distant day, and in the wild woods of Kentucky, a surgeon
was found who possessed both the ability and the courage to
execute successfully such a difficult and dangerous operation.
Tluxt surgeon was Dr. John P. Campbell, of Flemingsburg,
Kentucky. Tliis case of Dr. Campbell will be found reported
in full. [ Vide Case XXXV.]



SECTIOI^^ IV.

THE TREATMENT.

The treatment which holds out the greatest prospect of suc-
cess in these cases, is that which contemplates the establish-
ment of an artificial anus in the perinseum — Proctoplasty.
By this operation the cul-de-sac of the rectum is sought for,
through a passage made for this purpose by dissecting through
the tissues which separate it from the cutaneous surface ; and
when found of breaking up its adhesions, if any, seizing it
with forceps, bringing it down, opening it, emptying its con-
tents, and uniting its cut edges to those of the perinatal
wound in the natural situation of the anus, according to the
method of M. Amussat. If the blind sac of the rectum, how-
ever, cannot be brought down without undue force, in conse-
quence of the organ being too short, or its adhesions being
too numerous and strong, it must be opened where it is, by a
cnicial incision, and the passage which has been made to it,
must be kept open and supply and perform the functions of
that portion of the rectum which is wanting, according to the
ordinary method.

1. When should the Operationhe Undertaken? Mr. A. Cope-
land Hutchison advises in obscure cases of this character —
that is, in cases in which it is very difficult to determine from



Till'; THIRD SPKCIKS OK MALFORMATION. 97

present indications where the blind sue uf the rectum is, or
whether this organ exists at all or not — to postpone the opera-
tion, if possible, for twenty-four, or sixty hours after hirth, as
no inconvenience will generally arise from the delay ; the dis-
tention of the rectum by the meconium and fjiecal matter will
be in the mean time, a most invaluable guide to the surgeon
in making his incisions, and in searching for the cul-de-sac of
the rectum. {Op, clt. p. 257.)

Professor Dicffenbach recommends the operation to be per
formed on the second day after the birth of the child, for the
same reasons. {Die Operative Cldrurgie. Band 1. S. 672.
Leipzig: 1845.)

Although the delay advised by these authors is of much
importance in facilitating the operation, and the search for the
rectum, yet it is very liable to be abused, by being carried
too far, for it is by no means as void of danger as they
imagine. The primary object in such cases is to empty as
soon as possible the distended intestines — lest they become
inflamed, paralysed or lacerated, and thus jeopard the life of
the child. When the operation has been delayed too long,
the difficulty after its performance often is, that the bowels
will not act at all, having completely lost their peristaltic ac-
tion by having remained too long loaded and stretched with
meconium and gas, and the child generally dies in a day or
tw^o. I am of the opinion that the operation should be per-
formed as soon as the child manifests its sufferings, by its
cries or moans, and the agitation of its limbs, or its general
restlessness ; or at least it ought not to be postponed longer
than when free vomiting has taken place, because then the
distention of the rectum by the meconium and the gas, which
is so important in the search for the blind end of that organ,
is sufficient for the purpose.

The practice of administering purgatives for the purpose of
forcing down the rectum, preparatory to the operation, cannot

be too strongly reprobated.

7



98



THE THIKD SPECIES OF MALFOKMAIIOJT.



2. The Infant Pelvis. Some idea may be formed of the
average dimensions of the infant pelvis in the normal state, by
the' following admeasurements I made of it in two new-born,
well-developed male infants, at full time :

From one tuberosity of the ischium to the other —
one inch and one line.

From the os coccygis to the symphysis pubis — one
inch and three lines.

From the os coccygis to the jDromontory of the
sacrum — one inch and two lines.

From one tuberosity of the ischium to the other —
one inch.

From the os coccygis to the symjDhysis pubis — one
inch and one and a half lines.

From the os coccygis to the promontory of the
sacrum — one inch and one line.



In the instances in which the rectum is either partially or
wholly absent, the pelvis is generally of smaller capacity than
when normal, having also undergone to some extent an arrest
of development, and being deformed to a greater or less
degree. The tuberosities of the ischium approach nearer each
other, in consecpience of the narrowness of the pelvic cavity
common in these cases.

Deej) incisions into the infant pelvis, are, as a matter of
course, always attended with more or less difficulty and dan-
ger. This of necessity must be so in such cases, on account
of the small size of tlie pelvis as a theatre for such an opera-
tion, especially when we take into consideration the presence
of the important viscera which still further lessens its diame-
ters, and the close proximity of the iliac and hypogastric
arteries and veins which endanger the dissection in the search
for the rectum.



THE THIUD SPECIES OF MALFORMATION. 99

3. Introchtdioih of the Sound. Soinc surgeons, previous to
performing the o^Jcration, recommend the introduction of a
small silver sound or catheter into the bladder of the male,
and a large metallic sound slightly curved, into the vagina of
the female, to determine the direction and the position
of tliese organs, in order to guard against wounding them.
TJie first proceeding is difKcult and sometimes imj^ossible to
accomplish, and neither of them, in my opinion, absolutely
necessary, provided the oi^cration is cautiously conducted. 1
admit that the sound might considerably facilitate the searcli
for the rectum along the anterior wall of the pelvis, whicli
sometimes becomes necessary when the organ occupies an ab-
normal position.

4. The Form of Incision. In the operation for perineal arti-
ficial anus, surgeons have severally recommended the longitu-
dinal.^ the transverse, the crucial, and the T incision.

The longitudinal incision should, in my opinion, have the
preference, because by it a larger wound may be obtained
without danger, which sometimes becomes necessary in' mak-
ing a thorough and extensive search for the rectal extremitv.
This incision, if necessary, can be extended from the posterior
margin of the scrotum, or from the posterior commissure of
the labia majora, to the extremity of the coccyx. Another
very important consideration is that by it, the cicatricial tis-
sue which results from wounds in the vicinity of the anus is
much less extensive than in any of the other incisions, and
consequently greatly diminishes the risk of contraction after
the operation.

The transverse incision has no advantage whatever over the
longitudinal, and should it be carried to the necessary extent,
it might approach too near to the tuberosity of the ischium,
and run the risk of wounding the internal pudic artery, and
seriously injure also the sphincter ani muscles, as the pelvic
cavity in these cases, is generally narrower, and the tuberosi-
ties of the ischium much nearer each other than natural.



100 THE THIED SPECIES OF MALFORMATION.

Tlie crucial and the T incision are botli objectionable
on account of favoring the contraction of the anus by the
formation of a greater extent of cicatricial tissue.

Great care should be taken, that whatever incision is
adopted, that it be healed by the first intention, as sup-
puration always results in an increased extent of cicatricial
tissue, and thus favors a greater contraction of the newly-
formed anus.

5. The Sphinctores Ani Muscles. M. Eoux de Brignoles
advises that' the perinseal artificial anus should always be
established exactly in the mesial line of the sphincter ani mus-
cles, and that in conducting the dissection, the fibres of these
muscles should be most carefully separated, and their internal
margin loosed, so as to preserve their freedom of action, and
secure, what is of the greatest importance, their utility in the
act of defecation. {Archives Generales de Medicine. 2d Ser.
tome V. p. 475.)

Tliis advice of M. Roux is highly important and judicious,
and should, as far as practicable, be always followed, in all
the cases in which those muscles do really exist. The task,
however, of distinguishing and separating these muscular
fibres, is by no means so easy to accomplish, as one would
suppose from reading the remarks of M. Koux.

M. Yelpeau says that this method of Eoux has no superior-
ity over the ordinary one ; but this is a loose assertion of his,
and does not merit much attention.

Upon the subject of the invariable presence or absence of
the sphinctores ani muscles in these particular cases of con-
genital malformation, there is a singular diversity of opinion
existing among authors.

M. Eoux de Brignoles maintains that these muscles which
receive their nutrient arteries from the ischiatic, are never
wanting, that they exist independently of the rectum — ^lience
his advice so to conduct the dissection, as to preserve them in



TIIK Tllllil) SPECIES OF MALFORMATION. 101

connection with the iirtiticiul unus, luul thus euul)le the patient
to have control over the retention of the fajces. {Memoire de
VAcacUmie Iloyale de Medicine, tome 1 V. />. 183. Paris :
1835.)

M. Bhindin, on tlie contrary however, asserts that when
the anns is completely absent, he has ascertained that tlie
sphincter muscle is invariably absent also ; this being always
the case whether the skin does, or does not present an indica-
tion of the natural situation of the anns — hence he advises that
the artificial anus should be formed in the abdomen, because
an artificial anus in the perinseuin, destitute of a sphincter
muscle, would occasion incontinence of fseces to a greater ex-
tent, and be attended witli more inconvenience and discom-
fort, than one established in the abdomen. {Dictionnaire de
Medicine et de Chirurgie Pratiques. Paris : 1832.)

Tiingel, a late and very able German writer on abdominal
artificial anus, considers the absence of the sphinctores and
levatores ani muscles as a rule in congenital imperforation of
the anus and the rectum ; and uses this as a strong argument
against a perinoeal artificial anns, and in favor of an abdomi-
nal one. ( Uher KunstlicJie Aflerbildung. S. 203. Kid :
1853.)

M. Yelpeau is also of opinion that the sphincter muscle in
all such cases is always absent. {OpeTati've Surgery. Vol.
HI. p. 1090. Motfs English Versioii. New York : 1847.)

M. Goyraud mentions it as an undeviating rule that the
superior portion of the sphincter ani is always absent when
the inferior portion of the rectum is deficient ; but that the
inferior portion of this muscle, not only always exists, but is
preternaturally developed in these cases — ^hence he comes to
the same practical conclusions that M. Koux does. {Journal
Ileldornadaire des Progress des Sciences et Institutions Medi-
cales. tome III. p. 245. Paris : 1834.)

M. Petit observes that in all such cases of imperforate anus,
the sphincter ani muscle indeed exists, but it is so contracted,



102 THE THIKD SPECIES OF MALFOEMATION.

■wasted, and confounded with the surrounding parts, that it is
difficult, or rather impossible for it to resume its function,
with whatever care the operation may be performed. (Re-
marques sur les differens vices de conformations que les
enfans apportent en naissant. Mcmoire de V AcademieRoyale
de Cliirurgie. tome II. Paris: 1781.)

Mr. A. Copeland Hutchison mentions a case in which the
sphinctores ani were wanting, but the levatores ani were per-
fect and strong. {Op. cit. p. 271.)

The only just and practical conclusions to be drawn from
these conflicting opinions, are that, in some of these cases, the
sphinctores ani muscles exist, whilst in others they do not ;
but whether they are present or absent, the artificial anus
should always, if possible, be established in the natural situa-
tion in the perinseum, for should these muscles be absent, the
infirmity is greatly less, even in this depending situation, than
Blandin and Tiingel declare. Should these muscles, however,
be present, the operation should be so especially conducted,
as by all means to preserve their functions to the newly-
formed anus as recommended by M. Eoux.

I have elsewhere presented in full a highly interesting case
successfully operated on by M. Roux. This case will com-
pletely illustrate his peculiar and admirable method of ope-
rating. \_Vide Case CLXYIIi\

6. Abnormal Position of the Rectum. If the cul-de-sac of
the rectum should not be found through the incision made \(^
the full extent in the normal direction and position of this in-
testine, it is still no positive evidence that it does not exist, for
as I have elsewhere already observed, that besides being
abnormal, the rectum may sometimes occupy an abnormal
position in the pelvic cavity — hence the important necessity
of varying more or less the search for it before abandoning
the case ; for continuing the search in the same direction
would not only result in a failure to find it, but also,



THK THIRD SPECIKS OF MALFOUMA.TION. Hl3

in tlie loss of the patient. Instances have occuiTcd in ■\vliicli
the surgeon, after searching for the rectum in tlie natural
direction and position of tliis organ, failed to find it there,
and abandoned the case ; afterwards at the auto})sy he dis-
covered it in another jjosition in the pelvic cavity, from
which he might easily have drawn it into the incision he had
made in the perinaeum, without any difficulty or danger,
if during the operation this abnormal position of the rec-
tum had been known or thought of. [ Vide Plate XI V. ]

A number of cases will be found reported in this work, in
which the discovery was made at the autopsy, that if the
search for the end of the rectum had been varied even in a
slight degree from the natural direction of this intestine, it
would have been found, and the patient, in all probability,
saved. Or if the point of the bistoury or trocar, in the opera-
tion of puncture, had been slightly changed in its direction,
the end of the rectum would have been penetrated.

It is scarcely necessary to observe that during the oj^eration,
the blood, from time to time, should be well sponged out of
the wound, the haemorrhage, however, is generally but slight
if proper care is taken ; and that the dissection should be con-
ducted with as much dispatch as would be compatible with
the safety of the child. Infants, however, are found, as I have
elsewhere observed, to bear a great deal without any bad re-
sults, provided no imj)ortant vessel or structure is injured.

Y. The Method of Operating. When the operation is deter-
mined on, the little patient should be placed on its back on a
table, or on the lap of an assistant, as in the lateral operation
for lithotomy, its legs should be flexed and held apart by two
assistants, and the nates completely exposed and inclined for-
ward. If the catheter or the sound is decided on being used,
it must now be introduced and held by an assistant. The
surgeon placing himself in front, should with the thumb and
index finger of the left hand, stretch the integuments of the



104 THE THIRD SPECIES OF MALFORMATION.

perineum, and with the round-bellied scalpel in his right,
make a longitudinal incision on the median line through the
skin, commencing with the posterior margin of the scrotum,
or at the posterior j^oint of the commissure of the labia majora,
and extending to the termination of the coccyx, unless he
should think that a shorter incision would give him ample
room. The lips of the wound now being drawn apart, the
operator should dee23en the incision in the natural direction of
the rectum, by cautiously incising little by little the different
layers of the perinseum in succession as they present them-
selves, exploring well with the index finger of the left hand
before each stroke of the scalpel, to ascertain the position of
the bladder or the vagina, so as* not to wound it, and also to
recognize by the projection and the fluctuation, the blind sac
of the rectum. Tlie finger is better than either the probe or
the sound for this purpose, and it also serves to guide the
knife, being the best, if not only director, that should be used
in such cases. Extreme care should also be taken to avoid
the great pelvic vessels at the sides, and the sacrum behind,
lest as it regards the latter, the knife should get behind the
rectum, of which it is in search, and miss it altogether, or
wound it some distance above its cul-de-sac. After the opera-
tor has penetrated as far as the pelvic aponeurosis without
meeting the end of the rectum, he should then divide this tis-
sue also, and search for it in the pelvic cavity. The edges of
the wound may be kept asunder by crotchet hooks, so that the
cavity may be explored both by touch and by sight. The
finger can be introduced from two, to two and a half inches in
depth, towards the promontory of the sacrum, so that the end
of the rectum may be reached, if the organ is not enfirely
wanting, or if it is not interrupted in its superior portion and
adhering to the superior wall of the bladder. If in searching
towards the promontory, of the sacrum, the rectum cannot be
found, the operator should not fail to explore the anterior wall
of the pelvis. To this end, the perinatal wound, if necessarv,



TIIH TIIIKD SPECIES OF MALFOUMATION. 105

may be eiihir^xMl, in order to examine whether the tciiiiinul
end of til e rectnni may not be adhering to the bladder, to llie
vagina, or to the uterns.

Should the operator at any time during the search detect
with his finger a Huctuating tumor, more or less elastic, and
of a dark-br(nvn color, which he can ascertain if necessary by
the speculum ani, he may be assured that it is the rectum ;
and when thoroughly convinced of this, he should seize the
projecting end of it with the bull-dog forceps, or double
tenaculum, and endeavor to draw it gently downwards into
the perinteal wound ; no very considerable force, however,
must be applied, and if it does not yield, it wdll be owing to
adhesions which, if not too numerous and too strong, should
be carefully loosened by the fingers, if possible, using the
knife or scissors only when they are very firm, and rec^uire
great care in their division. It is important and always very
desirable that the projecting and terminal end of the rectum
should be brought down into the perin^eal wound, but if this
is impossible, in consequence of its locality and adhesions, the
operator should not hesitate to seize any easy movable portion
of the rectum which may be near, and bring it down into the
external w^^und, to serve in the formation of the anus. The
terminal end of the rectum being left in its position, and being
cut off from the circulation of the f^cal matter, will gradually
contract, and ultimately become obliterated.

As soon as the end of the rectum is brought down suffi-
ciently low, a needle armed with a double ligature should be
passed through it, by means of which, and the forceps or
hooks, it should be drawn down to the level of the integu-
ments. The cul-de-sac should now be opened by a longitudi-
nal incision from front to rear, its contents conq^letely emp-
tied, the wound thoroughly cleansed, and its cut edges
attached by six points of suture to the integument of the
corresponding edges of the perinssal wound, in the exact and
proper situation of the anus, care being taken that the mucous



106 THE THIKD SPECIES OF ilALFOEMATION.

membrane should overlap the external skin, in order to pre-
vent the stercoral matters from escaping into the cellular tis-
sue between them. The remainder of the perinseal wound,
both in front and behind the newly-formed anus, should then
be closed by suture. The child's legs should be bound
together by a bandage, the wound dressed with a compress
dipped in a cooling lotion, and frequently renewed, over
which the usual napkin should be applied to receive the dis-
charges, and the child placed by the side of its mother in bed
and kept warm.

After the operation, it is indispensable to success that
extreme care should be taken of the child. If the mother
cannot nurse it, choice must be made of a good wet-nurse.
Full baths and frequent emollient injections should be en-
joined, and an equable temperature should be maintained in
the apartment. The artificial opening, which always tends to
contract, should also be closely watched, and sufficiently
dilated, from time to time by the finger or elastic bougies.

8. Tlie Ordinary Method of Operating. By this method the
end of the rectum is sought for, much in the same manner as
by the preceding, but instead of being brought down when
found, it is opened and suffered to remain in the exact posi-
tion in w^hich it was discovered, and the passage which has
been made up to it through the perinseum, must be kept open
and supply that portion of the rectum which is absent. The
difficulty and the success of this proceeding depend in a great
measure upon the higher or the lower position of the blind sac
of the rectum, for in proportion to the distance of the cul-de-
sac from the skin of the perineum, will be the danger of faecal
infiltration, and the difficulty of maintaining a sufficiently free
and permanent opening after the operation.

If the surgeon, after having found the cul-de-sac of the rec-
tum, should find it impossible to bring it down into the
perinseal wound as already advised, in consequence of its



TIIK THIRD SPECIES OF aiALFORMATION. 107

peculiar position, its numerous and strong adiiesions, or its
shortness, lie slioukl have recourse to the ordinary method.

As soon as the rectum is discovered by the surgeon, its pro-
jecting point should be well exposed, and the sharp-pointed
bistoury, or a trocar, thrust into it, and the contents of the
bowel evacuated, especial care being taken to make the punc-
ture directly in the end, if possible, and not in the side of the
rectum. The puncture thus made should then be enlarged
crucially, with the probe-pointed bistoury guided by the lin-
ger, taking care to make it sufficiently free and permanent at
first, in order to avoid a second effort, as the tendency to con-
traction is always much greater in subsequent operations.
When the blind end of the rectum is thick, hard or knotty,
resembling cicatricial tissue, as is sometimes the case, the
whole of it, or as much of it as possible, should be removed,
provided it can be done safely. After the opening has been
sufficiently enlarged and the rectum completely emptied and
washed out by warm mucilaginous enemata, that part of the
perinseal wound, in front and rear of the portion designed for
the anus, should now be closed by suture, taking care, how-
ever, to leave a sufficiently ample opening, and in the proper
place, for the new anus. A silver canula much in the form
of a nipple, or similar to the tracheotomy tube, with a very
slight curvature adapted to the direction of the rectum, the
length of the newly-made passage, and about three-eighths of
an inch in diameter, should now be introduced and secured in
its situation by two strips of tape passed through rings at the
external end of the canula, and tied in front and behind to a
circular bandage fastened round the body. The usual napkin
and a compress dipped in a cooling lotion, should now be
applied, and the child put to bed.

It would be advisable to have several of these tubes of dif-
ferent sizes on hand, in order that while one was out and
being cleansed, the other might be in. They should be con-
structed with their superior extremity bevelled or rounded



108 THE TUIKD SPECIES OF MALFOKMATION.

off, to facilitate tlieir introduction, and their inferior extremity
should be furnished with a shoulder, anteriorly and poste-
riorly, with a ring in each to put the tape through, for the
purpose of confining them in their situation. [ Vide Plate

11, Figure 12.] The silver tubes are the best ; elastic
ones, however, if lined with flexible metal, are very good
and answer very well.

Tlie canula should be frequently withdrawn and cleansed
and the newly-made passage washed out, and should there
exist any undue irritation, the parts should be often well
bathed or fomented to allay it. The tube shields the raw and