A CASE 
OF 
LEFT INGUINAL COLOTOMY FOR 
IMPERFORATE RECTUM; 
RECOVERY. 
BY 
W. H. HAYNES, M. D., 
OF NEW YORK. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
July, 1884. Extracted from the 
American Journal of the Medical Sciences for July, 1884. 
A CASE 
OF 
LEFT INGUINAL C0L0T0MY FOR IMPERFORATE RECTUM; RECOVERY. 
By W. H. HAYNES, M.D.* 
Of New York. 
On the night of September 5, 1882, I was summoned to see the fourth 
child of Mrs. A., who had been born on the afternoon of the 3d, in con- 
sequence of its not having had a stool since birth. Upon arriving at the 
house, I found a male child apparently not suffering, and without any 
external marks of abnormality. Domestic cathartics had been adminis- 
tered without success, and the midwife, on attempting to give a warm 
soap-water enema, found that the nozzle of the syringe could be intro- 
duced within the anus only for a short distance, and the fluid injected 
immediately returned without causing a fecal evacuation. Proceeding to 
examine, I found 1 could only introduce the tip of my little finger within 
a naturally formed anus for about half an inch, into a cul-de-sac to which 
there was but one opening—that of entrance. Nothing distinguishable 
could be made out beyond the limiting membrane in the abdominal cavity. 
In other respects the child was perfectly natural; nursed, did not vomit, 
slept, and urinated. The condition of affairs was explained to the parents, 
who were warned against using any evacuant measures, but, if necessary, 
to administer small doses of paregoric p. r. n. 
The next morning the child was seen by Prof. Van Buren, who gave 
the opinion that the best procedure in this case was left inguinal colotomy. 
That night the child was restless, cried, and vomited a little curdled milk. 
On the 7th of September, just before noon, in my office, assisted by 
Drs. Hathaway, Church, and Busehe, the child being four days old, was 
chloroformed so that a thorough examination could be made previous to 
operating. It had urinated just before coming to my house. The abdo- 
men was noticed to be more distended and tympanitic on the left side, 
but no tumour could be detected. The anal cul-de-sac was examined by 
finger, probe, and by sight, through an ear speculum, without finding any 
internal orifice. It was thought by some of the gentlemen present, that 
a doughy mass was distinguishable upwards and to the left side ot the 
pelvic cavity. A trocar was carefully thrust in this direction, through 
dense unyielding tissue, as far as was thought justifiable, but nothing 
came through the canula. I then proceeded to open the colon in the left 2 
groin. An incision one-and-a-half inch long was made just above and 
parallel to Poupart’s ligament. The different layers of adipose and 
muscular tissue and peritoneum were laid open on a director. One vessel 
required a ligature ; I then introduced my finger into the abdominal 
cavity, traced up the colon (which was empty) from below, and, with a 
pair of thumb forceps, drew out the part nearest the wound. It was held 
fast by two ligatures, drawn out of the wound, an opening made giving 
exit to some gas and meconium, and the edges of the wound in the intes- 
tine united by a number of sutures to the wound, in the abdominal wall. 
The parts were cleansed with a warm, weak solution of carbolic acid and 
water, and the same was used throughout the operation for hands, instru- 
ments, and sponging. A piece of lint spread with vaseline was placed over 
the wound, and a diaper over that completed the dressing. The time 
occupied in the examination and operation was a little over an hour. 
When I saw the child at its home in the evening, it bad considerable 
fever, rapid pulse, and would not nurse. Two large stools had escaped 
from the upper opening of the gut in the wound. 
8th, 10 A. M. Temperature 99°; pulse 110. Has had another stool 
since last visit; nursed a little; slept though very restless. Abdomen 
swollen, particularly the parts around the wound, which is also very much 
congested and tender. Has passed no urine. Ordered a mixture of 
aconite, paregoric, and nitre. In the evening there was less fever, pulse 
120; slept all day; had two stools ; urinated, and nursed without vomiting. 
9 th, A. M. No jaundice; has slight fever ; is bright and lively; slept well; 
nursed without vomiting ; had stools and urinated. Abdomen softer, parts 
about wound less swollen and congested. Applied a salve of iodoform, 
bals. Peru, and vaseline to the wound, first cleansing it, after each stool. 
P. M. No fever ; pulse 110 ; nursing, sleeping, etc., the same as any baby 
in health. 
loth. Improvement continues. The ligature from off the vessel came 
away yesterday, and some of the sutures have been removed. 
26th. The baby has been suffering from indigestion, giving rise to 
diarrhoea, crying, and straining, and causing prolapse of the gut at the 
upper end of the wound, and oozing of some blood. The sutures have all 
been removed, and the wound is entirely united. 
30th. Under chloroform, and after urination, a sound was passed into 
the lower opening of the gut in the wound downwards and backwards, till 
its tip could be readily felt by the finger within the anus, seemingly only 
separated by a thin partition of tissue. A crucial incision was made, allow- 
ing the end of the sound to emerge at the anus, and the opening dilated 
with a small, soft urethral bougie and open forceps. A coil of lamp wick 
■was passed through the natural and artificial anal openings to serve as a 
guide for future measures. 
October 12. A bougie, No. 24 F., can be passed through the rectum 
and into the abdominal opening. Feces pass at both natural and artificial 
openings. 
31 st. The child’s general condition is very good. A metal pad and 
rubber bandage closes the artificial opening, restraining the passage of 
feces and prolapse of the intestine, so that all stools occur at the natural 
opening, which also allows of a free passage through the rectum of a large 
sized bougie. Dilatation was continued till I could pass the first phalanx 
of my index finger through the new rectal canal. During this time the 
abdominal opening had contracted over one half its original extent. I 3 
attempted to close it by paring the edges and uniting them with silver 
wire, but the sutures tore out, and no union was obtained. 
On December 10, 1882, the case was dismissed. All stools passed by 
the natural opening. The abdominal fistule was very small and covered 
by a metal pad and bandage. The mother was instructed to pass her 
finger through the rectum daily. 
August 2, 1883. The child is now eleven months old. Its skeleton 
has grown but its body is emaciated. Has the four first incisor teeth, and 
getting the others. The parents have neglected to keep up dilatation of 
the rectum, so that now there is only a fistulous passage; all stools pass- 
ing through the abdominal opening. This was the last time I saw the 
child. I afterwards heard that some time after I saw it the child was 
taken with convulsions ascribed to teething and died. 
“ Embryologists tell us that, during the early development of the foetus in the 
process of budding from the hypoblast, by means of which the various abdominal 
organs are envoived, the bud that branches towards the anus to form the rectum 
is sometimes arrested in its progress, so that it fails to meet the bud from the 
epiblast which forms the anus, and the result is an interval in which the rectum 
is wanting, either a mere partition, or bulkhead or a distinct space intervening, 
varying from half an inch in length, usually occupied by a fibrous cord.”1 
The above description succinctly states the nature of the deformity in 
that variety of imperforate rectum where the anal opening is properly 
formed, and in which class our case would be placed. 
As showing the effect of hereditary influence in these cases which is 
similar to that seen in all the other congenital deformities, I cite the fol- 
lowing remarkable instance reported by Dr. Githens to the Obstetrical 
Society of Philadelphia where the same parents had two children so 
deformed, and the mother’s maternal aunt had had five out of seven chil- 
dren deformed in like manner. All these seven children perished, two 
after operations for their relief. "W hat a stimulus this striking record of 
mortality should be, causing us to strenuously increase our efforts to seek 
out the best and safest methods of achieving success in these unfortunate 
cases. 
The symptoms pi’esented in our case wrere simply those of the non-per- 
formance of an important function, which is the only evidence ever 
presented in the early stages of this malady, and should cause us to make 
diligent examination for this deformity, lliis, I am sorry to say, is often 
neglected till grave constitutional symptoms present themselves, which 
make an unfavourable prognosis a foregone conclusion. Ibis latter train 
of symptoms often sets in early (after the first few days) on account of the 
tender nature of these young children, whereas an early operation is halt 
the cure. The diagnosis of this condition is so easy that it can be made 
by non-professional persons, as happened in this case, where the midwife, 
whose intelligence I must say is above the general average of midwives, 
1 Van Buren on the Rectum, revised edition, 1881, page 367. 
2 Medical News, vol. xli. page 552. 4 
had correctly made out the condition. The prognosis is undoubtedly fatal 
unless relieved by art or nature. Nature sometimes relieves these patients 
in one of two ways: either by ejecting the excrement matter through 
vomiting, or by the formation of a fistulous opening before birth, generally 
in connection with one or the other of the adjacent canals. Noteworthy 
examples of these two modes of nature’s cures are the following: “ Mr. 
Cripps reported to the Pathological Society of London1 the case of a child 
thirty days old with imperforate rectum, who was apparently quite well, food 
being well taken and fecal matter vomited three or four times a day;” and 
Curling mentions a case alive after twelve weeks of such existence.2 Dr. 
Fenwick of Montreal, at the last meeting of the Canada Medical Asso- 
ciation,3 narrated the case of a man who all his life had defecated through 
a fistulous opening which was situated at the root of the penis, and which 
communicated with the rectal tube. Other cases of this latter nature could 
be given, particularly as occurring in female children. 
The different plans which art has devised for the treatment of the various 
forms of rectal deformity found at birth may be classified under three 
general heads:— 
1. Perineal puncture and dissection, including Yerneuil’s operation of 
extirpation of the coccyx. 
2. Lumbar colotomy. 
3. Inguinal colotomy. 
Their different uses are so well discussed in the later works on surgery, 
and particularly in the latest monographs on this special branch, that I 
will not stop to discuss this part of the subject, simply stating that the 
treatment pursued in this case will be found to be in accordance with the 
rules laid down by these authorities, and with the eminent counsel we had 
to guide us before proceeding to operate, and that the result will add its 
testimony to the weight of opinion in favour of the operation performed. I 
found it to be simple, to be easy of performance, and to give immediate 
access to all the parts concerned. 
The result is the more surprising when the bad social and hygienic sur- 
roundings of the child are considered. Its parents were of the lowest 
order of society, very poor, living in such a wretched habitation as to be 
unfit for the performance of the operation, and they were constantly hoping 
death would release them of their burdensome charge. Only the com- 
monest antiseptic precautions were observed without the spray. One cir- 
cumstance that materially aided in the obtaining of so favourable a result 
was the early performance of the operation, before the usual evidences of 
debility from distress and suffering had shown themselves. This record 
adds another successful case to the short list given in the American 
1 Lancet, May 15, 1880. 
2 Curling on the Rectum, edition of 1876, page 221. 
3 Medical News, vol. xliii. page 303. 5 
edition of Holmes’s System of Surgery, 1882, vol. iii. p. 851, where is 
reported the only other successful case since 1859 by Dr. Pooley, who 
operated for imperforate rectum with a vaginal fecal fistula. 
One procedure in the treatment of this case I do not find discussed any- 
where in detail, namely, that of opening up a passage at the natural site 
for the canal, either simultaneously or subsequent to the operation open- 
ing into the gut. Where the two operations are to be performed at the 
same time, the first or inguinal opening is in the nature of an exploratory 
operation, and should be made small so as to admit of immediate closure, 
and return to the peritoneal cavity after a passage is secured at the 
natural site. If this latter is not secured, then the opening could be 
enlai'ged and made to serve the purpose of an artificial anus in the ab- 
dominal wall. The advisability of this procedure, however, is at present 
very doubtful, which only the experience of a number of operators can 
determine. Of the few cases so far undertaken in this manner that I 
can find recorded, my own case is the only one that survived the second 
operation. The other cases so treated were two by Owen, the latest and 
best authority on this subject, both of which died after successfully sur- 
viving left inguinal colotomy.1 He graphically sums up his experience 
in these cases as follows :— 
“Granted, then, that an artificial anus must be performed, let the groin be 
opened, and let no sharp instrument be at any time blindly thrust upward into the 
interior of the pelvis through the carefully performed dissection in the perineum. 
Let there be no delay, no waiting for symptoms, which in tender babes are but 
the beginning of the end; no expectation of a manifest bulging of the upper 
piece of bowel. It may never become filled at all, for, as in one of my cases, 
the meconium may grow firm and scanty from an absorption of the watery part; 
and should the operation be a success as regards saving life, at least let there be 
something more than hesitation at the subsequent proposal to attempt the con- 
struction of another artificial anus at the most convenient site.” 
My own single experience, though successful, does not lead me to 
advise this procedure, for the object of it will, during the early years of 
its life, be dependent on the exceedingly diligent and constant attentions 
of others whose affections and services, though the closest, are not to be 
depended on, as was demonstrated in my case. If the second operation 
is subsequent to the first, he will have a double annoyance, or be under 
the necessity of having a third operation performed for the closure of 
the opening first made, which is not unattended by danger to life or by 
doubts as to the result, and perhaps be under the necessity of having it 
reopened from neglect in the proper after-treatment of the new canal in 
the natural site. Whereas, if one is satisfied with having saved life in a 
manner which, as numerous cases testify, is not unenjoyable or full of dis- 
comfort, as used to be maintained, all dangerous risks of subsequent opera- 
tions are avoided, there will be no more dependence on other’s services 
than is natural, and many sources of distress that natural flesh is heir to 
will be obviated. 
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