endeavored by very plausible reasoning, to establish the con-
verse of this proposition, namely, the formation at once of
the abdominal anus, without making the attempt first, to form
the perinseal one ; and that this is at present the practice, to
a considerable extent, in some parts of Europe. M. Amussat
has of late recommended that in all cases, in which a distinct
fluctuation cannot be detected, through the integument of the
perinseum, an artificial anus should at once be formed in the
left lumbar region, as being a safer proceeding than the
attempt to open the rectum from the perineeal region.

Tiingel, one of the latest, and a most able writer on this
subject, says that — " The operation for abdominal artificial
anus should be employed for all forms of imperforate anus ;
it being manifestly the most rational, and with a certain limit
may always be employed ; for we cannot decide beforehand
whether we shall succeed in finding the rectum, or in draw-
ing it down to the skin of the perinseum, when it is found."
( Uher Kunstliche Afterbildung. S. 203. Keil : 1853.)

The fact of our being sometimes unable to decide at first,
as to whether we shall succeed or not in finding the end of
the rectum, is a very weak argument against the formation
of a perineal artificial anus, and no argument whatever in
favor of an abdominal artificial one. Our not knowing
exactly whether we shall find the rectum, is no reason why
we should not search for it, and endeavor to find it, and when
found, try to bring down the end of it, and form an anus in its



ABDOMINAL ARTIFICIAL ANUS. 297

normal situation; failiiifj in this, it is still tiiiu; ciioiioji
to establish the amis in the abdomen. Again, Tiingel ixiiiarks
that — " We must not forget that although the artificial anus
in the perinseum has its seat near the natural one, it never-
theless causes inconveniences equally as great as the artiticial
anus made elsewhere ; the liquid fseces are constantly escap-
ing, whilst those which are solid are voided with difficulty.
The cases in which defecation occurs voluntarily, notwith-
standing the absence of the sphincter and the levator ani, can
only be explained by the fact, that the contraction of the
artificial anus opposes an obstacle to the passage of the faeces,
to be overcome only by the pressure of the abdominal mus-
cles ; thus the influence of the will is possible in the act of
defecation. But as a compensation for this phenomena of
voluntary evacuation, the patient endures a still greater
suflering resulting from difficult and incomplete evacuation,
which may result fatally ; whilst the artificial anus in the
abdomen, enables us to prevent or combat the contraction,
and by j)roper bandages to hinder the constant and involun-
tary evacuation of fsecal matter ; and even when this is
impossible, this unfortunate condition of the patient by no
means endangers life. The presence of the sphincter in some
cases of imperforate anus seems incontestible, but it is rare,
and still more rare are cases in which it has been possible to
preserve the sphincter in the operation, as was done by
MM. Roux and Goyraud. Apart from tliese rare instances,
the artificial anus in the perinseum ought not to be regarded
as much more advantageous than one in the abdomen."
{Loco citato.)

The opinion of Tiingel that the perinaeal artificial anus has
no preference over the abdominal one, except merely that
of being located in its natural situation, is the very best
reason that could be given why it should not always be pre-
ferred to the abdominal artificial anus ; for as it regards con-
stipation, it is by no means a matter of indifi'erence whether



298 ABDOMINAL ARTIFICIAL ANUS.

the contents of the intestines pass by the rectum and perineal
anus, or reach only the opening at the sigmoid flexure of the
colon. The suppositions of Tiingel with regard to the perin-
seal artificial anus causing as much inconvenience as one in
any other situation, and the other various difficulties and
troubles which he enumerates, are certainly not in accordance
with facts, as any one can convince himself by carefully
examining the numerous cases successfully treated, and which
will be found reported in this work. He has certainly
forgotten to recall to mind the many dangers and difficulties
which accompany the formation of an anus in the abdomen.
In the abdomen no dilator and constrictor muscles ever exist,
and the faecal matter cannot be retained except by a compress
and bandage ; unless by the lucky prolapsus of a fold of the
intestine taking place across the aperture, filling it up and
acting as a valve, and thus preventing the efflux of the faeces,
as occurred at the artificial opening in the stomach of the
celebrated Alexis Saint-Martin.

These authors have entirely failed to prove that the abdo-
minal artificial anus has any preference whatever over the
perinaeal artificial one, or that it is in any respect a good
substitute for it.

Some very able surgeons denounce the operation, and con-
tend that no practitioner is ever justifiable in performing it.
This is the other extreme.

Professor Bigelow, of Boston, whom we have already
noticed, thinks it unnecessary to discuss the question of
" ekeing out the life of a new-horn haby ly an artificial anus
in the groin or hackP {Boston Medical and Surgical Jour-
nal. Vol. L YII. p. 512. Boston : 1858.)

I would observe that Dr. Bigelow is by no means alone in
his views of the impropriety of performing colotomy in the
case of new-born children. The very distinguished Professor
of Surgery, Dr. Gross, of the Jeff'erson Medical College of
Piiiladelphia, says in relation to this gperation {colotomy) —



ABDOMINAL ARTIFICIAL ANUS. 299

" We are struck with astonishment that any one possessed of
tlio proper feelings of humanity, eliould seriously advocate a
procedure so fraught with danger and followed, if successful,
by such disgusting consequences. I cannot, I must confess,
appreciate the benevolence which prompts a surgeon to form
an artificial outlet, for the discharge of the faices, in a case of
imperforate anus, in a child in whom the rectum is either
completely absent, or terminates blindly several inches above
its normal situation ; or in a case of scirrhus of the bowel in
an adult, in whom, from the very nature of the disease, life
cannot possibly be prolonged beyond a few brief weeks or
months at farthest. Let the surgeon, if he be a parent, ask
himself the question, whether he would not rather see his
child die without an attempt at relief, than to place it in a con-
dition that would only render it an object of disgust to itself,
and of loathing to every one around ; or if he be a husband,
whether it would not be more in consonance wdth the dictates
of humanity to abandon his wife to her fate, than to imder-
take to eke out for her a miserable existence by sncli a pitiful
and revolting an expedient ? I have performed the operation
but once, and I am sure nothing could ever induce me
to attempt it again. While it is impossible, I conceive,
to bestow too much praise npon those who first conceived
and executed the design of affording aid to this unfortunate
class of sufferers ; it is evident from the statistics which have
been published upon the subject, and to which special refer-
ence will be made by and by, that the operation is founded
npon a misdirected sympathy, and that it ought to be
discarded as among obsolete devices of surgery." (A System
of Surgery. Vol. II. Chap. XIII. p. 765. Philadelphia :
1859.)

M. Fourcart, in alluding to the lumbar artificial anus
according to the method of Callisen, says — " I will repeat,
that in ray opinion, the surgeon has no right to impose
this operation upon a child, and should not do so, unless



300 ABDOMINAL ARTIFICIAL ANUS.

forced by the formal demand of the parents." {Gazette
des Hopitaxix de Paris. N'o. LXX. Juin 16, 1835. jp. 280.)

I should think that no prudent, or intelligent surgeon, even
if he had the right, would, under any circumstance, impose
upon the ciiild any operation, especially one in which he had
no confidence ; and no sensible parents would ever make
such a demand ; if they did, I trust, for the honor of the pro-
fession, that no surgeon would be found to comply with
it. The duty of the surgeon is one thing, that of the parents
altogether another.

On one occasion the able and distinguished M. Paul
Dubois, at present accoucheur to the Empress Eugenie, w^as
called in consultation with M. Fourcart to see a child having
an imperforate anus. In consequence of the difficulties
attendins: this case, the formation of an abdominal artificial
anus after the method of Callisen, was spoken of; when M.
Dubois remarked, that if it were the case of his own child,
he would not consent to the performance of such an opera-
tion. The parents of the child, however, insisted upon it, and
these two surgeons were forced to yield, and to seek for the
colon in the lumbar region. The child, however, died in a
few days afterwards.

I will repeat, that when the surgeon has entirely aban-
doned all hope of making a perinseal artificial anus, it is his
duty to propose to the parents or friends of the child,
to establish an artificial anus in the abdomen ; explaining to
them, that an anus in so unnatural and inconvenient a situa
tion as the iliac or lumbar region, is indeed a very sad alter-
native, nevertheless, as it offers the only chance of preserving
the life of the child which otherwise must inevitably perish,
it should be established. Should the parents, however,
in behalf of their child, come to the conclusion, that death
would be preferable to life, encumbered with such an infirm-
ity, it would then be entirely left for tl:\em to refuse their con-
sent to the operation.



ABDOMINAL AKTIFICIAL ANUS. 301

Some surgeons seem to think that tlie proposition to
perform this operation, should always first ct»me from the
parents of the child, whereas nothing should come from them
but their consent to, or their rejection of it. T would like to
understand, what the parents would be likely to know, con-
cerning the necessity or propriety of such an operation, that
the proposition to perform it, should come from them. If the
operation confers any good w^hatever, the proi)osition to per-
form it should come from the surgeon. If it confers nothiuir
but death, or a miserable life, no surgeon should perform it
even if urged to do so by the parents. Any other course
would be undignified and absurd.

In my opinion, in by far the largest number of cases of
congenital imperforation of the rectum and sams, proctoplasti/,
in its j)resent improved state, as presented in this work, will
doubtless succeed ; and in those rare instances in which it is
entirely impracticable, the surgeon should not hesitate for a
moment to perform the iliac or the lumbar operation. It is
true, we observe how eloqnently and how earnestly the oppo-
site is maintained, namely, that no surgeon is justified, under
any circumstance, in prolonging the life of a child in whom
the rectum and anus are imperforate, upon as it is said, the
loathsome condition of an abdominal artificial anus, I, on
the contrary, however, maintain that such an opinion cannot
be justified upon any principle of morality, since an impera-
tive obligation and duty rest upon the surgeon, to employ to
the best of his ability, the means placed at his command for
the relief of human suffering and the prolongation of human
life. The principles of our art, as w^ell as the dictates of
humanity itself, command us to avail ourselves of this opera-
tion, notwithstanding it has been stigmatized as a ^^pitiful
and revolting exj^edient.''^

M. Araussat, when speaking on this very subject, says —
" An artificial anus in the lumbar region is no doubt a great
infirmity, but it is the sine qiia non — life or death. 1 have



302 ABDOMINAL ARTIFICIAL ANUS.

heard some persons say, ' I should prefer death to life with
such an infirmity.' I have assured them that they were not
in a position to decide ; and I have no confidence in these
courageous resolutions taken when one is sound in health ;
for in the cases of the afflicted, to whom this operation has
been proposed, if some have refused at first, all have ended
by demanding it most earnestly. Talma and Broussais would
doubtless have accepted it as a blessing.

" I have already said, and I repeat it, this infirmity is not
80 great as is generally believed, because it is always com-
pared to that wbich results from stercoracious fistulse of the
small intestine. But it is important to observe, that the arti-
ficial anus of the large intestine is not to be compared with
the accidental anus of the small intestine, which always
occurs in gangrened hernia. In this case there is always
incontinence of faecal matter, which is almost always liquid.
In the artificial lumbar anus of the colon, there is often, con-
stipation, on the contrary, and almost always a difficulty in
defecation, rather than too much facility ; consequently with
cleanliness, and a tent well applied, this infirmity is much
more endurable than is commonly thought, since the faeces do
not flow involuntarily and constantly, and there is no need of
a box or pouch as in case of the accidental anus.

" Notwithstanding all the slui-s which are so easily cast upon
this sort of infirmity, it may be said to be more endurable than
many others, because it is naturally concealed and easily kept
secret ; it is far better therefore, in view of what I have said,
to have an artificial anus, than to have a deformity which for-
ces itself upon the eye, and oflTends everybody." {L'Exam-
inateur Medical de Paris. Annee 18i3. tome III. p. 234:.)

I am not aware, that any surgeon in the United States, has
ever performed the operation for abdominal artificial anus on
an imperforate infant. If there is such a case reported, I
have not seen the record.

I will here remark, although it may appear out of place,



ABDOMINAL ARTIFICIAL ANUS. 303

that should the surgeon ftiil to form an artificial anus in the
periiuie.um, tlic abdominal operation should l)e postponed,
provided the condition of the child admitted of delay,
until it recovered from the exhaustion, consequent upon pain
and loss of blood, so as to enable it the better to endure the
second operation. By this delay too, the rectum perchance
might in the meantime present itself in the incision in the
perinaeum, sufficiently low down to be recognized ; for its
superior portion would be gradually becoming more and more
distended with meconium, and constantly impelled down-
wards by the natural efforts of the child to evacuate its bow-
els. A case of this character is related by M. Petit [Vide
Case LIII.] in which a surgeon failed to find the rectum
through the incision which he had made in the perineal
region ; but another surgeon three hours after, found the blind
end of the rectum distended with meconium, and protruding
through the wound. {Memoire de VAcadeinie Royale de
Chirurgie de Paris. Annee 1781. tome II. p. 237.)

It is of the greatest importance to the success of the opera-
tion for the creation of an abdominal artificial anus, that
great care should be taken to protect the cavity of the abdo-
men against the intrusion of liquids ; that the finger should
be introduced in the most gentle manner into the abdominal
wound in search of the intestine ; as it makes a very essential
difl:erence, whether the intestine to be opened, protrudes at
once in the wound of the abdomen, or whether the finger has
to be employed to search for it. It is also of the highest
importance that the little patient should be kept warm, and
well nursed to sustain it. Immediately after the operation it
should be put into a warm emollient bath, and then placed in
the arms of its mother in bed, so that the warmth of the
mother and the bed should be communicated to it. For the
want of these precautions cases are often lost.



SOi ABDOMINAL AKTIFICIAL ANUS.

SECTION II.
HISTORY OF THE OPERATION,

It is a singular circumstance in the history of the formation
of ahdoininal artificial amis, that two surgeons, Littre and
Callisen, who never performed the operation on a living sub-
ject, and who never, as far as is now known, published any ex-
act method of performing it, should be so universally acknow-
ledged as the authors of the two distinguished and highly im-
portant methods of operating now adopted.

I will confine myself to the history of the operation so far
only as it relates to cases of congenital malformation. It com-
mences with M. Littre, an eminent French anatomist, and
Member of the Royal Academy of Sciences. He was the
first individual in modern times, who, in certain cases of con-
genital malformation of the rectum, suggested the idea of
establishing an artificial anus in the abdomen, when in sucli
cases, it was found altogether impossible to re-establish the
natural one in the perinseum. This idea appears to have been
the result of reflections suggested from having examined post-
mortem an infant which had died of an imperforation of the
rectum, six days after birth. At the autopsy in this instance
M, Littre found the rectum normal, both below and above a
complete obstruction which divided this intestine into two
parts, presenting, as it were, a double cul-de-sac, directly op-
posite each other. [ Vide Case C]

The main idea of M. Littre seems to have been, to recom-
mend in all future cases of this character, a double operation —
that is the opening of the abdomen at some point, and through
such w^ound, the excising of the obstructed portion of the rec-
tum, and the uniting again by suture of its divided portions, and
if successful in this, the wound of the abdomen to be healed ;
failing, however, in this proceeding, then to unite the superior
portion of the rectum to the wound in the abdomen, and thus
create an abdominal artificial anus. This is dimly shadowed
forth in his description of the case alluded to, and in the fol-



ABDOMINAL AUTIFICIAL ANUS. 305

lowing liiiignagc which appears to ])e all iliaf is said mi t]\v
Biihject. " 11 faiidrait faire un incision auventre, etreeowJre
ensevMe les deux parties a2?rcs les avoir 7'ouveries,on dn m.'dns
faire mnir la partie superieure de V intestine^ a la plaie da
ventre^ (pie Von ne refermemer ait jamais, et quiferait la f una-
turn, d'anus^'' {Hlstoire de VAcademie Royali des Sciences de
Paris. Annee 1710. jr>. 30.)

There is nothing revealed here, however, \\\t\\ regard to the
exact locality of the abdominal aims, or with regard to the
manner of performing the operation. Not a word is said
about cutting into the cavity of the peritonaeum in the left iliac
region, opening the sigmoid flexture of the colon, securing the
opened intestine in contact with the abdominal wound by
means of a thread passed through the mesentery, &c. Tlie
idea, however, of an abdominal artificial anus is here clearly
enough suggested by M. Littre.

It is singular that not an author, for more than half a cen-
tury, who wrote on the subject of imperforate anus, commenc-
ing from M. Littre himself, ever mentioned the important pro-
position which this illustrious anatomist had proposed in 1710.

M. Pillore, a distinguished surgeon of Rouen, was really
the first individual who acted \\^on the suggestion of Littre,
or upon his own suggestion, from having witnessed several
cases of preternatural or accidental anus which had, within a
short period previously, come under his own observation.
Pillore in 1776, just sixty-six years after the proposition of M.
Litti-e had been published by M. Fontenelle, the Permanent
Secretary of the Academy of Sciences, executed in a modified
form the operation of Littre, under circumstances, it is true,
not contemplated by Littre. The patient of Pillore was an
adult, a wine merchant in the vicinity of Kouen, and the
operation was performed, not in consequence of a congenital
malformation of the rectum, but on account of a complete ob-
struction to defecation, caused by a scirrhus contraction of the

superior part of the rectum, and the inferior portion of the
2U



306 ABDOMINAL ARTIFICIAL ANUS,

colon. In this instance Pillore formed the artificial anus in
the caecum which was opened through the peritonaeum. The
patient survived the operation twenty-eight days, and the im-
mediate cause of his death seems to have been intense inflam-
mation of the jejunum, caused by two pounds of metallic mer-
cury having been administered a month previous to the oper-
ation, and which had lodged in, and displaced tnat portion of
the small intestine. {Actes de laSociete de Lyon. Annee 1797.
ip. 189. Also, Amussat. Menioire sur la PossihilitS d'etahllr
un Ames artijiGiel dans le Region loriibairS sans penetrer
dans le Peritoine. Paris : 1839.)

To M. Pillore then, is justly due the merit of having formed
the first abdominal artificial anus in a living subject, and with
him commenced that series of operations for this purpose
Mdiich I will presently give, confining myself, however, en-
tirely to those cases in which the operation was performed on
account of congenital malformation of the rectum.

M. Dubois was the first surgeon who ever dared to execute
the operation of Littre on a living imperforate infant. This
he did in 1783, just seventy-three years after the promulgation-
of Littre's proposition, and seven years after Pillore's opera-
tion. [ Vide Case CCL F.]

We must now introduce the celebrated Callisen, a highly
distinguished surgeon of Copenhagen, who as early at least as
1770, published another method of forming an abdominal arti-
ficial anus, intended doubtless as a great improvement on
Littre's method, rendering that operation, as Avas supposed,
less dangerous. Tlie operation, which is universally attri-
buted to him, consists in opening the descending colon
from the lumbar region without wounding the peritonaeum.
It is not known with whom this operation originated;
Calissen liimself does not claim the distinguished honor of
first suggesting it. M. Sabatier was tlie first surgeon who
attributed this proposition to Callisen. All Callisen himself
says in relation to it, is briefly as follows : — " Si cavum



ABDOMINAL ARTIFICIAL ANUS. 307

intcsthiale cultro vcl paraccnteslo attinr/l ncqueai^ vix servari
potei'it ceger. Qua) proposita suh Jioc reruiri static fuit incisio
intesiini cceci vel coli descendentis^ sectione in regione lumhari
unistra ad marglnetn musculi quadrati lamhorum facta^ ut
anus pai'etur artificiaUs, remedium pnnhet oinnio incerimro
iitqne hac operatione vix vita miscUi servari poterit. Quan-
gaavi intestinuni in hoc loco facilms aitingatur^ qxiam s\ip<'a
reglonein inguinalemy {Sijstema Chlrurgie Ilodiernce. tome
IT. p. 842. IlafmoB: 1817.)

We observe, by this language that Calliseii intimates that
the operation was proposed by some one else, but by whom
he does not say. lie neither claims it as original with him-
self, nor does lie at all allude to the great distinguishing fea-
ture of it — the preservation of the peritonaeum. The truth is
that very little is known in relation to the early history of
this operation, and that little by no means favorable to it.

The peculiar advantages claimed for Callisen's proceeding
over that of Littre, are — first, the integrity of the perito-
naeum — ■second, the more convenient situation of the artificial
anus, and third, the less liability in this situation to prolapsus
of the intestine.

M. Sabatier mentions that Callisen himself experienced
great difficulty in executing this operation on the dead body,
having failed in numerous instances, in consequence of una-
voidably opening the peritonaeum. He gives an instance in
which Callisen attempted this operation on the body ot a
child which had died of a malformation of the rectum, and
failed, by having opened the peritonaeum ; but in his second
effort on the same subject, he barely succeeded, by making
his second incision further back, and by introducing his fin-
gers into the first incision, in order to fix the intestine.
{Medicine Operatoire, tome III. p. 337. ^d Edit. Paris :
1824.)

Callisen's operation was indeed, with but few exceptions,
almost universally condemned. Among the numerous sur-



308 ABDOMINAL ARTIFICIAL ANUS.

geons who of late years condemned it, and wlio aided
ill keeping it consigned to oblivion, I will mention M. le
BaroQ Dupnytren ; {Dlctionnaire de Medicine et de Chirtir-
gie Pratiques, tome III. p. 12S) and Mr. Fergnsson, wlio, in