of the wound by five points of interrupted suture. By the
easy evacuation of the meconium the abdomen had already
diminished ; the child cleaned and warmed by placing near
the fire, was calm, and drank with avidity of sweetened
water.

The next day I received a very satisfactory account of the
child ; the abdomen was soft, and insensible to pressure ; it
drinks readily and exhibits no signs of suffering. The meco-
nium continues to flow freely by the artificial opening.

On the 27th of May, I visited the child in company with
Doctor Chains, physician at St. Maur. The abdomen had
completely returned to its normal condition : the wound is
open and of a pale color, the intestine is seen at its bottom ;
it is contracted, but it is so well fixed in place by a process of
agglutination that the threads attached only to the skin
can be removed : inflammation of the mouth which had given
me some uneasiness, seems to diminish.

At the fall of the sutures, the kidney caused a hernia in
the wound. The child died seven or eight days after the
operation.

Autopsy made on the 2nd of June, 1842, at half past six
in the morning, at Saint Maur, in presence of MM. Filhos
and Chains.

The abdomen is somewhat spotted, and the edges of the
wound are a little greenish.

The left pleura contains one or two spoonfuls of sanguina-
lent and glutinous fluid. The lung on this side is hepatized
for two-thirds of its extent below.

The stomach is distended with gas and fluids ; it also
contains greenish balls of curdled milk : the mucous coat
appears healthy.



ABDOMINAL AKTIFICIAL ANUS. 3-il

The caicuin is placed beneath the stomach : it continues
with the transverse colon, without any well defined line of
(loniarcation, after receivin<^ as usual the end of the small
intestine. The vermicular ap])endix is attached to the upper
part of the transverse colon. In consequence of this di.spo.si-
tit»n of the cajcum, there is no ascending colon, so that the
right lumbar region is occupied by the small intestines only.
On the lefc, the lumbar colon follows the transverse colon,
and preserves its position and ordinary relations ; but after a
passage of about two inches it terminates in nearly a right
angle ; the ileum which comes next, continues almost trans-
versely to the right, then returns to the left, thus describing
an arch whose extremities are directed to the left lumbaV
iliac region. The two portions of the intestine forming the
sigmoid flexure are joined and adherent for a large portion
of their entire length. Finally, the inferior extremity of the
arch continues with the rectum, which preserves all its nor-
mal relations, and which terminates at a very small distance
from the closure which hindered the passage of faecal matter
by the anus. We will add that tlie rectum is quite dilated
from its commencement at the sigmoid flexure throuo-h the
greater part of its extent, but that at a short distance from
the closure which separates it from the anal portion, it
assumes a conic form and occupies a very small space. This
disposition sufiiciently explains the want of fluctuation when
examination was made during life by the introduction of the
fore-finger as far as possible into the anus. In fact, the
dilated portion of the rectum not reaching to the closing
obstruction, only the conical extremity of the intestine could
be touched, in wdiicli there existed no matter capable of
afibrding a manifest fluctuation.

The closure which divides the rectum into two parts is
quite thick and resisting, it is situated about two inches from
the anus.

Adhesions exist between the skin and the portion of the
left lumbar colon wdiich had been opened. This portion of
the intestine is entirely deprived of peritonaeum. A well
marked projection exists at the point where the continuity
of the canal has been interrupted by the formation of the
artificial anus.

The peritonaeum contains neither serosity nor false mem-
branes, indicating that it had been the seat of inflammation.

Third Case.— On the 26th of January, 1843, M. le docteur
Berthier sent me a male infant, born the evening previous,
and who had not passed meconium. 'J he midwife discovered



342 ABDOMIN'AJL ARTIFICIAL AXrS.

i in perforation, but conviuced that the child could not live
more than twentN'-four or forty-eight hoiii-s longer, and that
no operation conld be performed, she had not thought of an
attempt being made. She had, besides, advised the mother
not to give it the breast, in order to avoid the secretion of
milk, which, as she thought, must soon be useless. The child
liad urinated, and the penis and scrotum were well formed.
On examination of the region of the anus, perinieum, and
coccyx, the following appeared: — First, There was no anal
opening. Second, The raphe continued from the scrotum to
the sacrum, with no other interruption than a depression at
the normal position of the anus, and a cicatrix adhering to
the sacrum at tlie point of the inferior and posterior portion
of that bone. Third, Tlie space comprised between the coc-
cyx, whose curve was quite small, and the pubis, was quite
small. Fourth, There was no kind of fluctuation in the re-
gions indicated. Fifth, When the child cries, and makes
efforts as if to void excrement, the fingers being applied to
the anal region, a sort of contraction is perceived, probably
indicating the presence of some fibres of the sphincter or
levator ani,

Without doubt an operation was clearly indicated, and we
were authorized to proceed to perform it at once ; but, con-
sidering on the one hand the absence of fluctuation in the
anal region, and on the other the condition of the child, which
was strong and active, we thought best to wait for the mor-
row, in order to see if the lower part of the large intestine,
more and more distended by meconium, would not cause pro-
trusion of the anal region. "We know, in fact, that in some
cases, the eflorts at expulsion, and the repletion of the upper
portion of the imperforate intestine, have enabled us at the
end of several days to perceive a fluctuation which it would
have been impossible to detect at an earlier period, the me-
conium not being then accumulated in the last portion of the
lai-ge intestine.

The next dav the child was brouo:ht to us. Its condition
was aggravated. It vomited and cried incessantly ; its skin
was of a violet hue, the abdomen much distended, and the
h^-pogastrium, the penis, and the scrotum were already the
seat of a serious infiltration which we had remarked in simi-
lar circumstances, and which with the violet color of the skin,
must necessarily supervene as a consequence of the oppres-
sion of the venous circulation caused by the distension of the
intestines.

A careful examination of the anal region, made bv us, as
well as by MM. Berthier Olifie, brothers, Duponchel, L.



ABDOMINAL ARTIFICIAL ANUS. 343

Boyer, Delarne, Duplan, Schuster, Grabowski, Leffiiillou,
Silvestre Dii Perron, Roljert, Maingault, Alplionse Ainnssat,
Le Vaillant, <kc., gave no indication of fluctuation, an<l we
consequently remained in tlie same state of uncertainty as on
tlie day before. Nevertheless, as this absence of fluctuation
WHS not an al)Solute indication that the large intestine termi-
nated very high up the pelvis, and as it was possible that it
mi^jht terminate in a cul-de-sac, or bv contraction at an inch,
or an inch and a half, more or less, from the anal region, it
seemed that prudence and the rules of surgery required that,
before making an anus in the left lumbar region, every pos-
sible effort should be made in the anal region to establish an
anus in the normal position. I therefore made a deep inci-
sion with the bistoury on the raphe, going even beyond the
coccyx. I then detached the point of the coccyx, in order to
excise it, in case of necessity. I then cut in two the fibrous
bands as they appeared. But not feeling any fluctuation in-
dicating the presence of the inferior end of the rectum, I de-
liberated with the assistants, and it was decidetl that since
the incision already made to a considerable depth had discov-
ered only fibrous tissue, it was not probable that we could
reach the intestine that way, and that besides we ought not
to continue an operation which gave no chance of success,
and which, by its continuance, took away those belonging to
the operation in the lumbar region, to which we must have
recou"i-se. I therefore decided, but with regret, to abandon
this operation, and make an artificial anus in the left lumbar
region.

The child was placed on its abdomen, and an assistant was
charged to place one hand on the abdomen, in order to com-
press the intestines and force the colon into the lumbar re-
gion. This being done, the child was placed a little inclined
to the right side, and they traced with ink the boundaries of
the region in wkich the colon might be met without the peri-
tonaeum. A transverse incision disclosed adipose tissue,
which was clipped and removed with the scissors: then the
muscles uncovered were incised in their turn. The wound
was kept well distended by M. Boyer, by the aid of crochets
devised for separating the 'eyelids in the operation for strabis-
mus. At the time of the operation, I consulted a plate repre-
senting the lumbar region, to assure myself that I was really
proceeding in the direction of the intestine ; I then incised
the quadrilateral lumbar space, hoping to discover the kidney
which would have served me for a guide. Abody presented
itself, glossy and of a violet hue, whose position and appear-
ance made us suspect it was the intestine. The touch gave a



34:4: ABDOMINAL ARTIFICIAL AlfUS.

sensation of fluctuation and elasticity analagons to that which
would 1)6 furnished by the intestine. In the doubt as to
identity, the body was seized with two tenacnla and slis^htly
incised. 1 tlien recognized that it was the kidney. Direct-
ing nny search farther on, and guided by this organ, I soon
discovered the colon, recognized by its green color and elas-
ticity. I fixed into its walls two tenacula a short distance
ripart, and incised the intestine with scissors between the two.
Immediately gas escaped with a whistling sound, and then
thick, black, and glutinous meconium passed. Two artery
forceps fixed to the edges of the opening just made, permitted
the meconium to pass freely, and to facilitate the evacuation,
a canula was introduced to break up the meconium; at the
same time light pressure was made on the child's abdomen.
Finally, a large amount of meconium having passed, the in-
testine T\'as fixed to the anterior angle of the skin by three
points of interrupted suture. Another suture was made to
unite the posterior angle of the wound to recover the kidney.

The child was then cleansed, and warmed, and carried
home by one of the neighbors of the mother, a woman whose
devoted faithfulness never swerved for a moment, and whose
admirable conduct was contrasted in a striking manner with
tiie inhumanity and ignorance of the midwife Mdio attended
the delivery.

Tlie next day after the operation, the child was in good
condition ; it sucked with extreme avidity ; the meconium
and faeces passed readily. It urinated well.

On the succeeding day, a considerable prolapsus of the in-
testinal mucous membrane was seen through the artificial
opening. But the prolapsus disappeared hy a light pressure
of the fingers, and did not hinder the exit of fsecal matter.

To jjrevent the increase of this prolapsus, compresses were
applied, kept in place with a bandage, which was recom-
mended to be continued, taking it off only from time to time
to afford exit to faecal matter.

On the fourth day, the sutures came away, even that which
had been made in tlie posterior part. The prolapsus tends
rather to diminish than to increase. The condition of the
child is very satisfactory ; it sucks with avidity, and there is
every reason to hope that it M'ill survive." {Troisihne Me-
moire, (&c. / also, L' Examinateu7' Medical de Paris, Annee
1843, tome III., No. XVIIL,2?p. 229, 230, 231, 232, 233.)

Case CCLXXXVII. — M. Baudelocque reports the case of
an infant, two days old, which had a natural anus, but upon
minute examination he found the rectum completely ob-



ABDOMINAL AKTIFIUIAL ANUS. 345

strnctcd about one inch above the anus, lie attem))ted to
open tlie conitnunicutioii by incisin<^ the mciiibraiie tenni-
natin<5 tlie rectal cul-de-sac, as he had successful Ij done on a
])revMous occasion, in, as he thought, a precisely similar case,
but completely failed to reach the meconium, lie tlien de-
termined to practice lumbar enterotomy, according to tlie
])r()cess of Callisen, modified by Amussat.

The child having been placed on its side, Baudelocque
made a transverse incision, an inch in length, in the lumbar
region. The aponeurosis of the external oblirpius was divided,
as were also some fibres of the quadratus lumborum, and the
colon, which was found in a layer of fat, was then opened.
A considerable quantity of meconium escaped, and the in-
testine was afterwards fixed by three sutures. On the fourth
day a little er3'si])elatous redness appeared around the wound,
and the child became feverish. Leeches were applied, the
nurse was changed and the child at once recovered. On the
eighth day after the operation it was doing well. {Memoire
de V Acadeniie Royale des Sciences, Paris, Aout et Octobre,
1841:. Also, London Lancet, Vol. /., Fehrtiary, 1845.)



SECTION XI.

APPRECIATION.

From a careful comparison of the two operative pro-
cedures of Littre and Callisen, together with their several
modifications, I am of opinion that the preference should be
given to the former, when infants are the subjects. M.
Baudeu's thinks that, from the mere fact of the great intes-
tine being less developed in the infant than in the adult, the
cellular space in the former must be so small as to occasion
great difiiculty in reaching it without wounding the perito-
naeum, and that consequently Callisen's oj)eration should be
limited to the adult. {Opus Citatum, p. 127.)

M. Amussat himself admits that his modification of Cal-
lisen's operation would not be uniformly practicable on the
infant. " I am," says he, " more and more satisfied that the



346 ABDOMINAL ARTIFICIAL ANUS.

anatomical dispositions favorable to the operation, are the
j'ule ; the reverse, tlie exception." {L* Examinatcxir Medical
de Paris. Annee 1843. Tome III.^ p. 235.)

The operative execution of Littre's process is certainly
much more simple and easy than Callisen's ; even M. Amus-
sat himself acknowledges that his pi'oceeding is greatly more
complicated than that of M. Littre. {Opus Citatum.)

It is true that in Littre's proceeding the peritonaeum is
opened, but this is by no means so grave an affair as is gene-
rally supposed, taking into consideration the success that
usually attends hernial operations. The operation even of
Callisen by no means insures us against the occurrence of
peritonseal inflammation.

The position, too, of the artificial anus, in my opinion, is
more convenient and more favorable in the groin than in the
loin. It being placed nearer the extremity of the great in-
testine, it is more analogous to the natural anus, and affords
a better opportunity to the excrementitious matters of being
more completely deprived of all their nutritive properties be-
fore reaching it.

* To repeat, I believe finally that, without absolutely reject-
ing either Callisen's or Amussat's method, it would generally
be better to have recourse to Littre's operation in the cases of
children.

M. Malgaigne is, however, of a contrary opinion. He
says: "The method of Callisen, avoiding the opening of the
peritonaeum, presents one real danger less than that of Littre,
and should be adopted at least as a general method. It has
been deemed as inconvenient to have the anus at the side,
and even a little behind ; and had we to consider nothing but
the sexual relations even, I should regard it as a great ad-
vantage not to have the artificial anus before." {Opus
Citatum^ p. 449.)



ABDOMINAL AKTIFICIAL ANUS. 347



SECTION XII.

THE PROCEEDING OF MARTIN.

M. Pakis, m his inaugural thesis, attributes to M. Dubois
the original idea of the method which M. Martin carried into
practice on the dead body, which he afterwards recommended,
and which now bears his name. Tiiis operation consists in
opening the sigmoid flexure of the colon in the left iliac
region, according to the process of M, Littre, being particular
in making the intestinal incision longitudinal and as short as
possible. Through this opening an exploring instrument — a
sound or a trocar — either with a proper curve or flexible,
should be conducted from above downwards, towards the
perinseum and natural situation of the anus, in order, if pos-
sible, to render it salient, and thus furnish the operator with
a certain mark by which to guide him in making his incisions
in the perinseum ; or, even to push the instrument entirely
through the parts which separate it from the perinseum, and
thus indicate the route of the bistoury. In either case the in-
cisions are to be made down to the cul-de-sac by the ordinary
method of forming an artificial anus in the perinseal region,
having the exploring instrument as the unerring guide to the
termination of the intestine. The wound in the abdomen is
to be healed in the usual manner.

This double operation of M. Martin is somewhat similar to
that which M. Littre proposed. It, however, exists only in
theory, as no surgeon, as far as my knowledge extends, has
yet had the courage and the rashness to execute it on the
living subject.

M. Yelpeau recommends a sonde-d-dard to be introduced,
if possible, through the pelvis, the arrow of which, pushed as
far as the outside of, and in the direction of the anus, would



348 ABDOMINAL ARTIFICIAL ANUS.

become the conductor of the bistoury during the remainder
of the operation. He considers it a much more suitable in-
strument than either the large flexible canula, or the enormous
trocar of M. Martin. {Wouveanx Elements de Medicine
Operatoire. Tome III.^p.^'&o. Paris, 1S32.)

M. Velpeau thinks that it would be improper to proscribe,
or to reject this operation indiscriminately, as cases might
occur in which it might be found valuable. {Oj)us Citatum.)



INDEX TO ILLUSTKATIYE CASES.



(A.)

Adair, William, Case LXXI., p. 171. Imperforate rectum above a

normal anus. Fourth Species.

Adriani, Petrus, Cases LYII. — LYIII., p. 156. Imperforation of the anus
and rectum. Third Species.

Ainsworth, S, F., Case CCIII., p. 274. Rectum terminated in the vagina.
Sixth Species.

Alix Mat, Franc, Case CXLXXXV., p. 266. Rectum terminated in the
vagina. Sixth Species.

Amatus, Lusitanus, Case CLXXXI., p. 265. Rectum terminated in the
vagina. Sixth Species.

Ammon, Friedrich August Von, Case XXVII., p. 86. Simple Imperfora-
tion of the anus. Second Species. Case L., p. 152. Imperforation
of the anus and rectum. Third Species.

Amussat, J. Z., Cases XLII XLV.— XLVI— CCLXXXVI., pp. 137—

145 — 341. Imperforation of the anus and rectum. Third Species.
Cases LXXXV.— CCLXXXIV— CCLXXXV., pp. 183, 334, 338. Im-
perforate rectum above a normal anus. Fourth Species. Case
CXLIV., p. 248. Rectum terminated in the bladder. Sixth
Species.

Andrews, S. L., Case XII., p. 73. Preternatural contraction of the intes-
tines. First Species.

Anonymous, Case CCLXXX, p. 323. Imperforation of the anus and
rectum. Third Species.
(349)



350 INDEX TO ILLUSTRATIVE CASES.

Arand, Case CLXXXVIII., p. 266. Rectum terminated in the vagina.

Sixth Species.
Arnott, James, Case CCLVIII., p. 288. Rectum entirely absent. Eighth

Species.
Aristotle, vide case, p. 226.
Ashton, T. J., Case VIII., p. 72. Abnormal narrowing of the anus. First

Species. Case XCIV., p. 194. Imperforation of the rectum above

a normal anus. Fourth Species.
Ayer, Cases XCVIII. — XCIX., p. 197. Imperforation of the rectum

above a aormal anus. Fourth Species.

(B)

Baillie, Matthew, Case CXLI., p. 247. Rectum terminated in the blad-
der. Sixth Species.

Barbout, Antonie Francois, Cases CCXII— CCXIII., p. 280. Vagina
terminated in the rectum. Seventh Species.

Baron, M., Case XLI., p. 136. Imperforation of the anus and rectum.
Third Species.

Bartholinus, Thomas, vide case, p. 59.

Barton, John Rhea, Case CXCVII., p. 268. Rectum terminated in the
vagina. Sixth Species.

Baudelocque, A. C, Cases LXXXVIII.— CCLXXXVII., pp. 187—342. Im-
perforate rectum above a normal anus. Fourth Species.

Baux, vide case, p. 59.

Beauregard, Case CCXXVII., p. 285., Rectum entirely wanting. Eighth
Species.

Bedford, Gunning S., Case XIV., p. 78. Occlusion of the anus by a mem-
brane. Second Species.

Bell, Benjamin, Cases XXX. — XXXI., p. 126. Imperforation of the anus
and rectum. Third Species.

Benivenius, Anthony, Case CLXXV., p. 264. Rectum terminated in the
vagina. Sixth Species.



INDEX TO ILLUSTRATIVE CASES. 351

Bertin, M., Case C XXXIII., p. 237. Rectum terminated 'in the bladder.

Sixth Species.
Billard, C. M., Case XVII., p. 81. Membranous occlusion of the anus.

Second Species. Case LXXX., p, 180. Imperforation of the rectum

above a pervious anus. Fourth Species.
Bils, Ludovicus de, Case CCLI., p. 292. The rectum and colon both

M'anting. Ninth Species.
Binninger, John Nicol, Case CCXXIL, p. 285. The rectum entirely

absent. Eighth Species.
Bird, P. Hinckes, Case XCIIL, p. 193. Imperforate rectum above a

normal anus. Fourth Species.
Bizet, Case CCLXXII., p. 317. Rectum entirely wanting. Eighth

Species. Case COLXXIII., p. 318. Imperforation of the anus and

rectum. Third Species.
Bodenhamer, William, Cases I — II., pp. 68, 69. Abnormal narrowing of

the anus. First Species. Case XIII., p. 78. Membranous occlusion

of the anus. Second Species.
Bonetus, Theophilus, Case CCXXIII., p. 285. Rectum entirely wanting.

Eighth Species.
Bonn, Andreas, Case CXC, p. 266. Rectum terminated in the vagina.

Sixth Species. Case CCXXXII., p. 286. Rectum entirely absent.

Eighth Species.
Bonnet, Aug., Case CLXII., p. 257. Rectum terminated in the urethi-a.

Sixth Species.
Bougon, Case CCLXXXII., p. 326. Imperforation of the anus and rectum.

Third Species.
Bravais, Case CLII., p. 256. Rectum terminated in the urethra. Sixth

Species.
Buckingham, C. E., Case CXLV., p. 250. Rectum terminated in the

bladder. Sixth Species.
Burns, Allen, Case CXIX., p. 217. Imperforate anus, with an abnormal

opening in the vulva. Fifth Species.



352 INDEX TO ILLUSTRATIVE CASES.

Bushe, George,*Case LXXXII., p. 182. Imperforate rectum above a normal
anus. Fourth Species. Case CXIII., p. 210. Rectmn terminated by-
two extremities in the perinfeum. Fifth Species. Case CCLIL, p.
293. Rectum and colon both absent. Ninth Species.

(C.)
Cabot, Samuel, Case XCVI., p. 195. Imperforation of the rectum above a

normal anus. Fourth Species.
Campbell, John P., Case XXXV., p. 127. Imperfor-.tion of the anus and

rectum. Third Species.
Camper, Pierre, Cases CCV.— CCVI.— CCVII.— CCVIIL— CCIX., p. 280.

Ureters terminated in the rectum. Seventh Species.
Carvenon, Case CCXLII., p. 287. Rectum entirely absent. Eighth

Species.
Caussade, Case CXXI., p. 218. Imperforate anus with an abnormal orifice

at the vulva. Fifth Species.
Cavenne, Case CXXXVIII., p. 243. Rectum terminated in the bladder.

Sixth Species.
Chamberlaine, William, Case LXXII., p. 173. Imperforate rectum above a

normal anus. Fourth Species.
Chonski, Casimir de. Case CXXXV., p. 239. Rectum terminated in the

bladder. Sixth Species.
Clark, A. Bryant, Case XCI., p. 191. Imperforate rectum above a normal

anus. Fourth Species.
Colson, A., vide case, p. 198.
Condie, D. Francis, Case LXXXVI., p. 186. Imperforate rectum above a

normal anus. Fourth Species.
Cooke, William, Case v., p. 71. Abnormal coarctation of the anus. First

Species. Cases CXCIV. — CXCV., p. 207. Rectum terminated in the

vagina. Sixth Species.
Copeland, Thomas, Case LXXIIL, p. 174. Imperforate rectum above a

normal anus. Fourth Species.



INDEX TO ir.H'STRATIVE CASES. 353

Courtial, Jean Joscpli, vide case, p. 198.

Ciuvc'illiicr, Joan, Case CV., p. 207. linperforate auus, with tlie rectum

terminating by an abnormal opening just below the meatus urinaiius.

Fifth Species. Case CXL., p. 247. Rectum terminated in the biail-

dcr. Sixth Species.

(D.)

Danzel, Case CCLXXVII., p. 319. Occlusion of the rectum above a nor-
mal anus. Fourth Species.

Davies, Redfern, Case LIT., p. 154. Imperforate anus and rectum. Third