[PAPER E.] 
Report of a Successful Operation for Artificial Anus, 
in a Case of Imperforate Rectum.—By Manning 
Simons, M. D., Charleston, S. C: 
P., a colored woman, was delivered on the 28th 
>f December. 1877, of a male child, above the average 
weight, and apparently perfectly formed and well de- 
el oped. 
There was nothing that attracted attention to the 
bid’s condition, or that caused solicitude as to its for- 
ation, until the second day after its birth, when it 
as discovered that there had been no passage from the 
>wels, whilst the urine had been voided naturally. 
I was requested to see the child on 29th December. 
Jn examination, the child appeared, externally, to be 
well formed; the anus was of normal size, in the 
proper situation, and of natural appearance; but it 
seemed to me that the tuberosities of the ischia were 
nore nearly approximated than usual, giving a pointed 
md conical shape to the buttocks. 
Not having a pocket-case with me, an examination 
vas made with the smooth, tapering quill end of a 
mall feather, and by this means it was discovered that 
,he anus formed & cul-de-sac, extending upwards about 
naif an inch, or a very little more. 
Provided with instruments, I made a more careful 
examination with a probe, which proved the correct- 
ness of the result obtained on the first occasion. With 
a little force the probe was made to pass through the 
obstruction at the further end of the cul-de-sac above 
mentioned, and it was hoped that the termination of the 
rectum might in this way be reached. 
After passing the probe to the extent of two and a 64 
Simons’ Operation 
half, or three, inches, a groove director was introduced 
alongside of it, the probe answering as a guide, and it 
was hoped that the groove in the director would serve 
the purpose of conducting a sufficient quantity of the 
contents of the gut to decide if it had been reached. 
This having failed to discover the gut, which, I 
thought, by being dilated by its contents, would the 
more easily be reached, a tenotomy knife was introduced 
along the groove director, and an incision made to facil- 
itate the manipulation necessary to the effort to reach 
the intestine, and to pull it down, in order to attach it 
to the margin of the incision. 
This also failed, although the groove director was 
passed up until the bones of the sacrum could be easily 
distinguished, even so high, as it appeared to me, as the 
promontory. 
d'he exploration was made quite to the limits of pru- 
dence, and I feared at the time that it might have 
reached even beyond the bounds of safety. 
The nature of the case was then explained to the 
father of the child, and the operation of colotomy was 
offered as the only possible means of prolonging its 
life; at the same time that the danger attending it was 
brought fully to his understanding. 
The operation was at first refused, on the ground, as 
the man said, that he had heard of children who had 
gone eight days without a passage from the bowels, and 
had then been relieved naturally. 
Under these circumstances I discontinued my visits, 
feeling satisfied that the only aid that could be ren- 
dered by art, was by the operative procedure just 
mentioned. 
On the evening of the eighth day after the birth of 
the child, its father called on me, with the request that 
I would perform the operation. 
On visiting the child the next day, I found it in a 
very wretched condition ; the abdomen was immensely 
distended with the intestinal accumulations of more for Artificial Anus. 
65 
than eight days; the respirations were very shallow, 
owing to the abdominal distention restricting the move- 
ments of the diaphragm, and causing it to encroach 
upon the contents of the thoracic cavity. In addition 
to this, castor oil had been administered from time to 
time, by the parents, since my last visit, and in this 
way the distress of the child had been very much aug- 
mented. 
Although the circumstances were much against the 
success of the operation, I determined to give the child 
the benefit of the attempt. 
After providing myself with the necessary instru- 
ments, I returned in the course of an hour, and with 
the assistance of my friends, Drs. H. W. DeSaussure, Jr., 
and T, Grange Simons, performed the following opera- 
tion : 
The child being put under the influence of chloroform, 
an incision of an inch was made longitudinally on the 
left side about an eighth of an inch above, and about 
the same distance behind the anterior superior spinous 
process of the ilium, its centre corresponding to the 
arbitrary line of separation between the lumbar and 
iliac regions. The skin, subcutaneous tissue, aponeu- 
rosis and muscles of this region were in turn cut 
through on the groove director until the peritoneum 
was seen uninjured in the bottom of the wound. This 
was cut through to the extent of the wound in the skin, 
and an exploration was made to find the sigmoid flexure 
of the large intestine. 
After some little trouble, the gut was seized and 
brought out of the wound, and I believe that it was the 
portion of intestine sought after. 
This having been done, it was retained in place by a 
large needle passed through the knuckle that was drawn 
out, the circumference was stitched to the edges of the 
wound with five points of an interrupted suture, silk 
being used for the purpose; and finally a circular piece 66 
Simons' Operation 
was cut from the gut with the scissors, corresponding 
to the centre of the imprisoned knuckle. 
A profuse discharge of the contents of the intestine 
took place from the wound, but gradually enough 
to avoid the injurious effects of sudden diminution of 
the tension of the abdominal walls. 
No effort was made to facilitate the flow by pressure, 
but it was left to be accomplished by the elasticity of 
the abdominal walls, the child being placed on the left 
side to avoid dragging on the wound. 
The change in the child after this had been accom- 
plished, was very remarkable and gratifying. 
The amount of meconium, together with the secretions 
of the intestines and faecal matter, accumulated during 
the nine days, that escaped, was very large, and whilst 
we were unable to measure it, I am within all bounds 
of probability when I place it at a pint. 
At my visit a few hours after the operation, the 
wound was cleaned and dressed with carbolized oil, the 
surrounding integument being protected from irritation 
by the discharges, by means of folds of linen with a 
circular piece cut from the centre, soaked in the same 
mixture. 
The child took the breast immediately, with avidity, 
and its distress and cries gave place to quiet and appar- 
ent relief from suffering. 
The wound healed in about ten days, and gradually 
contracted from the size of a silver quarter of a dollar, 
to that of a half dime. 
During the treatment of the wound, it was necessary 
to apply compresses to restrain the tendency to eversion 
of the mucous membrane of the gut, and to retain or 
receive the faecal discharges, and prevent their contin- 
uous flow. 
Since that time the child has had its operations reg- 
ularly, through the opening, and the mother says that 
it gives but very little trouble and inconvenience to 
attend to it. for Artificial Anus. 
67 
It is true, that there has been a tendency to contin- 
ued contraction and closure of the opening, and at one 
time, through costiveness of the child for two days, it 
closed so far as to require to be dilated with carbolized 
sponge tents. 
The opening is now sufficiently free to allow the pas- 
sage of the faeces with comfort to the child. I propose 
to place an ivory tube, or some other mechanical ar- 
rangement of that kind, to keep it open until the 
thinning changes in the cicatrix have reached such 
degree as to obviate the danger of the complete closure. 
At this date, more than three months since the 
operation, the child is well, to all appearances in good 
health, and is fat and well nourished. Above all other 
considerations, the parents are satisfied with the result. 
At some time I desire to pass a gum elastic bougie 
through the opening, downwards, and if it be found to 
reach a point to justify the attempt, to endeavor to 
bring the gut down to its natural outlet, there stitch it, 
and then close the artificial opening. 
This operation was prompted by the results of a post 
mortem examination performed on a child that died 
some years ago in the practice of one of my profes- 
sional friends, under circumstances somewhat similar to 
those that I believe to exist in the case reported. 
The examination discovered that the gut, from the 
sigmoid flexure to the anus, was little more than a 
fibrous cord, the canal of which was scarcely large 
enough to admit a probe. 
I am induced to report this case, as, after diligent 
inquiry, I have not been able to learn of a successful 
operation of this kind, under similar circumstances, 
previously done in Charleston, although other cases are 
recorded in the standard works on surgery, and the 
operation is one recognized by surgical authorities as 
justifiable. 
Charleston, S. C., March, 1878.