-
formed by some surgeons of the present day. They use for
this purpose a trocar, a pharyngotomus, a lancet, or some
other piercing instrument, and thrusting it into theperinseum
at the normal place of the anus, they make it follow the
natural direction of the rectum with the intention of penetrat-
ing the end of this intestine, should it be present and in its
normal position.



THE TIIIllD SPECIKS OF MALFOKMATION. 110

The metlioJ by puncture is recommended in consequence
of its being very simple and quickly executed in urgent cases,
even by tlie young and inexperienced surgeon. There are,
however, but few cases on record in which this operation lias
succeeded ; it should therefore be entirely abandoned at this
day, with the exception of those cases in which the end of
the rectum can be appreciated both by the sight and the
touch — that is, in which it lies near the surface and is
distended with gas and meconium, Tlie " hlind plunge''' of
such an instrument into the perinteum in those cases in M'liich
it is aboslutely requisite to penetrate deeply, is a most hazar-
dous proceeding, and one well calculated to inflict fatal
injury to some of the delicate and important organs of these
parts. Such an instrument is exceedingly liable to perforate
the bladder, especially as this organ, in cases in which there
is considerable deficiency of the rectum, occupies a lai'ger
space in the pelvis. There is indeed a great deal less cer-
tainty in the result of this operation than perhaps in any
other in surgery, "When the trocar or any instrument of the
kind is used in these cases, the operator is compelled to
follow the natural direction of the rectum, but, as I have
shown elsewhere, this intestine often deviates from its normal
course. Should the rectum be further in front or to either
side than natural, it might be missed or not opened in its
proper place, and the operation of course would fail, and the
patient be lost ; whereas in the operation by dissection, the
blind end of the rectum can be sought for, and if it exist, can
be found somewhere in the pelvic cavity within the safe
limits of the operation. Of all other openings too, those
made by puncture are the most liable to contract and become
obliterated. Puncture therefore, in my opinion, can never
be substituted for dissection in these cases, without great
uncertainty, risk and danger.

M. Petit, when speaking of the operation by puncture, ob-
serves that it is very difficult to find the right place for



120 THE THIKD SPECIES OF MALFOKMATIOIS".

inakiiii? the perforation into the blind end of the rectum, as he
o-enerally found it formed into a knot in these cases. For
performing such an operation, he recommends a trocar, the
canuhi and circuhir phite of which are so slit open, as to serve
as a groove for a lancet or bistoury to run in, to enlarge the