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 ON 
 
 THE CONGENITAL MALFORMATIONS 
 
 OF THE 
 
 RECTUM AND ANUS.
 
 \
 
 Plate 1. 
 
 Vide Case CX. I;.p. ?47.
 
 A r R A C T I C A L T II E A T 1 S E 
 
 ON THE 
 
 .ETIOLOGY, PATHOLOGY, AND TREATMENT 
 
 OF TIIH 
 
 CONGENITAL MALFORMATIONS 
 
 OF THE 
 
 RECTUM AND ANUS. 
 
 BY 
 WILLIAM BODENIIAMER, M. D. 
 
 " Necessitas medicinam invenit, experientia perfecit." Hippocratks. 
 
 " By .studying Nature in her Imperfections and Irregularities, we are more likely to 
 arrive at some Knowledge of her Laws, than if we regard her only in her Healthy con- 
 dition." Ramsbotham. 
 
 Illustrated by XVI Plates and Exemplified by CCLXXXVII Cases. 
 
 NEW YOEK: 
 SAMUEL S. & WILLIAM WOOD, 389 BROADWAY. 
 
 mdccClx.
 
 Entered, according to Act of Congress, in the year one thousand eight hundred and sixty, 
 
 Bt WILLIAM BODENHAMER, 
 
 In the Clerk's Office of the District Court of the United States for the Southern District 
 
 of New York. 
 
 J. H. 
 
 TOBITT, 
 
 
 COMBIXATIOK 
 
 -TTPE PBINTEK, j 
 
 1 Franklin 
 
 Square, iV. 
 
 r.
 
 TO 
 
 WILLIAM HUSTON BODENHAMER, 
 
 iSow A Student 
 At L^ Ecole-De-Medic'ine of Pakis, 
 
 THIS WO RK 
 
 IS 
 
 Most Respectfully and Affectionately 
 
 INSCRIBED 
 
 Ir 
 
 By his Father, 
 
 THE AUTHOR.
 
 r» R E F A^ C E 
 
 Whatever, may be said with regard t:) either the merits or the 
 demerits of this wort, all will admit that the subject of it is of the 
 highest importance, and that such a production as is hero aimed at, 
 is decidedly a desideratum in surgical literature. The utility of 
 oUch a treatise is undoubted, and will not be called in question. 
 
 No complete, systematic or practical work on the congenital mal- 
 formations of the rectum and anus, has ever been published in this 
 or any other country. The literature on this subject lies buried in 
 undigested confusion in the various channels throughout the range 
 of the science — hence it can only be found in brief and detached 
 articles and memoirs as presented in the transactions of societius ; 
 in some of the special treatises on the diseases of the rectum and 
 anus ; in the systematic works on surgery ; in the dictionaries ; or in 
 the various periodicals of the day. The voluminous and the expen- 
 sive character of most of these works, containing articles on this 
 subject ; their scarcity and the difficulty of obtaining them, as well 
 as the largest number of them being clothed in a foreign language, 
 render them in a great degree inaccessible to the largest majority 
 of practitioners. 
 
 To remedy this serious evil and to fill this void, the author has in 
 the present work endeavored to collect these scattered materials 
 into one continuous whole, adding to them his own reflections and 
 experience on the subject; and thus presenting in a systematic and 
 coniuH-tcd fi;rni, a complete and accurate exposition of the cougeni
 
 vi Preface. 
 
 tal malformations of the rectum and anus, their aetiology, pathology, 
 classification and treatment. 
 
 Notwithstanding several very able and highly valuable contribu- 
 tions on this subject have been made within the last half century, 
 nothing like a general treatise has been attempted. Of the princi- 
 pal contributors to this literature in later years, the names of Ben- 
 jamin Bell, Thomas Copeland, and A. Copeland Hutchison of Eng- 
 land ; MM. Amussat and Roux de Brignoles of France ; Von Ani- 
 mon and Friedberg of Germany ; and Dr. Bushe, Dr. Barton and 
 Dr. Gray of the United States, may be mentioned as the most im- 
 portant. " Th". Boston Society for Medical Lnprovement " has 
 within the last few years highly distinguished itself by investigating 
 this subject quite thoroughly, and Dr. Gay, already named, one of 
 its able members, has produced a valuable paper on it. It is, how- 
 ever, more especially to the genius and master pen of M. Amussat 
 of France that we are indebted for having drawn from oblivion as 
 it were, this long neglected and forgotten subject, and for restoring 
 it to that rank to which it is entitled. 
 
 Although these eminent surgeons have by their able productions 
 inaugurated a new surgical epoch with regard to the anatomy, the 
 physiology and the treatment of these congenital vices of conforma- 
 tion, yet it is surprising the little advancement which is being made 
 on the subject. A congenital imperforation of the anus and rectum 
 is still regarded by many surgeons merely as an anatomical lusus 
 naturcB, beyond the power of art to remedy, and is still to a great 
 extent the opprobrium medicum. 
 
 The investigation of these abnormal conditions of the rectum and 
 anus is invested with a deep interest, not only as an important pa- 
 thological inquiry, but above all as conducive to the adoption of 
 measures calculated to be highly beneficial to a class of little suffer- 
 ers, the most unfortunate and deplorable. The subject is a very im- 
 portant one, and is presented not for the benefit merely of the curious, 
 in anatomical pursuits, but on account of its practical relations, and 
 for the ultimate and permanent good of the little sufierers themselves ; 
 consequently it presents itself to the humane surgeon as an object 
 demanding his most deliberate and serious attention, for among the
 
 PREFACE. VI 1 
 
 many forms of death which surround the cradle and which are the ob- 
 jects of parental care and solicitude, those which depend upon a 
 malformation, or an imperfect state of tlic excretory passages, an' 
 perhaps the most distressing in their nature and make the most pain- 
 ful impressions upon the minds of the parents. 
 
 In the elucidation of this subject, the author disclaims all preten- 
 tious to an extensive practical and personal knowledge of it ; indeed 
 this seldom falls to the lot of any one practitioner, however exten- 
 sive his practice may be. 
 
 It may be alleged that in treating this subject, the author has 
 been guilty of great repetition and prolixity, but as the subject is 
 so importaut, and has been so little discussed, he thought it might 
 prove benedcial to enter into it somewhat in detail. 
 
 Whether this work will prove to be valuable or not, it has been 
 the result of much reflection and long labour, and the author claims 
 for it entire originality in the general design and treatment of tho 
 subject. The extent of his researches will be understood when it 
 is known that he has consulted and cited the large number of 
 authorities. presented in the Bibliography at the commencement of 
 the Introduction. This extensive Bibliographical Index forms of itself 
 a complete history of these congenital vices, and will greatly facili- 
 tate the study of them. 
 
 In this work the practitioner will find reported nearly 
 three hundred cases, collected from the numerous sources, 
 being by far' the largest number ever presented in any one 
 sino-le production on the subject. The record of these cases will 
 show their singular variety ; they have all been carefully classed 
 according to their species, and most all of them have been reported 
 in full, and as near as could be, in the precise language of their 
 authors. Many of these reports have been translated from the 
 French, the German, and the Latin, especially for this work. The 
 author has made but few remarks in relation to any of them, pre- 
 ferring to present in full the instances themselves, as facts, from 
 which each practitioner might form his own opinion, and draw his 
 own conclusions. It will be seen that the observations of authors 
 and the cases, have been generally collected from the original
 
 Vlll PREFACE. 
 
 sources, instead of, as is often the case, from the mere references 
 made to them by others. 
 
 It is a singular fact, and not unworthy of observation, that in 
 reading the French authors on these congenital deformities, one 
 will be strongly impressed with the idea that beyond the bound- 
 aries of France nothing whatever is known on the subject. The 
 same may be said with respect to the Germans. In their produc- 
 tions on these congenital vices, they scarcely ever, if at all, allude 
 to the French or the English ; and neither the French, the Germans, 
 nor the English ever refer to any American authority in relation to 
 them. Whether this should be attributed to ignorance of the gen- 
 eral literature of the subject, or to national pride or prejudice, the 
 author will not attempt to determine. In the following pages, how- 
 ever, he has brought together in one harmonious body, for the mu- 
 tual benefit of the whole, authorities, both English, French, Ger- 
 man and American. 
 
 This work will contain both the medical and the surgical treat- 
 ment in full from the earliest times, with all the improvements, 
 down to the present day. The last chapter will give a complete 
 exposition of the highly interesting subject of Abdominal Artificial 
 Anus, so far as it relates to new-born children. 
 
 The simple Classification which has been adopted, the careful 
 arrangement of all the cases under their appropriate heads, the 
 Alphabetical Index to these cases at the end of the work, and the 
 numerous LithograpJdc Ilhist rations, will, it is hoped, be found 
 highly convenient and useful. 
 
 In conclusion the author humbly submits this treatise to the pro- 
 fession with all its imperfections, hoping that it will supply a hiatus 
 in the resources of the surgical art. 
 
 854 Broadway, New York, ) 
 September, ISGO. |
 
 T^BLE OF COISTTENTS. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 SECTION I. 
 
 PAGE. 
 
 Bibliography, -- ______ 17 — 3G 
 
 SECTION II. 
 
 General Remarks. — The Rectum and Anus liable to congenital 
 malformations and niiperl'ections — The congenital closure of the 
 anus noticed from the remotest antiquity by the Greek, Roman and 
 Arabic physicians — The tenns used to designate these vices of con- 
 formation — The importance of examining minutely every infant 
 immediately after birth— The pernicious practice of purging new- 
 born children, irrespective of circumstances — These malformations 
 considered quite uncommon by some surgeons — The author differs 
 from this opinion — The impossibility of arriving at satisfactory 
 conclusions on the subject from the very meager data furnished, 37 — 41 
 
 SECTION III. 
 
 Etiology. — Nothing satisfactory has yet been ascertained with re- 
 gard to the primary cause which determines these congenital im- 
 perfections of structure — What the science of embryology teaches 
 on the subject — The herculean labors and the theories of the dis- 
 tinguislied and celebrated organologists MM. (Saint-Hilaire, 
 Serres, Meckel, Tiedmann, Andral, &c., noticed — Some of these 
 malformations are the result of disease in intra-uterine life — 
 Instances given to prove this — What influence does sex exercise 
 in the production of defective congenital developments, - 41 — 46 
 
 SECTION IV. 
 
 Anatomical and Pathalogical Characters. — These congenital 
 malformations present a great variety of forms from the most sim- 
 ple to the most complex —The anatomical and the pathological con- 
 ditions which constitute these defective developments, considered 
 separately — The historj' of the development of the rectum and the 
 anus, given — The manner in which many of these malformations 
 occur — Synopsis of the congenital malformations of the anus and 
 the rectum, -- ...._- 4G — 51 
 
 is.
 
 TABLE OF CONTENTS. 
 
 SECTION V. 
 
 PACE. 
 
 Classification. — The anatomical and the patliological condition of 
 these congenite vices of structure, taken as the basis of classifica- 
 tion — They are, for practical purposes merely, distinguished into 
 nine species — In this arrangement, convenience is considered, 
 rather than a show of scientific precision— The description of each 
 species, ___-__---- 52 — 5 -J 
 
 SECTION VI. 
 
 General Symptoms. — The existence of these congenital malfor- 
 mations manifests itself, in the majority of instances, bj' a train 
 of morbid phenomena, simulating strangulated hernia, the result 
 of the retention of meconium and other matter — If not relieved, 
 death generally takes place between the third and eighth day, 
 according to the vigor of the little patient — When protracted 
 beyond this period its life is purely vegetative, there is extreme 
 emaciation, and death results from the eifects of inanition — 
 Instances given in which children have lived a niunber of days, 
 and even months, without any passage from their bowels — 
 When death takes place, it is most usually the result of enteritis, 
 peritonitis and intestinal paralysis — The appearances after death — 
 The pathognomonic sign obtained by the direct inspection of the 
 anus and rectum, ----____ 54 — 57 
 
 section VII. 
 
 Prognosis. — These malformations, as well as those of the genito- 
 urinary organs, were looked upon anciently as necessarilj^ fatal, 
 and the unfortunate victims of them, regarded in the light of 
 monsters — These sentiments, even at the present day, prevail to 
 a certain extent — ^lany surgeons abandon nearly all such cases, 
 believing them to be bej^ond the power of art to remedy — This 
 is a grave error, which will be shown hereafter — From the great 
 improvements that have been, and are being made in modern sur- 
 gery, the evil is by no means deplorable, even in some of the 
 most desperate cases, as will be shown — The most formidable 
 cases are those in which there is considerable deficiency, or an 
 entire absence of the rectum, and in which no outlet whatever 
 exists — Even such cases can now generally be saved, eitlier by the 
 operation oi Proctoplasty or Colotomy—^o case should be abandon- 
 ed in despair — A doubtful remedj^ even, should be preferred and 
 attempted in preference I0 the certain death of the child — It is an 
 important fact, that cliildren sustain an operation much better 
 immediatel}- after birth, than at a later period, - - _ 57 (jj 
 
 CHAPTER II. 
 
 THE FIRST SPECIES OF MALFORJIATIOX. 
 
 SECTION I. 
 
 Description. — This species of congenital malformation is character- 
 ized by an abnormal narrowing of the anal orifice — This narrow- 
 ing may present all the different degrees of stricture, from that 
 into which the point of the smallest probe cannot be introduced, 
 and impossible for the meconium to pass, to that which opposes
 
 TABLE OF CONTKNTS. XI 
 
 PACK. 
 
 no obstruction to the common size probe, and but little to the 
 passage of the mecoiiiinii — The contraction may be organic, and 
 the result of previous iniliunmation, or it may be spasmodic — Tlie 
 situation and the form of the anus in this species— The signs by 
 which it maybe recognized — The syphilitic variety of this species 
 of congenital narrowing, and the signs by which it may be dis- 
 tinguished, - - 01— <j;i 
 
 SECTION II. 
 
 Till'. Treatment. — The treatment is by dilatation alone ; or, by incis- 
 ion and dilatation combined, according to the straightness of the 
 contraction — The dilatation must be ctfected by means of the wax, 
 gum-elastic, or metallic bougies — The wax bougie the best — The 
 measures to be adopted if the process of dilatation should excite 
 undue irritation or inflammation — The importance of early treating 
 even the slightest cases of this species, in order to prevent the 
 evil consequences which may result from such neglect, in the 
 after-life of the little patient — Two interesting cases are related 
 by M. Boyer, in which the contz-action of the anus was overlooked, 
 or neglected in infancy, .__---- C3 — 08 
 
 SECTION III. 
 
 Cases AND Kemarks, ------- G8 — /4 
 
 CHAPTER III. 
 THE SECOND SPECIES OF MALFORMATION. 
 
 SECTION I. 
 
 Description. — This species of congenital malformation, atresia ori- 
 ficii am, is characterized by. the closure of the anal orifice, by a 
 thin transparent membrane, somewhat resembling the hymen ; or, 
 b}^ a cutano-mucous lamina, sometimes quite thick and hard, and 
 simulating the common integument of the anal region — The signs 
 by which it is distinguished — It is the most simple form of 
 arrested development pertaining to the anus, and doubtless the 
 most common, --------- 75 — H) 
 
 section II. 
 
 The Treatment. — The treatment of this species is simple, and if 
 timely adopted, generally successful — It consists of a puncture 
 and a crucial incision — The method of operating and the after 
 treatment — There is in these cases but little disposition in the 
 newly formed anus to contract, especially if the occluding mem- 
 brane has been thin, and the anus well formed, as is usually the 
 case — The advice of Professors Hays and Pancoast, of Philadelphia 
 — M. Levret recommended a circular incision in these instances, 7Cj—77 
 
 SECTION III. 
 
 Cases AND Remarks, -__.--- 78 — 87
 
 Xll TABLE OF CONTENTS. 
 
 CHAPTER IV. 
 THE THIRD SPECIES OF MALFORMATION. 
 
 SECTION I. PACE 
 
 Description. — The atresia ani et intestini recti, is a species of 
 arrested development, in which the I'cctum docs not descend as 
 low in the pelvis as it should do, but terminates abruptly in a 
 form of cul-de-sac at a variable distance above its natural outlet — 
 No anus exists, and there is generally not even the trace of an 
 anus to be observed in aitu naturali — This is truly a deplorable 
 form of congenital imperfection, especially should a considerable 
 portion of tlie inferior extremitj^ of the rectum be deficient, - 88 — 89 
 
 SECTION II. 
 
 Physical Exploration — Diagnosis. — It is of the highest import- 
 ance, in these cases, in which there are no external signs, to make 
 a careful and minute exploration — The manner of conducting this 
 — Auscultation and percussion — The introduction of the sound 
 into the bladder, or into the vagina. The small excrescences or 
 elevations of the skin, which are sometimes observed in these 
 cases at the normal situation of the anus — Their deceptive char- 
 acter, with regard to their having any communication with the 
 rectum. The place of the absent anus is sometimes the seat of a 
 .small depression, pit, or a fissure or fissures of the skin, - 89 — 91 
 
 SECTION III. 
 
 Prognosis. — The prognosis unfavorable, but by no means hopelessly 
 so — A very fixvorable issue of the success of the operation in any 
 of these cases must not be too confidentl}^ prognosticated — The 
 difficulties and the dangers of maintaining the newly formed canal 
 patulous, after the ordinary operation, as enumerated by Bell, Vel- 
 peau and others, are by no means exaggerated or imaginary — Con- 
 siderations which induce many surgeons to repudiate all treat- 
 ment in such cases — The opinion of Professor J. H. Bigelow, of 
 Harvard University, on this subject — The highlj' encouraging re- 
 sults in a number of these cases reported, authorise and warrant 
 an attempt at relief by some operation. MM. Amussat, Roux de 
 Brignales and Goyraud, of France, in 1835, were of opinion that 
 all such cases, previous to that time, were never successfully 
 treated, if treated at all — They claimed the credit of introducing 
 free incisions in the perinajum with the scalpel, guided by the 
 finger, in search of the blind end of the rectum. Benjamin Bell 
 and A. C. Hutchison, of England, and Dr. Campbell, of America, 
 are proved to have successfully operated by this method, on just 
 such cases, many years previous, - - - _ _ gj yg 
 
 SECTION IV. 
 
 The Treat.ment. — That treatment which holds out the greatest 
 prospect of success in these cases, is that which contemplates the 
 establishment of an artificial anus in the perina3um, Proctoplaktu — 
 Description of this operation — When should the operation be un- 
 dertaken? — Theadvico of Hutchison and Dieffenbach on the sub- 
 ject — The infant pelvis — Ilie admeasurements of it in two cases — 
 The introduction of the sound into the urethra of the male, or into
 
 TABLE OF CONTKNTS. XI II 
 
 pa(;k. 
 tlie vagina of tlie fouiale — The form of incision— Tlic loiif:;itii(linaI 
 incision — Tlie transverse incision — The crucial incision — The T- 
 incision — The sphinctores ani muscles. The coniiicting opinion of 
 authors with regard to their invariable presence or absence in 
 these cases — The rectum in these instances is not only malformed, 
 but may occujiy an abnormal position in the pelvis — The nu;thod 
 of operating recommended by the author — The ordinary method 
 of operating — The liability of the newly made passage to coarcta- 
 tion — The opinions of Bell, Yelpeau, Dionis and Malyn, on the 
 sulijcct — The objections of jNI. Amussat to the ordinary method 
 of operation — Some of his objections shown to be untenable — The 
 method of M. Amussat — Its merits and demerits considered — 
 The operation of Amussat recommended and performed by others 
 — x\mussat abandons his beautiful operation in these cases, and 
 now performs colotomy instead — The operation by puncture — 
 'llie great danger and uncertainty, in these cases attending the 
 " hl'md ■plunge'''' of a piercing instrument — Perinaeal puncture, at 
 this day, shoidd be abandoned in these cases — The modification 
 of the operation by puncture, as practiced by Bell, Hutchison and 
 Dieflenbach — What to be done in case of the failure to form a 
 perina3al artificial anus, ------- 9G — 123 
 
 SECTION V. 
 
 Oases AND Remarks, _______ 123—161 
 
 CHAPTER V. 
 THE FOURTH SPECIES OF MALFORMATION. 
 
 SECTION I. 
 
 Description. — In this species of congenital malformation the anus 
 is usually quite normal, whilst the rectum at a variable distance 
 above it, is either obliterated, partially or wholly absent, or oc- 
 cluded by a thin or a thick annular membranous septum like a 
 diaphragm — The ano-rectal septum sometimes thick, and the con- 
 sistence of horn — A well-formed anus, no evidence that the 
 rectum above it is normal — This species presents a form well cal- 
 culated to deceive the most experienced — The importance of 
 making a visual and tactile examination of the anal region of 
 every child which fails to pass meconium within the first twelve 
 hours after birth — The speculum ani can be used iu these cases to 
 great advantage — The prognosis, ----- 162 — 165 
 
 section II. 
 
 The Treatment. — The method of opei*ating in those cases — The 
 peculiar method of M. Amussat, ----- 165 — 167 
 
 section III. 
 
 Cases and Remarks, __--__ 167 — 199 
 
 CHAPTER VI. 
 THE FIFTH SPECIES OF MALFORMATION. 
 
 SECTION I. 
 
 Description. — In this species of malformation the rectum near 
 its inferior extremity sends off a pipe-like prolongation, which
 
 XIV TABLE OF CONTENTS. 
 
 PAGE. 
 
 terminates externally in a preternatural orifice at some point in 
 the perinajum, or at various points beneath the urethra; at the 
 labia pudendi, or at some point in the sacral region — These ad- 
 ventitious canals resemble very much the ordinar}' fistulous pas- 
 sages — This species has been included in that which Papendorf 
 denominates " Atresia Ani Vesicalis — Urethralis — Vaginalis''' — 
 This arrangement improper for reasons given — The prognosis is 
 generaUy favorable, - - 200—202 
 
 SECTION II. 
 
 The Treatment. — The indications to be observed — The treatment 
 in the male subject — The process of Dieffenbach — The process of 
 Friedberg — The treatment when the rectum terminates in an 
 abnormal opening at the labia pudendi, the vulva, &c. — The pro- 
 cess of Vicq D'Azjr, 202— 20G 
 
 section iii. 
 Cases and Remarks, ._____- 206 — 224 
 
 CHAPTER YII. 
 THE SIXTH SPECIES OF MALFORMATION. 
 
 SECTION I. 
 
 Description. — In this species the rectum terminates by an abnor- 
 nal anus, either in the bladder, the urethra, the vagina, the 
 uterus, or in a cloaca in the perinaeum with the urethra and the 
 vagina — Generally no normal anus exists — This preternatural 
 alliance of the digestive, the urinal and the generative .systems is 
 analogous to the normal formation of some animals — This division 
 of the congenital malformations of the anus and rectum is the 
 " Cloaca Congenita''' of Meckel, and the " Atresia Ani Vesicalis, 
 Urethralis and Vaginalis " of Vixpendovt — The manner in which the 
 rectum communicates with the genito-uriuary passages — Physical 
 signs and diagnosis — The prognosis in each variety of this species, 225-231 
 
 section ir. 
 
 The Treatment. — The indications in the treatment of the various 
 varieties of this species — The treatment when the rectal open- 
 ing is either vesical or urethral, in the male — The proceeding 
 ©f Amussat in such cases — The proceeding of IMartin — The treat- 
 ment when the rectum opens in the vagina — Two very distinct 
 methods of operation proposed, with very ingenious modifications 
 — The method of Vicq D'Azyr — Modifications of it by Martin 
 and Velpeau — The method of Barton — Dieffenbach proposes two 
 methods, _.---..-_ 231—235 
 
 section III. 
 
 Cases and Remarks, - 236 — 277 
 
 CHAPTER VIII. 
 
 THE SEVENTH SPECIES OF MALFORxMATION. 
 section I. 
 
 Description. — In this singular species of malformation, the ureters, 
 the vagina or the uterus may terminate in tlie rectum by an ab- 
 normal orifice — IIow the ureters tenuinate in the rectum — How
 
 TABLE or CONTENTS. XV 
 
 I' AUK. 
 the vaii'ma or tlic uterus ti'ruiinates in the rectum — In these 
 cases tlie menstrual evacuation passes by the anus — I'he possibility 
 in such cases iif impregnation taking place by coitus jJcr (luiim, 
 and even parturition per ndum safely ellected — The celebrated 
 Thesis of M. Louis on this subject — Ihe presentation of this thesis 
 causes him to be prosecuted by the Parliament of Paris ; and the 
 Doctors of the Sorbonnc interdict him — The Pope grants him 
 absolution — His Thesis published in 1754, - - _ 278 — 279 
 
 SECTION II. 
 
 The Treatment. — Surgery seems altogether out of the question in 
 
 some, ifuot all, of these cases, . . - - - 279 — 280 
 
 section iii. 
 Cases and Remarks, __._-__ 280 — 282 
 
 CHAPTER IX. 
 
 THE EIGHTH SPECIES OF MALFORMATION. 
 
 SECTION I. PAGE 
 
 Description. — The rectum in this species is entirely absent, and 
 the colon generally ends in a cul-de-sac — There is no sign of a 
 normal anus present, yet an abnormal one does occasionally exist 
 — The pelvis in these instances is sometimes abnormally small and 
 contracted— Some authors arrange under the head absence of the 
 rectum , cases in which there is only a partial absence of the rectum 
 — The importance of this distinction — Hovr to establish the diag- 
 nosis — The manner of conducting the exploration, - - 283 — 284 
 
 section ii. 
 The Treatment, -------- 284—285 
 
 section iii. 
 Cases anu Remarks, ------- 285—289 
 
 CHAPTER X. 
 
 THE NINTH SPECIES OF MALFORMATION. 
 
 SECTION I. 
 
 Description. — In this species the rectum and the colon are both 
 wanting, and some other portion of the intestinal canal termi- 
 nates externally in an abnormal anus — No normal anus ever 
 exists — Fortunately this species of malformation is but seldom 
 met with — Sometimes there is no abnormal anus — The explora- 
 tion and the diagnosis, ---.-_ 290 291 
 
 SECTION II. 
 
 The Treatment. — Many of the cases of this species admit of pal- 
 liative treatment only, ----__. 291 292 
 
 section iii. 
 
 Cases and Remarks, --_-_-_ 292 294 
 
 section iv. 
 
 Recapitulation — A table comprising 287 cases, - - - 294
 
 XVI TABLE OF CONTENTS. 
 
 CIIAPTERXI. 
 ABDOMINAL ARTIFICIAL ANUS. 
 
 SECTION I. 
 
 PAGE. 
 
 Genekal Remarks — The term artificial amis indiscrimately applied 
 to the 'preternatural anus — This term is strictly applicable only to 
 such an anus as is designedly established by the surgeon — Preter- 
 natural abdominal anus, a merefascal fistula of the small intestines 
 — Two operations proposed and advised for the formation of an 
 ai'titicial anus in the abdomen — The establishment of su-ch an 
 anus should never be attempted, only as the last alternative — 
 Amussat and Tiigel on the contrary, however, recommend it first 
 and last — Some able surgeons proscribe the operation altogctlicr — 
 Their objections considered — Important considerations in relation 
 to the operation, - _ _ _ 295 303 
 
 SECTION II. 
 
 The History of the Operation. — Littre', the first individual in 
 modern times who suggested the idea of forming an anus in the 
 abdomen — Pillore, the first surgeon who executed the operation 
 of Littre, in a modified form — Callisen in 1770 publishes another 
 operation for forming an anus in the abdomen — The estimation in 
 which Callisen's operation was held — Amussat in 1839 revives, 
 improves and executes the operation of Callisen, - 304—309 
 
 section iii. 
 The Proceeding of Littre, . _ _ _ 309 311 
 
 section iv. 
 Cases and Remarks, - - - _ . gu 301 
 
 SECTION V. 
 
 Compendium. — A table comprising 25 cases, in which the operation 
 
 of Littre' was performed on new-born children, - - 321 — 322 
 
 section vi. 
 The Proceeding of Littre, as Modified by Pillore, - 323 — 324 
 
 SECTION vii. 
 
 The Proceeding of Callisen, - - _ _ 324 — 325 
 
 section viii. 
 Oases and Remarks, ----- 326 — 328 
 
 section ix. 
 The Proceeding of Callisen, as Modified by Amussat, 328 — 334 
 
 section x. 
 
 Cases AND remarks, - _ . _ . 334 — 345 
 
 section xi. 
 
 Appreciation, - - _ - _ 345 — 345 
 
 section xii. 
 
 The Proceeding of Martin, - - _ _ 347 — 343
 
 CORRIGENDA. 
 
 PAGE 
 
 •29. The ninth line from the top, for Ohirurgie read d« Chirurgie. 
 
 49. The top line, for (i/xiommiMaf read (XftdominaJ. 
 129. The fourteenth line from (he bottom, for <>e Recini read 01. Ricini. 
 168. The twenty first line from the bottom, for Iriaugular read triangular. 
 175. The ninth line from the top, for mdeoraie read mnderate. 
 191. The eighteenth line from the top, for Jnuraal read Journal. 
 202. The top line, for cases which read cases in which. 
 335. The eighth line from the bottom, for dilate read dilute. 
 
 Explanation of plate third. The second line from the top, for Case X/7/read Case XJ^VII.
 
 EXPLANATION OF THE PLATES.
 
 PLATE II. 
 Some of the Instruments employed in Proctoplasty, Colotomy, &c. 
 
 Figure 1, 
 
 Figure 2. 
 
 Figure 3. 
 
 Figure 4. 
 
 Figure 5. 
 
 Figure G. 
 
 Figure 7. 
 
 Figure 8. 
 
 Figure 9. 
 
 Figure 10. 
 Figure 11. 
 
 Figure 12. 
 
 EXPLANATION. 
 
 Small Bi-valve Speculum Ani. 
 
 Operating Scalpel of medium size. 
 
 Small size Scalpel for delicate work. 
 
 Probe-pointed curved Bistoury. 
 
 Cooper's Hernial Bistoury. 
 
 Gurved Sharp-pointed Bistoury. 
 
 Straight Sharp-pointed Bistoury. 
 
 Flexible-Silver grooved Director. 
 
 Bull-dog Forceps of Listen, for pulling down the end of the 
 
 rectum. 
 Tumor Forceps, for drawing down the blind end of the rectmn. 
 Round-bellied Scalpel, for making the first incision of the 
 
 perinasum. 
 Silver Anal Canula,
 
 Plar.p 11
 
 PLATE III. 
 
 Plate III. represents a case of membranous occlusion of the Anus, as seen 
 tij Von Amnion. [Vide Case XIII.] 
 
 EXPLANATION. 
 
 Figure 1, presents the external appearance of this case. 
 
 After Von Amman, 
 a — The penis in a constant state of erection. 
 h — A. considerable pit or depression near the natural situation of the 
 
 anus. 
 Figure 2, presents the appearance of the intestines. After Von Ammon. 
 a^ a, a. — The descending colon greatly distended with gas and meconium, 
 
 just where it terminates in the rectum. 
 h. — The small intestines turned over on the right side. 
 Figure 3, presents the inferior portion of the rectum. 
 
 After Von Ammon. 
 
 a. — The rectum. 
 
 h. — The place at which the anus was closed. 
 
 c. — A sound in the orifice made by the operation. 
 
 Figure 4, presents the rectum laid open through its entire length. 
 
 After Von Ammon. 
 a. — The inner surface of the rectum. 
 h. — The folds of the rectum, or columns of Morgagni. 
 c. — The internal sphincter, forming a wreath-like mass, from which the 
 
 membrane grew which had closed the anus. 
 cj^ (J, — The cut surfaces of the rectal walls greatly thickened.
 
 Plate 111. 
 
 FlQ. /. 
 
 J:' 
 
 \ "/ 
 
 
 ^ - / I 

 
 PLATE lY. 
 
 EXPLANATION. 
 
 Figure 1, represents tlie external appearance of an imperforate anus and 
 rectum, in a new-born infant. [Third Species.] 
 
 a. — The prominent and continuous raphd. 
 
 Figure 2, represents the parts immediately concerned in a case of imper- 
 foration of the anus and rectum, as they were observed by Von Ammon in 
 a five months' foetus. [Vide Case L.] After Von Ammon. 
 
 ffl.— The rectum. 
 
 h. — The cul-de-sac of the rectum. 
 
 c. — The cord-like rudiment of the rectum. 
 
 d. — The sigmoid flexure of the colon. 
 
 Figure 3, gives a representation of the parts concerned in Dr. W. P 
 Hill's case of imperforate anus and rectum. [Vide Case LXILJ 
 
 a. — A portion of the perinfeum. 
 
 t, h. — The ureters. 
 
 e. — The rectum terminating upon the neck of the bladder, 
 
 d.: — The urethra. 
 
 «.. — The- bladder.
 
 Plate IV 
 
 
 ife ^
 
 PLATE V. 
 
 Plate V. gives a full representation of the celebrated case of M. Amussat, 
 and his peculiar operation. [Vide Case XLII.j 
 
 EXPLANATION. 
 
 Figure 1, is an imaginary representation of this case. M. Amussat, in 
 order to render the details of his operation intelligiVjle, gave a plan of the 
 parts a-s he supposed them to exist before the operation. He took pains to 
 make the analogy as complete as possible, by taking his sketch from a left- 
 side view of the interior of the pelvis, in a female child who died a few 
 days after birth. All the organs of the pelvis had been cut in two, part of 
 the rectum was removed, to represent the deficient portion of the intestine, 
 and the anus was made to communicate with the vagina. After Boitrgery. 
 
 a, h. — The anus and vulva, which were properly formed, and communi- 
 cated with the vagina onl3^ 
 
 c. — The extremity of the rectum forming a cul-de-sac below tne sacro- 
 vertebral angle, and having no communication with either the anus 
 or vagina. 
 
 fZ.— The bladder. 
 
 e. — The superior portion of the rectum. 
 
 Figure 2, represents Amussat's operation in this case. 
 
 After Bourgery. 
 «, h. — The fingers of an assistant. 
 
 c. — The sound introduced into the vagina. 
 
 d. — The loop of a ligature. 
 
 f. — The bistoury. 
 
 Figure 3, represents the conclusion of this operation. The horizontal 
 wound is closed by sutures, and the margins of the longitudinal wound are 
 united to the divided portions of mucous membrane. After Bourgery,
 
 
 k-'^ 
 
 
 I 
 
 /r'> 

 
 PLATE VI. 
 
 EXPLANATION. 
 
 Figure 1, represents a case -of complete imperforation of the rectnm, 
 situated some distance above a normal anus. fFourtli Species.] 
 
 After Baillie. 
 
 a. — The rectum. 
 
 h. — The cul-de-sac and termination of the rectum. 
 
 c. — The normal anus. 
 
 d. — A bougie introduced into the short anal canal, as far up as to the 
 blind end of the rectum. 
 
 e. — The anterior surface of the bladder. 
 
 /. — The posterior surface of the bladder. 
 
 g. — A part of one of the ureters. 
 
 Figure 2, represents the part concerned in a case oNmperforation of the 
 rectum above a normal anus, as observed by Mr. Ford. [Vide Case LXX.] 
 
 a. — The rectum laid open through its entire length. 
 
 b. — The ligamentous substance described by Mr. Ford. 
 
 c. — The normal anus. 
 
 d. — The place at which the rectum was occluded.
 
 Plate VI 
 
 Fij. /. 
 
 / 
 
 w<. 
 
 .i>«t»v 
 
 6' d
 
 PLATE VII. 
 
 Plate YII. gives a representation of the rectum and part of the colon of 
 a new-born infant, seen by Yon Amnion, in whom existed a membranous 
 closure of the rectum three-fourtlis of an inch above a normal anus. The 
 child was in a dj'ing state when Von Amnion was called, and no operation 
 was performed. [Fourth Species.] {Op. Clt. Tah. X. Figs. 9, 10, 11.) 
 
 EXPLANATION. 
 
 Figure 1, presents a front view of the rectum, from the point of occlu- 
 sion to its connection with the colon. After Von Ammon. 
 a. — The rectum greatlj' distended. 
 /;. — The cul-de-sac of the rectum and point of occlusion. 
 c. — The sigmoid flexure of the colon. 
 (J.— The bladder. 
 
 Figure 2, gives a lateral view of the rectum in the same case. 
 
 After Von Ammon. 
 a. — The large sack-like rectum. 
 
 b. — The point of occlusion of the rectum. 
 
 r. — The circular fibres of the external sphincter. 
 
 L — The normal anus. 
 
 e. — The bladder, small and contracted. 
 
 /. — The urethra. 
 
 g. — The sigmoid flexure of the colon. 
 
 Figure 3, represents the inferior portion of the rectum laid open from 
 the verge of the anus to the occluding membrane. After Von Ammon 
 
 a. — The blind sac of the rectum. 
 h. — The membranous closure of the rectum. 
 <r, c. — The cut surfaces of the parietes of the rectum.
 
 PLATE VIII. 
 
 Plate VIII. gives a full representation of the interesting case reported 
 by M. Cruveilhier of a new-born infant in whom there existed an imper- 
 foration of the anus and a prolongation of the rectum. [Vide' Case CV. ) 
 
 EXPLANATION. 
 
 Figure 1, represents the perinaeum and the genitals of this case. 
 
 After Cruveilhier. 
 
 a — The artificial opening made at the normal situation of the anus. 
 
 h. — The rugose and prominent raphe' which became linear as soon as meco- 
 nium was voided. 
 
 c. — The abnormal aperture, or anus. 
 
 Figure 2, gives a clear idea of the origin, the direction and the termina- 
 tion of the accidental canal. After Cruveilhier. 
 
 a. — The rectum. 
 
 /'. — The cul-de-sac of the rectum. 
 
 f, c, c. — The accidental canal from its origin the rectum, to its termina- 
 tion at the glans penis. 
 
 d. — The glans penis. 
 
 Figure 3, presents still a further view of the relation of the parts of the 
 same case. After Cruveilhier. 
 
 a. — The bladder. 
 
 h, h. — The rectum. 
 
 c. — The cul-de-sac of the rectum. 
 
 rf.— The origin of the accidental canal.
 
 Plate Vlli 
 
 X. 
 
 FUf.J. 
 
 
 Wl 
 
 Ct-.-i 
 
 FCcj.Z. 
 
 F,^.3.
 
 PLATE IX. 
 
 EXPLANATION. 
 
 Figure 1, gives a horizontal section of the pelvis, representing an imagi- 
 nary case by Von Amnion, in which the anus is imperforate, and the rectum 
 comnmnicates with the vagina. After Von Ammon. 
 
 «, a. — The rectum and sigmoid flexure of the coloin. 
 
 &.— The bladder. 
 
 c. — The vagina. 
 
 d. — The recto-vaginal opening. 
 
 e. — A small elastic urethral bougie introduced by the vagina through the 
 recto-vaginal opening into the rectum, 
 
 /,/. — The uterus with the ovaria. 
 
 g The symphysis pubis. 
 
 li. The soft parts of the anal region. • 
 
 i. — The blind end of the rectum. 
 
 A". — The superior extremity of the left leg. 
 
 Figure 2, represents the parts immediately concerned in the case of an in- 
 fant, as seen by Wreisberg, in whom the anus was imperforate, and the rec- 
 tum terminated in the bladder. [Vide Case CXXXIV.] After Vun Ammon. 
 
 a. — The rectum. 
 
 h. — The bladder laid open. 
 
 c. — The urethra. 
 
 d. — The penis. 
 
 e, e. — The umbilical arteries. 
 
 /. — The umbilical vein. 
 
 g. — The ligament leading from the bladder to the umbilicus. 
 
 h. — The urachus within the ligament. 
 
 i. — The recto-vesical opening. 
 
 Figure 3, represents the remarkable case of Casimir de Chonski in which 
 the rectum was absent, and the colon terminated in the bladder by a pro- 
 longation. In this case existed bilobation of the bladder, of which \t i>i sl 
 beautiful specimen, umbilical hernia, and a "preternatural anus. [Vide 
 Case CXXXV.] After Von Ammon. 
 
 a. — The ileum severed. 
 
 ^.— The annulus umbilicalis. 
 
 c. — The funiculus umbilcalis. 
 
 d. — Hernia umbilicalis. 
 
 e. — Vena umbilicalis. 
 
 /• — The colon descending with a considerable curve and prolongation, to 
 communicate with the bladder. 
 
 9, g. — The bilobed bladder. 
 
 /t.— The termination of the prolonged colon in the bladder, between the 
 ureters. 
 
 i, i. — The ureters. 
 
 j- — A probe in the preternatural anus. 
 
 k. — The urethra severed. 
 
 /, m. — The two vasa deferentia.
 
 Plate IX
 
 PLATE X. 
 
 EXPLANATION. 
 
 Figure 1, represents the very interesting case reported by Mr. Lucas, 
 in which the rectum terminated in a cul-de-sac two inches above its natu- 
 ral outlet, and communicated with the bladder. [Vide Case CXXXVI] 
 
 After Mieban. 
 
 a. — The rectum, terminating nearly two inches from the anal aperture. 
 
 I). — The bladder. 
 
 c. — A probe passed through a small opening by which the pouch-like 
 termination of the rectum communicated with the bladder. 
 
 d. — A probe passed from the anal aperture upwards, showing its deter- 
 mination in the bladder ; the vesical oritice being guarded by a val- 
 vular fold of mucous membrane. 
 
 f, e, c. — A probe passed from the external orifice of the urethra aloug 
 that tube into the bladder. 
 
 /. — The distended portion of tho urethra, the diameter of which is equal 
 to a No. li bougie. 
 
 g. — The distended scrotum communicating with the urethra for fully 
 half its length, and lined with a coating of lymph, which presented 
 extravasation of the urine, and the liquid fasces into the cellular tissue. 
 
 /;. — A small cul-de-sac corresponding to the urachus. 
 
 Figure 2, represents the case reported by the late Dr. Steele, of Saratoga 
 Springs, in which the rectum terminated in the neck of the bladder. 
 [Vide Case CXXXIX.] 
 
 a. — The rectum and r)art of the colon. 
 
 6.— The bladder. 
 
 r. — The penis. 
 
 Figure 3, represents an imaginary section of the pelvis, to explain the 
 imperforation of the anus, and the urethra as they were supposed to exist 
 in M. Roux de Brignole's case. 
 
 ffl, a. — The interior of the bladder. 
 
 h, h. — Section of the prostate. 
 
 c. — The vesicula seminales. 
 
 d. — The vas deferens. 
 
 f, e. — The interior of the rectum.. 
 
 /; — Supposed termination of the rectum in front of the neck of the bladder. 
 
 g. — The penis. 
 
 h. — The opening of the meatus. 
 
 i. — The bulb of the urethra. 
 
 k. — The root of the right corpus cavernosum. 
 
 I. — Section of the pubis. 
 
 ni. — Space between the pubis and the bladder. 
 
 n, — The urachus. 
 
 0. — The muscles of the abdomen. 
 
 p. — The skin. 
 
 q, r. — The peritonaeum lining the cavity of the abdomen. 
 
 >v, s. — The sacrum. 
 
 /, t. —The incision in the perinseum. 
 
 n. — The bistoury, its point in the rectum.
 
 P]Qr o Y
 
 PLATE XI. 
 
 Plate XI. gives the representation of a remarkable foetus observed by 
 M. Cruveilhier, in which the anus was imperforate, and the rectum termi- 
 nated in the bladder. [Vide Case CXL.] 
 
 EXPLANATION. 
 
 Figure 1, represents the ano-perinseal region of this case. It will be 
 observed that the perinseimi is enormous in its antero-posterior diameter. 
 
 After Cruveilhier. 
 
 Figure 2, represents a section of the pelvic cavity containing the soft 
 parts. After Cruveilhier. 
 
 a. — The bladder. 
 
 h. — The rectum which opens into the bladder, and with the base of 
 which is perfectly confounded. 
 
 c, c. — The ureters. 
 
 d. — The prostatic portion of the urethra. 
 
 Figure 3, represents the rectum of this same case, opening into the 
 posterior part of the bas-fond of the bladder by a large infundibuliform 
 aperture. After Cruveilhier. 
 
 a. — The rectum opening behind the bladder. 
 
 h. — The prostatic portion of the urethra. 
 
 c. — The infundibuliform aperture of the rectum communicating with 
 the bladder. 
 
 d. — The bladder laid open, showing its interior.
 
 PlnhnX 
 
 Fifj. 1. 
 
 
 ^^I^r 
 
 ' itiy 
 
 iS^g!*'"' 
 
 Fii^ 3. jl
 
 PLATE XII. 
 
 Plate XII. gives the representation of the case of a male child, present- 
 ing an imperforation of the anus with the rectum terminating in the blad- 
 der. It was seen by Von Amnion, and operated on without success. 
 
 s 
 EXPLANATION. 
 
 Figure 1, gives the external appearance of this case. 
 
 After Von Ammon. 
 a, a. — The thighs slightly elevated. 
 
 h. — A depression or pit in the exact situation of the absent anus. 
 c. — The scrotum. 
 
 d. — Another depression corresponding with the termination of the rec- 
 tum within. 
 
 Figure 2, represents a side view of the internal parts directly concernec 
 iu this case. After Von Ammon 
 
 «.— The bladder. 
 h. — The inferior extremity of the colon. 
 
 c. —The rectum adhering to and terminating in the posterior part of tht 
 
 bladder between the insertion of the ureters. 
 
 d, d. — The ureters. 
 
 e,f. — The remaining portion of the integument and cellular tissue of tht 
 perinajum not cut away. 
 
 g. — The place where the depression was, and into which the bistour;y 
 was plunged. 
 
 Figure 3, presents another view of the relation existing between tin 
 several internal parts of this case. After Von Avimov. 
 
 ffl. — The bladder, presenting its posterior aspect. 
 
 h, h. — The ureters, the right one presenting a remarkable turn in it. 
 
 c, c. — The kidneys. 
 
 d. — The portion of the perinseum not removed, in which the depression 
 was at the normal situation of the anus. 
 
 e. — The rectum laid open and its cavity exposed, so that the ojifice com- 
 municating with the bladder is distinctly seen. 
 
 /. — The recto-vesical orifice between the ureters.
 
 V 
 
 n \' 
 
 FL(f. I.
 
 I
 
 PLATE XIII. 
 
 EXPLANATION. 
 
 Figure 1, represents the case reported by Fleischmann, in which the 
 anus and the rectum were entirely wanting, and the colon terminated in a 
 blind sac. The abdomen is opened and its parietes turned over, tha^ 
 aflfording a correct view of the situation of the intestines, especially show- 
 ing the character of the descending colon. [Vide Case CCLIV.] 
 
 After Von Amman. 
 a. — The liver above the commencement of the ascending colon. 
 b. — The ascending colon which here takes place of the caecum, and is 
 divided into two branches, from one of which springs the appendi- 
 cula vermiformis. 
 c. — The descending colon, hanging loosely in the abdominal cavity. 
 d. — The blind end of the colon, 
 e, e, e, e. — The parietes of the abdomen. 
 
 Figure 2, represents the anatomical condition of the colon in a case of 
 
 imperforation of the anus and rectum, as observed by Von Ammon. The 
 
 descending colon presents several sac-like dilations before passing down 
 
 behind the bladder to terminate in a cul-de-sac in the rectum. 
 
 After Von Ammon. 
 a. — The descending colon. 
 
 6, &. — The sac-like dilations of the colon. 
 
 c. — The bladder, behind which the colon passes. 
 
 d, e.— The small intestines in a normal condition.
 
 PlateX 
 
 Fi-vi . I 
 
 Fiq. 2.
 
 PLATE XIV. 
 
 Plate XTV. gives a representation of the case of a male child presenting 
 an imperforation of the anus and rectum, unsuccessful!}- operated on by Von 
 Amnion. The autopsy in this interesting case clearly revealed the cause 
 of the failure of the operation. l"he rectum for about two-thirds of its 
 entire length was greatly dilated, presenting the form of a pouch ; but 
 gradually tapered off, and terminated blindly in a small point within a 
 few lines of the posterior wall of the scrotum. 
 
 Notwithstanding the incision was made in the proper place, and deep 
 enough, yet it entirely failed to reach the rectum, because this organ was 
 further removed from the sacrum towards the front than the natural, and 
 thus occupying an abnormal position. [Vide page 102.] Had this fact 
 been previously known to Von Amnion, and his incision directed much 
 more towards the inter-pubic space than towards the sacrum, the rectum 
 would doubtless have been easily opened. (Opus Citatum, S. 48.) 
 
 EXPLANATION. 
 
 Figure 1, represents a front view of the pelvic region of this case. The 
 scrotum and penis are much corrugated, and drawn closely to the abdo- 
 men, the latter presenting a para-phimosis congenita. The right half of 
 the scrotum is turgid, and contains the ttisticle, w^hilst the left half presents 
 less turgesence, the testicle not having descended into it. 
 
 After Von Ammon. 
 «, a. — The interior parietes of the abdomen. 
 b. — The symphysis of the pubis. 
 c. - The scrotum. 
 d. — The penis. 
 
 f. — The right half of the scrotum. 
 /', q. — The dilated rectum. 
 
 //, /. — The colon with its sigmoid flexure much smaller in diameter than 
 natural. 
 
 Figure 2, represents a side view of a portion of the contents of the 
 j)e]vis. 
 
 After Von Ammon. 
 a. — The rectum. 
 
 '^- — 'f he rectum terminating blindly in a conical point beneath the penis. 
 '■•. — The bladder opened from the side. 
 d. — The urethra opened from the side, 
 f- — The artificial orifice made at the normal situation of the anus. 
 
 Figure 3, presents a po.-terior view of the contents of the pelvis. 
 
 After Von Ammon. 
 a, a. — Both halves of the scrotum. 
 h. — A probe indicating the entrance and the direction of Von Ammon's 
 
 incision behind the rectum, and between it and the sacrum, 
 f, c. — The superior part of the rectum descending in the form of a cone 
 
 in front of the incision. 
 (■?, d. — The intestines, 
 f, e. — The interior surface of the peritongeum.
 
 PlateXlV. 
 
 Fuf. 1.
 
 PLATE XV. 
 
 Plate XV. gives representations of the operation for the formation of 
 abdominal artificial anus. 
 
 EXPLANATION. 
 
 Figure 1, presents a front view of the surgical relations of the colon. 
 
 After Bernard and Huette. 
 a^ a. — The integuments. 
 h, h. — The external oblique muscle. 
 c. — The internal oblique muscle. 
 d. — The transversalis muscle. 
 e. — The lower edge of the liver. 
 /. — The distended caecum. 
 
 g. — The descending colon with the sigmoid flexure seen below. 
 h. — The transverse colon. 
 
 Figure 2, presents a posterior view of the parts concerned, as shown by- 
 removing the dorsal structures. After Bernard aud Huette. 
 
 a. — The peritonaeum. 
 
 It. — The kidney. 
 
 c. — The mesentery. 
 
 d. — The bowels. 
 
 e. — The colon. 
 
 /. — The spine. 
 
 Figure 3, represents the operation of Littrd for the formation of an 
 artificial anus at the right groin. After Bernard and Huette. 
 
 a, a. — The outline of the colon. 
 
 h, b. — The extent of inguinal incision in the integuments. 
 
 c, c. — An instrument passed beneath the distended colon, in order to 
 bring it to the front wound. 
 
 d. — The point of the colon which is to be perforated. 
 
 Figure 4, represents the shape and appearance of the anus formed by 
 the operation of Littre'. The long diameter of the opening corresponds to 
 the line of the groin, and the bowel is so attached to the edges of the in- 
 cision in the abdomen as to prevent contraction of the orifice, or the escape 
 of the bowel into the abdomen. After Bernard and Huette. 
 
 Figure 5, represents the operation of Littre', as modified by Pillore. 
 Section of the ca;cuni. After Bourgery. 
 
 Figure 0, represents Pillore's operation for iliac artificial anus completed. 
 The wound in the intestine united to the wound in the integument by six 
 I <;ints of twisted suture. After Bourgrry.
 
 PlahnXV 
 
 l'i(j . I . 
 
 Fiq. Z 
 
 d.. 
 
 "iW^.'^^^* 
 
 Fiuf 3 
 
 'A^^^^£-'^^^ 
 
 Fia. 
 
 '%%^ 
 
 d: :%
 
 PLATE XVI. 
 
 Plate XVI. illustrates Callisen's operation for abdominal artificial anus, 
 as modified by Amussat. 
 
 EXPLANATION. 
 
 Figure 1, represents the operation of Amussat, for tlie formation of aa 
 abdominal anus in the left lumbar region. 
 
 After Bernard and Huetle. 
 a. a. — The outlines of the descending colon. 
 6, 6. — The extent of the incision in the integuments. 
 
 c, c. — An instrument placed beneath the bowel to render it prominent. 
 
 d, d. — Ligatures passed through the bowel in order to attach it to the 
 
 sides of the wound, before it is perforated. 
 Figure 2, represents the appearance of the artificial anus formed in 
 Amussat's operation, showing the position of the sutures and the character 
 of the opening. After Bernard and Huette. 
 
 Figure 3, represents the lumbar artificial anus established bj' Amussat. 
 
 After Bonrgery.
 
 PlaLeXVl 
 
 F"J ' 
 
 .^^ia^^~ 
 
 Fvg 3 
 
 Ftg. Z
 
 ON THE 
 
 CONGENITAL MALFORMATIONS 
 
 OF THE 
 
 RECTUM AND ANUS. 
 
 CH^I^TER I. 
 
 INTKODUCTION. 
 
 SECTION L 
 
 BIBLIOGRAPHY. 
 
 A. 
 
 Adair (William.) Medical Facts and Observations. Vol. 
 
 IV. p. 27. London: 1793. 
 Adrian! (Petrus.) Ruyscli. Adversaria Anatomica. decad. II. 
 
 (J. 10. p. 43. 
 Ainswortli (S. F.) Boston Medical and Surgical Journal. 
 
 Vol. LVII. p. 239. Boston: 1857. 
 Albucasis. De CTiirurgia. Lih. II. cap. 79. Argent : 1532. 
 
 Folia. 
 Alix (Mat Franc.) Ohservata Chirurgica. tome III. p. 203. 
 
 Altenhurg : 1774. 
 Allen (Robert.) System of Pathological and Operative 
 
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 Amatus (Lusitanus.) Guratiomim Medicinalium. Cent. II. 
 
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 Ammon (Friedricli August Von.) Pie Angeborenen Chirur- 
 
 giscJien Kranldieiten des Menschen in Ahhildungen dar- 
 
 gesteUt und durch erlduternden Text erhldrt S. 40. 43. 
 
 Tal. X. XI Berlin: 1842. 
 
 17 2
 
 18 IXTIiODUCTTON. 
 
 Amussat (J. Z.) Histoire cfune Ojperation d^Anus artifi- 
 ciel jpn^atique avec sucees jpar un nouveau Procede, da/ns 
 un cas d ''Absence congeniale de I Anus ; suivie de quel- 
 ques reflexions silt les Obturations du Mectum. Lu d I ' 
 Academie des Sciences, le 2 Novembre. 1835. {Gazette 
 Medicale de Paris. 28 Novembre. 1835.) 
 
 Memoir e sur la Possihilite d ' etablir tin Anus artificiel 
 dans la Pegion loinbaire sanspenetrer dans le Peritoine. 
 Lu a I Academie Royale de Medicine, le I er Octobre, 1839. 
 Peuxieme Memoire sur la Possibilite dHablir un Anus 
 artificiel dans les Regions lomhaires sans wvrir le Peri- 
 toine. Lu a I Academie Poyale de Medicine. 6 Septembre, 
 1841. 
 
 Troisieme Memoire sur la Possibilite d^ etablir une ouver- 
 ture artificielle sur le Colon lombaire gauche sans ouvrir le 
 Peritoine, chez les Enfans imperfores. Lu d I Academie 
 Poyale des Sciences, le 4 Juillet, 1842. {JO Examinateur 
 Medical de Paris. Annee 1843. Nos. 16, 17, 18.) 
 
 Andral (G.) Precis d Anatomic Pathologigue. tome L. p. 
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 Andrews (S. L.) Peninsular Journal of Medicine and the 
 Collateral Sciences. 1839. 
 
 Arand ( ) Observat. Med. Chirurg. observ. LY. ])- 28. 
 
 Aristotle. De Generatione Animalium. Lib. LV. C. 4. 
 in fin. 
 
 Arnott (James.) Lectures on the Diseases of Lnfancy and 
 Childhood. By Charles West. Lecture XXXL. p. 376. 2c? 
 Amer. Edit. Philccdelphia : 1854. 
 
 Asliton (T. J.) A Treatise on the Diseases, Jnjxiries and Mcd- 
 f(yrmations of the Rectum and Anus. Chapter XIX. p. 
 326. London: 1854. 
 
 Aver ( ) Boston Medical and Surgical Journal. Vol. L VI L 
 p. 510. Boston : 1858.
 
 INTUODUCTION. 19 
 
 B. 
 
 Baillie (Mjittlicw.) Morh'id Anatomy, j^- ^^^- London : 
 
 1833. Ed. hy Wardrop. Also, Series of Engravings, p. 77. 
 
 Fasciculus. IV. Plate V. Figure 4. London : 1833. 
 Barbette (PjiuI.) Opera Chirurgico-Anatomica. Lih. I. 
 
 Cap. XIII. Lugd. Batac. : 1672. 
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 20 INTKODUCTION. 
 
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 22 INTEODTTCTION. 
 
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 INTUODUCTION. 25 
 
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 INTUODUCTION. 33 
 
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 SECTIOK II. 
 
 GENERAL REMARKS. 
 
 The rectum and its teriniiuil ap})aratus, the anus, like other 
 portions of the organization, are liable to malformations and 
 imperfections, the result of some extraordinary derangement 
 of the acts of the plastic energies at some period during the 
 evolution of the embryo or the foetus in utero. 
 
 From the remotest antiquity the congenital closure of the 
 anus or the rectum was noticed by the Greek, the Roman and 
 the Arabic physicians. They however looked upon it gener- 
 ally as beyond the power of art to remedy, and consequently 
 as possessing no interest in their estimation beyond that of a 
 lusus natui'CB. 
 
 These congenital vices of structure have been designated 
 
 by the terms — 
 
 Lnperforate Alius. — English. 
 
 Imperforatio. ] 
 
 Atresia Ani, v Latin. 
 
 Clausitra. ) 
 
 Imperf oration De V Anus. \ -p, -j 
 Impeiforation Du Rectum. \ 
 
 Yerschliessung Des Mastdarmes. — German. 
 
 There is however a manifest impropriety in the application 
 of some of these terms to many of the malformations of these 
 parts. Under the generic term — Imperforate A mis, malform- 
 ations of the anus and the rectum are included which differ 
 essentially from each other, with regard to situation, form, 
 cause and result. It is therefore imj^roper to denominate a 
 case imperforate anus, in which the anus itself is pervious, 
 although otherwise malformed ; or in wliich the anus is per- 
 fectly natural, the deformity or imperforation being in the 
 rectum, more or less distant above the normal anus ; or in 
 
 which there is an entire absence of the anus. Each one of 
 [37]
 
 38 INTKODUCTION. 
 
 these terms is too exclusive in its signification to embrace all 
 the malformations of these organs, or to be used as a generic 
 term in relation to them, consequently not one of them can 
 ever be so used with propriety. 
 
 Some of these vices of conformation are by no means un- 
 common, and all of tliem are in a practical point of view, 
 more or less important. Many of them are remediable, and 
 as they generally admit of no delay in their treatment, but 
 demand prompt means for their relief, a knowledge of all the 
 medical and surgical measures which experience has decided 
 to be best adapted to remedy each particular deformity, is of 
 the utmost importance to every surgeon and accoucheur. In 
 the absence of such knowledge no practitioner in this respect 
 is able to discharge his professional duties with satisfaction to 
 the public, or with an easy conscience to himself. In these 
 instances nothing can be expected from any efforts of nature 
 towards eflecting any substantial relief. If no operation is 
 undertaken, death must soon follow from necessity. Nothing 
 will avail but some surgical interference, for Nature has not 
 dealt with the human species as she has with some of the in- 
 sect tribes, for instance the ant^ which according to the ob- 
 servations of the great natural historian Keaumur, has neither 
 an anus nor any intestinal excrements that can be perceived. 
 {Memoire pour Vllist. des Insect, tome vi. Mem. 10.) 
 
 No accoucheur should ever neglect the important duty of 
 examining minutely every infant immediately after its birth, 
 and for a day or two subsequently, to ascertain without a 
 doubt that there is an anal aperture, that the canal for some 
 distance above is pervious, and that the parts perform their 
 normal functions. Tliis important duty is too often neglected 
 by persons engaged in the practice of midwifery. Tliere is 
 one thing, however, that is scarcely ever neglected, especially 
 by female accoucheurs and monthly nurses, and that is the 
 pernicious practice of thoroughly purging new-born infants, 
 irrespective of circumstances. One of the pleas set up for
 
 INTKODUCTION. 39 
 
 admin isteriug the v;iri(»iis nauseating- clniuglits to which new- 
 born children are subjected, is tlie great dread in southern 
 climates of trismus nascentiwm / the popular and erroneous 
 idea being that trismus is the necessary result of retained me- 
 conium. This practice is especially pernicious in cases in 
 which there is a permanent obstruction in the lower bowel 
 from malformation. In such cases it is obvious that purgative 
 medicine would prove not only useless, but highly injurious ; 
 indeed physic or improper food either would only induce pa- 
 roxysms of pain and vomiting, and hasten the fatal result. — 
 Tlic little sufferer thus often falls a victim, either to ignorance 
 or to a false philanthropy. It would be far better and much 
 more humane to suffer such patients to die slowly of inani- 
 tion, than to torture them to death rapidly by the free use of 
 improper food or medicine. In hopeless cases, if absolute 
 diet is enjoined, it is surprising how long the little patients 
 will survive apparently with but little suffering before they 
 succumb to the effects of inanition. Professor Dewees men- 
 tions two cases in point, " Dr. Hallam delivered a patient 
 of a fine muscular, fat and healthy child, which had an im- 
 pervious oesophagus, so that no food ever passed into the sto- 
 mach. The child lived thirteen days, but was so wasted that 
 its skin hung like a loose garment, and could be lapped and 
 folded over its limbs." In another instance says Dr. Dewees, 
 " a child was born with every external appearance of healthy 
 conformation, but upon attempting to give it a little molasses 
 and water, it had nearly strangled. Upon looking into its 
 mouth, it was discovered that there was no vault to it ; neither 
 was there a vestige of soft pallet. It never swallowed a drop 
 — ^indeed every attempt w^as followed with such terrible dis- 
 tress by the fluid passing into the trachea, that the trial w^as 
 abandoned. It lived ten days — became extremely emaciated 
 and very yellow^" {A System of Midwifery^ p. 215. Phil. 
 1832.) Food, in all cases of obstruction of the anus or the rec- 
 tum from malformation, should be very cautiously adminis-
 
 40 INTRODUCTION. 
 
 tered. or altogether proscribed, with the exception of the mo- 
 ther's milk, or a little sugar and water, until the obstruction 
 is removed ; and if this cannot be accomplished and death is 
 inevitable, let this event take place gradually by inanition, 
 rather than speedily by repletion. Purgative medicines in 
 all such cases are entirely inadmissible ; although I am aware 
 that some able surgeons advise them for the pui'pose of forc- 
 ing down, if possible, the end of the rectum preparatory to 
 searching for it. 
 
 It is generally believed that the congenital malformations of 
 these parts are quite unconmon. Mr. AVest says that " The 
 affection (meaning imperforate anus) in any form is so rare as 
 to render a correct estimate of the comparative frequency of 
 its varieties by no means easy." {Lectures on the Diseases of 
 L fancy and Childhood., Amei'ican Edit. p. ^74:. Phil. 185-t.) 
 Mr. Collins says that he only observed one instance of it out 
 of 16,645 children born in the Dublin Lying-in Hospital, dur- 
 ing his Mastership. {System cf Midwifery ., p. 509.) Dr. Lohrer 
 of Vienna says that he met w^itli it only twice out of 50,000 
 
 new-born children. {Constatfs Jaliresber fur 1842. Band I. 
 
 S. 456.) 
 
 Notwithstanding these statements, I am of the opinion that 
 these malformations in some form or other are of much more 
 frequent occurrence than is generally conceded, and that ma- 
 ny children born with some one or other of them, are sufiiered 
 to perish for want of proper and timely surgical assistance 
 through either the ignorance, the neglect, or the mismanage 
 inent of midwives and monthly nurses, l^one doubtless but 
 the most desperate and the most remarkable cases are evei 
 reported, the rest being either entirely overlooked, or passed 
 by unrecorded. But few cases appear to have occurred to 
 the older surgeons, in consequence no doubt of the general 
 employment of ignorant midwives, who, even if they discov- 
 ered them, never revealed nor recorded them. These several 
 circumstances may account for the paucity of information up-
 
 INTRODUCTION. 41 
 
 on tliis subject among the old, and to some extent also among 
 the modern surgeons. It is therefore impossihlc IVom the data 
 before me to draw any satisfactory conclusions on the subject. 
 
 SECTION III. 
 
 ETIOLOGY. 
 
 "With regard to the primary cause which determines these 
 or other congenital vices of conformation, nothing of a defi- 
 nite, or of a satisfactory character has yet been ascertained. 
 The science of embryology which is now being so successfully 
 cultivated, teaches that at any period during the evolution of 
 the embryo or the foetus, the action of the formative energies 
 in any part of the organization, may be so aifected, or so influ- 
 enced, as to become either partially or wholly suspended, or 
 augmented, and result in the production of imperfect or anom- 
 alous organs, or in an entire want, or non-production of them. 
 This is doubtless the source of many of the congenital mal- 
 formations observed in the anus and the rectum ; but as the 
 first or primary cause of this disturbance, or of this interrup- 
 tion of the plastic forces, is yet beyond our knowledge, and 
 merely conjectural, all in relation to it therefore, is hypoth- 
 esis. 
 
 Might not the result of power acting upon the foetus in 
 utero through the imagination, or the feelings of the mother, 
 be the cause of malformations ? Is it at all possible for the 
 'maternal imaginatio7i to be so wrought upon as to cause a 
 partial or a total arrest of development, or an excess of devel- 
 opment in any portion of the foetus ? Will any one deny 
 that a sudden fright of the mother might not be sufficient to 
 destroy the life of the foetus? or refuse to admit that vivid 
 and prolonged impressions of the mother, of whatever cliarac-
 
 42 INTRODUCTION. 
 
 ter, miglit not give rise to disease in the foetus, and such 
 disease ultimate in tlie malformation of some organ ? Might 
 not some of these malformations occur associated with certain 
 congenital and hereditary diseases, in the relation of cause 
 and effect ? 
 
 MM. Serres, Geoffroy Saint-IIilaire and Eoux de Brig- 
 noles, concur in opinion that the congenital malformations of 
 the anus and the rectum depend upon the deviation, the 
 imperfection, or the absence of the hfemorrhoidal arteries. 
 Indieed their opinion is that the evolution of the organs in the 
 foetal state proceeds in a strict ratio with their supply of 
 blood ; consequently that the imperfection, atrophy, or absence 
 of the organs generally, is attributable to the imperfection, or 
 the absence of their nutrient arteries. 
 
 According to M. Serres, the incomplete development, or 
 absence of a part depends upon deficient development of the 
 artery which should convey to it the materials for its nutri- 
 tion. If the artery is only partially developed, the part to 
 which it is distributed remains in a state of atrophy ; if it is 
 totally wanting, the organ does not exist. M. Beclard in com- 
 menting upon this last assertion of M. Serres, says that it 
 seems natural enough that the artery of a part should be want- 
 ing, when the part itself did not exist, and that it seemed 
 impossible for him to decide which of these two facts, the 
 absence of the organ, or the absence of the artery, was the 
 cause or the effect ! 
 
 Tiedemann, on the contrary, believing that the nervous sys- 
 tem was developed before any of the other parts of the body, 
 was of opinion that congenital malformations or anomalies 
 depend upon the imperfection, or the want of certain portions 
 of the nervous system. He found that whenever certain por- 
 tions of the nervous system were defective or missing, the 
 part to which such nerves were, or would have been distrib- 
 uted in the normal state, was also correspondingly defective
 
 INTRODUCTION. 43 
 
 or wanting-. lie is of opinion that tlio nervous system con- 
 trols the Ibrnuition and development ol" the; embryo, and 
 determines the particular form and disposition of the organs — 
 hence he concludes that most deformities have their fii-st cause 
 in the irregular development of this system. (London Medical 
 and Physical Journal^ July, 1820. Also Edinburgh Medical 
 and Surgical Journal, January, 1829.) 
 
 Tiedemann, in my opinion, has by no means proved clearly, 
 as he pretends to have done, that the nervous system is devel- 
 oped before the sanguineous, that it determines the particular 
 form and disposition of the oi'gans, and that its imperfection 
 is a first cause in the production of deformities, &c. The evi- 
 dences, on the contrary, are decidedly in favor of the view 
 taken by M. Serres, namely, that it is the imperfection of the 
 arterial system, -svliich, in fact, exerts such powerful influence 
 in the production of malformations. 
 
 M. Andral sets forth the principle that whenever a part of 
 an organ is imperfectly formed, or found to be partially or 
 wholly wanting, those parts that precede it in the normal state 
 have themselves undergone an arrest of development, to a 
 greater or less extent. {Precis d'' Anatomic Pathologique, 
 tome 1. p. 109. Paris : 1829.) 
 
 But these highly distinguished authors entirely fail to give 
 the primary cause of these malformations. The question still 
 remains unanswered ; and it might still be asked them too, 
 with propriety — what is the cause of the deviation, the imper- 
 fection, or the absence of these arteries, or of these nerves ? 
 A logical mind can hardly be satisfied with the explanations 
 they have given. The truth is, that all we hnoio with cer- 
 tainty is, that we hnow nothing certain on the subject ; and 
 it yet remains a problem for future organologists to solve. 
 
 Some of the organologists endeavor to prove that all con- 
 genital malformations or anomalies have their origin in 
 " arrested development,^'' which theory is now erected into a
 
 44 
 
 INTRODUCTION. 
 
 law by Meckel and Geoffroy Saint-Hilaire, and most ingen- 
 iously illustrated by Serres in his various wori^s on transcen- 
 dental anatomy, and by Isodore Geoffroy Saint-Hilaire {tlie 
 son) in his work on Teratology. Tliis theory has been carried 
 BO far that some of its enthusiastic advocates even contend 
 that " a woTYian is only an imperfect or incomplete man / a 
 man arrested in his develop') nent.^^ This law, however, fails 
 to apply to a number of the congenital irregularities of struc- 
 ture, of not unfrequent occurrence, so that M. Isodore Saint- 
 Hilaire has been compelled to add another law — that of 
 " execs de developpement^^ in order to account for some of these 
 anomalies ; his father Geoffroy Saint-Hilaire, however, attrib- 
 utes all such to certain accidents during foetal life ; whilst 
 Meckel reo-ards them as the results of disease in the ovum. 
 But it was not my intention, neither does it fall within the 
 scope of this work, to enter minutely into the subject of the 
 cause of these congenital imperfections; and as I have 'per- 
 haps already devoted too much time to it, I must not any 
 longer detain the reader by instituting any further examin- 
 ation into the theories of these authors ; nor into that which 
 attributes all the congenital defects to the principle " of the 
 original germ heing imperfect / or of its becoming so after 
 impregnation^ Those readers who wish to know more on 
 this most important and curious subject, and to trace the her- 
 culean labors of the distinguished organologists, the immortal 
 Geoffroy Saint-Hilaire, who was one of the most profound 
 and indefatigable men of France in his day : the celebrated 
 Prof J. F. Meckel of Halle in Germany, whose reputation 
 as an anatomist and as a man of profound science is unequaled, 
 and M. Serres one of the most accomplished and distinguished 
 anatomists of France, will find it of infinite advantage to con- 
 sult their writings. 
 
 There are some of the congenital malformations of the anus 
 and rectum which do not depend upon either an arrest of, nor 
 on an excess of development, but are the result of disease in
 
 INTUODUCTION. 45 
 
 iiitra-utcriiie life. A few such cases have coiue under my 
 own observatit>u. For instance the anornuil narrowing or 
 contraction of the anus, which is sometimes observed in new- 
 born children, and which, when attended with more or less 
 thickening and induration of the integument, is the result of 
 inflamuuition of the anus during foetal life. At other times 
 this congenite contraction is caused by a preternatural activity 
 of the sphinctores ani muscles. In such a case the coarctation 
 from being at first purely spasmodic, may gradually become 
 organic and permanent. 
 
 Obliteration of the anal aperture, or of the rectum for a 
 greater or less distance above the anus, may be caused by 
 rectitis during foetal life. In such a case the inflammation 
 within the rectum causes, in process of time, a coalescence of 
 its parietes, and thus produces the malformation in question. 
 The same may ultimately result froin permanent contractions 
 of the anus and the rectum. 
 
 Peritonitis may occur during intra-uterine life, giving rise 
 to adhesions between the intestines, aud to effusion of lymph 
 and serum into the abdominal cavity, and thus occasion mal- 
 formations, if not the death of the foetus. 
 
 M. Desormeaux records the case of a child whom at birth 
 displayed all the evidences of violent enteritis, but afterwards 
 recovered. He is of opinion that the congenital contractions 
 and obliterations of hollow canals — such as the oesophagus, 
 intestinal canal, anus and urethra, &c. ought to be referred to 
 the influence of previous inflammation. {Dlctionnaire de 
 Medicine de Paris, tome XY. j). 403.) 
 
 Dnges relates the case of a new^-born child, in whom the 
 abdominal viscera were found agglutinated by a yellow col- 
 ored and firm lymph. There were false membranes on the 
 liver, the spleen, the bladder, &c. The epiploon was adher- 
 ent to the intestines, which were agglutinated into a lump, 
 were yellow, hard and thick. {ReoherGhes sur les Maladies
 
 46 iNTRODUCriOKi 
 
 les plus importantes et les moins connites des enfans noit- 
 veaux — lies. Paris. 1821.) 
 
 Otlier instances, of the eflfects of former inflcanimation in the 
 intestines of new born children, are related by the following au- 
 thors — M. Billard. {Traite des Maladies des Enfans nmtveaux 
 — iicset d la Mamelle, p. 441. Paris. 1828.) Cams. {Lehrhuch 
 der Gynah>lag.i^. Band. 11. S. 251. Leipzig. 1820.) M. Cruveil- 
 hier. {Anatomie PatJiologiqae dii Carps Ilamain. Livraison. 
 XV. PI. XI. p>. 2. ols. 2. Bruxelles : 1833.) 
 
 It is not easy to determine to what cause these diseases of 
 intra-uterine life should be attributed, at a time when the 
 foetus in utero is so completely protected from all those influ- 
 ences from without which may induce inflammation after 
 birth. 
 
 Sex has been supposed by some to exercise great influence 
 in the production of defective congenital develojjments. It is 
 most certainly true that malformations are most common 
 among males ; but why it should be so seems to me not easy 
 of explanation. 
 
 SECTION lY. 
 
 ANATOMICAL AND PATHOLOGICAL CHARACTERS. 
 
 The congenital malformations of the anus and the rectum 
 present a great variety of forms, from the most simple to the 
 most complicated, so that it is by no means an easy task to 
 enumerate and to describe them, M. Guersant says that he 
 has ■ operated on more than thirty cases, and that each and 
 every case was dissimilar. {Gazette des Ilopltaux. No. 
 LXX. p. 280. Paris : 1857.) 
 
 I will now consider the anatomical and the pathological 
 conditions which constitute the most common of these vices 
 of structure.
 
 INTRODUurloN. 47 
 
 1. The anus may be more or less prctcmaturally naiTowed 
 at its margin and sometimes for a short distance above. This 
 congcnite coarctation, in such cases, is most always organic or 
 structural, yet sometimes, though not often, it is purely spas- 
 modic. 
 
 2. The marginal integuments of the anus may sometimes 
 extend over the border of the sphincter ani, thereby inducing 
 both deformity and contraction. 
 
 3. The anus and the rectum may be normal, but the simple 
 thin and delicate membranous septum of foetal life may still 
 exist, and thus produce a complete occlusion of the anal ori- 
 fice. The anal aperture too, is sometimes completely closed 
 by a very thick and hard membrane, or a substance analagous 
 to it. 
 
 4. The anus may be entirely absent, no sign whatever indi- 
 cating where it should be ; the scrotal raphe being continued 
 without interruption back to the coccyx. In such a case the 
 rectum may also be partially or entirely absent, and the 
 sphinctores ani, may or may not be present. 
 
 5. In the absence of the natural anus there may be a pre- 
 ternatural one, performing the functions of an anus, and 
 occupying some extraordinary situation. In these instances 
 the rectum may be partially or totally absent, and the colon 
 also may be wanting. 
 
 6. The rectum at some point in the pelvis more or less 
 distant above its natural outlet, may terminate in a cul-de-sac, 
 and either hang loosely or be attached to some of the sur- 
 rounding parts, there being no indication wdiatever of an 
 anus. 
 
 7. Tlie rectum may be interrupted at a variable distance 
 above a naturally formed anus, by a thin or thick annular 
 membranous septum like a diaphragm. Sometimes it is com- 
 pletely closed at several points by such membranous septa, its 
 diameter, however, at those points remaining undiminished,
 
 48 INTRODUCTIO?r. 
 
 and the canal, with the exception of these j)artitions being 
 entirely natural. 
 
 8. The anus being normal, the rectum for a greater or less 
 distance above it, may degenerate into a solid mass resem- 
 bling a cord, or be entirely wanting ; or this degeneration may 
 be confined only to its superior portion, and reassume its 
 cylindi'ical shape again as it approaches the anus, forming, as 
 it were a pouch at its inferior extremity. 
 
 9. The rectum may be completely obliterated throughout 
 its whole extent, by a thickening of its coats, its walls approx- 
 imating and firmly adhering as though glued together; or 
 this obliteration may take place at one or two points only in 
 the course of the rectum, the canal at these places appearing 
 as if tied with a tape ; the anus and intervening spaces being 
 natural. 
 
 10. The rectum may be present and present its cylindrical 
 form, whilst its cavity may be completely blocked up with a 
 substance of a cellulo-fibrous character; no anus being 
 present. 
 
 11. Tlie rectum may terminate in the bladder or the ure- 
 thra ; or in the vagina, or the uterus ; or in a cloaca in the 
 perinsEum, with the urethra and the vagina. In these in- 
 stances there is generally no sign of a normal anus ; yet some- 
 times, though rarely, it does exist, and permits the introduc- 
 tion of the end of the probe for a few lines. 
 
 12. Tlie rectum may terminate in the sacral region by an 
 abnormal anus ; it may be prolonged in the form of a fistulous 
 sinus, and terminate by an abnormal opening at difterent 
 points in the perinaeum ; at the glans penis, labia pudendi, 
 &c. In these cases the normal anus is generally absent. 
 
 13. The rectum may be entirely wanting and its place sup- 
 plied by a fatty cellular tissue. In these instances the colon 
 ends in a cul-de-sac, with or without a ligamentous appendage 
 in continuation, and is either ^dherent,or floats loosely in the
 
 INTKODUCTION. 49 
 
 pelvic, or abdoniiiuiml cavity. No iionnul {iims exists, but 
 sometimes an abnormal one does. 
 
 14. The rectmn and the colon may botli ])o absent. In 
 these instances there is no natural anus, but often a preterna- 
 tural one situated in some unusual or extraordinary region of 
 the body, communicating either with the cajcuni or some 
 portion of the small intestines. 
 
 15. With any of these malformations there may coexist iu 
 the same patient a further deformity of some of the neighbor- 
 ing sexual organs in a greater or less degree ; or of some 
 arrest of development — as fissure of the scrotum, witli the 
 glans penis and the meatus in the perinaeum, spina bifida, 
 the absence of a portion of an extremity, &c., &c. 
 
 I here consider it important, for the better understanding 
 of the subject, to give a short retrospective view of the history 
 of the development of the rectum and the anus. 
 
 These two organs, the rectum and the anus, in their evolu- 
 tion, like other portions of the organization, pass through 
 several types and degrees of development before they 
 attain that perfect form and arrxingement destined to 
 represent their permanent condition. The formative process 
 may be impeded at any one of these stages of development, 
 and cause such derangement of their evolution, as would more 
 or less interfere with their normal growth, and exhibit at 
 birth the precise character which was impressed upon them 
 when the liinderance first occurred. 
 
 In the early period of fcetal life the rectum and the amis 
 are isolated, the former is lodged in the abdominal cavity, but 
 it gradually descends into the pelvis to meet the latter ; tliey 
 both continue to progress, and to approach each other, attain- 
 ing their proper dimensions by successive accretions, the first 
 from the mucous and the second from the serous layer, and in 
 due time their extremities meet and coalesce, and the common 
 conduit is thus formed. Should arrest of development occur 
 at any period during this natural process, in one or the other of
 
 50 IXTKODUCTION. 
 
 these organs, or in both of them at the same time, various 
 malformations peculiar to each might be produced. 
 
 The rectum during embryonic life is confounded with the 
 bladder, the urinary and genital canals terminating in one 
 common cloaca — Whence a derangement of the formative pro- 
 cess, at this period, in either the rectum, or in any one of the 
 genito-urinary organs, might cause one or all of them to be 
 more or less defective — resulting in either a limited or an ex- 
 tensive imperforation of the rectum, or in some anormal com- 
 munication between it and the bladder, the urethra or the 
 
 '? 
 
 vagina. 
 
 At an early period of foetal life the anus, together with the 
 other external openings of the body, is covered with a peculiar 
 skin, somewhat analogous to that which covers the surface of 
 the body. Tliis skin, should the evolution of the fostus go on 
 naturally, becomes gradually thinner, appearing ultimately 
 as a peculiar secreting membrane, and is finally removed from 
 its situation over the anal orifice by absorption. Should this 
 normal process of absorption be arrested, or cease to go on, 
 however, this skin or membrane would remain stationary over 
 the anal aperture and consequently form an atresia ani. It 
 will thus be seen that in such instances of imperforation of the 
 anus, that the occluding skin or membrane was, in the early 
 stage of foetal existence, a normal formation.
 
 rSTUODUCTION. 
 
 51 
 
 SYNOPSIS. 
 
 The Congenital 
 Malformations ^ 
 of the Anus. 
 
 1. Preternatural narrowing. 
 
 2. Occlusion by a tliin int'inl)rane. 
 
 3. Occliision by a thick hard nicmbraiic. 
 
 4. Partial or complete absence. 
 
 5. Abnormal. 
 
 Occlusioyi of 
 the Meet am. 
 
 Obliteration of 
 the Mectuniu 
 
 The Congenital 
 Malformations \ 
 of the, Rectum. 
 
 Preternatwral 
 
 termination 
 of the Rectum. 
 
 Pretematiival 
 
 termination of 
 
 other organs %n 
 
 the Rectum, 
 
 "1. By one membranous 
 
 septum. 
 2. By two or more mem- 
 branous septa. 
 
 '1. By the agglutination 
 of its parietes, 
 
 2. By the j)uekering of 
 
 its parietes. 
 
 3. By the thickening and 
 
 the induration of its 
 parietes. 
 
 1. In a cul-de-sac. 
 
 2. In the bladder. 
 
 3. In the urethra. 
 
 4. In the vagina. 
 
 5* In a cloaca in the peri- 
 naeum with the vasri- 
 na and urethra. 
 
 6. In the ano-perinteal 
 
 region, at difierent 
 points. 
 
 7. In the sacral region. 
 
 1. Of the ureters. 
 
 2. Of the vagina. 
 
 3. Of the uterus. 
 
 Absence of the ( 1. Partial. 
 
 Rectum, 
 
 {I: 
 
 Complete.
 
 52 INTRODUCTION. 
 
 SECTION V. 
 
 CLASSIFICATION. 
 
 Taxing as a basis of classification, the anatomical and tlie 
 pathological condition of the various congenital malforma- 
 tions and imperfections of the anus and the rectum, I will dis- 
 tinguish them all into nine species, each one of which may 
 comprise a greater or a less number of varieties. In this ar- 
 rangement I have considered convenience and usefulness ra- 
 ther than an appearance of scientific precision, I am well 
 aware that it is not perfect, but I trust it will be found sufii- 
 ciently plain, comprehensive and correct for all practical jjur- 
 poses. Tliis division corresponds somewhat to that suggested 
 by Papendorf many years ago, whose divisions and definitions 
 of the congenital malformations of the anus and the rectimi^, 
 although quite imperfect, yet, are, for the purposes designed, 
 as good as any I have observed of a later date. {Dissertatio 
 sistens observationes \de ano infantum imperforato. Lugd, 
 Batav. 1781. Uo.) 
 
 FIEST SPECIES. 
 
 This species consists of a preternatural narrowing of the 
 anus at its margin, and occasionally extending a short distance 
 above this point. 
 
 SECOND SPECIES. 
 
 In this species there is a complete occlusion of the anal 
 aperture by a simple membrane ; or by the common integu- 
 ment, or a substance analogous to it, more or less thick and 
 hard. 
 
 TIIIKD SPECIES. 
 
 In this species there is no anus whatever, the rectum being 
 partially deficient and terminating in a cul-de-sac at a greater 
 or less distance above its natural outlet, without any commu- 
 nication whatever, either externally or internally.
 
 TNTRODUCTIOJr. 53 
 
 FOURTH SPECIES. 
 
 The anus in tliis species is normal, but the rectum at vari- 
 able distances above it, is either deficient, obliterated, or com- 
 pletely obstructed by a membranous septum. 
 
 FIFTH SFECIES. 
 
 In this species the rectum terminates externally by an ab- 
 normal anus, located in some unnatural situation, as at some 
 point in the sacral region ; or the rectum is prolonged in the 
 form of a fistulous sinus and terminates by an abnormal anus, 
 at the glans penis, the labia pudendi, or at different points in 
 the perinagum. The natural anus being generally absent, its 
 functions are performed by the abnormal one. 
 
 SIXTH SPECIES. 
 
 Tlie rectum in this species opens preternaturally into the 
 bladder, the urethra, or the vagina ; or into a cloaca in the 
 perinseum with the urethra and the vagina. In these 
 instances the normal anus does not generally exist. 
 
 SEVENTH SPECIES. 
 
 In this species the rectum is normal, with the exception 
 that either the ureters, the vagina or the uterus, open preter- 
 iiiiturally into it 
 
 EIGHTH SPECIES. 
 
 In this species the rectum is entirely wanting. 
 
 NINTH SPECIES. 
 
 In tbis species the rectum and the colon are both absent, 
 ,and there is usually an abnormal anus situated in some extra 
 .ordinary part of the body.
 
 '.54: INTKODUCTION. 
 
 SECTION VI, 
 
 GENERAL SYMPTOMS. 
 
 Should any of these congenital vices of structure have jm- 
 fortunately escaped the observation of the accoucheur or the 
 nurse at the time of the hirth of the child, its existence in the 
 majority of instances would sooner or later manifest itself by 
 a train of morbid phenomena simulating, strangulated hernia,, 
 the result of the retention of the meconium and other matter. 
 K no alvine dejections take place within twelve or twenty- 
 four hours after birth, the child gradually becomes restless,, 
 and by its peculiar plaintive cries manifests the suifering it 
 now begins to endure. These cries are generally attributed 
 by the nurse, to colic, and the little suiferer is treated accord- 
 ingly with all kinds of medicines, but generally to none but 
 the worst of purpose. The abdomen, especially in the hypo- 
 gastric region, now becomes enlarged, tense, hot, shining, and 
 painful upon pressure, the respiration becomes difficult and 
 irregular, and the pulse frequent, small and contracted. To 
 these symptoms, if no amendment soon takes place, vomiting 
 will be added, first, of all the milk and other fluids swallowed, 
 then of the mucous and biliary secretions, and finally, of the 
 meconium, or a dark brownish matter analogous to it» 
 Should no relief still be afforded the little sufferer, these 
 symptoms will become augmsented in violence ; the diaphragm 
 and other abdominal muscles will become excited to violent 
 expulsive efforts, during which respiration will sometimes 
 become suspended, the face will become swelled, discolored 
 and covered with perspiration ; the voice sooner or later will 
 become almost extinct ; there will be hiccup, with coldness- 
 and flexure of the extremities and convulsions. In the male,, 
 inflation of the scrotum and penis sooner or later takes place. 
 Should matters thus continue, death is inevitable and is soon 
 ushered in ; and it usually takes place between the third and 
 the eighth day, according, to the vigor of tlie little patient.
 
 INTliODUCTION. 55 
 
 Before death occurs there is often a ^^encral yellowness oi' tlie 
 skin. When the case is protracted for a number of days the 
 emaciation becomes extreme, and the patient dies from the 
 etfects of inanition. 
 
 Strange to say, that cases of complete occlusion of the rec- 
 tum have occurred, in which life had been prolonged for a 
 number of days, and even for months witliout any evacuation 
 from the bowels, and before any violent symptoms had taken 
 place. 
 
 Wolf mentions a case of imperforation of the anus and rec- 
 tum in which, strange to say, the deformity was not discover- 
 ed and no unfavorable symptoms manifested themselves until 
 the evening of the twelfth day, the child during this time not 
 having had any motion from its bowels, when it was attacked 
 with vomiting, hiccup and convulsions, attended with disten- 
 tion and hardness of the abdomen and great prostration. 
 [Yide Case LIX.] 
 
 A still more remarkable case of imperforate rectum is re- 
 ported by Dr. A. B. Shipman of Courtlandville, in the State 
 of New- York. In this instance the child lived three months 
 without passing anything from its bowels. He says the child 
 was nearly as large as ordinary children of that age, and was 
 not afflicted with vomiting or crjang more than many are, 
 who are considered healthy. [Yide Case XXIX.] 
 
 Mr. West says that Mr. Arnott communicated to him a case 
 in which the child lived seven weeks and three days, the rec- 
 tum being entirely absent, and the colon terminating in a 
 blind sac, and floating loosely in the abdominal cavity. {Ojj. 
 cit.p. 376.) 
 
 De La Marre mentions an instance of a child having an anal 
 imperforation, which lived six months without ever having 
 had any evacuation from its bowels. In this case the milk 
 and everything else taken into the stomach were constantly 
 ejected by vomiting. {.Journal de Medlcme de Paris, annee. 
 1770. tome XXXIIL ^. 510.)
 
 56 INTBODirCTION. 
 
 A case is reported iii tlie " Provincial Medieal and Surgi- 
 cal Journal " for March, 1851, in which a child having an im- 
 perforate anns lived one hundred and two days without hav- 
 ing any evacuation from its bowels, and dm-ing this time 
 never vomited. 
 
 Death in instances of imperforation of the anus or the rec- 
 tum, is usually the result of enteritis, peritonitis and intestinal 
 paralysis. 
 
 Sometimes previous to death in consequence of the violent 
 expulsive efforts to overcome the obstruction, the colon, or 
 some other portion of the intestinal canal bursts, and its con- 
 tents are poured into the peritonseal cavity, death being 
 ushered in by the sudden supervention of a state of collapse. 
 A. case of this kind is related by M. Fourcade. {RevueMedi- 
 cale de Paris, annee. 1830. tome VI. y. 52.) 
 
 On dissection, the intestines will be found enormously dis- 
 tended with gas, meconium and other matters, and highly 
 inilamed. 
 
 The distention or tympinitic state of the abdomen in these 
 cases is caused, in part, by the disorganization which, at an 
 early period takes place in the contents of the intestines, by 
 which great quantities of gas are disengaged. The intestinal 
 nerves become affected, hence the spasms. The blood vessels 
 of the lower extremities too, become compressed, and this 
 comj^ression induces congestion of the heart, lungs, and brain. 
 This phenomenon is very evident when the distended cavity 
 of the abdomen presses upon the thoracic viscera. The com- 
 pressed lungs no longer admit full respiration ; the vital 
 transformations of the blood are inadequately made, and at the 
 same time, as the excrementitious matters of the body cannot 
 be carried off by defecation, the composition of the blood 
 becomes such as no longer to afford any nourishment to the 
 vital organs. 
 
 Conjointly with the general signs of intestinal obstruction, 
 there are in each case some special indications of the peculiar
 
 INTRODDCrriON. 57 
 
 form of niixlforination to which the obstruction is due. These 
 special symptoms will be fully given in the following clia})ters, 
 on the different species of malformation. 
 
 The pathognomonic sign is obtained by the direct inspection 
 of the anus and the rectum. 
 
 SECTIOi^" VII. 
 PROGNOSIS. 
 
 Anciently the malformations of the anus and the rectum, 
 together with those of the genito-urinary organs, were looked 
 upon as necessarily fatal, and the unfortunate victims of them 
 were regarded in the light of monsters, and left to perish. 
 Even at tlie present day this sentiment prevails to a certain 
 extent, and the subject is still surrounded by no inconsider- 
 able degree of mystery, the most insignificant deviations from 
 the natural standard being apt to be exaggerated and invested 
 with an importance which by no means legitimately belongs 
 to them. 
 
 When we take into consideration the fragility of the sub- 
 jects, the deplorable nature of some of the species of these 
 malformations, and the formidable character of some of the 
 operations 'necessary for their relief, the hope of ultimate suc- 
 cess does indeed appear but slight ; yet such are the great 
 improvements that have been, and are being made in modern 
 surgery, that the evil is by no means deplorable, even in some 
 of the w^orst cases, as will be shown hereafter. 'No case 
 should be abandoned in despair, although surrounded by the 
 most discouraging circumstances. Many of the cases may 
 be relieved immediately by simple and appropriate trea-tment, 
 and others admit of certain relief, by prompt surgical meas- 
 ures, which not only save, but prolong life, Tlie surgeon
 
 58 INTRODUCTION. 
 
 must be very careful, however, not to promise the parents or 
 the friends of the child too much even in the most simple 
 case, recollecting how natural it is for them to imagine that 
 if the operation succeeds, all will be well, and that the child 
 will be left in every respect perfect. This would be a great 
 mistake, as every surgeon knows who has had any experience 
 in endeavoring to remedy defective formations. Therefore, to 
 prevent misconception on this point, and the evil conse- 
 quences of it, the surgeon must previously explain to them 
 that the operaition may indeed afford an outlet and immediate 
 relief ; but that such an artificial opening or anus, not being 
 formed by nature for the specific purpose, cannot be expected 
 to possess all the powers or to perform all the functions of 
 which the natural anus would have been capable. 
 
 The most favorable cases of course are those which require 
 the least surgical assistance — such in which there is a con- 
 traction of the anal orifice, and requires but simple dilatation, 
 or such in which the anal orifice is obstructed by a membrane 
 which only requires to be divided. 
 
 Tlie most formidable cases are those in which there is a 
 considerable deficiency, or an entire absence of the rectum, 
 and in which there exists no outlet whatever. In all such 
 cases, without an operation, death soon takes place from 
 necessity. Some surgeons, however, consider all such cases 
 necessarily fatal, and beyond the power of art to remedy : 
 yet, as I will hereafter show, even a number of such cases have 
 been relieved, by either the operation of proctoplasty or colot- 
 omy. In such a case even a doubtful remedy should be 
 2)referred and attempted in preference to the certain death of 
 the infant, 
 
 Tliose cases in which the rectum opens into the bladder by 
 an abnormal anus, or into the urethra, or the vagina ; or in 
 which there exists a preternatural anus on some part of the 
 body, are not so formidable and do not terminate in death so 
 quickly. Some of them may be entirely relieved, others
 
 INTRODUCTION. 39 
 
 greatly benefitted, whilst otliera again admit of palliative 
 treatment only. 
 
 Some very remarkable cases are recorded of life having 
 been sustained and prolonged for days, months, and even 
 vears, in which no anus whatever existed, nor in which had 
 any operation been performed. In these instances there was 
 consid(^-able deformity too of the genito-urinary organs, 
 
 A man forty years of age was seen by Bartholin, in whom 
 no anus existed, but who discharged his fseces from his mouth 
 by means of a horn, made for the purpose, and who voided 
 his urine from the umbilicus. {Historia Anatomicce, cent. I. 
 ohserv. LXV. f, 113.) 
 
 Baux saw a girl fourteen years old who had neither an anal, 
 a genital, nor a urinary opening. There was not the least 
 appearance of these apertures, the skin being smoothly contin- 
 ned over the situation naturally occupied by them, as on other 
 parts of the body. At the end of every third day she experi- 
 enced considerable pain around the umbilicus, and immediately 
 after would eject faecal matter by vomiting. Her urine was 
 entirely voided by the nipples every three or four hours. 
 This girl was well formed in other respects, and of a veiy 
 agreeable person. She had a good appetite, slept well, and 
 had general good health. {Journal de Medicine de Paris 
 tome YIII. J). 59.) 
 
 These, however, are extraordinary cases, they form the 
 exception to the rule, and they must not lead the practitioner 
 to the conclusion that in cases similar no operation for their 
 relief should be undertaken. !No one will dispute the neces- 
 sity of an operation in a case of atresia ani, because single 
 cases have been known to exist in which children have lived 
 for days, months, and even years without such surgical inter- 
 ference. Tlie observation made by the celebrated Callisen 
 many years ago, still stands firm, and must not be forgotten. 
 " The. atresia ani," says he, " will certainly be followed by 
 death, unless a passage is formed and maintained." (Sy sterna 
 Chii'urgie^ Hod. tome II. p. 840. Hqfnice. 1800.)
 
 60 mTRODUCTION. 
 
 The operation for the establishment of an artificial anus, 
 either in the perinaeum, or in the abdomen, seems so grave a 
 one for a child at so tender an age, that many surgeons 
 decline it altogether. This consideration alone, however, 
 should by no means deter the surgeon from operating, for it 
 is an established fact, and the knowledge of it should be more 
 universally known — that children sustain an operation much 
 better soon after birth, than at a later period. This is doubt- 
 less in consequence of the small vital development of new- 
 bom children, who, in this respect, are similar to the inferior 
 animals. This analogy rests upon the recuperative power 
 common to them both, by virtue of which wounds in both 
 are followed by very slight inflammation, or even none at all, 
 and show a direct tendency to heal by the first intention.
 
 CH^I^TER II. 
 
 THE FIRST SPECIES OF MALFOEMATION. 
 
 SECTION I. 
 
 DESOKIPTION. 
 
 1. This specieis of congenital malformation is characterized, 
 as has been already observed, by an abnormal narrowing of 
 the anal orifice, which contraction, however, is by no means 
 always confined to the verge of the anus, but is occasionally 
 found extending up into the canal itself, and consisting some- 
 times of numerous folds projecting into the cavity of the 
 rectum, and which, according to their degree of development, 
 more or less obstruct the physiological functions of it. Some- 
 times the marginal integument of the anus extends over the 
 border of the sphincter muscle and thus produces both con- 
 traction and deformity. 
 
 2. This congenital narrowing is usually organic, being 
 attended with more or less thickening and induration of the 
 integument about the anus, the result doubtless of previous 
 inflammation; at other times however, the contraction is 
 purely spasmodic, depending upon a peculiar condition of 
 the sphinctores ani muscles which are found to be preternatu- 
 
 rally active. 
 
 3. The anal opening and the cavity of the rectum, in these 
 instances of congenital contraction, may present all the diflerent 
 deo-rees of stricture, from that into which the point of the 
 smallest probe cannot be introduced, and impossible for the 
 meconium to pass, to that which opposes no obstruction w^hat-
 
 62 THE FIRST SPECIES OF MALFOEMATION. 
 
 ever to the common sized probe, and but little to the passage 
 of the meconium or the excrementitious matters. 
 
 4. Tlie situation and the form of the anus in this species of 
 malformation are generally normal, but the preternaturally 
 contracted or puckered-up orifice, always presents the pli- 
 cated appearance of the mouth of a purse tightly drawn. 
 
 5. The signs of the congenital coarctation of the anus, or 
 the rectum, are the absence or the deficiency of the meco- 
 nium in the napkin which the child wears, the progressive 
 and painful tension of the abdomen, and vomiting. The 
 pathognomonic sign is furnished by the direct inspection of 
 the anus. 
 
 6. There is one variety as it may be termed, of this species 
 of malformation which must not be omitted here ; it is the 
 anal contraction sometimes observed in new-born children 
 who have a syphilitic taint which is the cause of it. It is of 
 the utmost importance that the surgeon or the practitioner of 
 midwifery should make the distinction between it and the 
 other varieties, as it requires an entirely difi'erent treatment. 
 
 His attention will be first called to it by some of the same 
 signs which characterize the other varieties of this species — 
 such as pain, severe straining efforts and difficulty, at each 
 evacuation, and a peculiarly small aperture. On a proper 
 examination, however, there will be discovered other signs 
 or appearances which will explain the true nature of the case 
 — such as discolorations of the surrounding integument ; 
 excoriations, and even superficial ulceration in the adjacent 
 structures, with a considerable exudation ; small fissures of 
 the anus, as well as about the commissures of the lips ; soft 
 granulations, or condylomata are also sometimes present at 
 the verge of the anus, discharging a tenacious matter. 
 Other constitutional symptoms are also usually present — such 
 as copper-colored blotches on the skin ; a tendency to crack- 
 ing and excoriation of the skin about the hands, feet and
 
 TlIK FIRST SPECIES OF MALFORMATION. G3 
 
 nates ; an imperfect development of, or a tendency to a sep- 
 eration of tlie nails ; general emaciation ; suspicious appear- 
 ances about the mouth and tongue, and a very remarkable 
 and peculiar hoarseness in crying. Many, if not most of 
 these symptoms, aided by the history of the parents will lead 
 the surgeon to distinguish this peculiar congenital contrac- 
 tion of the anus, and enable him to make his diagnosis 
 accordingly. 
 
 7. There are but few cases of this species of malformation 
 on record — hence many imagine that it is quite rare. I am, 
 however, of opinion that it is much more common than is 
 generally supposed, and the reason that so few cases are 
 reported, is that they are usually so simple in their nature 
 and so easily remedied that no further notice is taken of them 
 by the surgeon. The slight ones too, are doubtless often 
 entirely overlooked. Two cases only of this species have 
 come under my own observation. 
 
 8. Immediate attention should be given to children who 
 have a congenital stricture of the anus or the rectum. 
 
 SECTION II. 
 
 TREATMENT. 
 
 1. The treatment of this species is generally simple, easy of 
 accomplishment and most always attended with success. It 
 is either by dilatation alone, or by incision and dilatation 
 combined, according to the nature and straitness of the con- 
 traction. In all cases in which the common probe can be 
 passed, simple dilatation, if persevered in for a short time, 
 scarcely ever fails to effect a cure, especially if commenced 
 in time. It is not only applicable to the organic contraction,
 
 64 THE FIRST SPECIES OF MALFOKMATION. 
 
 but equally so to that caused by a preternatural activity of 
 the sphinctores ani muscles. 
 
 2. The dilatation should be effected by means of wa'x, 
 gum-elastic or metallic bougies, similar in construction to 
 those used for the urethra, but about two-thirds shorter. I 
 prefer the wax bougie for this purpose, to all other kinds. 
 The bougies should consist of a regular series of gradually 
 increased sizes. The first one should be of such a size as to 
 pass the constriction easily, care being taken not to make too 
 rapid or too great distension, but to use the same instrument 
 for a day or two in succession before exchanging it for a larger 
 one. The bougie should be used once at least in twenty-four 
 hours, by simply passing it through the contraction, and then 
 immediately withdrawing it. Prolonged dilatation — that is, 
 the retention of the bougie for a length of time, I repudiate 
 in such cases. An enema of warm flax-seed tea with a little 
 pure olive oil in it, should be administered about an hour pre- 
 vious to using the bougie, in order to empty the rectum, and 
 prevent the dangerous accumulations which are liable to take 
 place, as well as to facilitate the introduction of the instru 
 ment. The bougie should always be warmed and well 
 lubricated with simple cerate previous to its insertion. 
 
 3. This course should be persevered in until the orifice 
 has acquired it normal size, or until the full amplitude of the 
 canal is restored. It is important, however, even after the 
 dilatation has been carried to the full extent, to use the 
 bougie occasionally in consequence of the disposition of the 
 orifice sometimes to contract again. It should therefore be 
 closely watched for some time afterwards. 
 
 4. Should any undue irritation or inflammation be excited 
 in the parts during the process of dilatation some soothing 
 means should be used to allay it — such as warm mucilaginous 
 and opiate enemata, frequently repeated, or the repeated 
 employment of the warm hip bath which is one of the very 
 best means for this purpose ; indeed the frequent employ-
 
 THE FIllST SPECIES OF MALFOKMATION. 65 
 
 meiit, during the use of the bougie, of warm injections of the 
 decoctions oi althea or Jlax-seed^ conjoined with the warm hip- 
 bath, would greatly tend to, if not entirely, prevent irritation 
 or inflammation. 
 
 5. In the treatment of some of these cases, the little linger 
 of the child's mother or nurse if eitlier of them is intelligent, 
 might be substituted for the bougie, after the orifice has 
 been sufficiently dilated by that instrument to admit the 
 finger. The finger would greatly aid the bougie in over- 
 coming the stricture and preventing its return, being one of 
 the best instruments for that purpose, as it can be so easily 
 insinuated into the orifice, and in such a manner too, as to 
 cause but little, if any pain, and no injury. 
 
 6. The congenite contraction in some instances is so slight 
 that it is apt to be overlooked or neglected during the 
 whole period of infancy, and in other instances the treatment 
 is abandoned too soon, or before the dilatation has been 
 carried far enough ; all owing doubtless to the fact that in 
 infancy the faeces *are quite thin or soft, and small in quantity, 
 and expelled with comparative ease, and with but little pain 
 even through a small orifice. This immunity from imme- 
 diate difficulty and danger will not always exist, however ; for 
 as the child advances in years, the f;»ces becon:ie more 
 abundant, more consistent or solid, and consequently more 
 difficult to expel through a small aperture — hence it is highly 
 important to treat those cases, at an early period, even if 
 there should exist but slight obstruction to defecation, for the 
 evil consequences resulting from such neglect, in the after 
 life of the little patient, should never be lost sight of. M. 
 Boyer relates two very interresting cases of this character, in 
 wliicli the congenital narrowing had been either overlooked 
 or neglected in infancy. One was a male eighteen years of 
 age, the other was a female thirty-four years old. Both 
 were cured by incision and dilatation, and both sufi'ered 
 severely every day of their lives previously. {Traite des
 
 G6 TilK FIRST SPECriOS OF M \LFOKMATION. 
 
 Maladies Chirurgicales. tome. F/.j^. 406. P«m, 1S49. Cin- 
 quicme Ed.) 
 
 7. In extreme congenital narrowing of the anal orifice, in 
 which the contraction is so small, rigid and unyielding, that 
 it would be most difiicult if not absolutely impossible to 
 insinuate even a small probe, incision is essential to success, 
 especially if considerable time has been suffered to elapse, 
 and the symptoms have become urgent. Here the process 
 by dilatation alone, is too slow, as the child is in imminent 
 danger of perishing from the effects of the accumulation and 
 the retention of the meconium and other matters, and 
 requires immediate relief. The indication in such a case is 
 to make one or two lateral incisions of just sufficient extent 
 to afford complete exit to the contents of the intestines ; to 
 keep the orifice and canal pervious by the use of soft tents 
 and subsequently, if necessary, to complete the cure by 
 dilatation. A slight incision on each side should first be 
 made with the sharp-pointed bistoury to allow a passage to 
 the pent up feecal matters ; an enema of warm flax-seed tea 
 should then be administered so as to unload the rectum 
 completely, and afterwards the incisions should be enlarged 
 if necessary, by the probe-pointed bistoury, either with or 
 without the director, according to the extent of the contrac- 
 tion. If the director is used, it should be introduced to the 
 depth of from five to eight lines, with the bistoury carried on 
 its groove, its handle drawn outwards, that the extremity' of 
 its blade may press in the groove of the director ; and then 
 it should be drawn obliquely downwards and outwards 
 toward the ischiatic tuberosity in such a manner that the 
 inferior part of the incision may extend out from two to four 
 lines from the verge of the anus. The opposite side should 
 in like manner be operated on. In making these incisions 
 care should alwavs be taken, not to extend them out too far 
 lest all the muscular fibres of the spliincter be cut across, 
 causing them to retract and pulling the edges of the incision 
 
 ♦
 
 THE FIKST SPECIES OF MALFORMATION. 67 
 
 too far from each other, and thus giving rise to an ever after, 
 or long continued, troublesome, involuntary discharge of 
 fseces. To avoid this great evil, some of the muscular fibres 
 should always be left undivided, and the cure finished by 
 dilatation. In order to prevent the reunion of these divided 
 parts and to keep the orifice and canal pervious, tents made 
 oi patent lint,, well besmeared with simple cerate, or dipped 
 in glycerine should be introduced, kept in situ by the T 
 bandage, and removed frequently and fresh ones inserted. 
 After using the tents for several days, the bougies should be 
 used daily until the orifice and canal are sufficiently dilated, 
 and the cure completed. 
 
 8. I wish it distinctly understood that I protest against 
 incision except in exti-emely urgent cases ; for it is an indu- 
 bitable fact that the smallest contraction may sooner or later 
 be overcome by gradual dilatation ; and it is also equally 
 true, that even after incision has been performed, dilatation 
 is absolutely necessary in almost every case to complete the 
 cure. 
 
 9. When the anal stricture is the result of a riirid or 
 powerful contraction of the sphinctores ani muscles, and nu 
 time left to practice dilatation on account of the urgency of 
 the symptoms, a division of some of the fibres of those 
 muscles will at once be required : in all the instances, 
 however, in which it exists in a mitigated form dilatation 
 will relieve it, and render the operation of division unneces- 
 sary 
 
 10. When the malfonnation consists of an extension of the 
 marginal integument of the anus, this should be nicked in 
 several places, or divided in several places with the probe- 
 pointed bistoury, from within, outwards, and a meche of 
 charpie besmeared with simple cerate introduced, and 
 constantly worn for several days ; then the bougie should be 
 used until the cure is finally accomplished. 
 
 11. The syphilitic contraction of the anus will generally
 
 68 Tim FIRST SPECIES OF JIALFOKSrATKMST.. 
 
 yield to an alterative course of medicine, such as the nature- 
 of the case shall denote to be neeessaiy. The local difficulty 
 disappears as the constitution is restored to health. Soothing 
 emollient applications are the best topical remedies. Should 
 there be any excoriation or ulceration about the part, the 
 surface should be slightly stimulated daily by a solution of 
 the nitrate of silver, or by the ordinary mercurial lotions^ the' 
 black or the yellow wash^ 
 
 SECTION III. 
 
 CASES AND REMARKS. 
 
 Case i. — On the 21st of January^ 1848, 1 was called,, at the 
 request of Mr. W. D. Oreenwood, to see a large and healthy 
 looking male mulatto child, three days old, whose motherj- 
 Sai'ah Fry, was a free woman and resided in an alley between 
 Camp and Magazine streets. New Orleans ; I was told that 
 the child, had taken quite a quantity of molasses and water 
 to purge it ; had not passed more than a tablespoonful of 
 any thing from its bowels since its birth, and that it was con- 
 stantly making fruitless eiforts to do so. Upon examination, 
 I found the situation and the form of the anus to be normal, 
 but its orifice was so contracted that it offered almost the 
 same resistance to the expulsion of the meconium as though 
 it were completely imperforate. The contraction was con- 
 fined solely to tlie verge of the anus. The other organs were 
 all normal. Vomiting had already commenced and there 
 was considerable tumefaction of the hypogastric, as well as 
 of the anal region, the cliild being quite restless and rapidly 
 becoming dangerously ill,, from the retention of the meconium 
 and gas, and the distention of the rectum. I at once deter- 
 mined on the operation, and whilst Mr. Greenwood held the 
 child, properly placed upon his knees, I thrust into the con- 
 tracted anus the straight shaii3-pointed bistoury and made an 
 incision on the right side, of from three to four lines in extent. 
 A large quantity of meconium and gas at once followed the 
 withdrawal of the instrument. The opposite side was tlien 
 incised in the same manner. A warm enema of milk and
 
 THK TLRST SPECIES OF MALFORMATION. 69 
 
 •Kviiter Avas now thrown up into tlie rectntn, -wliicli wns soon 
 followed by a still I'liilher evacuation ot" nicconiiun and ijas ; 
 after which a tent nia<Je of lint and besmeared with simple 
 cerate was introduced and the child placed by the side of its 
 mother in bed, already ranch relieved. The haemorrhage 
 was (j^uite inconsiderable. The after treatment advised in 
 this chapter was strictlyfollowed up, and at the end of ten 
 ■days the incisions were entirely cicatrized, leaving a suffi- 
 ciently ample anus which performed its natural functions 
 admirably without any further treatment. 
 
 Case II. — Mrs. Spangler, an intelligent German, the wife 
 ■of a poor laboring man residing on Dauj)hin street, New 
 Orleans, brought to my office, on the 20tli of February, 1852, 
 a quite feeble and emaciated female infant six weeks old ; 
 stating tliat from its bii'th it has had the greatest difficulty in 
 voiding its stools, owing to the anus being almost closed. I 
 found upon examination no imperfection whatever of the 
 parts, except the narrowing of the anal orifice, which extended 
 a few lines up the canal, and which scarcely admitted the 
 -end of the common pi-obe. The mother informed me that 
 her child never had an evacuation from its bowels without 
 struggling and crjang, and tliat during such paroxysms, quite 
 a swelling in the anal region would take place, and that the 
 fluid taeces would sometimes be forcibly discharged in jets 
 trom the little orifice, like from the pipe of a small syringe. 
 I expressed my surprise that the child sliould have lived so 
 long with so small an anal opening ; when she remarked that 
 she was in the constant habit of injecting warm water into 
 the bowel with an ear syringe, whenever the child 
 -experienced more than usual difficult}^ in voiding the fasces, 
 and that she frequently inserted a knitting needle into the 
 orifice in order to remove the slightest obstruction that 
 might occur. These means she said never failed to cause a 
 tolerably free discharge of thin fiEces, especially when she 
 made pressure with her fingers on each side of the anus. It 
 was quite evident to me that the life of the child was thus 
 far prolonged by the use of these important and judicious 
 measures. She also informed me that three of the physicians 
 of the city had examined her child and had proposed the 
 operation by incision, but that she had in the most positive 
 manner refused her consent. 
 
 I immediately commenced the treatment of this case by 
 dilatation, using for this purpose the wax bougie according 
 to the directions already given in this chapter. By assidu- 
 ■ouely pursuing this course for four weeks, a most decided
 
 70 THE FIRST SPECIES OF MALFORMATION. 
 
 improvement bad taken place, and on the iirst of May, ten 
 weeks from the commencement of the treatment, I dismissed 
 the child, cured. Nine months afterwards the child contin- 
 ued welL 
 
 Case III. — E-oonhiiysen mentions the case of a femak- 
 infant four months old, M'hose mother from its birth had con- 
 stantly been compelled, in consequence of the smallness of 
 the anal orifice, to press out the faecal matter with her hands^. 
 The orifice however, at length became so small that the fseces 
 could no longer be pressed through it. Great distention of 
 the abdomen soon followed, attended with violent pains and 
 excessive fever, which seriously endangered the life of the 
 child. An incision with an abscess lancet was at once made 
 through the skin surrounding the anus, and the incision fur- 
 ther enlarged with scissors, upon which a large quantity of 
 excrementitious matter was discharged. The aperture thus 
 made was subsequently kept open and enlarged by the use 
 of tents made of lint and embued with some mild ointment,, 
 and the child soon recovered. {Medico- Chirurgical Ohser- 
 vations. Translated ^rom the German. Part II. Ohser- 
 vation 2. Also,., Appendix of Observations, Part IL 
 Observation I. London : 1676.) 
 
 Case 1Y. — The celebrated Soultetus reports a case of 
 this species which occurred in his practice. In l&iO he was 
 called to see a male child, son of a citizen of Ulm, the anal 
 orifice of whom was so small as scarcely to admit the end of 
 a slender probe. He advised a surgical operation, but the 
 parents of the child were unwilling to allow him to perform 
 it ; consequently he attempted the dilatation of this narrow 
 orifice, and ultimately succeeded by the continued use of 
 tents made of the roots of ^e^?5ia7i, dipped in oil, introduced 
 and suffered to remain in until by imbibing the moisture of 
 the parts, they would become swollen and thus enlarge the 
 almost imperforated anus. Scultetus mentions having known 
 a midwife of Patavia who was in the practice of perforating 
 the anus when wholly closed, with a sharp-pointed probe^ 
 and of enlarging the opening thus made with tents of gen- 
 tian roots. {Armarrhentariunh Chirurgieum. Observatio, 
 LXX VIL ^.323. Amstelmdami : 1741.) 
 
 I would hero remark that various substances which from 
 their nature rapidly increase in bulk, by attracting or imbi- 
 bing fluids — such as the GentiaJioe radix, sponge tent, cat-gut^
 
 THE FIRST SPECIES OF MALFORMATION. 71 
 
 &c., are even at the present day reconimendorl in tlie treat- 
 ment of the cases under consideration. This nictiiod of dress- 
 ing, however, simple and innocent as it seems, may cause 
 serious accidents; for the use of such substances in such 
 cases is by no means void of dan^^er. M. Guersant mentions 
 a case in which an operation liad been performed for an 
 imperforate anus, and at the close of which a piece of pre- 
 pared sponge was placed in the wound, and suffered to 
 remain too long in, producing peritonitis and subsequent 
 death. {Gazette des Hopitaux de Paris. 1857. No. LXX.]y. 
 277.) 
 
 Case Y. — Mr. A. Copeland Hutchison, of England, 
 reports the following case of contraction of tlie anus, with a 
 communication of the rectum with the vagina. I have 
 classed it among my first species, although in reality it does 
 not belong here. " My friend, Mr. Barthurst, of Strood," says 
 Mr. Hutchinson, " had a case where the faeces came per 
 vaginam, the natural anus being barely sufficient to admit of 
 the entrance of a good sized probe, but communicating witli 
 the gut. By gradually dilating the natural anus with bou- 
 gies in early infancy, the faeces were expelled with as much 
 freedom, after a certain time, as if the passage had never 
 been closed ; and what is remai'kable, the communicating 
 aperture in the vagina experienced a spontaneous cure. The 
 child is now, (N"ovember 1825,) ten years old. {Practical 
 Observations in Surgery, 'ind Ed. p. 257. London. 1826.) 
 
 Case YI. — "The expulsion of the meconium," says Cooke, 
 translator of Morgagni, " is sometimes prevented by an ex- 
 tremely rigid contraction, so that a probe can scarcely be in- 
 troduced. A child was brought to me some years ago with 
 this imperfection, and the faeces passed through the vagina." 
 {CooMs Morgagni. Vol. II. p. 110. Boston: 1824.) 
 
 Case YH. — The following case is reported by Mr. W. Fer- 
 gusson. "In a new-born infant, brought to me some time ago, 
 tlie opening at the lower part of the rectum was so small that 
 the meconium could not be discharged only by drops ; a large 
 collection above had taken place, and the proti-usion in tlie 
 perinaeum was considerable. A probe-pointed bistoury was 
 introduced, and four notches were made which permitted a
 
 72 THE riKST SPECIES OF MALFOEMATION. 
 
 copious evacuation." {A System of Practical Surgery^ 'p- 5-15, 
 Fhil. : 1853.) 
 
 Case YIII. — Mr. T. J. Ashton of London mentions a case, 
 in wliicli it appears no surgical treatment had been adopted 
 until the child was two years old. He says, " Some years 
 since I saw, in conjunction with Mr. Morton, a child about 
 two yeai's old, with congenital contraction of the anus, which 
 would not admit a larger instrument than a number eleven 
 bougie ; the belly was tumid, and the general health im- 
 paired. Dilatation was had recourse to ; in a short time the 
 bowels could be entirely relieved, and with the aid of tonics, 
 the patient progressed favorably." {Diseases, Injuries and 
 Malformations of the Rectuiti and AnuSy jp. 27. London : 
 ISoi.) 
 
 Case IX. — J)r. Townsend, Senr., saw a child at the Massa- 
 chusetts General Hospital, which was born on Sunday, the 4th 
 of September, 1854, and which had an imperforate anus. JN'o 
 operation was permitted on it at that time. It was seen again 
 on the Thursday following. A little meconium had passed 
 through a small pin-hole aperture. A probe passed in, and 
 the opening freely dilated, tlie rectum being found free. The 
 child did well. {Becords of the Boston Society for Medical 
 Improvement. Vol. 11. p>-^'^- Boston: 1856.) 
 
 Case X. — Dr. Seaverns, of Jamaica Plain, presented to the 
 '■Boston Society for Medical Improvement^ through J. B. 
 Jackson, M. D., September 13th, 1848, a specimen of con- 
 erenital stricture of the anus. The child died at the age of 
 eighteen months, of a dysenteric affection. At birth the open- 
 ing was only large enough to admit a probe. It was gradually 
 enlarged by the aid of bougies. The intestine above the stric- 
 ture was considerably dilated. {Records of the Boston Society 
 for Medical Improvement. Vol. Ill p. 270. Boston: 1859.) 
 
 Case XI. — M. Devilliers met with a case in his practice, 
 and which he reported to the " Medical Society of Paris,^'' of 
 a child which had both an obliteration of the anus and of the 
 uretln-a. Upon examining the child with care, M. Devilliers 
 found that the malformation arose from ao-gluti nation of the 
 integument at the anus. He cautiously separated the lips 
 of the anus, and the walls of the rectum, for an extent of 
 about six lines with his right index finger, then using a grooved 
 sound, he reached the point where the meconium was, and
 
 TIIK FIRST SrECIES OF MALFORMATION. 73 
 
 thus conij)let(!ly opened the passai^e. lie attempted in a 
 siniihu- nuumcr to overcome the agghitination of the uretlira, 
 hut failed ; he, however, finally suceeded hy the aid of a small 
 sound. The child died iiftcen days after. No autopsy. {lie- 
 vue Mcdicale de Paris. Mai, 1835.^^. 280). 
 
 Case XII. — The following case was reported to the " Pen- 
 insular Journal of Medicine and tiie ColUxteral Sciences," by 
 S. L. Andrews, M. D. " In a private letter from my friend, 
 Dr. Baldwin, of Lahaina, Sandwich Islands, I have an in- 
 terestinsj^ account of a case ot congenital contraction of the 
 intestinal canal. As Dr. B. has given me the case more in 
 detail than is needful for your Journal, I have abridged it for 
 your use. The child, a fine-looking, plump female, weighing 
 8i|- lbs., was born Dec. 5th, 1838. The first indication of any- 
 thing abnormal was the rejection of a little sweetened water 
 given a few hours after birth. On the following morning 
 castor oil was rejected with bilious vomiting. A judicious 
 use of cathartics, including suppository and enemata, the lat- 
 ter sometimes administered through a gum-elastic catheter 
 introduced several inches into the rectum, failed to produce 
 any adequate evacuation of the bowels. Castor oil and other 
 cathartics, and sometimes enemata, only excited vomiting, 
 usually bilious. At length, the contents of the intestines, in 
 a very offensive state, were thrown off by vomiting. All that 
 was passed, per anum, was fragments of hardened meconium, 
 shaped to the intestines, and amounting to several inches in 
 length. The last fragment tapered to a point at its upper ex- 
 tremity. Death on the 13th. 
 
 '• Diagnosis, contraction of the intestine, which was con- 
 firmed by the autopsy. 
 
 "The rectum and colon were about half the natural size, or 
 perhaps a little more, except a portion in the middle of the 
 arch, where it was reduced to about half the diameter of that 
 on each side of it. The caecum was natural, but for twelve 
 inches above it the small intestine was small indeed, not 
 larger than the narrowest tape, and the canal too narrow to 
 admit anything solid ; the next six inches, proceeding towards 
 the stomach, was very narrow, but contained a few small 
 pieces of hardened meconium. Eighteen inches above, this 
 was larger, but crowded with viscid meconium. The re- 
 mainder of the intestine to the stomach was twice the natural 
 size. The gall-bladder was large and full. The stomach and 
 upper part of the intestine was filled with a liquid appearing
 
 74 THE FIRST SPECIES OF MALFORMATION. 
 
 like a mixture of bile and milk. The child had nursed until 
 the last day. 
 
 "The father of the child, an efficient and devoted missionary 
 under the American Board, has disproportionately short limbs, 
 both upper and lower. He is also afflicted with exostosis. A 
 sister is afflicted in the same manner, and some of the children 
 of both brother and sister have the same morbid state of the 
 bones." — {Peninsular Journal of Medicine and the Col- 
 lateral Sciences. 1839.)
 
 CH^I^TER III. 
 
 THE SECOND SPECIES OF MALFORMATION. 
 SECTION I. 
 
 DESCRIPTION. 
 
 1. This species of malformation, «^ym« orificu arid, is char 
 acterized by the closure of the anal orifice by a thin transpa- 
 rent membrane, somewhat resembling the hymen, through 
 which the meconium may often be seen, yet sufficiently strong 
 to prevent its escape from the rectum. This membrane, or 
 cutano-mucous lamina, however, is sometimes quite thick and 
 hard, and simulating the common integument of the anal 
 region. 
 
 2. This vice of conformation is readily indicated by a 
 small soft and fluctuating hemispherical tumor, usually 
 observed several hours after birth, at the natural situation of 
 the anus, caused by the pressure of the accumulated meco- 
 nium and gas against the occluding membrane. It may also 
 be easily distinguished too, by the yielding of the prominence 
 to the pressure of the fingers, and then projecting again 
 when the pressure is removed ; by the tumor becoming 
 larger, firmer and more ap]3arent whenever the child cries* 
 struggles, or makes efltbrts to expel the contents of the 
 bowels ; by a fluctuation more or less evident, as well as a 
 cavity which can be distinctly felt under the occluding 
 membrane ; and lastly by a bluish or livid spot, usually in 
 the centre of the prominence, indicating clearly the position 
 of the anus. Fabricius ab Aquapendente in describing the 
 
 same deformity says : '• Msi ani locus velliGula abductus est 
 
 75
 
 70 THE SECOND SPECIES OF MALFOEMATION. 
 
 tamen orificii vestigium et taiujentibus persentitur vaeuum 
 intus.''^ {Opera Chirurgica, part 1. Cap. 88. Patav. 1617, 
 I'olia.) 
 
 3. This species of malformation is the most simple form of 
 arrested development pertaining to the anus, and it is 
 doubtless the most frequent, yet if the number of cases on 
 record are to be taken as evidence of this fact, it fails entirely 
 to establish it, for there are indeed but few cases reported. 
 
 SECTIOIT II. 
 
 TREATMENT. 
 
 1. The anus and the rectum, in this species of malformation 
 are most always well formed, including the ^phinctores ani 
 muscles, the only imperfection being the membranous 
 closure of the anal orifice ; consequent!}'- the surgical measures 
 recommended for the relief of this impediment are simple 
 and uniformly successful, if timely adopted. 
 
 2. The treatment consists of a puncture and a crucial 
 incision. The straight sharp-pointed bistoury should first be 
 plunged into the most prominent part of the tumor, in the 
 direction of the rectum, through the occluding membrane to 
 the seat of the meconium ; or into the presumed centre of 
 the anus indicated most always hy the livid spot. This 
 puncture will afford an exit to tlie contents of the intestine, 
 and by their evacuation the most urgent symptoms will at 
 once be relieved. The puncture thus made should then be 
 sufficiently enlarged in the antero-posterior and transverse 
 direction with the probe-pointed bistoury, cutting the mem 
 brane from witlun outwards ; and if it be very thick the 
 angles of the flaps formed by the crucial incision should be 
 seized witli the forceps and excised with tlie curved cissors.
 
 THE Ki:CO]Sfr> SPECIES OE MALFORM4'riO:Sr. 77 
 
 After the complete eviiciuitioii of the distended rectnrn hy 
 warm eiiemata, a tent or meche of lint spread with simjde 
 cerate, or dipped in olive oil should be introduced into the 
 opening and renewed from time to time until complete 
 cicatrization has taken place. It is scarcely ever necessary 
 to use the bougie in these cases, and even the meche of lint 
 may often be dispensed with, after the sixth or seventh day, 
 as there is generally no disposition in the parts to contract 
 too nmch, especially if the membrane has been thin, and the 
 anus well formed as is usually the case. 
 
 3. Professor Hays, of Philadelphia, the very able and 
 distinguished editor of the " American Journal of the 
 Medical Sciences," advises the operation to be performed at 
 the moment when the infant makes efforts to expel the 
 contents of the rectum, and the membrane is most tense. 
 He thinks it wholly unnecessary to cut off the angles of the 
 membrane formed by the crucial incision, as they soon 
 retract towards their base and become confounded with the 
 margin of the anus. {Aineriean Cyclo^CBdia of Practical 
 Medicine and Surgery. Vol. II. Article^ Imperforate Anus, 
 p. 151, Phil. : 1841.) 
 
 4. Professor Pancoast, of Philadelphia, in his invaluable 
 treatise on " Operative Surgery," says that the employment 
 of bougies, or of catheters, after the operation of opening the 
 anal orihce, for the purpose of keeping open the passage, or 
 enlarging it, is not unattended with dangei", in consequence 
 of the soft and delicate organization of the mucous membrane 
 of the rectum, at this early age — hence he recommends that 
 the newly made opening should be preserved patulous by the 
 daily introduction of the finger previously oiled. {Operative 
 Surgery, p. ^'dQ. Phil.: 1841.) 
 
 5. M, Levret recommended, in these cases of anal occlusion, 
 circumscribing the obstructing membrane by a circular inci- 
 sion. This operation, however, is never practised.
 
 78 THE SECOND SPECIES OF MALFORMATION. 
 
 SECTIONIIL 
 
 CASES AND REMARKS. 
 
 Case XIII. — In February, 1840, I was sent for in haste 
 
 by Mr. H of Bourbon County, Kentucky, at the request 
 
 of the attending midwife, Mrs. S to see his child, a stout, 
 
 healthy boy, forty-eight hours old. It appeared that in conse- 
 quence of the feeble condition of Mrs. 11 , who required 
 
 a great deal of attention, that the child had been neglected, 
 and the discovery had just been made, that it had not passed 
 anything from its bowels since its birth, and that it really had 
 no anal opening. Upon examination I found the anal orifice 
 completely occluded by a tolerably thick brownish mem- 
 brane, surrounded by considerable puckering of the adjacent 
 integument. The obstructing membrane was distended by 
 the meconium and formed a soft projecting tumor as large as 
 a filbert. The child was continually vomiting the milk as fast 
 as taken into the stomach, and its abdomen was slightly 
 swelled and tense. It was perfect in other respects, and urin- 
 ated freely. The cliild was properly placed upon its back on 
 the lap of the midwife who held it firmly with its thighs eleva- 
 ted and nates separated, whilst I plunged a sharp-pointed bis- 
 toury into the centre of the projection, through which opening 
 the contents of the bowels were at once discharged. I then 
 with a probe-pointed bistoury enlarged the opening by incising 
 the membrane from within, outwards and crucially ; the angles 
 of the flaps thus formed were seized with the forceps and ex- 
 cised with a curved scissors. A tent of lint dipped in olive oil 
 was now introduced into the newly made orifice and frequently 
 removed afterwards, and replaced by a new one, until the 
 cure was complete, which took place in less than three weeks. 
 To my surprise, considerable haemorrhage occurred, but not 
 suflicient to cause any bad result. In this case the occluding 
 membrane was of a dark brownish color, quite elastic and 
 about two lines in thickness. I saw this boy in 1854, when he 
 had attained his fourteenth year, and he had as well formed 
 an anus as could be desired. 
 
 Case XIY.— Gunning S. Bedford, M. D., the able and 
 distinguished Professor of Obstetrics and the Diseases of 
 Women and Children in the Medical Department of the Uni- 
 versity of the City of New York, mentions a case of occlusion 
 of the anal aperture. A male child one week old was brought 
 to the Professor's Gli7iique, ajjparently in great agony, not hav- 
 ing had anything to pass its bowels since its birth, refusing
 
 THE SECOND SPECIES OF MALFORMATION. 79 
 
 tlie breast and constantly moaning, I prefer presenting a 
 part of this case in the inimitable style of the professor hini- 
 eelf. 
 
 " That is not your child, madam — is it? No sir ; its mother 
 is too weak to come out. So I should think, my good woman. 
 That little infant is rather young to be brought here. Yes 
 Sir; I know it is, but the poor little dear suffers so much 
 that its mother begged me to let yon see it. Well, madam, 
 we will do what we can for it. Are you certain that it has 
 not had a passage since its birth ? Oh yes Sir — I know it has 
 not. Does it pass its water ? Yes Sir. Have you given it 
 any medicine ? Indeed, Sir, it has taken all sorts of things. 
 What has it taken, madam ? Molasses and water, and castor 
 oil and rhubarb, and — There my good woman, that will do. 
 Why, Sir, I have not told you half. You have told me suf- 
 ficient to satisfy my mind that the poor little infant, young 
 as it is, has passed through a martyrdom ! Does that child 
 vomit ? Oh yes, sir ; for the last four days it could not keep 
 anything on its stomach. Is its little belly large? Oh yes, 
 Sir ; it is very much swelled. Has it been attended by a 
 doctor? Yes, sir ; and he said the child's bowels had the 
 torpids. You mean torpor, do you not, madam ? Well, Sir ; 
 it was something that way. I think we shall discover, my 
 good woman, that the torpor was in the doctor's brain." 
 
 CFpon examination the professor found a complete occlu- 
 sion of the child's anus, which at once accounted for the 
 uon evacuation of its bowels. 
 
 " Madam, it is not necessary for me to tell you that this 
 child is in a very dangerous situation. Oh, no Sir ; I see it, 
 poor little dear. There is but one thing, my good woman, 
 that presents the slightest ground of relief, and that is an 
 operation. What, Sir ; to open its stomach? jSTo madam, 
 we do not open stomachs here — and you need have no fear of 
 the operation of which I speak. Shall I do what I think is 
 proper, and which, in fact, is the only thing that can be 
 done? Yes, Sir; I am sure the poor babe's mother will 
 consent to anything. What I propose doing, gentlemen, is to 
 divide by a simple incision, the membrane which you perceive 
 has caused an imperforation of the anus." 
 
 The child was placed on its back, the thighs elevated by an 
 assistant, and tbe occlusion being well exposed, the Professor 
 with a bistoury, made the incision ; and immediately a large 
 quantity of meconium passed from the bowels ; the tumefac- 
 tion of the abdomen became very much diminished, and the 
 infant's countenance gave evidence of relief. 
 
 " In order, gentlemen, that the incision I have made may
 
 so THE SECOND SPECIES OF MALFOEMATIOX. 
 
 be kept open, it will be necessary for a day or two to intro- 
 duce into it a small pledget of lint, well smeared with simple 
 cerate ; and it will also be proper to throw up the bowel two 
 wine-glasses of tepid water this evening, with a view of pro- 
 moting a free evacuation," 
 
 In a subsequent lecture the Professor alludes to the same 
 case again : 
 
 "You will scarcely recognise, gentlemen, in this infant, the 
 little sufferer brought here some time since apparently in a 
 moribund condition. To be frank with you, 1 am surprised 
 to see it alive. This is the infant, you will remember, with 
 imperforate anus, on which I operated when it was about a 
 week old. At the time when I performed the operation, I 
 very distinctly mentioned that such was the low condition of 
 the infant, I could make no assurance of a successful issue. I 
 am now agreeably disappointed, and this recovery affords 
 another evidence of the extraordinary tenacity of life." 
 {Clinical Lectures ofi Diseases of Woman and Childt'en. 
 Uh Ed. pp. 295, 325. Wew York : 1857.) 
 
 Case XY. — Mr. Hutchison relates a case of this species : 
 " A male child one day old was brought to the Westminster 
 General Dispensary by the attending midwife ; and as the 
 gut visibly caused a protrusion of the parts, when gentle 
 titillation was made over the situation where the anus sliould 
 have been, which was marked, the point of a lancet was intro- 
 duced about the eighth of an inch or upwards, which entered 
 the gut, and was sufficient to liberate the contained meco- 
 nium. Tills opening was afterwards enlarged with a bistoury; 
 a small piece of lint dipped in oil was now introduced, to pre- 
 vent the sides of the incised wound from again uniting ; and 
 the infant was discharged cured in about three weeks, with a 
 well-formed anus." {Ojj. cit. p. 261.) 
 
 Case XVI. — ^The following case of simple occlusion of the 
 anal orifice was reported to the " Suffolk District Medical 
 Society of Massachusetts," by E. B. Moore, M.D. 
 
 " A male child was born on the 22d of jN^ov. 1853. Where the 
 anal opening should have been, there existed a sac projecting 
 three-fourths of an inch from the body of the child. Dr. 
 Moore operated three days after birth with a trocar, and after- 
 wards dilated the opening by bougies, beginning with one 
 the size of a pipe-stem^ and gradually increasing the size 
 until one three-fourths of an inch in diameter could be passed. 
 December 3d, eight days after the operation, the child was 
 dismissed as cured, lie has been generiilly, and is now.
 
 THE SECOND SPECIES OF MALFORMATION. 81 
 
 (1857) well and hcai-tv." {Boston II edhxil and SurgicalJour- 
 ncd, Vol. L VI L 2>. 510. Boston, 1858.) 
 
 Case XVII. — M. Billard reports tlie following case of sim- 
 ple iinpcrforatidii of the anus. This child would doubtless 
 have been sav-ed by the operation, had it not been for the 
 gastro-eiiteritis. 
 
 " Grenel, aged two days, entered by the Creche [the 
 Jiatno given to the apartment, in which infants are depo- 
 sited when Urst brought to the liospital] on the ninth of 
 March. This child had passed no meconium since birth ; the 
 abdomen was tumid and very painful, for the child cried and 
 the fjice became pinched whenever the abdomen was touched. 
 Tiie course of the colon could be felt through the parietes of 
 the abdomen. He vomited green substances ; the cry was 
 feeble ; skin cold ; and the circulation very slow. The anus 
 was imperforate, although there existed the appearance of its 
 orifice in the perimeum. I passed through a sharp-pointed 
 bistoury, being careful to turn the back towards the bladder, 
 and after having made the incision, I enlarged it in a back- 
 ward direction. A large quantity of meconium immediately 
 issued from the opening ; the swelling of the abdomen at 
 once subsided, and the pains apparently ceased, for the child 
 stopped crying, and the face no longer exhibited the expression 
 of pain. He was immersed for half an hour in a bath of 
 marshmallows ; but notwithstanding all these precautions, the 
 vomiting continued, and he died at night. 
 
 " The autopsy : On examining the body, a passive conges- 
 tion of the pharj^nx was found, and on the mucous membrane 
 of the stomach several patches of a vivid red, together with a 
 universal redness and tumefaction of the inner membrane of 
 the small intestines ; the muciparous follicles were very 
 numerous in the large intestines ; the circumference of each 
 of these follicles was surrounded by a red circle ; the rectum 
 was continued to the perineeum, where it was only closed by 
 a simple membrane. A large quantity of meconium \vas 
 found in the laro^e intestines. The remainder of the intesti- 
 
 
 
 nal tube contained some yellow adhesive matters. The cir- 
 culatory and cerebral systems were healthy." {A Treatise 
 on the Diseases of Infants. Stewart'^s English Version, p. 
 281. JS'ew York, 1839.) 
 
 Cases XVIII. — XIX. — Mr. Ilowship reports the two 
 following cases of simple imperforation of the anus. 
 
 J^irst Case. — " S. P., a woman aged twenty-six years, was 
 friglitened in the eighth month of her pregnancv, by a rat 
 6 ^
 
 82 THE SECOND SPECIES OF MALFOEMATIOX. 
 
 leaping repeatedly at lier. Her alarm was considerable, but 
 she recovered, and went her full time. In the birth the 
 infant was observed to have a large belly. 
 
 " On the second day after the child was born, the nurse 
 observing there had been no appearance of stool, examined 
 more particularly, and found there was no passage. The 
 infant was therefore taken to a medical person in the neigh- 
 borhood, who with a lancet divided the integument that cov- 
 ered the end of the intestine. Meconium immediately 
 appeared, and in due time faecal matter. 
 
 " The evacuations from the bowels were always very thin, 
 nearly black and extremely offensive. The discharge did 
 not appear at intervals, as in common, but continually oozed 
 out upon the napkins, showing there was no power of reten- 
 tion in the parts. 
 
 " In six months the child was again taken to the person who 
 had punctured the intestine. The mother said that she was 
 sure the passage was not sufficiently free. The surgeon, how- 
 ever, was of a different opinion, insisted upon it, ' that every- 
 thing was right,' and giving a powder for the infant, sent her 
 away. 
 
 " When the child was able to run alone, it was still neces- 
 sary to keep a napkin constantly upon him. The stools 
 passed without his knowledge, he was well enough aware of 
 it afterwards, but although naturally a sharp boy, he never 
 was conscious of it at the moment of its taking place. 
 
 " His belly continued to enlarge, and when a year and a 
 half old, it had formed a very large tumor, but unattended 
 with any apparent inconvenience. The appetite was so 
 excessive, that it amounted to a constant and unnatural crav- 
 ing for food. He was perpetually observed to pick up, and 
 eat whatever might be lying near him upon the ground, small 
 l)its of stick or broom straws, plum, or fruit stones, etc. He 
 seemed never to be satisfied, but would eat heartily, every 
 hour through the day, nor did anything appear to disagree 
 Nvirli him. 
 
 " lie had been seen by several medical gentlemen, none of 
 whom were satisfied as to the particular nature of his com- 
 phiint. There was, indeed, a very large tumor in the abdo- 
 men, but no sensation like tliat conveyed by a collection of 
 water ; nor any hardness, or particular sensibility about the 
 region of the liver, to warrant any suspicion of hepatic 
 disease. 
 
 " When two years old, the child was still suckling. The 
 niotlier, from his peculiar state of health, considered he was 
 not strono; enou2:h to be weaned. About this time he had
 
 THE SECOND SPECIES OF MALFORMATION, 83 
 
 haen out, and made some complaint of nneasiness and pain in 
 his t)clly, and on roturrn'nr^ home, lay di>wn in the cradle, 
 still nnea.sy. The i'ollowing (hay lie was worse, with a hot 
 and dry skin, white tongue, thirst and extreme restlessness. 
 Tiiere was now a constant and most distressing sense gf 
 uneasiness in the helly. In the night he would creep to tlie 
 edge of the cradle, and partly out, he would hang over, rest- 
 ing his hands on the lloor, while the abdomen was pressed 
 by the edge of the cradle. This posture appeared to give 
 him partial relief." 
 
 " Tlie i'ever and general irritation continued to increase daily 
 to his death, Vv'hich took place six days subsequent to the 
 commencement of the attack." 
 
 " Post-Mortem Exammation. — The abdomen was exceed- 
 ingly enlarged. On cutting into the cavity, a soft, white, 
 elastic tumor was found. This tumor, traced by its connec- 
 tions, proved to be the lower part of the intestine rectum. 
 The stomach and small intestines were healthy, but the 
 whole of the great intestine was enlarged to at least double 
 its natural size. 
 
 " Just where the rectum commences, the coats of the in- 
 testine were suddenly expanded, forming a great oval pouch, 
 or bag, sufficiently large to contain three pints of fluid. The 
 structure of this bag was more dense and strong than that of 
 tlie intestine in its natural state. 
 
 " The contents of this bag were a very large quantity of fruit 
 stones, with bits of stick, straws and dirt ; together with a 
 large collected mass of fluid, dark fgecal matter, M-ith which 
 the whole of the colon was more or less filled, as well as the 
 large sac that contained the stones. 
 
 " The enlargement of the rectum had extended itself quite 
 down to the anus, so that to remove the tumor entire, it be- 
 came necessary to dissect out part of the integuments which 
 formed the artitical anus. The latter opening was found to be 
 so confined, that it was with difficulty a bougie of middle 
 size could be pushed through it. This opening consequently 
 could give passage only to the thinnest kind of faacal matter." 
 {Practical Ohservations in Surgery and Morhicl Anatomr/. p. 
 317. London: 1816.) 
 
 Second Case. — " A medical friend, Dr. Samuel Merriman," 
 says Mr. Howship, "to whom I mentioned the above case, 
 acquainted me, that he had seen an instance, which he be- 
 lieved to be of a very similar nature with the'preceeding one. 
 A child was born with imperforate anus, and an enlarged 
 abdomen. The integuments were punctured with a trocar,
 
 S4 THE SECOND SPECrES OF IVfALFDEl^rATION'. 
 
 the meconium first appeared, and ftjecal matter subseqnentljr„ 
 It was intended in this instance, to have formed an enhirged- 
 and adequate orifice by the nse of bougies, or such other 
 means as might liave been necessary ; bat the mother, botb 
 ignorant and obstinate, was not to be prevailed upon to allow 
 any thing more being done on tlie child's behalf- The infant 
 went ott tolerably well for about six months, althouigh the- 
 enlargement of the abdonaen continued to increase. He sub- 
 sequently became poorly, and died. The body was not ex-^ 
 amined." {Loe. cit. ;p. 320.) 
 
 Cases XX. — XXI. — M, Di^areque records two cases- 
 of this species of malformation upon which he operated. 
 
 The first case was that of a child which had not passed 
 meconium for thirty-six hours after birth. M. Bnpareque 
 having acertained that there was imperforation of the anus,, 
 opened it with great success. {Bevvoe Medicale de Paris. 
 J/cn', 1835. jt?. 284.) 
 
 M. Dupareque's second- case was a child to which he was- 
 called in consultation, and wliich for thirty hours after Birtli 
 had ])assed no meconium. M. Duparque having acertained 
 that there was imperforation of the anus, succesfully per- 
 formed the operation with a strait and narrow bistoury, A 
 gum-elastie canula was placed in the rectum. Twelve or 
 fifteen hours afterwards, all the signs of eflfu'sion of the ab- 
 domen manifested themselves, and the child succumbed. At 
 the autopsy the rectum was found to be softened and punc- 
 tured at the point of union with the- sigmoid flexure of the 
 colon. This accident was produced by the gmu-elastic canula, 
 which from carelessness by the nurse had been too far ad- 
 vanced, and kept too long in. {Loc. dt. jp. 285.) 
 
 This case should be a warning to both surgeons and nurses- 
 how they use canulas and bougies. In my opinion, the canula 
 was by no means indicated in this instance, and should not 
 have been used. Soft tents with the occasional use of the 
 little finger were all that were i-equired to keep the passage 
 patulous. Several cases in which similar accidents have occur- 
 red from the careless manner of usiug canulas and bougies will 
 be found recorded elsewhere in this work. 
 
 Case XXIL — M. Petit reports, with several otliers, the 
 case of a cliild presenting an imperforate anus, in which no 
 sign of such an organ was visible. On the third day the
 
 THE SECOND SPECIES OF MALFORMATION, 85 
 
 mcinbrano elosini:; the anns, wliieli was both thick and firm, 
 was incised by iiiin with a hanoet. The inecoiiium passed, but 
 the child died in coiividsions. {Memoir-e deV AeademieJivyal/G 
 U Clvirunjie de Paria. tome II. ]). 237. 1781.) 
 
 Cask XXIII. — M. Petit m\ another occasion witnessed a 
 new-born child which was destitute of an anus, or any sign 
 of one- lie first attempted to incise the membrane which 
 covered tlie anus, with a hmcet, but failed. He then empk)yed 
 a trocar, when the meconium passed out freely ; nevertheless, 
 the infant died on the ft^llowing day. {pj>. cit.) 
 
 Cask XXIY.' — M. Saviard, Mdio was, at the time, chief 
 •surgeon of the Hospital Hotel Dieu, in Paris, relates a case 
 of simple occlusion of the annal orifice. 
 
 " On the 16th of Kovember, 1693, an infant four days old 
 was brought to tlie Hotel Dieu, whose anus was closed. Sa- 
 viard examined the place where the natural aperture ought 
 to have been, and perceived a membrane extended across" it, 
 through which he could distinguish the meconium by its dark 
 fiolor. He incised this membrane with a strait sharp-pointed 
 bistoury, which afforded a passage to the contents of the 
 bowels. After this he dressed the wound three days with a 
 tent dipped in digestive to prevent its reunion, and the child 
 was cured." {Nouveau Reoueil d^ Observations Chirurgicales. 
 Ols.iri Park: 1702.) 
 
 Case XXY. — The following account of a case of mon- 
 strosity, having a closure of both ears, an imperforate anus, 
 and a double fissure of the palate, was received from W, Otis 
 Johnson, M. D., of Cambridge, Mass., and read to the Boston 
 Society for Medical ImprovemeM, July 12th, 1858, by Jeffries 
 Wyman, M. D., who also showed easts of the ears. 
 
 " On the 16th of June, 185S, I was called early in the after- 
 noon to Mrs. F., an intelligent woman, wife of a respectable 
 zVmerican mechanic. In half an hour she was easily delivered 
 of her third child. The first is living and is an unusually hand- 
 some girl of about five years; the second died before the 
 family came to Cambridge. Mrs, F, had previously told me 
 that she had continued to nurse her second child three montlis 
 ;after her last conception, which of course, there is reason to 
 4oubt, She considered her ' time ' as at hand. 
 
 " The ' monster' gave no signs of life for more than a minute 
 •f'cfter birth, and was what is professionally called hlue. The 
 .coi'd was about the neck. In about tifteeu minutes after
 
 S6 THE SECOND SPECIES OF MALFORMATION. 
 
 birth, having in the mean time made but a few faint cries, he 
 gave out some half a dozen of the most unearthly shrieks for 
 an infant I ever heard. These were repeated some eighteen 
 hours afterwards. 
 
 -' I found the ears closed and undeveloped^ as your casts 
 will show ; a double fissure of the palate, and an imperforate 
 anus. The ensemble of the features was idiotic ; the remain- 
 ing development was perfect, and seemed to be that of a six 
 months' or six and a half months' foetus. 
 
 ''Thirty-six hours after birth, a fihn, of apparently mucous- 
 membrane protruded from the anal fissure, and,, after reaching 
 the size of about half an inch in diameter, burst, and meco- 
 nium escaped. 
 
 " The child continued to show an increasing vitality till 
 about the thirtieth hour after birth, from which; time it began 
 to sink, and died easily, forty -live hours after birth." {Records 
 of the Boston Society for Medical Improvement, Vol. III. 
 p. 214. Boston : 1859.) 
 
 Case XXVI. — Ruysch saw a child whose anus was closed 
 by a membrane. On the fifth day after its birth there was a 
 spontaneous rupture of the occluding membrane and death 
 soon followed. {Adversaria Anatomica, decad. II. Cajy. 10, 
 p. 13.) 
 
 Case XXYII. — Von Ammon reports the case of a male 
 eliild in whom there existed an imperforation of the anus by 
 a simple membrane which, he at once incised. In this 
 instance there was quite a depression at tlie natural situation 
 of the anus, and what was remarkable, the penis was in a 
 constant state of priapism which continued until after the 
 operation of incising the occluding membrane, and the 
 complete evacuation of the rectum. 
 
 This child was well formed in other respects and lived four 
 months after the operation, the anus and the rectum perform- 
 ing their functions admirably, the sphiuctores ani being- 
 present and well formed. The child died of a scrofulous- 
 diarrhoea. {D-le Angehorenen Ckirurgischen, KranTcTieiten 
 Des Menschen, S. 4A. Berlin, 1S4:±) [Vide Plate. III.] 
 
 The following authors have also seen and described cases 
 of this peculiar species of malformation. 
 
 Fabricius of Hildanus. {Ohsei^atiomtm Chirurrjicarum 
 Genturia.. Cent. 1. Ohser. 73, p. 51. Basil^ 160G. Folia.)/ 
 Fabricius ab Aquapendente. {0^. cit^-
 
 TUE SECOND SPECIES OF MALFOliMATIOX. 87 
 
 Villi Meeckrcn. [Olservationes Medico-Chirurgka. cap. 
 XXIV. p. 114. Amstelod, 1G82. 8w.) 
 
 Littre. {ITistoire de V Academic Royale des Sciences, annee 
 
 1710,^.47.) 
 "Wagner. {Commer, Utierar. Xorimherg, p. 3G1, annee 
 
 1735.) 
 Motais. {Mernoires de V Academic des Sciences., annee 1771, 
 
 p. 5T9.)
 
 CT3:-A.P»TEIl IV. 
 
 THE THIRD SPECIES OF MALFORMATIOIS. 
 
 SECTION I. 
 
 DESCRIPTION. 
 
 Atresia Ani et Intestini Recti. In this si^ecies of arrested 
 development the rectum does not descend as low in the pelvis 
 as it should, but terminates abruptly in some form of cul-de- 
 sac, at a variable distance above its natural outlet, and either 
 hangs loosely in the pelvic cavity, or adheres to the anterior 
 surface of the sacrum, or to the bladder, or to some contig- 
 uous part. ISTo anus exists, and there is generally not even 
 the trace of an anus to be observed in situ naturali^ the 
 perinseal raphe being extended from the scrotum to the point 
 of the coccyx without interruption. [ Yide Plate lY.,, Fig. 1.] 
 The space which should, have been occupied by the anus and 
 the absent portion of the inferior extremity of the rectum, is 
 filled with some intermediate substance of a cellulo-fibrous 
 nature. 
 
 This is truly a deplorable form of congenital imperfection, 
 especially should a considerable portion of the inferior 
 extremity of the rectum be deficient ; then indeed the case 
 becomes most serious and embarrassing to the surgeon, as 
 there are no external signs by which he can ascertain posi- 
 tively where the end of the rectum can be found, or, indeed, 
 whether the organ even exists at all or not ; and to add fur- 
 ther to the perplexity and the difficulty, the rectum, besides 
 being abnormal, sometimes occupies an abnormal position. 
 In all these respects, it will be observed that this species dif-
 
 TIIIO TIIIUI) SPECIES OF MALFORMATION. 89 
 
 fers most widely from the second species, in wliicli a swelling, 
 a fluctuating tumor, or an accompanying projection or depres- 
 sion in tlic natural situation of the anus, indicates the exist- 
 ence and the position of the rectum, and directs the surgeon 
 at once where to find it. 
 
 From the nunihcr of cases of this species which are re- 
 corded, and which I have presented, it might he inferred, 
 that it is much more common than the first and second 
 species ; but this would by no means be a rational conclusion, 
 inasmuch as such cases scarcely ever escape notice, and are 
 doubtless every one of them reported, both on account of 
 their formidable, as well as their peculiar character. 
 
 SECTION II. 
 
 PHYSICAL EXPLOKATION— DIAGNOSIS. 
 
 In these cases, in which there is no external indication 
 whatever of either an anus or a rectum, it is of the utmost 
 importance to success, that a minute and careful exploration 
 should be made as a preliminary step to the treatment. 
 
 The index finger of the right hand should be placed in the 
 normal position of the anus, and pushed firmly np tow\^rds 
 the pelvic cavity in the direction of the rectum, whilst, at the 
 same time, with the left hand firm pressure upon the anterior 
 walls of the abdomen, should be made, both inward and 
 downward towards the finger in perinsieo. In this manner the 
 ajjproach of the rectum towards the index finger, may be 
 detected if it exists. 
 
 Sometimes by the finger alone in the perinseum the fluctua- 
 tion of the distended end of the rectum can be detected, 
 should it not be too far distant. 
 
 After having made an incision of the ]3roper depth in the di-
 
 90 Tin: TllliU) SPECIKS OF ^[ALFOKMATIOX. 
 
 rectiou of the rectiim, without discovering the end of it, the in- 
 dex finger of one hand should be introduced to the bottom of 
 the incision, whilst with the other hand, or the hands of an 
 assistant placed upon the anterior walls of the abdomen, the 
 intestines should be pressed down into the pelvic cavity. In 
 this manner, if the rectum exists, it might be detected by 
 the fino;er in the wound. 
 
 . In these cases auscultation and percussion may also be used, 
 in order to discover the presence or absence of the rectum. 
 The stethoscope should be applied to the perinseum, and at 
 the same time percussion should be made upon the walls of 
 the abdomen. By these means the presence of the rectal 
 exti*emity filled with gas and fsecal matter may be dis- 
 covered. 
 
 In arriving at a correct diagnosis in these obscure cases, con- 
 siderable aid will be afi'orded by the introduction of the sound 
 into the bladder, if possible, or into the vagina. Tlirough 
 these media much may be discovered in relation to the exist- 
 ence and the exact locality of the blind sac of the rectum. 
 
 Mr. A. Copeland Hutchison recommends in these cases, 
 gentle titillation of the skin with the finger, over the natural 
 situation of the anus, which, he says, invariably causes the 
 child to strain, or make efibrts to evacuate its bowels, and 
 thereby produces a protrusion of this part, if the rectum is 
 distended with meconium, which will be conspicuous, or felt 
 in proportion to the contiguity of the intestine to the external 
 surface ; unless indeed the rectum terminates quite high up, 
 then there will be no protrusion whatever, and no fluctuation 
 felt. {Oj>. cit, p. 269.) 
 
 In some of the cases of congenital imperfection of the anus 
 and the rectum, especially in the peculiar species under con- 
 sideration, there is sometimes found a small excrescence or 
 elevation of the skin in the form of a button, or of a crest, as 
 will be observed in several of the cases I have reported. 
 These excrescences, from their peculiar conformation, might at
 
 THE THIRD SPECIES OF MALFORMATIOX. 91 
 
 first sight, be regarded by a superficial observer as indicative 
 of an anus, and also lead to the supposition that the rectum 
 would be found in their immediate vicinity ; but sucli would 
 not be the case, as they are altogether cutaneous in their 
 structure, and liave no connection or communication wliatever 
 with the blind end of the rectum which in these instances is 
 generally quite remote from them. 
 
 Sometimes a small dejjression or a pit, or a fissure or fissures 
 of the skin exist at the place of the absent anus. Some exam- 
 ples of this kind will also be found reported. 
 
 SECTIOK III. 
 
 PROGNOSIS. 
 
 It has been a source of much regret that the treatment 
 heretofore, of those cases, in which there is an absence of 
 from one and a half, to two and a half inches of the inferior 
 extremity of the rectum, has not been crowned with more suc- 
 cess. "When, however, the serious and sometimes almost des- 
 perate character of such cases is taken into consideration, as 
 well as the many difliculties attending the old and imperfect 
 methods of operating, the numerous failures heretofore, have 
 nothing in them to cause surprise. One can well imagine the 
 gravity of such an operation, and how difficult a thing it 
 would be, even after having found and opened the end of the 
 rectum, to establish permanently a canal in so soft and porous 
 or spongy a substance as the peculiar tissue which in these 
 cases fills the wliole space which the intestine itself should 
 naturally occupy, and through which the artificial canal 
 would necessarily have to pass, and how very inadequate 
 such tissue would be as a substitute for the muscular rectum. 
 The dilficultieSj therefore, enumerated by Bell, Yelpeau and
 
 92 THE THIRD SPECIES OF MALFORMATION. 
 
 others, of keejjing such a canal patulous, are by no means 
 exaggerated or imaginary. These various considerations have 
 induced many surgeons to look upon all such cases as entirely 
 hopeless, considering the operation for their relief to be too 
 grave and uncertain, and more hazardous and injurious than 
 beneficial — hence they repudiate it altogether. Dr. J. H. 
 Bigelow, Professor of Surgery in the Massachusetts Medical 
 College of Harvard University, says that — " Judging from 
 results, I do not consider the operation for imperforate rec- 
 tum, or even for imperforate anus, a desirable one. I believe 
 that in the present state of the art, it is better that a child 
 born with either of these imperfections, should die without this 
 operation ; although it must occasionally be performed in 
 deference to established opinion." [Boston Medical and Sur- 
 gical Journal, Vol. Z VII., p. 24:0. Boston: 1858.) 
 
 I am surprised that so able a surgeon as Dr. Bigelow should 
 have given this as his deliberate judgment ; that such doc- 
 trine, so directly contrary to the genius of this age of real 
 progress should have emanated from so high a source as the 
 chair of surgery in the Medical Department of Old Harvard 
 University. Should the sentiments of Dr. Bigelow be strictly 
 and universally adopted, when, I ask him, would the " present 
 
 * 
 
 state of the art " arrive at that degree of j^erfection which would 
 justify the operation ? Such views, if carried out to their le- 
 gitimate consequences, would for ever close all the avenues to 
 future improvement in the art, and be the burial ground of 
 all further progress. Admit for the sake of argument, that 
 the operation heretofore has utterly failed in every instance ; 
 what then ? Are we on this account to abandon all such 
 cases to their fate, in future ? Are we to sit down, fold our 
 hands, quietly look on, and not make another earnest and in- 
 telligent effort to save such ? Dr. Bigelow, however, says 
 that this operation must occasionally be performed in defer- 
 ence to established oj>inion. Can it be possible that Dr. Bige- 
 low, through mere regard fjr established opinion would,
 
 Till': Tllliif) SI'ECIKS ()!•' MAi;i'"OKMATIUN. 93 
 
 imclor any circumstance, perfonii oi- :i(l\is(,' an ()})cratiou in 
 which he had no conlidence whatever, and wliich he believed 
 woiikl confer nothing, at best, but a lingering miserable deatli 
 on the unfortunate little j^atient ? 
 
 I admit that the results of the operation heretofore, have, in 
 a majority of instances been unfortunate, but a much lai-ger 
 number of cases have been saved by it, than is generally sup- 
 posed ; and many of the fears of surgeons with regard to it, 
 are ill founded and greatly exaggerated, as well as are their 
 denunciations of it, unjust. Notwithstanding this proscription 
 of the operation by several eminent surgeons, it is nevertheless 
 sufficiently justified, even admitting the uncertainty and the 
 danger attending it, by the success of a number of cases of a 
 most desperate character, which wdll be found recorded in 
 full in this chapter. The highly encouraging results in these 
 cases, authorise and warrant an attempt at relief by some op- 
 eration. An operation may not be followed by the desired re- 
 sult, still an attempt should be made, unless there should be 
 other complications or conditions of the system that would 
 contra-indicate it. A very favorable issue, however, of the 
 success of the operation in any of these cases must not be too 
 confidently prognosticated. 
 
 Some surgeons denounce the operation as being a cruel, a 
 most barbarous proceeding, and on this account decline alto- 
 gether to perform it. I would most respectfully refer all such 
 to the reports of several cases given in this chapter, in which 
 the little dying patients were so astonishingly relieved by the 
 operation, that they immediately after nursed vigorously, slept 
 most tranquilly, and ultimately recovered. 
 
 The disrepute into which the treatment of such cases hereto- 
 fore has fallen, may be in a great measure justly attributable 
 to ignorance of the anatomical and pathological conditions 
 and relations that pertain to these cases ; to the w^ant of skill 
 in the operator ; to an imperfect method of operation ; to the 
 operation being contra-indicated, &c.
 
 94 THE TriTKD SPECIES OF MALFOR:\IATIO^*. 
 
 Tlie treatment laid down and recommended in tliis chapter, 
 if perse veringly carried out witli judgment, caution and tact, 
 will, in my opinion, in the majority of cases, if not in all, not 
 only preserve the life of the child, but also j)revent those sad 
 consequences which so often unfortunately attended the treat- 
 ment heretofore pursued. 
 
 The celebrated French surgeons, MM. Amussat. Eoux de 
 Brignoles and Goyraud, in their various publications on this 
 subject, during the years 1834 and 1835, declared that pre- 
 vious to that time, such cases as we are now considering, were 
 never successfully treated, if treated at all, but were suflPered 
 to perish, because, as they imagined, their predecessors had 
 not sufficient skill and courage to make free incisions in the 
 perinasum, in order to search for, and to find the blind end of 
 the rectum, when it laid deep. Tliey claimed great merit to 
 themselves for introducing as something entirely new in such 
 cases, free incisions with a scalpel guided by the finger, instead 
 of the old method of punctures with the lancet or the trocar. 
 
 Although these gentlemen deserved great credit for calling 
 public attention to this entirely neglected, but most important 
 subject, at that time, and for introducing several valuable im- 
 provements in the mode of operating, they nevertheless were 
 egregiously mistaken in supposing that no bad cases of this 
 kind were ever previously treated with success, and that 
 they had the honor of first suggesting and putting into prac- 
 tice the method by dissection with a scalpel guided by the 
 finger. The evidence that will be adduced in this chapter 
 will place this matter beyond all controversy. It will estab- 
 lish the fact that such cases, even of the most desperate char- 
 acter, Avere sometimes successfully treated both by dissection 
 as well as by puncture, for years previous to the promulgation 
 of the views of these gentlemen, and that they were by no 
 means the originators of the method by dissection. 
 
 Benjamin Bell more than half a century previous, not only 
 taught, but successfully performed dissection in just such
 
 THE THIRD SPECIES OF MALFORMATK i.V. 95 
 
 cases. His directions for the performance of this operation, 
 I will give in his own language. — " In such cases," says lie, 
 " when the gut is found to lie deep, on the child heiug ])roperly 
 secured, an incision of an inch in length should Itc made di- 
 rectly on the spot where the anus ought to be ; and this 
 should be continued by gradual and repeated strokes of the 
 scalpel, in the direction the rectum is usually known to take ; 
 not in a direct course through the axis of the pelvis ; for in 
 that direction the vagina or bladder or perhaps both might be 
 brought to sufter; but backwards and along the coccyx, 
 wdiere there is no risk of w^ounding any part of importance. 
 The best director in every case of this kind, is the finger of 
 the operator. The fore finger of one hand being pushed in 
 towards the coccyx, the surgeon with the scalpel in the other, 
 should dissect gradually in this direction, either till he meets 
 with fffices, or till the scalpel has reached at least the full 
 length of his finger ; and if after all the feeces are not ' evacu- 
 ated, as death must undoubtedly ensue if something further 
 be not attempted, a long trocar should be pushed forward 
 upon the finger in such a direction as the operator thinks will 
 most probably meet with the gut." — (^1 System of Surgery. 
 Vol. II. Ckaj). XIX. I). Ta. Edlnhurgh: 1787.) 
 
 These were the graphic instructions of Mr. Bell, and he 
 'himself put them into successful execution in two formidable 
 cases. [ Vide Cases XXX. — XXXI^ 
 
 Tliis operation too was successfully performed in the year 
 1822, by the late and distinguished Mr. A. Copeland Hutchi- 
 son, of England, whom I have already favorably noticed. 
 The case upon wdiicli he operated w^as one among the worst 
 on record, and the operation did not difter essentially from 
 that recommended by Mr. Bell. I have reported the case in 
 full. ■[ Vide Case XXXVI.^ 
 
 A formidable case was successfully treated in the year 1800, 
 now sixty years ago, in our own country, and in the then 
 wilds of my owai adopted State — ^Iventucky. I feel proud to
 
 96 THE THIRD SPECIES OF MALFORMATION. 
 
 inform those distinguislied French snrgeons, that even at that 
 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 
 highly delicate surface of the newly-made canal from the irri- 
 tating effects of the excretions, giving it, to some extent, that 
 protection which a mucous surface affords ; it also, perhaps 
 better than any other, preserves the continuity between the 
 opened end of the rectum and the external parts, for the free 
 passage of the faaces. The fulfilment of these indications is 
 absolutely essential to the success of the operation. 
 
 After the hollow instrument has been used for some time, 
 or until complete cicatrization has taken place, it may be laid 
 aside, and the finger, or the wax or elastic bougie occasionally 
 passed, in order to preserve the passage patulous. 
 
 9. The Liability to Coarctation. To prevent coarctation or 
 obliteration of the newly-formed canal, constitutes the most 
 difficult, troublesome, and serious part of the after treatment 
 of this, the ordinary method of operating, and a great obstacle 
 to the success of the operation, especially in all instances in 
 which the blind sac of the rectum has been found at consid- 
 erable depth from the external surface. Mr. Benjamin Bell 
 especially directs attention to this diflaculty in the two cases 
 upon which he successfully operated. [ Vide Cases XXX— 
 XXXI.^ Mr. Miller, of Methven, has recorded an interestinir 
 case of this character, in which the tendency to the closure 
 of the newly-formed opening was so great, that he was com- 
 pelled to repeat the operation ten times before the little pa-
 
 THE THIRD SPKCIE3 OF MALFOKMATIOls'. lOO 
 
 tient was eight mouths okL [Vide Case CXXXVII?\ An- 
 other simihir and interesthig case is rehited by Mr. Francis 
 McEvoy. \yid6 Case XXXI V?[ M. Velpeau says, '-The 
 last portion of the intestine can never be reestablished but in 
 a ver}^ imperfect manner. It is a listula which we substitute 
 in place of the natural tube. The species of mucous surface 
 which ultimately becomes developed, can but very feebly 
 represent the tunics of the anus. Though the system be inca- 
 pable of entirely closing up stercoral fistulas, it has a constant 
 tendency to diminish them, so that they soon become nothing 
 more than mere ducts for the passage of fluid matters. The 
 absence of the sphincter, especially, is a fatal bar to success. 
 When this is the case, it would be extremely probable that 
 the anus w^hicli had been artificially reestablished would be 
 one of the most difficult to keep open." {Op. cit. p. 1090.) 
 
 Some surgical writers declare, however, that if the opera- 
 tion is properly performed — that is, if the incisions are suffi- 
 ciently extensive, no contraction or disposition to obliteration 
 of the artificial canal will take place, and consequently no 
 difficulty will be experienced in keeping it pervious. Among 
 those authors may be named the celebrated French surgeon 
 Dionis. {Cows d'' Operations de Chirurgie. Edit. IV. me. 
 par La Faye. tome I. p. 391. Paris : 1740.) And also Mr. 
 Malyn, a late English surgeon and writer, who says — '' Great 
 stress is laid by some authorities on keeping a plug in the 
 anus, to prevent the reunion of the sides of the wound. This 
 misht be of some service if the incisions were so slight as 
 only to serve for present exigencies ; as then the remainder 
 of the cure must be effected by dilatation. But when the 
 operation has been properly performed, there is no occasion 
 for a plug, inasmuch as the cut having passed across the 
 direction of the muscular fibres, they will retract and drag 
 the faces of the incision away from each other, so that if the 
 object were to reunite them, it would be most difficult to ac- 
 complish." {Cyclopaedia of Practical Surgery. By W. B.
 
 110 THE THIRD SPECIES OF MALFOEMATIOX. 
 
 Costello, 2L D. Vol. I. Article^ AnxLS. p. 3-i3. London : 
 1841.) 
 
 It appears to me, however, that such an operation as Mr. 
 Malyn here recommends would completely destroy the power 
 of the sphincter ani muscles, if they existed, and ever after 
 occasion incontinence of faeces, an infirmity which might not 
 be preferable to death. 
 
 10. The Objections of M. Amussat. Twenty-five years ago 
 the celebrated JVI. Amussat, whose highly improved method, it 
 will be observed, I have in part recommended and adopted, 
 discarded the ordinary operation in these cases, in conse* 
 quence of what he conceived to be the insurmountable difii- 
 culties that always attend it. He declared most positively, 
 that the ordinary method by simply incising down upon the 
 rectum, when the blind sac of this organ laid deep, was en- 
 tirely inefficient, and ultimately attended with uniform fail- 
 ure. This he attempted to establish and maintain in a 
 remarkably able paper, which was read before the Academy 
 of Sciences on the second day of ]S"ovember, 1835, styled — 
 " Histoire d'une Operation d? Anus artijiciel 2>'''':i'i^^ue cweo 
 succes par un nouveau Precede^ dans un cas d^ Absence con- 
 geniale de VAnus / suivie de quelqnes reflexions su?' les Obtu- 
 rations du Rectum.'''' {Gazette Medicate de Paris. Ifovetn- 
 bre 28, 1835.) 
 
 It appears that M. Amussat was first led to reject the 
 ordinary operation, from the circumstance of his having per- 
 formed it unsuccessfully upon two cases, in each of which the 
 rectum terminated between one and a half and two inches 
 from the cutaneous surface of the perinseum. The operation, 
 he says, was performed in the ordinary manner, by simply 
 cutting down on the rectum, but both infants died jaundiced 
 in a few days, which event he attributed to the absoi-ption of 
 the bile and the meconium, consequent upon their coming in 
 contact with a wound of such considerable extent. That M.
 
 THE THIRD SPECIES OF MALFOliMATION. Ill 
 
 Aniussat, however, lias considerably exaggerated the imper- 
 fections, difficulties and failures of the ordinary method, will 
 be sufficiently obvious when we take into consideration the 
 success which has attended it in numerous instances ; some of 
 them, it will be observed, were of a most discouraging char- 
 acter, the operation having been performed under the most 
 unfavorable and embarrassing circumstances. lie has in thus 
 imputing uniform failure heretofore to this operation, done 
 injustice to the several able and distinguished surgeons who 
 have in several instances performed it so successfully. 
 
 The main objection that ]\^. Amussat urges against the op- 
 eration, and the one which led him to reject it altogether, is, 
 that the bile and the meconium are liable to be absorbed by 
 the fresh surfaces of the wound made by the operation, and 
 thus cause jaundice, or mortal degeneration of the blood. It 
 was to this circumstance alone he attributed the loss of his 
 two cases, already alluded to. M. Amussat, however, failed 
 to verify this positive declaration of his, by 2^ jpost-mortem ex- 
 amination of the biliary organs of his two unfortunate cases. 
 I do not believe that the icteroid appearance of these cases 
 had anything whatever to do with his operation — that this 
 appearance of the skin was not caused by absorption of the 
 bile and the meconium, in the manner he imagined. They 
 doubtless would have died jaundiced had he not performed 
 the operation, for it is a notorious fact that by far the largest 
 number of such cases have this yellow tinge of the skin, inde- 
 pendently of any operation. Nearly all such cases, unless 
 completely relieved by the operation, die jaundiced ; the jaun- 
 dice, however, is neither the result of the absorbtion of the 
 bile and the meconium by the wound, nor is it the immediate 
 cause of death. The operation, if timely and judiciously per- 
 formed, instead of inducing jaundice, is the first step towards 
 removing it, if it already exists, and of preventing it, if it does 
 not exist. The icteroid tinge of the skin in these instances 
 may be the result of the too long retention of the meconium
 
 112 THE THIRD SPECIES OF MALFORMATION. 
 
 in the intestines, or it may be tlie result of inflammation of 
 tlie umbilical vein, or of the biliary ducts ; indeed, this icter- 
 itious appearance is a phenomenon not unusual in infants of 
 from two to three days old, even when no malformation at all 
 exists, doubtless consequent upon a temporary excess of the 
 colorino; matter of the bile in the serum of the blood, for I 
 have myself often observed in the new-born the whole surface 
 of the body, as well as the tunica conjunctiva, to acquire a 
 yellow hue, more or less intense, the result of a slight or a 
 severe acute hepatitis w^hich obstructs the circulation of the 
 bile and causes its passage intq the blood. About one-third 
 of all infants born, are more or less affected with icterus. The 
 main objection of M. Amussat, to the ordinary operation uj^oii 
 this ground has, therefore, in my opinion, no foundation in 
 truth. His objections, however, to the operation, on account 
 of the liability to closure of the newly made passage, to infil- 
 tration and the formation of stercoral abscesses in the vicinity 
 of the artificial anus, are much more plausible, for these acci- 
 dents sometimes certainly occur, and they are serious obsta- 
 cles to the success of the ordinary operation. 
 
 11. The Method of M. Amussat. The chief feature, or pecu- 
 liarity of the method of M. Amussat, is the application to the 
 anus of the principles and the practice which Dietfenbach ap- 
 plies to the lips, in cases of narrowing and closure of the 
 mouth. {Traits sur Vart de restaurer lea defformites de la 
 face, par deplacement. Montpellier : 1842. Atlas.) 
 
 I have already shown at the commencement of this section, 
 that M Amussat advises the blind end of the rectum when 
 found, to be detached from its adhesions for the purpose of 
 bringing it down even with the external opening made by the 
 incision, and there attaching its mucous membrane by sut- 
 ures to the lips of skin formed by the edges of the cutaneous 
 wound. It will thus be seen that the object of M. Amussat's 
 method is to supply the whole track of the artificial canu'.
 
 TIIK TIIIKD SPECIES OF M^y.FORMATION. 113 
 
 with the luitunil tissues, wliich in these cases is the sreat 
 desideratum, these tissues being already prepared and 
 adapted to the exercise of" tlie functions Avliich tliey are 
 designed, and will be called upon to perform. 
 
 It must be admitted that M. Amussat's modification of tlie 
 ordinary proceeding is in several respects a most decided and 
 most admirable improvement — that it is highly ingenious and 
 deservedly meritorous ; but it also must be admitted, how- 
 ever, that it cannot be universally adopted ; that it is by no 
 means void of danger, for by depressing the rectum too much, 
 serious if not fatal consequences might be the result ; and 
 that it is not, in every case, as essentially necessary'- to success 
 as he intimates. It will doubtless succeed well in all cases 
 in which the cul-de-sac of the rectum does not lie deep, and 
 having no adhesions, floats loosely in the pelvic cavity, as it 
 does in some instances ; or when it can easily be separated 
 from its adhesions, or these themselves are capable of being 
 stretched, so that it can be drawn down without much force 
 or difficulty to its external position in the perinseum. It is 
 however, on the contrary, impracticable when there is consid- 
 erable deficiency of the rectum, the very cases in which it 
 would be the most essential. The great difficulty in such 
 cases is elongating the rectum sufficiently. In order, how- 
 ever, to obviate this difficulty, M. Amussat advises that the 
 artificial anus be established in the coccvofeal, instead of the 
 perinEeal region, in as much as the blind end of the rectum, 
 lying nearer the former than the latter, would consequently 
 have a shorter distance to traverse in reaching the surface, 
 by being drawn directly backward, than by being pulled 
 downwards to the natural situation of the anus. He there- 
 fore advises the external incision to be made immediately 
 anterior to the coccyx, or to the left of this bone. He even 
 advises the excision of the os coccygis, if necessary to gain 
 room ; having himself on one occasion for this purpose, 
 
 removed the extremity of this booe in a case of this kind. 
 8
 
 Hi THE THIKD SPECIES OF MALFORMATION. 
 
 The child, however, died a few days afterwards. [ Vide Case 
 CXLIV.] 
 
 It will be observed that M. Amussat, unlike M. Roux de 
 Brignoles, in this respect, attaches no importance whatever 
 to securing for the benefit of the artificial anns, the sphincter 
 muscles, by bringing down the end of the rectum into imme- 
 diate contact with them ; but on the contrary deprecates any 
 attempt of the kind. For the purpose of making his favorite 
 method sufhciently elastic to extend to all cases in which the 
 end of the rectum can be reached, he would sacrifice both 
 the natural situation of the anus, and the sphincter ani mus- 
 cles. But to discard these invaluable adjuncts, on this 
 •account merely, when they could be preserved by the ordi- 
 nary method, or by that of M. Roux, would be a great error 
 which should itself be discarded ; for without these it is 
 impossible to establish the complete function of the artificial 
 anus. The practice of M. Amussat, however, corresponds 
 with his theory on this subject, which is that the interior 
 outlet of the body is disposed in such a manner, indepen- 
 dently of its muscular apparatus, as to favor voluntary reten- 
 tion of the faeces ; consequently that the power of retaining 
 and controling the discharge of the faeces does not solely 
 depend, upon the sphincter muscles, for patients have been 
 known to retain control over the alvine evacuations, after the 
 excision of the inferior extremity of the rectum. He tliere- 
 fore comes to the conclusion that the same power will exist 
 after his operation for artificial anus in the coccygeal I'egion, 
 and hence he imagines there is no necessity for the sphincter 
 muscles. In this it will be seen he differs but little in opin- 
 ion from Mr. O'Beirne. {JVew Views of the Process of Defe- 
 cation. Dublin , 1833.) 
 
 It was the dutv of M. Amussat, however, to have estab- 
 lished his theory by undoubted facts, before drawing such 
 conclusions from it. This he never did, and until he does, 
 whether the operation is performed by the ordinar}-^ method.
 
 THE THIRD SPECIES OF MALFOUMATION. 115 
 
 or by Ills own, tlie iiutural Bituiitiuii ot" the uiius in the periii- 
 seal region should be selected, and the sphincter muscles, if 
 they exist, should always, if possible, be secured, so that the 
 power of retaining the faeces by the artificial anus would 
 without doubt fail to be preserved. 
 
 The first case upon which M. Amerssat executed his inval- 
 uable operation, was a very complicated and difficult one ; 
 and as it is highly interesting and most fully illustrates his pecu- 
 liar method, I have produced it entire. [ Vide Case XLII.\ 
 
 12. The Ojyeration of M. Amussat, performed hy others. Mr. 
 Waters of Parsonstown, England, records a case of imperfor- 
 ate anus and rectum, in which in 1.842 he performed a similar 
 operation to that performed by M. Ainussat seven years pre- 
 vious, (1835.) Complete success attended this operation. It 
 is said that Mr. Waters was not at all aware of the method of 
 M. Amussat when he performed this operation, but was led to 
 adopt the plan he followed, solely by his own reflections 
 upon the case. This may all be true, and it may afi'ord 
 another example that good surgeons every where think alike 
 and come to the same conclusions. One thing however is 
 certain, that the operation of M. Amussat was notorious for 
 seven years in France, previous to that performed by Mr. Wat- 
 ers, and that the Channel only divided the two surgeons. I 
 have presented Mr. Waters' case in full. [ Vide Case XLIII.] 
 
 Mr. W. G. Smith of Vauxhall-Walk, London, in 1846, 
 adopted in part the method of M. Amussat, in a very extra- 
 ordinary case. Complete success was the result of the oper- 
 ation. [^Vide Case XL IV.] 
 
 Mr. West says that he was a witness to the great advanta- 
 ges of M. Amussat's method in a little boy upon whom Mr. 
 Shaw operated successfully a few years since at the Middle- 
 sex Hospital. {Lectures on the Diseases of Infancy and 
 Childhood. Led. XXXI. p. 377. Phil. 1854.)
 
 110 THE THIKD SPECIES OF ISIALFORMATION. 
 
 Dr. Hermann Friedberg, of Berlin, in a late and very able 
 essay on Artiiicial Anus, higlilj extols the method of M- 
 Amnssat, which he has more or less improved and faithfully 
 carried out. He successfully operated on a grave and very 
 interesting case by this method, somewhat modified by him- 
 self, and as this case fully illustrates his method of operating, 
 I have presented it in detail, translated from the French, 
 having been unable to procure a German copy of his work. 
 [Vide CaseXZVIL] 
 
 Mr. Redfern Davies, of Birmingham, England, also highly 
 approves of the method of M. Amussat, and proposes a modi- 
 fication of it. His remarks on the subject are practical and 
 certainly deserve attention. He did not, however, adopt his 
 own suggestions in a case of imperforate anus and rectum 
 upon which he operated. [ Vide Case Lll?^ The considera- 
 tions, however, which influenced him not to do so in this 
 case appear obvious enough. " The reasons," says he, " that 
 induced me, at the time when the rectum was opened, to 
 forgo even the attempt to bring it down were— that I deemed 
 the distance, two and a quarter inches, at which it was 
 situated from the external opening, to be so great as to 
 preclude the possibility of so doing. Bound down as the 
 rectum is by its foldof peritonseum, the meso-rectum, I feared 
 to encounter the almost certain dangers of peritonitis, or 
 pelvic cellulitis, which must inevitably be the probable 
 consequence of the laceration of its connective tissues, to 
 permit of its descent for such a distance. Besides, at such a 
 depth, how great an uncertainty there must be as to what 
 the forceps might seize hold of." And again, he says : — 
 
 " With all due deference to the opinions of others, and in 
 hopes that it will receive whatever of attention it may merit 
 in their hands, I beg to lay before the opinion of my moi-e 
 experienced professional brethren the following modification 
 in the operative interference usually adopted in these cases,
 
 THE TIIIliD SPECIES OF MAI.FOKMATIOX. 117 
 
 wliicli T li;i(l intended, had the patient survived a sufficient 
 length of time, to carry into clFect. As far as can be judged 
 by the evidence of the published cases, death is the conse- 
 quence of different causes, according as the rectum is, or is 
 not, brought to the opening of the wound. If it is, death 
 ensues from the injuries inflicted, by so doing. If it is not, 
 death ensues, but secondarily, iu consequence of the difficulty 
 to defecation being only partially removed. I would propose, 
 therefore, to combine these two procedes, and endeavor to 
 obtain, by extending the operative measures over a consider- 
 able time, immunity from the evils of both : viz., supposing, 
 in the first instance, that an opening had been made (as was 
 done) into the rectum, nature being relieved, had not other 
 influences intervened, the child would have lived pro tern. ; 
 but then comes into consideration the subsequent difficulty in 
 passing the stool, owing to a gradual narrowing of the passage. 
 All this is said to be due to the mucous membrane not beiuo- 
 continuous with the outlet. 
 
 To remedy this, therefore, when the parts have recovered 
 from the efiects of the first operation, introduce a pair of 
 forceps, and, seizing hold of the lips of the opening into the 
 rectum, endeavor to bring it down, not by one vigorous and 
 decisive holding on by the forceps, and by main force 
 bringing the gut to the external orifice, but by gently and 
 repeatedly soliciting its descent, introducing the forceps at 
 certain intervals, and gradually endeavoring to accomplish 
 the end. If the rectum can be so moved from its position, 
 and be brought lower down in the pelvis (and so by repeated 
 attempts it has been proved) by one forcible extension, and 
 even that sometimes crowned by success, how much more 
 liively is it that success should attend the proceeding, when, 
 by the almost imperceptible tractions made upon it, the great 
 causes of failure, viz., peritonitis and pelvic cellulitis, would 
 be removed, owing to the small amount of disturbance that
 
 lis THE THIRD SPECIES OF MALFORMATION. 
 
 ■would take place in the soft parts. Although, as far as I am 
 aware, this procede by successive stages has never before 
 been broached in any writings on the subject, the idea was 
 taken from a case reported in the " Lancet," vol. i. p. 493, 
 1S46, [ Vide, Case XLIY^ in which an incision was made into 
 the perineum for a distance of three inches, and on the second 
 day an attempt was made, by gently pulling, to draw down 
 the gut, which was not, however, fastened to the external 
 opening. One month afterwards the child was doing well. 
 
 I am fully aware that there is a vast deal of essential 
 diflference between this procede and the one I advocate : 
 nevertheless, accomplishing the end by successive stages, is 
 in this case shadowed out, and will, I trust, assume a definite 
 status in surgery." {Ediiiburgh Medical Journal, March, 
 1S5S. m. XXXIILp. 811.) 
 
 Although M. Amussat, in his very able and highly inter- 
 esting and practical paper already alluded to, laid down his 
 beautiful process for the establishment of an artificial anus in 
 the perineeum, and demonstrated its practicability and com- 
 plete success in the very first case upon which he executed 
 it ; yet strange, passing strange, he never afterwards in other 
 cases pursued this method to its consequences, but in place of 
 it, adopted and practiced colotomy. He thus seemed to have 
 designed and built a most beautiful superstructure, merely to 
 gaze upon it for a moment, and then to demolish it. 
 
 13. The Operation hy Puncture. Perinseal puncture was the 
 earliest method of operating in cases of congenital closure of 
 the anus or the rectum, and is still recommended and per- 
 formed by some surgeons of the present day. They use for 
 this purpose a trocar, a pharyngotomus, a lancet, or some 
 other piercing instrument, and thrusting it into theperinseum 
 at the normal place of the anus, they make it follow the 
 natural direction of the rectum with the intention of penetrat- 
 ing the end of this intestine, should it be present and in its 
 normal position.
 
 THE TIIIllD SPECIKS OF MALFOKMATION. 110 
 
 The metlioJ by puncture is recommended in consequence 
 of its being very simple and quickly executed in urgent cases, 
 even by tlie young and inexperienced surgeon. There are, 
 however, but few cases on record in which this operation lias 
 succeeded ; it should therefore be entirely abandoned at this 
 day, with the exception of those cases in which the end of 
 the rectum can be appreciated both by the sight and the 
 touch — that is, in which it lies near the surface and is 
 distended with gas and meconium, Tlie " hlind plunge''' of 
 such an instrument into the perinteum in those cases in M'liich 
 it is aboslutely requisite to penetrate deeply, is a most hazar- 
 dous proceeding, and one well calculated to inflict fatal 
 injury to some of the delicate and important organs of these 
 parts. Such an instrument is exceedingly liable to perforate 
 the bladder, especially as this organ, in cases in which there 
 is considerable deficiency of the rectum, occupies a lai'ger 
 space in the pelvis. There is indeed a great deal less cer- 
 tainty in the result of this operation than perhaps in any 
 other in surgery, "When the trocar or any instrument of the 
 kind is used in these cases, the operator is compelled to 
 follow the natural direction of the rectum, but, as I have 
 shown elsewhere, this intestine often deviates from its normal 
 course. Should the rectum be further in front or to either 
 side than natural, it might be missed or not opened in its 
 proper place, and the operation of course would fail, and the 
 patient be lost ; whereas in the operation by dissection, the 
 blind end of the rectum can be sought for, and if it exist, can 
 be found somewhere in the pelvic cavity within the safe 
 limits of the operation. Of all other openings too, those 
 made by puncture are the most liable to contract and become 
 obliterated. Puncture therefore, in my opinion, can never 
 be substituted for dissection in these cases, without great 
 uncertainty, risk and danger. 
 
 M. Petit, when speaking of the operation by puncture, ob- 
 serves that it is very difficult to find the right place for
 
 120 THE THIKD SPECIES OF MALFOKMATIOIS". 
 
 inakiiii? the perforation into the blind end of the rectum, as he 
 o-enerally found it formed into a knot in these cases. For 
 performing such an operation, he recommends a trocar, the 
 canuhi and circuhir phite of which are so slit open, as to serve 
 as a groove for a lancet or bistoury to run in, to enlarge the 
 aperture, after the trocar has been pushed into the blind end 
 of the rectum. {Memoire de VAoadmnie BoyaleldeChirurgie. 
 
 tome I.) 
 
 Wolf mentions a very bad case of imperforation of the 
 anus and rectum, in which he used the pharyngotome with 
 complete success. [ Vide Case LIX.I 
 
 Yon Schleiss, of Munich, reports a highly interesting case 
 of imperforation or absence of the rectum, above a normal 
 anus, in which he succeeded admirably by the happy phmge 
 of a trocar. [ Vide Case XC] 
 
 Dr. James Jones, of New Orleans, Professor of tlie Practice 
 of Medicine in the Medical Department of the University of 
 Louisiana, and a co-editor of the Kew" Orleans Medical and 
 Surgical Journal, reports three interesting cases of imperfora- 
 tion of the anus and rectum, in which the operation by punc- 
 ture M'as performed with apparent success, but unfortunately 
 these cases terminated fatally in a short time after the opera- 
 tion. [ Vide Cases ZX, LXL, LXXX VIII.'\ 
 
 14. Modification of the Operation l>y Puncture. The late 
 able and distinguished surgeon, A. Copeland Hutchison, whom 
 I have already several times quoted, proposes a modification of 
 the operation by puncture. His method is to use the trocar 
 after iiaving made an incision in the ordinary manner with 
 the scalpel a certain depth without finding the rectum. He 
 says — " After having cut to the depth of about an inch and a 
 half with the scalpel, which will be as deep as can be done 
 with safety with tin's instrument, and there is no appearance 
 of meconium ; we should then lay aside the scalpel and 
 recommend the introduction of the point of a middle-sized
 
 THE THIRD SPECIES OF MALFOKMATION, 121 
 
 common trocar to the l)ottom of such incision. This instrn- 
 ment should then he puslied gently upwards and hackwards, 
 inclining rather to the left of the hollow of the sacrum and 
 natural descent of the rectum, as far as the surgeon lliinks it 
 prudcMit, or nnlil he imagines, from a want of resistance to the 
 force employed, that he has penetrated the gut." {Oj). cit. 
 p. 2(jO.) 
 
 It will he perceived that the process of Mr, Hutchison does 
 not differ very essentially from the ordinary operation by dis- 
 section, and hut little from that of Benjamin Bell; consisting 
 mainly in this — that he considers it too unsafe to carry the 
 incisions with the scalpel heyond one inch and a half, and 
 that from this point the trocar is the best and safest instru- 
 ment. He operated successfully on a case of imperforation 
 of the anus and rectum, Mdiicli I have given entire, and 
 which will illustrate his method of operating, and prove 
 highly interesting on account of the great depth which had 
 to be cut through, before the blind end of the rectum was 
 penetrated. [ Vide Case XXXVI.] 
 
 Dieffenbach has also modified the operation by puncture. 
 He coiftmences the operation in the perinseum by a small 
 crucial incision, excises the flaps to make more room, and 
 continues the depth of the crucial incision, esj)ecially the lon- 
 gitudinal one, directing it graduall}'- backwards until he 
 reaches one inch in depth. If no evacuation of fsecal matter 
 takes place, he then lays aside the bistoury for a small trocar, 
 and making a firm compression of the abdomen, pushes the 
 instrument upward and backward from the bottom of the 
 wound, following the concavity of the sacrum for a depth of 
 an inch and a half to two inches. After the stilette is with- 
 drawn from the canula, he introduces a large solid silver 
 sound, and endeavors by this means to reach the cavity of the 
 pelvis. When by plunging the stilette yet further, a measure 
 which he regards as very hazardous, he does not reach the 
 rectum, he withdraws the canula, introduces into the canal a
 
 122 TIIE THIRD SPECIES OF MALFORMATION, 
 
 piece of soft sponge, and postpones the rest of the operation 
 to the next day. If notwithstanding the distention jjroduced 
 hj the sponge, lie perceives no intestinal extremity in motion, 
 from the pressure of faecal matter which fills it, he closes the 
 wound with pieces of adhesive plaster, and has recourse to 
 colotomy. But if the sound penetrates into a cavity, and is 
 easily introduced for some distance, and if a little meconium 
 flows, he proceeds to enlarge the wound. In order not to 
 lose the opening, he withdraws the canula upon the sound, 
 which he leaves in place, introduces by its side a large 
 grooved director, withdraws the solid sound, places the 
 director in the hands of an assistant, and following the groove, 
 introduces into the rectum a strait blunt-pointed bistoury and 
 enlarges on four sides the wound made with the trocar. When 
 at last the opening is sufficiently large to allow a perfectly 
 free passage, he injects with tepid water, by means of a short 
 elastic canula, evacuates the bowel as thoroughly as possible, 
 and then by means of the sound inserts a pledget of lint 
 besmeared with cerate. If it is possible, he brings down the 
 opened end of the rectum, and unites it to the edges of 
 the wound in the skin. {Die Operative Chirurgie. Band. I. 
 S. 673. Lei2)zig : 1845.) 
 
 15. Failure to foi^n a Perinceal Artificial Anus. Should the 
 surgeon, in consequence of the absence or the great dejDth of 
 the rectum, fail to reach it, and consequently fail to establish 
 an artificial anus in the perinseal region by the directions and 
 improved method I have already presented for this purpose ; 
 or should the case be of such a character, that these measures, 
 or the ordinary operation would be considered altogether im- 
 practicable, he should then proceed at once to form an artifi- 
 cial anus in the abdomen. This operation, however, should 
 never be performed but upon the most mature reflection, 
 after having made a most minute and careful examination of 
 the case, and from a firm conviction that it offers the only
 
 THE THIRD SPECIES OF MALFORMATION. 123 
 
 terms upon ■which tlie life of the little patient can he pnr- 
 cliased. [ Vide the chapter on ^^ Abdominal ArtlJiQial Anus.''^^ 
 
 SECTION V. 
 
 CASES AND REMARKS. 
 
 Case XXVIII. — M. Fenerly reports the following very in- 
 teresting case of imperforate anus and rectum :' 
 
 " On "the 30th of March, 1857, a male child was brought to 
 M. Archigene, born at full time twenty-live hours previously. 
 The child appeared well developed and healthy. The parents 
 as well as the midwife did not perceive at first the malforma- 
 tion which caused them to call him in. It was not till 
 eighteen hours after birth, and when the child began to toss 
 about and cry, that the parents discovered the absence of the 
 anal opening. 
 
 " At the hrst visit the symptoms were as follows : The child 
 was very restless, cried violently, and refused the breast. The 
 respiration at first normal, soon became short and laborious, 
 ;he skin was blueish, the abdomen swollen and painfully dis- 
 tended ; the child seemed to suffer excruciatingly wdth colic. 
 
 " On examination of the perinfeum there appeared no mark 
 or vestige of an anal opening. Tlie raphe existed very clearly ; 
 it commenced at the inferior extremity of the coccyx, and 
 continued into the perinseal region ; the skin presented no 
 change of structure. No depression existed at a point cor- 
 responding with the anal orifice ; only when the child made 
 efibrts to cry, a slight elevation was perceived. 
 
 " The scrotum contained but one testicle, the right one was 
 still retained within the ring ; the child had already urinated 
 several times. 
 
 "Tlie imperforation being quite evident, M. Archigene and 
 M. Fenerly proceeded to the operation. After having placed 
 the child upon the table, the legs flexed and separated, M. 
 Fenerly explored the perinaeal region, and precisely on the 
 spot which raised up, during an eflort, he made an incision. 
 He first divided the skin to the extent of about one inch, then 
 the underlayers in succession to the depth of five-eighths of 
 an inch, taking care to direct the bistoury, at first perpendic- 
 ularly, then inclining it gradually towards the sacrum, so as
 
 124 THE THIRD SPECIES OF MALFOEMATIOiq^. 
 
 to avoid the bladder, and following the usual course of the 
 sacrum. The fore-finger which directed the bistoury, at the 
 same time that it explored the depth of the wound, felt now a 
 fluctuating point ; into this the bistoury was plunged, and 
 immediately a large quantity of meconium issued. Ihe child 
 was at once relieved, the respiration became normal, and the 
 abdomen decreased in size. After having evacuated the intes- 
 tine and washed out the rectum, he introduced an elastic 
 sound smeared with cerate. The child sucked vigorously and 
 slept perfectly well. The third day after the operation, MM. 
 Fenerly and Archigene saw the child again. The blueish 
 color of the skin had disappeared ; the evacuations were nor- 
 mal, yellow in color and more moderate in quantity ; the 
 general health of the child was good. They continued to intro- 
 duce an elastic sound of large caliber. 
 
 " On the twelfth day after the operation the child was well ; 
 the wound completely cicatrized without contraction. The 
 little patient now has an anus whose opening is nearly five- 
 eighths of an inch in size." {Gazette des Hojntaux de Paris. 
 Aunee 1857. A?>. XCVIII. p. 391. From Gazette Medi- 
 cate d^ Orient.) 
 
 Case XXIX. — The following very interesting case is re- 
 ported by Dr. A. B. Shipman, of Cortland ville, X. Y., in a 
 letter to the editor of the " Boston Medical and Surgical 
 Journal,^'' dated October, 18i0. 
 
 " On the 30th of October, 1838, Elizur Graves, of Solon, in 
 this county, consulted me respecting a child of his, ^t. three 
 months, for a malformation of the anus, which was congenital. 
 It was not discovered until some days after birth, when, after 
 repeated exhibition of cathartic medicines, no evacuation 
 taking place, the nurse, on attempting to exhibit an enema, 
 found no opening. A practitioner Avas consulted, who gave 
 ► an unfavorable prognosis as to any remedy, and the child was 
 considered as among the incurable. But as it continued to 
 live, and even to tlu-ive, at the end of three months the parents 
 brought it to me. On examination, there was no opening 
 into the rectum, but a little posterior to the natural situation 
 of the anus a slight projection of the skin was observed, which, 
 on examination, gave an obscure feel of fluctuation. Tlie skin 
 was also slightly inflamed. I advised an opening into this 
 point, which the parents readily assented to, and it was accor- 
 dingly made, and about a tablespoonful of pus discharged, but 
 no faeces as was expected. I next examined the opening with 
 a probe, but could find no communication w,ith the bowel. I 
 next passed a sharp-pointed narrow bistoury, with the edge
 
 TIIK TIIIKD SPECIES OF ^fALFOltMATION. i25 
 
 towards tlic yacnim, in tliu diiveti(jii oi" lliu ivctuiii, the dis- 
 tance of tlirce Indies. It was witlidrawn, and the ])oint found 
 smeared with foeces. Considerable luiiinorrhage followed. I 
 next introduce<l an elastic g'um catheter, of small si/A'/nsini^ 
 different sizes until the largest ones could he passed without 
 dithculty. Some warm water was now injected through the 
 tube, which brought away a (quantity of liquid faeces. 1 
 directed that the tube should be passed twice a day, and an 
 injection thrown in each time, and in the intervals a wax 
 bougie of large size worn constantly. Tlie next day after the 
 operation, a pint of faeces escaped at one time, and the same 
 amount continued to escape daily for a week. Before the 
 operation the child had fits of crying and straining ; the abdo- 
 men was also much enlarged and very hard. Ihese ceased 
 at the end of a week. The child was also troubled with vom- 
 itings before the operation, which now no longer were pre- 
 sent. The bougie was persevered in for four weeks, at the 
 end of wdiicli it was discontinued, and the child improved 
 very fast in flesh ; the evacuations from the bowels became 
 natural, and it has continued well ever since. The control 
 over the bowels is as perfect and natural as in any healthy 
 child. 
 
 " There are some features in this case which make it more 
 than ordinarily interesting. In the first place, the length of 
 time which elapsed before the operation, and the question how 
 long this state might have continued without serious conse- 
 quences to the life of the child ; and second, whether nature 
 Avould have finally effected a cure by suppuration or ulcera- 
 tion. These are questions which may with propriety be 
 asked. As to the length of time which elapsed, the child was 
 nearly as large as ordinary children of that age, and w^as not 
 afflicted with vomiting or crying more than many are who 
 are considered healthy. Tlie process of nutrition and chylifi- 
 cation went on regularly, and the fteces were formed as in 
 health. The large intestines must have become much dilated 
 to have contained the quantity which had accumulated in 
 them. 
 
 " Whether nature would have accomplished an opening for 
 the contents of the rectum, is not so easily answered. I am 
 convinced that the small cavity containing pus did not open 
 into the rectum, and also that the termination of the bowel 
 was much higher than that of the abscess. Yet it is possible 
 that the ulcerative process might have finally done what was 
 accomplished by art." {Boston Medical and Surgical Jour- 
 nal. Vol. XX til. 2). 210. Boston : 1840.)
 
 126 THE THIRD SPECIES OF MAXFOEMATION. 
 
 Cases XXX — XXXI. — The two following cases of imper- 
 foration of the anus and the rectum, were successfully treated 
 by Mr. Benjamin Bell. In both of these instances the chief 
 difficulty, after the operation, consisted in maintaining the 
 newly formed passage patulous. 
 
 Mr. Bell says, " I myself have had two such cases, in both 
 of which the gut lay deep, and in both I was fortunate enough 
 to form an anus, which for a good many years has continued 
 to answer the purpose sufficiently. But in each of these a 
 great deal of difficulty was experienced in preserving the pas- 
 sage sufficiently wide and open ; for as soon as the dossils of 
 lint, and other tents made use of for preserving the passage, 
 were withdrawn, such a contraction occurred as for a consid- 
 erable time rendered the evacuation of the fceces extremely 
 difficult. Sponge tent, gentian root, and other substances 
 which swell by moisture, were at different times employed, 
 but these were uniformly found to produce so much pain and 
 irritation as rendered their continuance altogether inadmissi- 
 ble. Applications of this kind are frequently, indeed, recom- 
 mended in such cases; but any person who has ever used 
 them, in parts so exquisitely sensible as the rectum always is, 
 will readily acknowledge the impropriety of the advice." — 
 (6>p. cit. ]). 278.) 
 
 Cases XXXII — XXXIII. — Latta mentions two cases of this 
 species of malformation, in which he operated \vith complete 
 success. He says he found it necessary in both these cases to 
 make an incision of one inch and a half in depth before the 
 rectum could be laid fully open, so as to allow free exit for 
 the faeces. Oval canuljB were introduced and removed once 
 every twenty-four hours. In two months there was a cure. 
 The instrument, however, was used for nine months, to pre- 
 vent contraction. {A Practical System of Surgery. Vol.11, 
 p. 8T. Edhiburgh : 1795.) 
 
 Case XXXIV. — Mr. Francis McEvoy reports the following 
 case in a letter to the Editor of the " London Lancet,''' dated 
 Balbriggan Dispensary, October, 1846. 
 
 "Sir, — My father, who held the same medical office in this 
 dispensary as I now hold, was requested to see an infant, 
 whom he found with imperforate anus. There was no indica- 
 tion whatever of an opening, no discoloration or elevation, 
 but the skin was quite natural. The child was twenty hours 
 old, and had had several convulsive lits, and three or four 
 doses of castor oil, and some warm baths had been adminis- 
 tered. Before discovering the imperfection which my father
 
 THE TniRD SPECIES OF MALFORMATION. 127 
 
 was cdlcMl to treat, an openiiifv was nia<lc, about an inch in 
 Icngtli and half an inch in depth, into the rectum, the meo- 
 Tiiuni was discharged, and everything else done that is usually 
 reconitnended. The case progressed favorably for six or eiglit 
 weeks, when the anus l)egan to exhibit symptoms of closing, 
 and tiiuilly did close, despite every means to keep it open. 
 On the day after, an abscess formed, and pointed about a 
 quarter of an incli anterior to the junction of the scrotum with 
 the perinaaum, which, being opened, gave exit to a quantity 
 of very offensive feculent matter, which still continues dis- 
 charging from the same oritice. The boy is now fifteen years 
 of age, enjoys excellent health, suffers no inconvenience or 
 annoyance from this condition of the parts, retains his i'sQCcs 
 well, and, in tine, has as good a sphincter as man need desire. 
 Last spring he sailed, accompanied by his parents, for Amer- 
 ica, in sound health. I thus trespass on your columns, from 
 the case being recalled to my recollection on seeing, in The 
 Lancet of August last, under the head of " British Journals," 
 a case, operated on by M. Amussat, of Paris, in which reten- 
 tion was complete, and which has since been under the obser- 
 vation of Sir P. Crampton." {London Lancet. Vol. LV. i?. 
 568. December: 18i6.) 
 
 Case XXXY. — The following interesting case of imperfor- 
 ation of the anus and the rectum, \vas communicated by Dr. 
 John P. Campbell, of Flemingsburg, Ky., to Dr. Samuel 
 Brown, of Lexington, Ky., in a letter dated March 9th, 1801. 
 upwards of three months after the operation. This letter was 
 subsequently published in the "Medical Eepository," one of 
 the oldest medical journals in this country, and is as follows : 
 
 " November 23, 1800, I was called to visit the child of Mr. 
 Hutson, in the vicinity of this place, on the second day after 
 the birth. The case was an imperforate anus. As an opera- 
 tion was inevitable, the next day was determined upon for 
 that purpose. On the third day, when I went to operate, the 
 child was very fretful and uneasy — the abdomen was much 
 distended and discolored, and from the information of the 
 nurse, the faeces had been frequently vomited up through the 
 day. I began the operation by making a longitudinal incision 
 on the place where the anus should have been, which was 
 slightly marked by nature. This incision I extended in the 
 direction of the os sacrum, with a lancet, until that instrument 
 could be no longer serviceable ; and no faeces following it 
 when withdrawn, I introduced the scalpel, and carried it up 
 in the same direction until I had the pleasing sensation ot 
 having reached a cavity. The instrument was withdrawn,
 
 128 THE THIRD SPECIES OF MALFORMATION. 
 
 and the niecoiiium flowed plentifully. The child was placed 
 in a warm bath np to the middle, for a few minutes; and 
 after this a tallow bougie being introduced to keep the orifice 
 open, the little sufferer dropped into a pleasant sleep. The 
 bougie and warm bath were continued but a few days, with 
 tlie occasional use of some magnesia alba and rhubarb, till the 
 child recovered, and every expectation to be derived from the 
 operation was fully answered. At this time the child does 
 well, and the mother assures me she observes nothing in its 
 present condition diflerent from that of others which she has 
 already nursed. My only fear was that the sphincter muscle 
 might be destroyed ; but I am now convinced no inconveni- 
 ence will ever result from that quarter. It was a female 
 child; and the length of the canula, which I ascertained by 
 measuring the instrument, appeared to be about three inches." 
 {Medical Repository. Vol. V. jp. 45. Neio York : 1802.) 
 
 Case XXXVI. — The following exceedingly important case 
 of imperforation of the anus and rectum, is reported by Mr. 
 A. Copeland Hutchinson : 
 
 "The fourth and last case," says Mr. Hutchinson, " was 
 the son of a Mr. Smith, a tinman residing at Ko. 43 Whit- 
 comb Street, and hud been born forty-eight hours when the 
 operation was performed, on the 17th of IS'ovember, 1823, in 
 the presence of Di*. Granville, the father of the child, and the 
 midwife. 
 
 " The raphe was the only guide we had for the operation, 
 there being neither hollow nor depression to mark the spot 
 where nature had failed in complethig her design. Dr. 
 Granville kindly assisted me, at the operation, b}-- securing 
 the child, and keeping its lower extremities in a proper 
 position during the operation, which was done by nuiking an 
 incision about an inch and a half in length with the scalpel, 
 through the skin and fat, nearly as deep as the incision was 
 long, but narrowing it two-thirds at its fundus. ISTot having 
 reached the intestine with the scalpel, and considering that 
 we could not so safely proceed further upwards in the direc- 
 tion of the gut M'ith that instrument as with the trocar, the 
 latter instrument was preferred, and directed gently upwards, 
 backwards, and inclining to the direction of the sigmoid 
 flexure of the colon for about an inch ; when on withdrawing 
 the stilette, we found the intestine had not yet been reached ; 
 the stilette was, therefore, again passed through the canula, 
 ■which was still kept in the ])arts, and pushed upwards half 
 an inch further, when, from a want of resistance, I suspected 
 tliat we had at length succeeded, and on withdrawing the
 
 THE THIKD SPECIES OF MALFORMATION. 129 
 
 stilcttc the second time, inccoiilum iluucd through the cunuhi 
 in considerable quantity ; and liere it was curious to witness 
 tlie instinctive straining of the child to relieve itself for tlie 
 first time, and whieli wouhl suggest tlie advantage to be 
 derived from the practice of gently iriitating the external 
 skin over the situation of the anus in such cases, with a view 
 of ascertaining the probable distance of the gut from the 
 surface as before noticed ; for, on this occasion, the contorted 
 features of the infant were precisely those of an adult who 
 was constipated, .and straining to relieve himself. 
 
 " The canula was secured by tapes, and retained in the 
 parts three days. It was then withdrawn, cleaned, and again 
 introduced, the fiBces passing through it during that period. 
 
 " After about a week or ten days the canula was removed, 
 and an old made sponge tent introduced in its stead ; but 
 whether from its age, or from there being too much wax in 
 its composition, it did not expand, and consequently did not 
 dilate the parts. Som.e sponge tents recently made were also 
 tried and likewise laid aside, from their inefficiency. The 
 common smooth made bougie of the largest size, was, after 
 some weeks, substituted, and was found to answer the purpose 
 much better. The tents used were about three inches and a 
 half in length, and, as they were introduced close up to their 
 thickest extremity, we ascertained precisely the distance of 
 the intestine from the surface, by measuring the tent with a 
 scale ; the end of the part tinged with bile indicating the 
 termination of the gut, and the verge of the newly-formed 
 anus marking the length of the artificial canal, and w^hich we 
 found to be exactly three inches. 
 
 " The child's bowels were occasionally constij)ated for two 
 or three weeks ; but this was as frequently obviated by tlie 
 administration of small doses of the oe Recini. Two months 
 had now elapsed from the operation, when the mother was 
 directed to introduce the bougie for a few hours only, every 
 day, and I then took my leave. 
 
 " At the end of three months the mother brought the child 
 to my house, and stated, that although its i30wels were 
 regular, and the usual quantity of faeces evacuated, she had 
 that morning observed, for the first time, that its urine was 
 in some degree tinged Avith faeces ; but on being further 
 questioned, she stated that she had no reason to believe the 
 urine ever passed per anum. The child fed well, grew, was 
 healthy, and some teeth appeared at the usual period ; yet 
 still the urine continued to be occasionally tinged with foeces, 
 and until the morning of the day on wdiich it died, the 29th 
 9
 
 130 THE THIRD SPECIES OF MALFORMATION. 
 
 September, 1823, being more than ten months after the 
 operation, I heard of no circumstance to lead me to suppose 
 that the child had been otherwise than well. 
 
 "The mother was reproached for having forborne to send 
 for me during the six days that the child had been observed 
 to be out of health from teething, and a slight bowel com- 
 plaint. She replied, that she did not conceive the child to 
 be in any danger, as her other children, who are alive and 
 healthy, had all, during dentition suffered in the same way. 
 
 " It may be necessary here to state, that during the last 
 seven months of the child's life, I had observed that its evac- 
 uations per anum were as healthy and well formed, or figured, 
 as were ever passed by any child of its age. 
 
 " On examining this child post-mortem, the artificial anus 
 was found situated in a hollow, so precisely as if it had been 
 originally natural, that the best anatomist would have been 
 ■deceived by it ; and this fact is more worthy of record, when 
 it is borne in mind, that at the period the operation was per- 
 formed, there did not appear the smallest depression or fis- 
 sure on any part along tlie line of the raphe, both nates pre- 
 serving a continuous convex surface. When the abdominal 
 contents were exposed to view, by reflecting tlie divided par- 
 ietes, a somewhat extraordinary disposition of the bowels pre- 
 sented itself ; for the small intestines were, apparently, all 
 lying on the left side, resting on the sigmoid flexure of the 
 colon ; the intestinum rectum was very large, and distended 
 with air, being at its widest part, (viz, five inches above the 
 external aperture or artificial anus,) si/x inches a7id three 
 fourths in circumference / and passing from the centre above 
 the pubes to the right side, it rested upon the cjBcum caput 
 coli ; and then turned downwards behind the bladder to the 
 artificial anus. The lower part of the rectum adhered to the 
 bladder by its peritonajal reflection in the usual manner. The 
 sigmoid flexture of the coh)n was found in situ, and of its 
 natural size, owing probably to tlie small intestines resting 
 upon it ; and the transverse arcli, though in its place, was 
 also somewhat larger than natural, and likewise distended 
 with air. The omentum was wanting. The stomach quite 
 empty and flaccid, lay hidden by the arch of tlie colon. The 
 small, intestines were not all distended with air, were of a 
 healtliy appearance, and almost empty. The bladder was 
 empt}--, natural, and adhering to the pubes up to its fundus, 
 evidently pressed into that situation by the contact of the 
 distended rectum posteriorly ; and at its fundus there was 
 found a long round substance or membrane, something like 
 tlie uracus found at this part of the bladder in calves. There
 
 THE THIRD SPECIES OF MALFORMATION. 13 J 
 
 was also a coiTcspoiuling mark in the interior of the bladder, 
 which would almost lead one to suppose that this chord had 
 once been pervious. 
 
 " Ail the other viscera were in a healthy and natural state, 
 there being, in fact, not any mark of diseased action any 
 where to be found throughout the whole examination, if we 
 except a slight appearance of inflammation on the villous 
 coat of the great arch and sigmoid flexure of the colon. 
 
 '•Tlie alimentary canal was removed from the stomacli down- 
 wards, including tiie artificial anus, with its surrounding fat, 
 bladder, and part of the urethra, with all their adhesions to 
 each other, left entire ; and, during this part of the examina- 
 tion, we found the sphincter ani muscle wanting, but the 
 levatores ani were perfect and strong, 
 
 " A section of the bladder and urethra was made anteriorly, 
 when a small valvular aperture was discovered communica- 
 ting with the rectum, and situated about the eighth of an inch 
 anterior to the caput galinaginis or verumontanum ; the aper- 
 ture into the urethra admitting only of the passage of thin 
 fgeces, it being barely suflicient to admit the end of a com- 
 mon probe, but from its valvular structure precluded the 
 urine from passing per anum ; and not any appenratice of 
 fseces having ever been in the bUidder was observable ; the 
 lining membrane of this viscus was also perfectly healthy. 
 
 " It is worthy of remark, that, throughout the extent of the 
 intestinum rectum, tlie parietes of this gut were conslderahlij 
 tfiicher than usual, but particularly towards its lower part ; 
 the muscular coat being here probabl}'' increased in thickness, 
 because of the additional muscular force required to project 
 the fteces through the long and narrow canal from the ter- 
 mination of the gut to the external parts, a distance (even 
 after the removal of the parts, and maceration in spirits for a 
 fortnight) of one inch and two-eighths ; and there appears to 
 me to be no other way of accounting for the shortening of 
 the artificial canal sinoe the operation, than by supposing that 
 the lower part of the rectum had been, by its own muscular 
 action, forced gradually down towards the external part in the 
 acts of stercoration ; and such constant pressure on this 
 immense thickness of adipose matter thereby occasioning the 
 condensation and absorption of great part of the latter." ( Vide 
 Observations on the Principal Diseases of the Rectum and 
 Anus. By Thomas Copeland, Esq., '^nd Edition, p. 107. 
 London : 1814.) 
 
 " The substance through which the artificial anus passed was 
 so compact and condensed, that it seemed almost semicartila- 
 ginous ; and it is somewhat curious to observe, in the prep-
 
 132 THE THIRD SPECIES OF MALFORMATION. 
 
 •nratiou, how in one part of the raucous membrane of the rec- 
 tum approaches, in a conical form, towards the verge of tlie 
 artificial anus; and how in like manner, the external skin 
 passes upwards to meet the descending mucous membrane, so 
 that in one part of the artificial canal will be seen meeting 
 each other the villous coat of the intestine and the external 
 skin, like a dove-tailing of conical processes ; or, as Mr. 
 Clift (the able and intelligent curator of the Royal College 
 of Surgeons, who was present at the examination of the 
 parts, and of their admeasurement, as have been here 
 described) aptly remarked, a Vandyking of the parts into 
 each other." 
 
 " I am also inclined to believe, that the situation in which 
 we found the rectum (on the riglit side) was not its situation 
 at birth, but that it occupied its natural place ; first, because, 
 from the direction in which I made my incision, upwards, 
 backwards, and inclining to the left side, I think I should 
 not, otherwise, so readily have struck it witli the trocar ; 
 secondly, from the unusual size of this gut, it is to be pre- 
 sumed, that, from the length and nan-owness of the artificial 
 anus, and its frequent distention by faeces, it may have been 
 gradually thrown out of its place; thirdly, had it remained 
 in its usual situation, attached to the sacrum, its muscular 
 power in expeiling its contents may possibly have been con- 
 siderably lessened ; and fourthly, because, in a case of intro- 
 susception of the ileum and cfecura which lately came under 
 my observation, the whole of the latter gut and ascending 
 colon were lodged in the left side, resting upon the sigmoid 
 flexure. The preperation alluded to I presented to the 
 Koyal College of Surgeons ; and at tlie same time, published 
 a short account of the case in the Medical and Physical 
 Journal of London. 
 
 " There is yet one more remark, as it strikes me, which the 
 post mortem examination of the child Smith seems to call 
 forth ; viz, the obliteration of the aperture between the rec- 
 tum and urethra. In the first place, it was so minute, that 
 no material inconvenience might have resulted from it had it 
 remained open ; secondly, from its situation in the urethra, 
 and the progressive increase of the prostrate gland as the 
 child grew up to manliood, it may by this circumstance alone 
 have eventually been closed ; and thirdly, if this latter result 
 had not occurred, the stimulus or irritation communicated 
 to the part, at a proper period, by the introduction of a com- 
 mon or armed bougie, might have produced the desired effect, 
 -^-or otherwise the part might have been cut dow^n upon, as 
 in fistula in perinseo,"
 
 THE Tllllil) SPECIES OF MALFORMATION. 133 
 
 " In conclusion, L liuvc only to ol)scrvc, that this case lias 
 proved so highly satisfactory as to the result of the operation 
 for imperforate anus, notwithstanding the great distance of 
 the gut from the external parts, that 1 should hope there is not 
 any surgeon who will now abandon an infant to its fate, under 
 simihir circumstances, until he has i)roceeded with his incis- 
 ion as far, at least, as was done in this case, taking care that 
 the incision be made in a proper direction, — the operator 
 being guided by the pressure of the gut on the finger intro- 
 duced 'into the wound." ((9/>. clt. P.jp. 2G6— 274.) 
 
 Case XXXVII. — A case of imperforation of the anus and 
 rectum, similar in many respects to the preceding one — Mr. 
 Hutchison's, but occurring thirty-five years hxter, was com- 
 municated to " La France Medicale,^^ and copied into the 
 " Gazette des Ilopitaux,^^ the editor of which being ignorant 
 of the case of Mr. Hutchison, says that this case of M. Foucart 
 raises a very important question of surgery, at the same time 
 constitutes of itself a result of the greatest interest. The ques- 
 tion is this^ — 'When there is no indication through the integu- 
 ments that the closed intestinal extremity is placed immedi- 
 ately behind the obstructing membrane, and when after hav- 
 ing made an incision of a certain depth the intestine is not 
 reached, are we authorized to pursue the search in the same 
 direction, or should we, renouncing the first attempt, imme- 
 diately proceed to form an anus in an unnatural position? 
 It has been seen that this question was answered many years 
 ago by Mr. Bell, Mr. Hutchison and M. Amussat. Tlie fol- 
 io win o- is the case alluded to. 
 
 M. Foucart on the -ith of February 1857, was called to see 
 a male child, born on the preceding evening at eleven o'clock, 
 and who from the moment of its birth, say forty hours, had 
 passed no meconium. Born at full time, of average size, the 
 child appeared otherwise perfectly healthy. It did not seem 
 to suffer at all, there was no tension or tenderness about the 
 abdomen, and it had sucked several times. 
 
 Examination of the anal region showed no trace of an open- 
 ing ; the skin passed from one nates to the other, presenting 
 a sort of median raphe, slightly prominent, wdiich was in con- 
 tinuation of the raphe of the scrotum. The most careful ex- 
 amination failed to discover the slightest trace of fluctuation 
 along this median line which could lead one to believe that 
 the inferior extremity ot the rectum was immediately adja- 
 cent to the skin. There being necessity for prompt action for 
 fear of losing all chance of success by delay, M. Foucart 
 determined to act at once as if he had only to do watli that
 
 IBi THE THIRD SPECIES OF MALFOKMATIOX. 
 
 kind of malfonnatioii whicli M. Boyer lias made the second 
 species of his division, and which consists in sinijjle imperfor- 
 ation or occlusion of the anus by a membrane immediately 
 behind which the rectum is found. The usual measures and 
 precautions being taken, he j^roceeded with the operation as 
 follows. Tlie child was placed on its abdomen, across the lajj 
 of a nm*se, and an incision of about half an inch long was 
 made in the antero-posterior direction. Tlien gradually layer 
 by layer, he reached more tlian one quarter of an inch 
 in depth without meeting any vestige of the intestine ; 
 the bistoury met only with cellular tissue. Tlie extrem- 
 ity of the little finger introduced by the cutaneous wound, 
 felt no fluctuation as would have hai:)pened, if it had come 
 in contact with the inferior extremity of the rectum. The 
 wound being gradually enlarged in the same manner as before 
 until it was half an inch long, the operator by means of a hol- 
 low sound separated the tissues forming the bottom of the 
 wound, and introduced the fore-finger to the depth of at least 
 three quarters of an inch, but with no result. He rested here, 
 but by no means renouncing the hope of reaching the intes- 
 tine, notwithstanding these fruitless attempts, intending to 
 establish an artificial anus either in the groin, or in the lumbar 
 region as advised by Amussat. However, he did not wish to 
 take the whole responsibility of further operations. M. Mai- 
 sonneuve being called in, thought the hope of reaching the 
 lower end of the rectum by no means unreasonable, and re- 
 solved to push the attempt yet further. 
 
 He first introduced into the wound the blades of a strong: 
 pair of dressing forceps, and opening them several times forc- 
 ibly, he endeavored to enlarge the commencement of the canal 
 already made in the cellular tissue, by dilatation alone with- 
 out division of the tissues. Tliis done, he introduced the ex- 
 tremity of the finger, but could not any more gain evidence 
 of the presence of the rectum. Then armed with a very slen- 
 der exploring trocar, and following as near as possible the 
 direction of the sacrum, he pushed the instrument slowly up- 
 wards ; at a certain moment, he thought he felt the trocar 
 enter a cavity. He withdrew the blade of the trocar, and- 
 tlien shortly after the canula, which contained meconium. 
 There was no longer any doubt ; the rectum lay about one 
 incli and three quarters in depth. A stylet was introduced 
 through the opening made by the trocar, then upon the stylet 
 a hollow sound, and finally M. Maissonneuve used this last as 
 a conductor to plunge into the intestine the slender blade of a 
 Itistoury. A flow of meconium immediately followed. He 
 inti-(xluced his finger into the wound and thought he felt
 
 THE THIRD SPECIES OF MALFORMATION. 135 
 
 sonietliiiit!; auuloij^oiif^ to a spliiiictor. 'No dressiiii,^ of tlio 
 ■svoinul was made; only frequent lotions and the utmost clean- 
 liness were advised. 
 
 On visitinij; the child next day, it was found to have passed 
 a ii'reat (pnintity of meconium ; the na])lvins were also much 
 stained with blood. The child, however, had been ti'aiupiil 
 all nii;-ht, had slept and did not seem weakened; no more 
 blood'^passed from the wound. On the following days the 
 child did not seem to suft'er, cried no more than children or- 
 dinarily do, sucked with avidity, and grew fat sensibly. 
 Gradually the stools acquired the yellow color usual at this 
 age, and when three months old, the child was in perfect 
 liealth. — {Gazette des Ilopltaux de Paris. Fevrier 21, 
 Annee l!S57. From La France 2Iedicale.) 
 
 Case XXXVIII. — The following case is reported by M. 
 Foro-et. A child of the female sex, thirty-six hours old, and 
 not voiding the meconium, in spite of the existence of an anus, 
 apparently well formed, Avas submitted to my examination. 
 On the spot occupied by the abnormal anus w^as observed a 
 cavity surrounded by diverging folds which all met towards 
 its base ; this cavity entirely formed by the skin, terminated 
 in a true cul-de-sac. On widely separating the nates, the 
 folds which surrounded and in part formed this cavity were 
 effaced, and its base was observed to become depressed and to 
 be stretched transversely on the slightest effort of the child. 
 The examination by the finger, practised whilst contraction 
 was taking place, transmitted the sensation of a firm and toler- 
 ably resisiting surface, and not at all that of fluctuation. Tlie 
 child was in other respects well formed. Tlie genito-nrinary 
 oro-ans were in the natural state. The urine was passed with- 
 out admixture of meconium. No vomitting had taken place. 
 The exploration of the anus with a small trocar did not give 
 issue to any excremental liquid. The child died eight days 
 afterwards. — {Union Med icale. Paris. 1850.) 
 
 Case XXXIX. — ^Tlie following, a somewhat similar case to 
 M. Forget's, was read before the "-Boston Society for Medical 
 Lnpromment^ by C. G. Page, M. D., on the 12th October, 
 1857. Tlie infant was a patient of Dr. F, Higginson of Brattle- 
 boro, Vermont. 
 
 " Tlie child, a female, apparently perfect in form, was born 
 Mav 2d, 1855. The anus presented a wrinkled depression re- 
 senibling the umbilical pit, but w^as lined with true skin ; there 
 was no appearance of mucous membrane. An attempt to re- 
 lieve by operative interference was made first with the tr "car,
 
 13G IHK TIIIKD SPECIKS OF MALFOEMAllON. 
 
 and afterwards with the knife, but without result. The cliild 
 hved eighteen days. At the autopsy the following appearan- 
 ces were observed. The intestines were distended with Hatus. 
 The bladder contained a small quantity of dark-colored urine. 
 It was drawn up out of the j)elvis and lay almost entirely over 
 the symphisis pubis, the urethra making quite a sharp curve 
 under the pubic arch. The uterus was drawni from its normal 
 position and rested on the posterior wall of the bladder, the 
 whole space at the brim of the pelvis being occupied by the 
 iuHated rectum. This portion of intestine teianinated in a cul- 
 de-sac at a point just above the levator ani muscle, where the 
 peritonaeum is reflected over from the posterior wall of the 
 uterus. At the lowest part of this cul-de-sac was an ecchy- 
 mosis, a few lines in length, where the muscular coat seemed 
 to have been divided ; the wound did not extend into the tnu- 
 cou^ mcwhranc. Tlie bottom of the sac was about on a level 
 with the brim of the pelvis, having apparently been drawn up 
 by the excessive distention, and carrying with it the other 
 pelvic organs." — {Boston Medical and Surgical Journal. Vol. 
 L YII. p. 238. Boston : 1857.) 
 
 Case XL. — The follovtring case was communicated to the 
 " Boston Medical and Surgical Journal,^'' on the 29th of De- 
 cember, 1857, b}^ P. Pineo, M. D., of Queechy, Vt, 
 
 " A case of imperforate anus and rectum came under my 
 observation last year, in this place, in consultation. A 
 slightly wi-inkled depression was perceptible where the anus 
 should be, and, on straining, the distended bowel could be 
 felt pushing downward. An incision was made, and the rec- 
 tum reached, within about an inch of tlie external opening. 
 A gum-elastic tube was introduced, and free fsecal discharges 
 obtained. The child died when about a week old. No au- 
 topsv." {Boston Medical and Surgical Journal. Vol. L VII. 
 p. 281. Boston : 1858.) 
 
 Cask XLI. — M. Baron exhibited to the " Academic Royale 
 de Medecine," in November, 1835, tlie urinary defecating 
 orgatis of a young male child, born without an anus. 
 
 In this case M. Veipeau had been called in. He incised at 
 the place where the anus should have been, in the direction 
 of the rectum, until he reached a cavity, from which he 
 thought he saw meconium to flow. Bad symptoms, however, 
 soon followed, and the child died. 
 
 At the autopsy the cul-de-sac of the rectum was found to 
 be arrested about the level of the fundus of the bladder, but 
 having no communication with that organ. The bladder was
 
 THE THIRD SPECIES OF MALFOliMATION. 137 
 
 found to lill the whole pelvic cavity, and was, by tliis distin- 
 guished sui^i^eon, unavoidably injured in the operation. {Re- 
 vue Mtdicale de l*arls. Deeeml/re, 1835. ^j>. 418.) 
 
 Cask XLII. — M. Aninssat relates the following case of a 
 female inlant, in whom the rectum terminated in a cul-de-sac, 
 about two inches above an apparently normal anus. In the 
 canal just below the blind sac of the rectum, a conununica- 
 tion existed with the vagina. This exceedingly complex and 
 difficult case was treated with com})lete success, and is highly 
 interesting on account of its being the first case upon which 
 M. Ainussat practiced his i)eculiar method. This case, at lirst 
 view, might seem to belong to my fourth, or my sixth species. 
 In reality, however, it does not belong to either, but to the 
 third, in which I have classed it. It will be observed that 
 the rectum terminated in a blind sac, and had no communi- 
 cation whatever with the genito-urinary organs, nor with the 
 apparently well formed anus. The anus communicated and 
 was confounded with the vulva, being nothing more than a 
 sujDerlluous opening. [ Vide Plate V.] 
 
 " On the 8th of September, 1835, I was summoned about 
 midnight by an English lady, sent to me by my friend, Dr. 
 Dubreuil. She handed me a letter from M. Deneux, addressed 
 to M. Blandin, who happened not to be at home. h\ this 
 letter M. Deneux said, ' the case is one of occlusion of the large 
 iiitesii/ies, in a new-horn i/fant, the anus is lo ell formed ', the 
 rectum communicates with the vagina, and the obstruction 
 seems to he high up.'' 
 
 " I arrived at tlie house of M. B***, an Englishman, situa- 
 ted at the Rond-Point des Champs-Elysees, about one or two 
 o'clock in the morning. I there met M. Deneux, who had 
 delivered Madam B. He informed me that the child was 
 born on the 6th of September, at four o'clock, p. m., and was 
 consequently now thirty-three or thirty-four hours old ; that 
 no meconium had yet passed. 
 
 "The nurse told us that tepid Tvater injected by the anus 
 passed out by the vulva. She also assured us that she had 
 found the diapers quite wet with urine. This seemed doubtful 
 to us. 
 
 "This first child by a second marriage, although born at 
 seven months, seemed to be lively and of a vigorous constitu- 
 tion ; the abdomen was, however, hard and distended ; the 
 anus and vulva were well formed. A flexible canula intro- 
 duced by the anus, readily penetrated about two inches, and 
 v/ater injected through it came out immediately by the vulva.
 
 138 THE THIED SPECIES OF MALFORMATION. 
 
 A sontid passed by the vulva into the vagina readily met the 
 canuhi previously introduced into the anus. 
 
 " We thought that the rectum was obstructed at the height 
 of about two inches, and that it communicated with the va- 
 gina; that is to say, we thought we recognized a recto-vaginal 
 Jidida, or in other words, that the septum by which the rec- 
 tum and vagina are parted, was deficient to a considerable 
 extent. 
 
 "During the examination of the parts, which was continued 
 some time, the nurse dipped her little linger in sweetened 
 water, and gave it to the child to suck. After having once 
 more carefully determined tlie state of the case as above 
 given, our first care was to inform the parents of our conclu- 
 sion. They understood from us that there were but two ways 
 of aflbrding issue to the meconium ; viz — first by the anus, or 
 the natural passage ; second by the abdomen. 
 
 " We readily made them comprehend the danger of either 
 method of operation, as well as the inconveniences attending 
 them ; and we added, that in case we succeeded in reaching 
 the rectum by the vagina, there would necessarily be a com- 
 munication between the intestine and the vagina. Notwith- 
 standing this, the parents immediately rejected the idea of an 
 operation after the method of Littre, and coincided with us in 
 thinking it far better to attempt to reestablish the natural 
 anus, even with the inconvenience of a fistula, than to form a 
 new one in the abdomen. 
 
 " It was then determined that we should pursue the search 
 for the obstructed rectum. With this view I proposed dila- 
 ting the anus with prepared sponge. At four o'clock, a. m., a 
 piece of this sponge about an inch and a half long, but some- 
 what smaller than the little finger, with a thread attached to 
 one end, was introduced into the anus, and kept in place by a 
 compress and a T bandage. It was agreed that I should re- 
 turn about eight o'clock in the morning, to replace this with 
 a longer and thicker piece, and that we would meet again at 
 noon and perform an operation, if one were necessary. 
 
 "At eight o'clock I withdrew the sponge, moist and swol- 
 len ; the anus was considerably dilated. I could introduce 
 my little finger, which was easily seen by the vulva, but I 
 was stopped higher up by a cul-de-sac. As it was doubtful 
 whether the child had urinated, I sought for the urethra Avith 
 a small, strait silver sound, without, however, discovering the 
 passage. The little girl, however, urinated abundantly dur- 
 ing my search, owing no doubt to the titillation of the meatus 
 urinarius with my sound. A new sponge, a little thicker and
 
 THE TIIIKD SPECIES OF MALFORMATION. 139 
 
 longer tlian the first, was introduced int<j tlie anus, wliere it 
 was retained as already described. 
 
 " At noon, according to agreement, M. Denenx returned 
 with me to deliberate upon the course to be pursued. I in- 
 troduced M. Lebaudy to tlie consultation, who had expressed 
 n desire to assist. 
 
 "After removing the sponge which had yet more dilated 
 the anus, I introduced my little finger as deeply as possible 
 by this opening, without recognizing anything besides the 
 cul-de-sac already spoken of. 1 again easily caused the end 
 of my little finder to appear in the vulva. Messieurs Deneux 
 and Lebaudy also did the same. 
 
 " We then endeavored to discover the rectum, distended 
 with meconium, with the intention of puncturing it. 
 
 " The parents were informed that in the latter case there 
 would necessarily be a recto-vaginal fistula. Not satisfied 
 with our exploration, although the child was already quite 
 fatigued, I determined to introduce the right fore-finger into 
 the anus. In this new examination, both above and behind, 
 I found only a soft pouch, wdiich I thought must be formed 
 by the rectum. However, above and in front of the cul-de- 
 sac which arrested my finger, I discovered a species of fun- 
 goid contraction, which I at first took for the contracted or 
 obturated point of the intestine. 
 
 In explanation of what I had discovered I remarked to M. 
 M. Deneux and Lebaudy that the body which I had touched 
 produced the same sensation that would be produced by the 
 effaced and soft neck of the uterus, and the opening of which 
 was very narrow. Each of these gentlemen, on examination, 
 recognized the same sensations, and M. Deneux told us that 
 it must be the neck of the uterus of the little girl. A new 
 examination was made confirming the opinion of M. Deneux. 
 It was then established that a vagina existed, into wdiich the 
 anus opened without a rectum, and that the vulva and the 
 anus communicated with the vagina ; there were also by a 
 strange anomaly, two openings in the perinEeum in place of 
 one, and both terminated in the vagrina. 
 
 After assuring ourselves that we had to do with an extra- 
 ordinary malformation, consisting of the absence of the rectum, 
 or a part thereof, I resolved to carefully explore the entire 
 pelvic cavity, through the walls of the vagina, at the same 
 time introducing the fore-finger by the anus, or second open- 
 ing of the vagina, with the intention of seeking for the 
 wanting intestine. After having thoroughly explored the 
 long walls of the pelvis in front and rear and on the sides, I 
 recognized with some difficulty in front, the bladder, in the
 
 140 TIIK THIRD SPECIES OF MALFORMATION. 
 
 rear the sacrum and the sacro-vertebral angle which I care- 
 fully examined. I sought for tlie pouch which should be 
 formed by the rectum distended with meconium ; feeling 
 towards the left of the sacro-vertebral angle with the end of 
 the finger across the posterior wall of the vagina, I felt a 
 flattened body which escaped from the finger when it pressed 
 a certain distance. I repeated the experiment several times, 
 and always wntli the same result. Reflecting on this fact, I 
 concluded the object which I touched must be the rectum. 
 I communicated my discovery to my associates who coincided 
 with me in opinion after making the same examination. 
 
 At once the diagnosis hitherto so difficult, became more 
 clear and certain with relation to the facts already established, 
 namely, that tlie vagina, larger than ordinary, appeared 
 alone to occupy the pelvic cavity, and that above and 
 behind, at tlie left of the sacro-vertebral angle was placed the 
 extremity of the imperforate rectum. 
 
 I now felt quite relieved and freed from the difiiculty 
 presented by an operation so delicate, and I immediately 
 resolved to put into practice the method I had long since 
 devised for similar cases of absence of the rectum. 
 
 I described the process which I proposed adopting in this 
 case, and w^hich was as follows : to make an opening in front 
 of the coccyx and behind the vaginal anus, detaching with the 
 finger and the bistoury the posterior wall of the vagina from 
 the coccyx and the sacrum ; to penetrate as far as the cul-de- 
 sac of the large intestine, recognizing it both by the vagina and 
 by the natural passage ; to seize it with the tenaculum ; to 
 free its attachments rather with, the finger than with the 
 bistoury, to bring it down to the opening of the skin ; to 
 open it thoroughly, allow the meconium to pass off, and then 
 to fasten in a proper manner by interrupted sutures, the 
 opening of the intestine to that of the skin. 
 
 Examination was again made ; the diagnosis and indica- 
 tions seemed then so clear that they thought since the last 
 examination that everything was wonderfully favorable to 
 the bold operation which I had proposed. From this moment, 
 being perfectly agreed, the operation was decided upon and 
 the chances were laid before the parents, who comprehending 
 the unfortunate condition of their child, were resigned to 
 whatever })lan we judged best to adopt. We did not conceal 
 from them the dangers of such an operation. They were, 
 however, informed in opposition to what we had heretofore 
 told them, that if we now succeeded in effecting an evacua- 
 tion of the meconium, not only would we save the child, but 
 there would be no recto-vaginal fistula.
 
 TIIK THIRD SPECIES OF MALFOKMATION. 141 
 
 "During all this time tlic cliiM had been placed in an 
 emollient bath, to calm the irritation caused by such a 
 todions and ])aint"nl but unavoidable examination, 
 
 " Everything being prcpare<l a new examination relative to 
 the ])ertbrmance of the operation having been made, and the 
 child being placed upon the table, as if to be dissected, I 
 made a transverse incision with a short and round edged 
 bistoury, six or eight lines in extent behind the vaginal anus ; 
 another incision towards the coccyx gave the form of a T to 
 the opening by wliicli my linger was introduced, to make a 
 passage between the vagina, on the one liand, and the coccyx 
 and sacrum on the otlier ; having previously placed a sound 
 in the vaginal anus to serve as a guide to protect its posterior 
 wall from injury, I partly tore and partly cut the cellular 
 tissue uniting these parts. Thus I penetrated at least tAvo 
 inches >'nd found the extremity of the rectum. At the 
 moment the child made an instinctive effort, I was enabled 
 to recognize the termination of the rectum much better than 
 I hitherto had done by the vagina. The end of the intestine 
 was pouch-like. My associates were as much delighted as 
 myself upon recognizing this condition of the parts. 
 
 " I then decided to seize this pouch with a double tenaculum ; 
 drawing it towards me. I separated the intestine from the 
 slight adhesions which it had to the surrounding parts, except 
 on the side of the vagina, where I was obliged to use the 
 bistoury with much caution. By this means the traction Avas 
 so much facilitated that we soon perceived the intestinal 
 pouch at the bottom of the wound, and with great satisfaction 
 recognized the meconium oozing out by the side of the hooks 
 of the tenaculum. I then transfixed the cul-de-sac of the 
 rectum with a needle armed with a double ligature, and by 
 the aid of this and the tenaculum the intestine was brought 
 down to the surface of the wound in the skin. A sufficiently 
 large opening having been made between the ligature and 
 the tenaculum, a great quantity of gas and meconium imme- 
 diately gushed out. After cleaning the child, who was much 
 relieved by this evacuation, I terminated the operation in 
 the following manner : — 
 
 " Having assured myself that the intestinal opening was 
 sufficient, I seized witli bull-dog forceps, the edges of the 
 opening, I placed these forceps in the hands of assistants who 
 were to make continued traction upon the intestine until the 
 part seized upon should extend beyond the opening made in 
 the skin. I then made three points of suture at each angle 
 of the wound ; but I noticed that the traction exerted upon 
 the intestine made it ascend, and that it was no longer even
 
 142 THE TIITRD SPECIES OF MALFORMATION. 
 
 with the skin. I then made with more care six or eight 
 points of suture in the circumference of the intestine, the 
 mucous membrane I spread outside in the form of the mouth 
 of a trumpet. [ Vide Plate V. Figures. 1,2,3.] During the 
 whole operation but little blood was lost. Injections into the 
 new rectum were made immediately afterwards, and the 
 child was placed in a hip bath. The linen of the child was 
 changed five or six times in two or three hours after the 
 operation, and the meconium was always found mixed with 
 a marked quantity of blood which seemed to ooze out from 
 the left angle of the wound. Several injections were made 
 both in the artificial and vaginal anus. Poultices of flax-seed 
 meal were applied to the wound. During all this time the 
 little patient seemed to grow w^eaker. She grew pale and 
 her extremities became cold. Hitherto she had been left in 
 her cradle ; she was now placed by the side of her mother in 
 bed, who restored her to warmth and vigor in a short time. 
 From seven to eleven o'clock at night she was cleansed several 
 times, and she took a bath of ten minutes. At each cleansing 
 the quantity of meconium and blood diminished. The breast 
 was frequently oflfered to her, at first without efi:ect; but she 
 soon sucked strongly and finally went to sleep. There was 
 no appearance of fever, and twelve hours after the operation 
 there was no disturbance at tlie points of suture. The 
 wounded parts preserved their redness, but the inflammation 
 made no great progress. 
 
 " On the 9th of September, at eleven o'clock, A. M., a con- 
 sultation was had with the following results : First, the gene- 
 ral health of the child w^as satisfactory — second, the excretion 
 of fffical matter was perfectly well made — third, there was no 
 ie,YQ,r— fourth, the swelling around the circumference of the 
 vaginal anus had considerably abated — -fifth, the inflammatory 
 redness which surrounded this part, as well as the surgical 
 anus, had lost much of its intensity — sixth, the points of suture 
 being well sustained, everything conduced to make us think 
 the operation entirely successful. 
 
 " On the 11th of September, the wound and the surround- 
 ing parts were found to be in a satisfactory condition. The 
 functions of nutrition and excretion were satisfactorily accom- 
 plished ; in a word, the child appeared as well as if she had 
 been born without anv deformity." {Gazette JSLedicale dc 
 Paris. Nov. 28, 1835— A^o. XL VIII. p. 753.) 
 
 The success of the operation in the preceding case was com- 
 plete, for the patient was reported as being in excellent health 
 upwards of eight years after. {Gazette Mtdieale de Paris. 
 1843. p. 100. Gazette des Hopitaux de Paris. 1843. p. 67.)
 
 THE TIIIKD SPECIES OF MALFORMATION. 143 
 
 Dr. Ileriuann Fricdhcrf^ of ]>erlin, in liis Essay on Artifi- 
 cial Anus, remarks, tliat when lie visited Paris i)i 1854, ho 
 learned from M. Amussat that this very ^irl was then in 
 excellent health, and about to be married. She was nineteen 
 years of age. 
 
 Case XLIII. — ^Tlie following case of imperforation of the 
 anus and rectum is reported by Mr. Waters of England, pre- 
 viously referred to, in which a precisely similar operation was 
 performed, to that of M. Amussat : 
 
 " On the 10th of February, 1842, Mrs. M was confined 
 
 of a strong nuile child. She was attended by a nurse, wli(» 
 did not discover till the following day that the child had been 
 born with imperforate anus. I was called in on the lltli. 
 The child had had two or three doses of castor oil before the 
 malformation was discovered. I found it suffering intensely. 
 The abdomen tense and painful on pressure ; no vomiting. 
 Tlie central raphe of the periiifeum w^as well marked, but 
 there was not the slightest trace of an anus. Pressure over the 
 abdomen did not produce any tension or fullness in perineo. 
 
 " As there w^as not any time to lose, I emptied the bladder, 
 and made a free incision into the central line of the pe- 
 ri]in3um, and carried the wound upwards and backwards 
 above an inch without discovering any trace of the intestine. 
 I then had recourse to a bistoury, and succeeded in finding 
 the extremitv of the rectum, terminatino- in a distinct cul-de- 
 sac, opposite the promontory of the sacrum, filled with hard- 
 ened meconium, which I had some difliculty in dislodging. 
 I got hold of the edges of the intestine which I gradually 
 hrouglit down., and united to the edges of the integuments by 
 four points of suture ; I did this with the idea of presenting a 
 continuous mucous surface to the passage of fseces, and so 
 prevent irritation of the Avound, and also, if possible, to ijre- 
 vent adhesion by presenting two mucous surfaces to each 
 other. The bowels were freely acted on immediately after 
 the operation, and the abdomen fomented until pain, (fee. were 
 removed. 
 
 " The sutures were removed on the third day, and every 
 thing progressed favorably until about ten days since, wdien 
 the wound commenced to contract rapidly. I counteracted 
 this by the regular introduction of a large bougie, and occa- 
 sionally pieces of prepared sponge. The contraction only 
 exists at the surface, the remainder of the passage is lined by 
 the intestine, and. does not appear disposed to narrow its 
 calibre. 
 
 " April Yth. Mr. "Waters writes, I may add that the case
 
 li-i THE THIRD SPECIES OF MALFORMATION. 
 
 is going on most favorably. The child's general health is 
 very good, and there is not any difficulty experienced in 
 keeping the opening in the integuments sufficiently dilated. 
 The tendency to contract only exists in the mere integu- 
 ments, above this the intestine preserves its natural size." 
 {The Diiblhi Journal of Medical Science. Vol. XXI. p. 
 321. lSi2.) 
 
 Case XLIV. — ^The following highly interesting case was 
 reported by W. G. Smith, M.D., of Vauxhall-Walk, London, 
 April, 1846. It will be seen that the case w^as a desperate 
 one, the end of the rectum having been found about three 
 inches from the surface, but evidently without adliesions, 
 floating ; or it could not have been brought down so easily. 
 The operation was skilfully performed, and cro^vTied with 
 comj^lete success, the rectum having been brought down in 
 the manner directed by M. Amussat, but not attached by 
 sutures. 
 
 " A male infant, born at ]^o. 45, Catharine-Street, Lambeth, 
 had been in the world for two days before the parties attend- 
 ing it discovered the malformation described below. The 
 child had refused the breast — had been vomiting and liiccup- 
 ing ; the abdomen w^as swollen and hard. It was obvious 
 that the rectum lay deep, there being no indication, either by 
 color or touch, of its situation, or of any external preparation 
 for an anus. My friend, Mr. Smyth, of Lambeth-walk, agreeing 
 with me that this was not a case to admit of a moment's delay, 
 with his assistance I proceeded to search for the rectum, the 
 child being placed on the midwife's knee, on its belly, being 
 less likely to kick or to be troublesome in that position. 
 Making an incision in the middle of the perinseum, the 
 sphincter was observed to be straight, its inner sides being in 
 close contact. This was cut through, and part of the levator 
 ani and the fatty matter beneath were divided to the depth 
 of an inch ; but I could find no indication of where the rec- 
 tum lav. I enlarged the external wound in both directions, 
 and then continued to cut cautiously upwards and back- 
 wards ; and having arrived at the depth of about three 
 inches — being able to touch the pubes in front and the sacrum 
 behind, the wound being large enough to bury the index fin- 
 ger — on examining with great care, we could not discover 
 any appearance of a rectun"i. However, when the child cried, 
 a slight impetus was felt — a descending from behind — towards 
 which, through the intervening substance, I pushed a trocar, 
 as slender as an exploring needle ; and on the second applica- 
 tion, the escape of gas through the caimla satisfied us that the
 
 THE TIIIKD 8PECIE3 OF MALFORMATION. 145 
 
 howel had boon vcacliod. T made an nttoinpt to onlari^^o the 
 opeuiiii^ with a^ director and a bistoury, but found there was 
 no room to act with certaintj. A full-sized trocar I easily 
 introduced ; and by pressing on the bowels, a considerable 
 quantity of meconium was expelled ; a bougie Avas then left 
 in the wound. On the next day, a probe was passed, along 
 which the canula was easily guided into the bowel, which it 
 reached when pressed into the external wound ; but it was 
 only by squeezing the bowels that the contents could be made 
 to flow outwardly. 
 
 " It was quite evident how difHcult, if not impossible, it 
 would be to make an efficient opening for the faeces to pass 
 through this lono; and rather curved channel : and how diffi- 
 cult it would be to prevent such an opening from closing ; 
 and also how unlikely the power of either voluntarily expelling 
 or retaining the faeces would be obtained. I therefore con- 
 sidered it expedient to bring the bowel down into the wound ; 
 for this purpose, I passed a small pair of case-forceps along 
 the canula, and laying hold as near the opening into the bowel 
 as I could reach, I gently and gradually pulled it down upon 
 the canula. This being repeated tw^o or three times, the 
 opening into the bowel was brought down to near the mouth 
 of the external wound. No means were used to retain it, and 
 the injection of warm water now thrown np was returned 
 with power. The canula remained in the bowel for ten days, 
 the foeces being freely expelled through it by the muscles of 
 the rectum. The greater portion of the wound healed by the 
 iirst intention around the canula by granulations. The 
 sphincter now acts well, and a good anus is formed — if ^any- 
 thing, a little too far back ; the bowels act naturally, a bougie 
 being occasionally passed. A month has elapsed, and no bad 
 svmptom has occurred." [London Lancet. Vol. LV. p. 125. 
 1846.) 
 
 Casks XLV. — XLYI. — Tlie two following interesting cases 
 of imperforation of the anus and rectum are reported by M. 
 Amnssat. In these cases he established the artificial anus in 
 the coccygeal region, but unfortunately each case terminated 
 fatally in a few days. 
 
 Llrst Case. — "At seven o'clock, A. M., on the 15th day of 
 May, 1842, Dr. Garnier, physician at Charonne, sent me a 
 male infant twenty-four hours old. The child had passed no 
 meconium ; its abdomen was hard and distended, and it vom- 
 ited several times. I examined it attentively and observed 
 that the raphe existed, and at the point where the anus should 
 have opened there was an ovoid tumor or rather a longitudinal 
 crest, several lines in length. In fine, the space contained be- 
 10
 
 14:G THE THIRD SPECIES OF MALFOKMATION. 
 
 twecn the tuberosities of the ischium, on the one hand, and 
 between the scrotum and the coccyx on the other, seemed to 
 me distended, and I perceived a very sensible fluctuation in 
 tliis region. I will also add that on pressing the tumor placed 
 at the point where the anal opening should have existed, 1 
 thought I perceived a depression apparently bounded by the 
 two halves of this sphincter. The same sensation of fluctua- 
 tion was also perceived when during expiration the left hand 
 was laid on the abdomen, whilst pressure with the right was 
 made in the peringeum. Having made these facts clearly evi 
 dent to all the assistants, I had an almost perfect conviction 
 that the rectum, distended w^ith meconium, terminated at no 
 great distance from the skin. 
 
 " Tlie child being then placed on a table suitably arranged 
 for operation on the sub-pubic region, I explored anew the 
 jjerinseal region, whilst M. Boyer pressed upon the abdomen, 
 and at the point where I perceived a sufficiently manifest fluc- 
 tuation, and near the median tumor already spoken of, I forc- 
 ibly plunged the blade of a bistoury from above downwards, 
 and from front to rear. This deep incision gave vent to no 
 matter, to my great astonishment, making me fear an error in 
 the diagnosis 1 had made. But on enlarging the opening just 
 made, towards the front, when I withdrew my instrument a 
 black glutinous meconium flowed out. I now introduced a di- 
 rector, and passed a bistoury on it, and enlarged the opening 
 towards the rear. After this incission the meconium flowed 
 abundantly. 
 
 " The child was very feeble ; it was cold and of a violet 
 hue, and breathed with difficulty, perhaps during the opera- 
 tion the head had been left in a too low position. They raised 
 the head, agitated the chest, and presently the respiration be- 
 came full and the eyes moved. Sleconium still continued to 
 flow, at flrst of a black color, it became clearer and mixed 
 with gases, as if it came from the small intestines. Some 
 streaks of blood were also seen in the matter which was passed. 
 The child was cleaned and placed near the fire to w'arm it, 
 and a pledget of lint was inserted in the opening which had 
 been made. Death supervened one or two days after the op- 
 eration. 
 
 " The Autopfty. — It was discovered that the rectum, much 
 dilated throughout its full extent, and especially in its lower 
 part, terminated aljout one inch from the artificial anus which 
 had been made, and that it was necessary to reach that depth 
 to touch it with the instrument. The left lumbar colon was, 
 as in every other case which I have observed, fixed, so to say, 
 to the lumbar wall, and free from peritonteal coat in the lower
 
 THE THIRD SPECIK3 OF MALFORMATION. 147 
 
 tliird, at least, of its caliber, and circumscriLed within by the 
 kitlney covered with the anterior fold of the i)erit()nieii:.n. 
 The mesenteric and lumbar ganglions were tilled with pus. 
 Ilie intestinal nnicous membrane was red and injected throif'-h 
 a gi-eat })art of its extent." — {Troisicme Memo'ire sur la I'os- 
 sihil'tte (Tetahlir une ottverture artijicial sur la Colon lombaire 
 gauche sans ouvir le Jr'eritoine chez les Enfans imperfores. 
 
 Lu a VAcademie lioyale des Sciences, le 4 Julliet^ 1842 
 
 Alm^ IJ Examinateur Medical de Paris. Annie 184:3. 
 tome III. p. 216.) 
 
 Second Case. — " I was called by M. le docteur Yignola to 
 see a female infant having an imperforate anus and rectum. 
 In this case there was no perceptible fluctuation in the anal, 
 perinaeal and coccygeal region. An incision was made in 
 the region of the coccyx, but not deep enough to reach the 
 rectum. In order to penetrate to a still greater depth, a sec- 
 tion of the point of the coccyx was made, which in this case 
 w^as very much curved. 
 
 " At last, fearing that prolonging the incision, some impor- 
 tant organ might be injured without finding the rectum, I 
 proposed to M. Breschet, who assisted in the operation, to 
 establish an artificial anus in the left lumbar region. The pro- 
 position was submitted to the parents of the child, but they 
 rejected it. The operation was then continued in the region 
 in which it had been commenced, and the rectum was 
 found attached to the upper part of the vagina. Some 
 meconium was evacuated, then the intestine was fixed in the 
 skin by two points of twisted suture. The child died on 
 the fourth day, and the parents were unwilling to allow a 
 post-mortem examination. 
 
 " It is evident in this case, that death was caused by the 
 severe inflammation resulting from the very long search neces- 
 sarily made to discover the rectum distended with meconi- 
 um." — {Log. cit. .) 
 
 Case XLYII. The following very interesting case of imper- 
 foration of the anus and rectum is related by Dr. Hermann 
 Friedberg of Berlin, already alluded to. 
 
 " Ernest Adolph S was born, at full time, without dififi- 
 
 culty, on the 31st of August 1851, at three o'clock P. M., (a 
 first confinement.) In the warm bath which was immediately 
 given the child, it uttered loud cries, and slept afterwards for 
 several hours ; towards evening it took several spoonfuls of 
 chamomile tea, and slept tranquilly till nearly midnight. It 
 awoke with cries and manifested much restlessness, drew up
 
 \ 
 
 148 TITE THEKD SPECIES OF MALFOEMATIOX. 
 
 *" its knees and tossed from side to side, bent in its tlnimbs and 
 passed urine frequently. The cries soon gave place to groans, 
 ■W'tiich lasted until the following day, M'hilst the tossings con- 
 stantly increased. During the afternoon of the first of Sep- 
 tember, the child was visited by the nurse, who thought it to 
 ])e sufl:ering from colic, and wished to give it an injection. 
 Not finding any anus, I was called to see the child. 
 
 Tlie following symptoms presented themselves at my an-i- 
 val. — The body quite well formed, was in good condition ; 
 the extremities pale and cold, presented frequent contractions, 
 which, began also to appear in the muscles of the face, which 
 was pale and cold. The pulsation of the heart, very feeble, 
 could hardly be counted. The abdomen was unusually prom- 
 inent, and its teguments of a bluish color, were warm and 
 very sensitive to percussion, which gave a tympanitic sound. 
 The pelvic cavity seemed not fully developed ; the sciatic 
 tuberosities were somewhat drawn together, and the point of 
 the coccyx was considerably bent forward. The perinseal 
 region was neither arched nor contracted, and altogether had 
 the form of a truncated cone ; the raphe was not strongly 
 developed, and reached to the coccyx ; there was no trace of 
 an anus. Two or three lines in front of the point of the coc- 
 cyx, there was an elevation about the size of a lentil seed, 
 and of a cup-like form, which seemed to be formed by the 
 skin and by the hypertrophied cellular tissue. Tlie hollow 
 of this excrescence reached the level of the surrounding skin, 
 and was lined with skin of normal appearance. This excre- 
 sence could be depressed without feeling any cord beneath, 
 as an evidence of communication with the organs of the pel- 
 vic cavity. Tlie child continually groaned in a very feeble 
 and gentle manner, breathed irregularly, and endeavored 
 from time to time to put into action the pressure of the 
 abdominal muscles. Besides the countenance had now 
 become livid ; in the perinjieal region there was manifest 
 pressure of the rectum, while the child placed in the usual 
 bent position in which children are held. I did not hear 
 either by the stethoscope applied to the peringeum, or by per- 
 cussion of the anterior wall of the abdomen, anv sound indi- 
 cating the presence of the rectal extremity filleu with gas and 
 fsecal matter. Several times I pressed with the end of my 
 left fore finger on the perinseum, towards the pelvic cavity, 
 and at the same time made percussion with my right hand 
 upon the anterior wall of the abdomen, but without discover- 
 ing any approach of the rectum towards my fore-finger. 
 Although from this fact as well as the narrowness of the 
 pelvic cavity, I concluded there must be a considerable dis-
 
 THE THIRD SPECIES OF MALFORMATION. 149 
 
 tancc botweoii the terminal end Cjftlie rcfiiim and the pcrhi- 
 {.eiun. 1 could not admit that this end couimiiuicated with 
 the bladder or the urethra, since the urine passed, contained 
 no mixture of fiscal nuitter. The excrescence below the coccyx 
 made me suspect that the rectum might be above it. As t'lie 
 intensity of the morbid symptoms presented by the child, 
 warned me to empty the intestinal canal promptly, as a first 
 attempt I plunged a lancet into the cavity of the excrescence, 
 and then cut through its anterior edge. No evacuation of 
 faical matter followed, although I had pushed the lancet 
 nearly an inch deep, toward the sacrum. 
 
 " I prescribed syrup of saffron with syrup of poppies, and 
 cold compresses on the abdomen, and forewarned the parents 
 of the necessity of recurring to an operation for artificial 
 anus. Meanwhile the consent of the parents being gained, 
 the child had to be baptized, so that it was not till an hour 
 after noon, and consequently twenty two hours after birth, 
 that I was able to commence the operation. The condition of 
 the child was much worse, and a distressing hiccup had set 
 in. The urine was evacuated immediately before the opera- 
 tion. With the kind assistance of Dr. Wagner, I proceeded 
 to the formation of an artificial anus in the following manner: 
 — The child was placed with its back on a cushion, the legs, 
 flexed, were held asunder. I first enlarged the former incis- 
 ion towards the front, so that it could be penetrated with the 
 little finger. However, as I could not thus reach the intes- 
 tine, I incised the integuments of the perinaeum, on the 
 median line from a point three lines distant from the scrotum, 
 and I continued the incision longitudinally, and backward 
 until I could easily see into the cavity of the pelvis. At the 
 depth of an inch and a half, I then perceived a deep green 
 tumor, tense and fluctuating, which extended from the prom- 
 ontory, towards the bladder. This tumor descended a little 
 when the abdominal walls were pushed backwards towards 
 the cavity of the pelvis. I no longer doubted that this was a 
 part of the rectum, and I did not hesitate to seize it with the 
 forceps and bring it down. It descended to the surface of the 
 perinaeal wound, when I incised it from front to rear. At 
 the same time the meconium gushed out, with a great quan- 
 tity of inodorous gas. The child then ceased groaning, 
 breathed deeply and regularly, and became immediately tran- 
 quil. The evacuation lasted some time before it ended; 
 daring this time the edges of the intestinal wound were firmly 
 held by means of dissecting forceps, quite clear of the perin- 
 aeal wound, and afterwards were cleansed by thorough wash- 
 ing with cold water. Then by means of three points of
 
 150 THE THIRD SPECIES OF MALFORMATION. 
 
 sntnre, I fixed the edges of the intestinal wound in the posi- 
 tion of the normal anus, so that the mucous membrane was 
 united to the skin of the perinreum. After cutting off the 
 excrescence situated below the coccyx, and, giving an extent 
 of three quarters of an inch to the perimeal wound, I united 
 tlie edges before and behind this excrescence, and then fixed 
 by points of suture, the anterior and posterior angles of the 
 intestinal and perinseal wound exactly together. The 
 haemorrhage during the operation was slight. While the 
 operation lasted the child gave no evidence of pain, but pre- 
 served the appearance of one dying, up to the moment when 
 the contents of the intestine were voided. Immediately after 
 the operation, the expression of the countenance was sensibly 
 ameliorated, the abdomen decreased in volume, and ceased to 
 be hot and painful, and the extremities grew warm ; all mus- 
 cular contractions ceased. Half an hour after, the child took 
 the breast for the first time and sucked heartily. It fell 
 asleep upon the breast and did not wake for four hours, when 
 it uttered loud cries. When its mother raised it from the 
 bed, she found it had evacuated a considerable quantity of 
 fiscal matter, so that the dressing I placed had been displaced. 
 The child passed the night sleeping and sucking by turns. 
 It was found soiled every time it was taken up. 
 
 " The next morning, I found the child in a satisfactory con- 
 dition, but somewhat weakened ; but the wound presented 
 no sign of inflammation. I ordered warm chamomile, baths, 
 and for the wound, frequent lotions of pure tej^id water. The 
 application of wet compresses could be of no avail because 
 fiecal matter of a yellowish brown color was constantly pass- 
 ing ; the edges of the wound seemed perfectly united all 
 round. 
 
 " The fourth day after the operation, the anus already pre- 
 sented an oval form, even when excretion was not taking 
 place ; for this function began to present appreciable inter- 
 vals, lasting nearly half an hour, as the mother told me. 
 I myself remarked an interval which lasted about sixteen 
 minutes. After taking the child and washing the wound 
 with injections of warm water, in the midst of slight but 
 nevertheless appreciable dilatations of the perinsBum, the 
 wound taking a circular form, allowed a small quantity of 
 half liquid, yellow fsecal matter to pass rapidly, and its con- 
 tact did not seem to cause any pain to the child. Immedi- 
 ately after new faecal matter passed from time to time with- 
 out any perceptible motion of the perinaeura, or the edges of 
 the wound. After which the edges gathered together until 
 the wound recovered its oval form, the longitudinal diameter
 
 THE THIRD SPECIES OF MALFOKMATION. 151 
 
 corresponding; to tliiit of the perinanira. About sixteen 
 niinutc'S tlieii passed betui-c the signs above mentioned, 
 announced a new evacuation. There appeared no tumet'ac- 
 t'on or redness of the edges of tlie wound, and from this time, 
 the posterior angle only from which I iiad cut the excrt'scrnce, 
 secreted a small quantity of matter containing a few puru- 
 lent globules. 
 
 " I'he sixth day after the operation two sutures were so 
 much loosened, that I removed them. As the others caused 
 no suppuration, and the pinkings did not seem enlarged, 1 left 
 them untouched ; three days after, I removed them entirely. 
 Some of the pinkings lasted four or five days, and. healed 
 without any appreciable suppuration. At this moment cica- 
 trization was complete in the whole extent of the wound. 
 The form of the anus rounded no more, and the edges 
 ascended a little towards the rectum. The power of the child 
 to retain its stools increased to such a point that the evacua- 
 tion of semi-liquid yellow fiscal matter occurred only every 
 half hour, and. sometimes only every hour. Four weeks after 
 the operation, the evacuation ceased simultaneously with a 
 manifest contraction of the anus ; and afterwards fiscal matter 
 of good consistence passed only three or four times in twenty- 
 foin- hours. The child prospered and throve, so that at eight 
 months old it could stand, alone, and could pronounce some 
 words. 
 
 " The anus, with the exception of some slight scars result- 
 ing from the sutures, presented no trace of the operation, and 
 seemed altogether like a normal anus. I had no more occa- 
 sion to visit the child, and learned what follows from the 
 mother. 
 
 " During the ninth month two incisor teeth were cut, 
 accompanied with violent morbid symptoms, especially a 
 bronchitis which lasted eight days ; and enteritis. At the 
 beginning of June, 1852, the cutting of an upper incisor tooth 
 was accompanied with frequent cough, and engorgement of 
 the sub-maxillary glands. These phenomena persisted in 
 spite of medical treatment, and with an astonishing emacia- 
 tion of the child, until death occurred on the twenty-fourth 
 day of June, 1852. Consumption of the glands, and convul- 
 sions were stated, to be the causes of death. ]N"o autopsy was 
 made." {ReGherohes CUniques et Critiques Siir L'Anus 
 Artificiel. In Archives Generales De Medicine de Paris. 
 Juillet, 1857. p. 50.) 
 
 Case XLYIII. — Schultz reports the case of a child that 
 was born entirely destitute of an anus, or any sign of one.
 
 152 THE THIRD SPECIES OF MALFORMATION. 
 
 The usual operation was performed, but nothing except some 
 blood was discharged, and the child died on the follow 
 ing day. 
 
 At the autopsy, it was discovered that the rectum, for the 
 distance of nine fincjers' hreadth, was completely obliterated, 
 being entirely without a cavity, and that it was twisted like a 
 rope, down to the place which the anus should have occupied. 
 {Miscellanea curiosa sive ep/iem, acad. natur. curiosor. decur. I. 
 ann. III. observ. 9,. p. 5.) 
 
 Case XLIX. — Lieutand mentions the case of an infant in 
 whom the rectum terminated in a cul-de-sac, and by a fila- 
 ment at the upper part of the sacro-vertebral angle. Tliere 
 was no trace of a normal anus. {Bulletin de la Societe Atiat 
 Paris. Mai, 1839. j). 86.) 
 
 Case L. — Yon Ammon observed in a four or five months' 
 foetus an imperforation of the anus and rectum. In this case 
 the rectum terminated in a cul-de-sac high up, and was 
 thence continued down in the form of a rudimentary cord, 
 and attached to the sacrum. [ Vide Plate IV, Figure 2.J 
 
 This malformation Von Ammon considered to be the result 
 of an arrest of development. But might not the cord-like 
 projection have been an obliteration of this portion of the rec- 
 tum, and the result of rectitis during foetal hfe ? {Die 
 Angehorenen Chirurgischen KranJcheiten des Menschen. S. 44. 
 Berlin: 1842.) 
 
 Case LI. — Tlie following case was communicated to the 
 " Boston Medical and Surgical Journal by S. Mitchell, M.D., 
 in a letter dated Cameron Mills, N. Y., May 21st, 1851. 
 
 '^I was_ called on the 16th instant to see an infant son of J. 
 L. F., which was three days old. Upon examination, I dis- 
 covered the nates to be perfectly adherent ; and, instead of 
 the natural fissure between them, there appeared to be only a 
 slight ridge, which was continuous with the raphe of the scro- 
 tum. There was not the slightest trace of the anus to be dis- 
 covered ; but by placing the finger upon its region, and mak- 
 ing firm pressure while the child struggled or cried, the boM-el 
 could be felt to press upon the finger. The child appeared 
 otherwise to be perfect, and I learned from the nurse that it 
 had been lively up to the evening before, when it began to be 
 so drowsy that it was with much difiiculty it could be aroused, 
 even suflicient to open its eyes. At the time of my visit, the 
 stupor was still ^ more profound, with a purplish and mottled 
 Btate of the skin; eyes smiken and countenance pinched;
 
 THE THIRD SPECIES OF MAUOUMATION, 153 
 
 denotiiif^ tliat tlic vital powers of the RyKtein were f?Iving 
 way, probaljly from tJie irritation ariaiii^ from the retained 
 secretions in the bowels. I gave it as my opinion to the 
 parents, that, on account of its weakness, it was quite proba- 
 ble that an operation would not ])revent a fsxtal termination ; 
 but, of course, its only chance for life was in o])erating. They 
 decided for me to operate. Accordingly, with the assistance 
 of my brother. Dr. John Mitchell, 1 proceeded as follows. 
 The child was placed upon the knees of an assistant, with its 
 face downward, and the nates exposed. I then made an 
 incision, Avith a small scalpel, seven or eight lines in length, 
 commencing a little anterior to the os coccyx, cutting througli 
 the skin and a firm ligamentous growth immediately beneath. 
 I now used a long narrow straight bistoury, which I carried 
 up in the direction of the curve of the sacrum about one and 
 a half inch, when it entered the bowel, which was followed 
 by a copious discharge of gas and meconium. There was not 
 more than one • or two teaspoonfuls of blood lost during the 
 operation, and yet, at its termination, I found my little patient 
 was sinking rapidl}^ from the shock upon the nervous system. 
 Various remedies and expedients were resorted to, to arouse 
 him, but without success. His gasps for breath continued to 
 grow less and less frequent, until he ceased to breathe ; but, 
 as his heart continued to beat freely, my brother commenced 
 tlie use of artificial respiration. I could feel his heart beat 
 stronger and faster every time his lungs were inflated ; and, 
 after using it for five or ten minutes, we had the satisfaction of 
 again seeing the little fellow catch for breath, which he con- 
 tinued to do more and more frequently until natural respira- 
 tion was established. I mention this as an example of the 
 efficacy of artificial respiration, when properly applied. The 
 child, undoubtedly, was in a state of syncope, so profound 
 that all the usual remedies had failed to arouse him. A mod- 
 erate dose of castor oil was now ordered to be given, to sweej) 
 out the bowels, and a few drops of brandy to be taken at 
 short intervals in a little sweetened milk and water, until he 
 should rally ; and a tent, smeared with simple cerate, to be 
 constantly kept in the artificial orifice to prevent its union. 
 
 " Saturday, ITtli. — Less stupor. Bowels have moved seve- 
 ral times since last evening, but he still remains quite feeble. 
 
 " Sunday, 18th. — Sank and died from inanition. 
 
 " I have every reason to believe that had the operation been 
 performed earlier, before the vital powers began to give way, 
 it would have been successful." {Boston Medical and Surgi- 
 cal Journal. Vol. XLIY. xj. 376. Boston : 1851.)
 
 154 THE THIRD SPECIES OF MALFORMATION. 
 
 Case LII. — Mr. Eedfern Dnvies, of Birmingham, England, 
 reports the following case of imjoerforate anns and rectum : 
 
 " The mother of the child, a healthy primipara of twenty- 
 eight years of age, was delivered of it at full time, on Decem- 
 ber 19th, 1857. The child seemed to all appearance at birth 
 well and flourishing ; but on the third day, no meconium hav- 
 ing come away, the medical attendant elicited, in answer to 
 his inquiries, that there existed some malformation about the 
 child's hottom^ which the nurse explained not having seen be- 
 fore, owing to her bad sight. An imperforate anus was at 
 once found to exist. 
 
 " On being summoned, December 22d, by my friend. Dr. 
 Cornelius Suckling, under whose care the child was, the fol- 
 lowing appearances presented : — a well formed male child ; 
 seems weakly, but is tranquil. Urine quite clear, and made 
 freely. On examining the perinseum no anal aperture is 
 seen ; the skin passes continuously from side to side ; median 
 raph^ very marked and distinct. In the site of the anus the 
 integument puts on a different color to adjacent parts; it is 
 darker and has a peculiar appearance, simulating the usual 
 anal wrinkles. On examining with the finger, and at the 
 same time pressing upon the abdomen, or when the child 
 cries, it is thought that in the direction of the rectum a fluc- 
 tuation can be made out ; the sensation is, however, by no 
 means defined or certain. In all other directions an elastic, 
 firm and resisting structure is evident. The bony outlines of 
 the pelvis natural. The abdomen is bulging, hard and tym- 
 panitic on percussion. 
 
 " Diagnosis. Absence of anus and of a portion of the rec- 
 tum, probably from one to two inches. Rectum does not 
 open into viscera. 
 
 "An incision which upon measurement, was found to be 
 five-eighths of an inch, was commenced in the central line of 
 the perinseum, down to the coccyx, in the part alluded to as 
 marking the sight of the anus. Introducing the little finger, 
 the sensation of the end of the rectum, though very distant, is 
 now certain. Guided by that sensation, by the curve of the 
 sacrum, and by the tuberosities of the ischium, the incision 
 was carried by very gentle progression, cutting fibre by fibre, 
 to a distance of two inches and a quarter, as was ascertained 
 by actiial measurement both at the time and afterwards. Tlie 
 extremity of the gut being satisfactorily recognised, an inci- 
 Bion was made into it, and a gi-ooved director pushed into 
 the gut. An immediate escape of gas, wliich was very per- 
 ceptible both to the ears and noses of the bystanders, as also 
 by the welling out by the side of the director of meconium.
 
 THE TllUtD SPECIES OE MALEUKMATKJN. 155 
 
 announced that tlic rectum was opened. There was hut very 
 little loss of hlood, estimated hy the nurse as under a teaspoon- 
 ful. A dose of castor oil administered directly ; a small oiled 
 tent introduced into the wound ; the child was put to hed. 
 
 " Vesj)ere, 10 P. M. — No more meconium luis passed. 
 Child seems easy. 
 
 " Deceviher 23cl. 10 A. M. — No meconium passed ; child 
 refuses the hreast, seems fretful and ailing. On withdrawing 
 the tent and introducing the finger into the wound, a few co- 
 agula are found at the top, closing the opening into the gut ; 
 on their being removed, a fresh escape of flatus and meconium, 
 which now passes easily through the wound. He was ordered 
 a j)urge of jalap. 
 
 " Vesj)ere, same day. — Child seems easy, but refuses nour- 
 ishment ; meconium comes away ; urine clear. 
 
 " December ^Uh. — Meconium and faeces come away easily. 
 Child refuses nourishment. 
 
 " Vesj>ere. — About the same, 
 
 " December 2bth. — Died about noon. 
 
 " Post Mortem. — Body of a dwindled appearance. Upon 
 opening the cavity of the abdomen, no signs of peritonaeal or 
 inflammatory miscJiief could be any where traced ; the con- 
 tents appeared quite healthy, and the anatomical relations of 
 the viscera as usual, save that there is a deficiency in the rec- 
 tum, which is found to terminate in an infundibuliform cul-de- 
 sac, about the middle of the sacrum. Upon oj)ening it, it 
 is found to contain healthy fjBces ; and presents about one 
 fourth of an inch posterior to the cid-de-sac, on its lower sur- 
 face, an aperture three eighths of an inch in diamater, through 
 which a jjrobe being introduced, passes out through the arti- 
 ficial anus in the perinseum. The bladder is found quite nat- 
 ural. Tlie rectum, as before said, terminated in a cid-de-sac 
 of an infundibuliform shape, from which is prolonged, for 
 about three fourths of an inch, a fibrous cord. No muscular 
 fibres could be found corresponding to the anus, though looked 
 for, even by the microscope." — {Edinhurgh Medical Journal. 
 m. XXXIIl. March, 1858. p. 808.) 
 
 Case LIU. — Petit gives the case of a child in which both 
 the anus and the rectum were imperforate. A deep incision 
 was made with the lancet into the integument of the ])art 
 where the anus ought to be, and the wound thus made was 
 dilated with the finger, yet no rectum could be discovered. 
 Three hours afterwards, a soft and dark tumor, the size of a plum, 
 presented itself at the opening and completely concealed it. 
 This tumor was punctured, the meconium discharged, and the
 
 156 THE THIRD SPECIES OF MALFOEMATIOX. 
 
 child much relieved ; yet it did not entirely rally, but contin- 
 ued to linger on, suffering more or less, until the eighth day, 
 when it expired. 
 
 At the autopsy Petit discovered that the tumor was the 
 posterior jDart of the superior portion of the rectum, which had 
 been forced down into the incision, by the straining efforts of 
 the child to evacuate its bowels, and that it formed a kind of 
 hernia. The inferior portion, or lower third of the rectum 
 was found obliterated, without the sign of a cavity and like a 
 hard cord, and into which a very fine pointed probe was with 
 much force and difficulty introduced. — {Memoire de VAcad- 
 emie Royal de Chirurgie. tome II. p. 237. Paris : 1781.) 
 
 Case LIY. — Saviard reports the case of a new-born child, 
 which presented an imperforation of both the anus and the 
 rectum. Tliere was no sim whatever of an anus, and the 
 rectum terminated in a cul-de-sac. He plunged a lancet into 
 the place which the anus should have occupied, in the direc- 
 tion of the rectum, and after penetrating to the depth of two 
 finger'' s Jjreadth it entered the blind sac, and simultaneously 
 Avith the withdrawal of the instrument, the meconium flowed 
 out abundantly, and the child was saved. {Oj?. clt.) 
 
 Cases LV — LYI. — Heister observes that he saw two chil- 
 dren, in both of whom the anus was imperforate, and the 
 rectum completely closed and terminating as high up as the 
 superior part of the sacrum. The operation in each case was 
 performed with a trocar ; but the result in both cases was 
 death. {Institutiones CJdrurgiccB, P. 11, Sec. Fi, Chajy. 
 CLXIIl. Amstelcedami, 1739.) 
 
 Cases LYII — LYIII. — Adrian! reports having seen two 
 infants, in both of which there was imperforation of the anus, 
 the rectum terminating in a blind sac. In one of the children 
 a trocar was plunged in the direction of the rectum to the 
 depth of the little finger, the cul-de-sac was reached and 
 meconium flowed, l3ut the child died. Tlie other one died 
 without operation. {Puysch, Adve?'sarla Anaiomicd Decad. 
 II. c. 10. p. 43.) 
 
 Case LIX. — ^Tlie following case of imperforation of the anus 
 and rectum is recorded by Wolf, who after having thrust a 
 large lancet into the perineum a few lines in front of the os 
 coccygis, to the depth of two inches, failed to reach the 
 meconium. lie afterwards, however, with a pharyngotomus 
 succeeded in piercing the end of the rectum, and letting out
 
 Tin: TIIIUD Sl'ECIKS OF MALl'OKMATION. 157 
 
 its contents. What was very rcmarlvublo in this case, the 
 maltVtniKition was not discovered till the eveiiiiio- of tlie 
 twelfth day after the birth of the child, it having liad no evac- 
 uation from its bowels during all this time ; when it was 
 attacked with vomiting, hiccuj) and convulsions, the abdomen 
 was distended, hard and painful upon pressure, and there was 
 great prostration of strength. The operation uuder these 
 unfavorable circumstances was performed on the thirteenth 
 day, and subsequently by the use of enemata and tents, the 
 child ultimately recovered. {Langenheck, Neue Bihliothek 
 far die Chiriwgie %uid Oj>hthalmologle. Band III. S. 231. 
 Hanover, 1813—22.) 
 
 Cases LX — LXI. — ^Professor James Jones, of New Orleans, 
 previously alluded to, reports the two following unfortunate 
 cases of imperforation of the anus and rectum. 
 
 I'ii'si Case. — " My next case," says Dr. Jones, " was in 
 consultation with my friend Dr. Richard Bein, on the lltli 
 of August, 1856, The little boy was born on the ninth, pre- 
 sented the usual symptoms, and Dr. B. made an attempt, in 
 company wath Dr. Hunt, to cross the river during the gale of 
 August the 10th, to relieve him by an operation ; but after 
 several hours drifting about they returned home without being 
 able to get across. Dr. H. being unwell, I went over next 
 day, with Dr. Bein, We found the child in great distress, 
 the abdomen very tumid and renitent, with constant vomiting 
 of a yellowish thin lluid. On examination, the anus being 
 imperforate, we proceeded at once to open it with a bistoury, 
 which, after being carefully introduced to the depth of an 
 inch and a quarter, gave issue to a large quantity of meco- 
 nium. The accumulated cathartics produced so much purga- 
 tion that Dr. B. was compelled, during the evening, to 
 administer an anodyne mixture to check their debilitating 
 operation. 
 
 " On the twelfth we introduced a caoutchouc tube to keep 
 the passage open. The abdomen was greatly reduced, the 
 child sucked and swallowed, and we hoped that it would con- 
 tinue to improve. 
 
 " On the 19th I saw it again. The operations had ceased ; 
 the abdomen was again hard, although not so much inflated. 
 Tlie opening having contracted, we dilated it by introducing 
 the dressing forceps and gently spreading the blades ; the 
 orifice was again kept dilated with a gum catheter. The 
 general appearance of the child was wretched ; it moaned
 
 158 THE THIRD SPECIES OF MALFORMATION. 
 
 and whined continually, never slept, rejected everything, and 
 exhibited signs of peritoneal inflammation of a fatal tendency. 
 By the use of camphorated mercurial ointment to the abdo- 
 men, emollient enemata, and two or three minute doses of 
 calomel, it revived slightly and had a few oj)erations, urinat- 
 ing as usual." 
 
 " On the 23rd I saw it again by the request of Dr. B. and 
 although evidently sinking, it lingered until the 25th. 
 
 " On the 26th the body was opened by Dr. Bein, myself, 
 and Dr. F. Poland, at that time a student of medicine. The 
 intestines were somewhat distended, and were also generally 
 adherent by organized bands of lymph. Internally there was 
 much disseminated inflammation. The rectum terminated in 
 a pouch, which being doubtlessly softened in its attachments 
 by inflammation, pealed off entire from the pelvic surface of 
 the perinseum. I have it now in alcohol. Tlie friends were 
 waiting to bury the infant, and we did not examine into the 
 state of the sphincter or of the other muscles." 
 
 " It was very evident that in this case enteritis and perit- 
 onitis were the causes of death. The only question being 
 how they should have occurred, when the operation had 
 been so successfully performed at so early a period. 
 
 Second Case. — "On the morning of the 17th of ISToveraber, 
 1857," says Professor Jones, '' I was called, before day, to 
 see Mrs. R, Franklin Street, in labor. I found, on my 
 arrival, that she had been delivered several hours previously 
 of one child and that she was much exhausted by her efforts 
 to expel another. I found the membranes of the second 
 ovum unruptured, and felt the hand and arm presenting 
 through them. I immediately ruptured the bag, pushed up 
 the right hand and arm, brought down the head, and in three 
 pains it was delivered. I felt the chord prolapsed and pulse- 
 less as I pushed up the hand. The child was born in five or 
 six minutes after I commenced to interfere, but it was 
 asphyxiated, without the slightest pulsation about the heart, 
 and nothing could revive it. 
 
 " On the 18th, in the morning, the surviving child had 
 passed nothing from its bowels, although unfortunately, it 
 had taken considerable quantities of castor oil, olive oil, and 
 all of the usual teas children are compelled to swallow. Its 
 belly was already tumid and tense the enlarged veins 
 showing the intestinal obstruction. On returning, several 
 hours afterwards, with the proper instruments, I found the 
 child worse ; it was very restless, evidently in pain, and had
 
 THE THIRD SPECIES OF MALFORMATION. 159 
 
 rejected latterly, every tliirifij put into the stomach. It had 
 never attcin])ted to suck. Dr. Stone beinir in the vicinity, 
 we examined the case together, and found tlje anus completely 
 imperforate. A small incision made unsuccessfully with the 
 bistoury, was repeated afterwards with the lancet, which 
 beino; driven to the depth of more than an inch, was 
 followed by a copious evacuation of meconium and flatus ; 
 the belly subsided immediately ; the vomiting ceased, and 
 the child did not give much indication of pain ; but refused 
 to suck ; swallowed with difficulty, and continued to decline. 
 
 "On the 20th, a gum catheter was introduced, after 
 extending the puncture, more meconium followed. In the 
 evening of the same day, the child died. 
 
 " On the morning of the 22nd, M. Capdevielle and my son 
 made a post mortem examination, and brought me the 
 intestines. The peritongeum was inflamed ; the intestines 
 somewhat distended, and the colon very much inflamed, and 
 tilled with a mixture of meconium and of blood, which 
 probably came from the incision I made last, in enlarging 
 the opening. The rectum terminated, as in the case with Dr. 
 Bein, in a pouch, on the pelvic side of the perinieum. The 
 incision Avas through cellular membrane, and there was no 
 appearance of a sphincter." {New Orleans Medical and 
 Surgical Journal. Vol. XV. Pp. 99, 101. 1858.) 
 
 Case LXII. — Tlie following interesting case was communi- 
 cated to the ^^ Boston Medical and SurgicalJournal^^ by Dr. 
 Thomas P. Hill, of Sanbornton, IST. H., in a letter dated 
 December 4th, 1839. 
 
 " Some time in August last I w\as called, in the niglit, to 
 visit Dr. Webster's family, of Hill. Mrs. W. had been con- 
 fined, the previous afternoon, of a male child, and M'as then 
 comfortable. JSTothing unusual appeared in the child at 
 birth ; its exterior was perfect, so far as had been discovered, 
 and its features were uncommonly beautiful. Very soon, 
 however, it was seized wath spasms, attended with a livid 
 appearance over the face and neck, and in some degree over 
 the whole body, more especially when anything was put into 
 its mouth. The nurse told me, on my arrival, that she 
 believed the child could not swallow. Finding nothing in 
 the mouth to obstruct the passage to the throat, and in order 
 to satisfy myself as to wdiat the nurse had stated, I directed 
 her to give a teaspoonful of warm drink. The child made no 
 effort to swallow, but was immediately convulsed, accompa- 
 nied with the lividity above mentioned, and the drink which
 
 160 THE THIRD SPECIES OF MALFORMATIOX. 
 
 had been given was returned by tlie mouth and nose, mixed 
 with bloody mucus. Supposing- there might possil.)ly be some 
 spasmodic stricture of the oesophagus, and that gently stinni- 
 lating the rectum would remove the difficulty, I advised an 
 injection of warm water per anum. But in attemjjting to 
 comply with the direction, no outward passage could be 
 found ; not even the vestige of an anus was seen ; all was as 
 smooth as the hand, except the raphe, which extended from 
 the scrotum to near the point of the coccygis. All the cir- 
 cumstances of the case considered, it was not thought advisa- 
 ble to attempt any operation, and I took my leave, expecting 
 soon to hear that the child was dead. It remained, however, 
 much the same till the next day ; it would sometimes lay 
 quiet, as though nothing ailed it ; and the anxious j)arents, 
 desiring that something might be done, if possible, to relieve 
 the little sufferer from its imj)ending fate, sent for me again, 
 and two others of the faculty. The result of this consultation 
 was, that an attempt be made to open a passage into the rec- 
 tum. An incision was made in the integuments, about an 
 inch long, half way between the scrotum and coccygis, and 
 an abscess lancet introduced about an inch and a half in the 
 direction to pierce the lower portion of the gut, if it were in 
 its natural situation. No portion of the intestine was reached, 
 and, of course, the operation failed — and the poor little thing 
 was again left to its fate. It lingered a day or two, without 
 any change of symptoms, and expired. 
 
 " Postmortem Examination. The abdomen was consider- 
 ably swollen, from gaseous distention of the intestines. No 
 other abnormal appearance was noticed in the alimentary 
 canal, except at its extremities. On dissecting out the lower 
 portion of the track it was found that \X\q rectum, instead of 
 pursuing its natural course down the concave surface of the 
 OS sacrum and coccygis, took an anterior direction towards the 
 bladder, and terminated in a cul-de-sac upon the posterior 
 portion of the neck of that viscus. The bladder could be 
 inflated from the rectum by means of a blow-pipe, though 
 the communication could not be traced by a common probe. 
 [ VhU Plate IV, Figure 3.] 
 
 " The condition of the upper end of the tube was still more 
 remarkable. The pharjmx terminated in another cnl-de-sac 
 about two inches below the fauces. The oesophagus, tracing 
 it upward from the cardiac orifice of the stomach, diminished 
 in size as it ascended, till it finally ended in a few scattered 
 fibres, jjassing through an opening in the posterior -\)SA't of the 
 trachea, to be inserted upon its inner surface." {Boston Med-
 
 TIIK THIUD 6PECIK8 OF MALFORMATION. 161 
 
 ical and Surgical Journal. Vol. XXL r>. 320. Bo!<- 
 ton: 1839.) 
 
 The following cases all belong to this the third species, und 
 should be thus classed. Their history and descri2)tion, for 
 obvious reasons, will be given in the chapter on Abdominal 
 Artificial Anus. [ Vide Chapter XI.'] 
 
 Cases— CCLY— CCLVI— CCLYIII-CCLXI— CCLXIV 
 CCLXV— CCLXYI — CCLXIX — CCLXX — CCLXXI — 
 CCLXXm — CCLXXIV — CCLXXYI — CCLXXVIII — 
 CCLXXX— CCLXXXI— CCLXXXII— CCLXXXVI. 
 
 11
 
 THE FOUETH SPECIES OF MALFOEMATION. 
 
 SECTION I. 
 
 DESCRIPTION. 
 
 This species of malformation is characterized by the anus 
 being usually quite normal, whilst the rectum at a variable 
 distance above it, is either obliterated, partially or wholly 
 absent, or occluded by a thin or thick annular membranous 
 septum, like a diaphragm — presenting, as it were, a double, 
 or an external and internal cul-de-sac. [ Vide Plate VI, 
 Figure 1.] 
 
 Sometimes the rectum is intercejDted at several points by 
 transverse membranous septa ; its diameter, however, at these 
 points remains undiminished, and the canal, with the excep- 
 tion of these partitions, being perfectly normal. 
 
 Dr. Friedberg, of Berlin, mentions a case in which the walls 
 of the rectum some distance above a well-formed anus, were 
 adherent at two points, and the canal at these places obliter- 
 ated. [ Tide Case LXXXIV.^ 
 
 Professor James Jones, of New Orleans, saw a case in 
 which the anus was normal, but the rectum a short distance 
 above it, was entirely wanting. [ Vide Case LXXX VII.] 
 
 Schenck relates a case in which the parietes of the rectum 
 
 above a natural anus, were closely united at two places, as if 
 
 glued together ; and at two other points the rectum was occlu. 
 
 ded by two annular membranous septa. [ Vide Case ZXIIL] 
 
 M. Yoillemier reports a case in which the rectum, above a 
 (102)
 
 THE FOUIITII SPECIES OF MALFORMATION. 163 
 
 natural amis, was divided by four membranous partitions. 
 [ Vide Case ZXXXIIL] 
 
 The late and lamented Dr. Buslie, of New York, mentions 
 a case in Avhicli the rectum, above a normal anus, was 
 obstructed by two membranous partitions. [ Vide Case 
 ZXXXII.] 
 
 Goeschler, of Prague, reports a similar case to that of Dr. 
 Bushe. [ Vide Case XCII.] 
 
 The situation of the obstruction or membranous partition 
 will be found to vary from one half to two and a half inches 
 from the margin of the anus. It is sometimes quite delicate, 
 thin and semi-transparent, and easily perforated or ruptured, 
 by the probe or the finger ; at other times it is thick and 
 hard. Trioen relates a case in which the ano-rectal septum 
 was one inch thick, and of the consistence of horn. [ Vide 
 Case ZXVII.] 
 
 Engerran witnessed a case in which the rectum, above a 
 well-formed anus, was indurated, puckered and drawn into a 
 knot. [ Vide Case LXVI.] 
 
 In some instances, at the normal situation of the anus, a 
 wrinkled depression like the umbilical pit is observed, but 
 when you come to examine carefully and separate the wrin- 
 kles you will find no anus there, but merely a slight depres- 
 sion. Such cases must not be confounded with those under 
 consideration. [ Vide Cases XXXVIII — XXXIX?\ 
 
 From the preceding observations it will clearly appear tliat 
 a well-formed anus does not by any means prove that the rec- 
 tum is normal, that it is not obstructed, or that it is not par- 
 tially or wholly wanting. This species of malformation pre- 
 sents a form, therefore, which is at once well calculated to 
 deceive the most experienced, unless an exploration is made. 
 The circumstance of tlie normal state of the anus in these 
 instances is the more serious, because it never leads to the 
 suspicion that an obstruction of the rectum exists, but quite 
 to the contrary — thus leaving the nurse or the accoucheur, or
 
 164 THE FOUKTH SPECIES OF MALFOEMATIOX. 
 
 both, in a fatal securitj', till aroused sooner or later by grave 
 symptoms presenting themselves. 
 
 Every nurse and accoucheur should be impressed with the 
 importance of making a visual and tactile examination of the 
 anal region of every child which fails to pass meconium or 
 fsecal matter within the first twelve hours after birth, and not 
 to wait for urgent symptoms to present themselves before this 
 exploration is made. The examination may be made by 
 either introducing the extremity of the little finger well oiled, 
 an elastic bougie, or a probe, into the anal orifice ; or by an 
 injection of a little warm water, which if it meets with an ob- 
 struction will be immediately returned. An ignorant nurse, 
 however, may here be deceived herself, and deceive others. 
 She will declare that the child's fundament is natural, and 
 that she has given the child several injections into its bowel, 
 when perhaps not a drop of the fluid has passed from the 
 syringe, the end of the pipe having been pressed against the 
 obstruction in the bowel which closed it, the fluid passed by 
 the piston as it was slowly pressed down, and accumulated at 
 the head of the cylinder, without a drop passing out. This 
 can be verified at any time by filling the cylinder with a fluid, 
 and placing the finger firmly against the end of the pipe, and 
 then slowly forcing down the piston. 
 
 The exploration in these cases should be conducted in the 
 same manner as recommended in the preceding chapter. The 
 finger inserted into the anus can generally at once detect the 
 membranous variety of this species, by the fluctuation, pro- 
 vided sufficient meconium and gas have accumulated, especi- 
 ally during the straining efforts of the child to deficate ; 
 sometimes by these eff"orts the distended membrane is forced 
 down so low as almost to be visible, and by dilating the anus 
 a little may be brought to view. When seen, the protrusion 
 is of a dusky color. The small speculum ani can here be used 
 with advantage to dilate the anus and canal, and enable the
 
 THE FOUUTir SPKCIES OF MALFORMATION. 105 
 
 snri^eon to ceo tlie obstruction, lie can also in tliese cases 
 <i])erate through tliis instrument. 
 
 From tlie number of recorded cases of this species of con- 
 genital malformation, I am naturally led to the conclusion 
 that it is by no means uncommon. 
 
 Prognosis. Should the obstruction of the rectum consist of 
 a mere superficial membranous septum, the treatment would 
 be simple and easy, and the success highly probable ; on the 
 contrary, however, should it consist of a dense and thick mem- 
 brane, a partial or total absence of the rectum, or a puckered 
 and indurated condition of its parietes, the case would be in- 
 finitely more serious, and the success of the treatment much 
 less certain. 
 
 SECTION II. 
 THE TREATMENT. 
 
 1. If the obstructing membrane is thin and friable it may 
 be broken down wath a probe or -with the little finger. Should 
 it, on the contrary, be firm and unyielding, it should be punc- 
 tured w^ith the sharp-pointed bistoury, wrapped with thread 
 or a narrow strip of linen, to within a few lines of its extrem- 
 ity, and cautiously carried into the passage on a grooved 
 director, or glided along the finger. This puncture should 
 then be freely enlarged crucially with the probe-pointed bis- 
 toury. The opening thus made should be kept free by the 
 frequent introduction of the little finger well oiled, or by 
 tents of lint besmeared with cerate, and afterwards dilated by 
 elastic bougies ; or the silver or elastic tubes should be used, 
 as already recommended. 
 
 2. When the ano-rectal partition is very thick and hard, the 
 method of M. Amussat is the best — that is, after having dila- 
 ted the anus, or slit it at its posterior part, and on its side, to
 
 166 THE FOURTH SPECIES OF MALFORMATION. 
 
 detach the mucous membrane, draw down the rectum from 
 the pelvic cavity, cut olf its inferior extremity above the sep- 
 tum, and then suture it either to the sphincter or to the skin. 
 Tliis method should always be adopted if it possibly can be 
 done, as the tendency to contraction at the situation of the 
 occlusion is always very great in these cases. If this is im- 
 possible, the end of the rectum should then be opened as by 
 tlie ordinary method and treated accordingly. 
 
 3. In an interesting case of imperforate rectum accompa- 
 nied with a normal anus, M. Amussat operated, as if no anus 
 whatever existed, and as if the rectum was completely defi- 
 cient throughout the entire extent of its anal extremity, by 
 cutting backward and drawing the rectum not downwards to 
 the anus, as he at first advised, but directly backwards. This 
 case I have translated entire, together with bis reflections 
 upon it. [ Vide Case LXXX F.] 
 
 4. M. Amussat is of opinion that in these cases the mere 
 destruction of the septum, however thin and delicate it may 
 be, is entirely insufiicient, and always fails in consequence of 
 the difficulty of keeping an opening above the anus patulous 
 — and " that no case can he cited in favor of that method.'''' 
 In this, however, M. Amussat is egregiously mistaken, as I 
 shall now prove by citing a number of cases in favor of it, 
 many of them having been successfully treated for years be- 
 fore any other method was ever thought of. 
 
 5. When the rectum above the normal anus is absent, or its 
 entire cavity obliterated, or from some other cause the natural 
 anus cannot be brought in communication with it, an artifi- 
 cial anus should be formed in the abdomen. [ Vide Chapter 
 on Ahdominal Artificial Anus.'\
 
 THE FOUKTII SPKUIKS OF MALFOUMATION. 167 
 
 SECTION III. 
 
 CASES AND REMARKS. 
 
 Case LXIIL — It is said by Sclienck, that Jessen saw a 
 female infant whose anus was perfectly formed, but when a 
 sound was introduced into the rectum the lirm resistance of 
 a membrane was perceived, a short distance above the anus. 
 This membrane was incised and a small quantity of thick 
 matter was discharged. No injection, however, could be 
 made to enter the cavity of the rectum, and the child died, 
 when sixteen days old. 
 
 At the autopsy it was observed that the walls of the 
 rectum were adherent at two points, and at two other points 
 the rectum was closed by two annular membranous septa. 
 The hmguage of the author is, that at the post-mortem, he 
 found that " Rectum intestlnum his lateribiis concreveTaty 
 his orhiculari intei'sejnebatur memhrana.'''' {Schenck. Ohser- 
 vatioiiuin Medicarum, novaruin^ aiimir ah ilium ^ et monstros- 
 arum. Lih. III. Ohserv. V. ]). 38^. Frankf. 1609. Folia.) 
 
 Case LXIV. — Wagner examined an infant who had an 
 imperforation of the rectum, but whose anus was so well 
 formed that he was enabled to introduce an ordinary sound 
 to the depth of one inch and a half, when it met with such 
 resistance as made it impossible to push it up any further. 
 The child died on the tenth day after its birth, no operation 
 having been performed. 
 
 At the autopsy it was discovered that that portion of the 
 rectum which was beyond the obstruction, was filled with 
 gas and fseces, and was reflected upon the superior part of 
 the sacrum, to which it was firmly attached. {Commcr. lit- 
 ter ar. p. 36-4. Norimherg. Annee 1734.) 
 
 Case LXY. — It was observed in a child, having a normal 
 anus, but an imperforate rectum, that it had discnarged 
 nothing from its bowels for two days after its birth, and that 
 its abdomen was painfully distended. Attempts were made 
 to administer an enema, but the fluid returned by the anus as 
 fast as it was forced out of the syringe. Petit now saw the 
 child, and to recognize the nature of the defect, introduced 
 into the anus a flexible sound with a small ball on the end of 
 it. This instrument could be easily inserted one inch, but no
 
 16S THE FOURTH SPECIKS OF MALFORMATION. 
 
 further. Fetit introduced his finger by the side of the sound 
 and felt a rather thin membrane above the sphincter, which 
 completely obstructed the cavity of the rectum, transversely. 
 By means of his pharyngotomus inserted up to the obstruc- 
 tion by the side of his linger, he incised tlie membrane which 
 ofl'ered but little resistance. The child at ouce discharged 
 the meconium, and for the two months that it lived afterwards, 
 continued to discharge its fseces freely. The child did not 
 die of the operation nor any anal disease. 
 
 Petit observed, that in this case the sphinctores ani 
 muscles existed, were normal, and performed their functions 
 well ; for wlienever he inserted his finger into the anus, 
 which he had frequently done, he always perceived by the 
 touch, the same sensitiveness existing, and the same resistance 
 which are perceived on introducing the finger into the anus 
 of any child. {Memoire de VAcademie Royale de Chirurgie, 
 to7ne 11. 2>- ^oO. Paris: 1781.) 
 
 Case LXVI. — A child was witnessed by Engerran, in 
 which the anus existed, but the rectum was found to be 
 imperforate. Nothing had passed its bowels for four days, 
 and it vomited. A sound, which was introduced, came in 
 contact with a hard body. This substance was pierced with 
 a sharp-pointed triangular probe, and immediately a large 
 quantity of fffical matter was discharged. The faeces, how- 
 ever, soon gradually accumulated again and the child died 
 one month afterwards. 
 
 At the autopsy it was observed that a part of the inferior 
 extremity of the rectum was indurated, puckered, and drawn 
 up in a knot, like the umbilicus of the adult. {3femoh'e de 
 VAcademie lioyale do Chirurgie^ tome 11. pp. 253, 25-1, 255. 
 Paris: 1781.) 
 
 Case LXYII. — ^Trioen mentions the case of a female child 
 who had an imperforation of the rectum, but whose anus was 
 well formed. On introducing a sound it soon met with firm 
 resistance. The opposing substance was incised, but the child 
 died in three days. 
 
 At the autopsy it w^as discovered that the rectum M^as 
 completely obstructed about a, finger' s-lreadth above the anal 
 orifice by a membrane which was ten lines in thickness, and 
 almost the consistence of horn. {Ohservationum Medico- 
 Chirurgicarurii. J), ^^y Ludg. Bat. 1743.) 
 
 Case LXVIII. — Smellie relates the following case : 
 
 " Several years ago, I delivered a woman of her first child.
 
 TIIK rOUIlTII SPECIKS OF MALFORMATION. 169 
 
 When T callcMl next day, tlic nnrso told itic that s1k\ luul i2;ot no 
 stool, although she had given .several times the oil and syru]), 
 and she was afraid there was no ])assage at the fundament, she 
 having tried to introduce a stalk of parsley and butter. I in- 
 spected the part, and lubricating my tinger, inti-oduced tlie 
 same a little way into the anus ; but plainly found a smooth 
 obstruction about an inch or less from the entry. 
 
 " I informed the father of the case, and the danger the child 
 was in, unless an artificial o]»oning was made, and advised liini 
 to send for the sui'geon of the family; on which Mr. Gattaker 
 was called. After he had examined and found the same, lie 
 advised, as the case was uncommon, to send for Mr. Middle- 
 ton. They were of the same ojMuion with me, that it was 
 right to try to nuike a perforation immediately, for although 
 the success was uncertain, yet if the attachment was slight, it 
 might succeed. It was then agreed to perform the oj^eration 
 with the trocar. Mr. Middleton sent for his, as it was of a 
 lai"ger size than common. Mr. Gattaker introduced the in- 
 strument, and pushed the point and sheath through the adhe- 
 sion in a line, as near as he could judge, along the common 
 course of the rectnm. Xo meconium appeared, or followed 
 on withdrawing the instrument. After this he introduced a 
 large bougie, which went np a great way. "We called next 
 morning, and to our great satisfaction observed some meconi- 
 nm come down on extracting the bougie. Another somewhat 
 larger was again introduced ; the child now seemed to be in a 
 fair way of doing well ; but next day the nurse showed us a 
 small swelling on the npper and back part of the right pari- 
 etal bone, which was turning livid, and indeed had not been 
 observed by me at the delivery. On examining the tumor, 
 we found a round opening in the bone about an inch and a 
 half in diameter, and some of the brain pushed through it ; 
 but this could not be reduced, and no doubt was begun to 
 mortity, for the child died next day." — (A Collection of Pre- 
 ternatural Caf<es and Observations in Midwifery. Vol. III. 
 Collect. XL VI. p. 461. Zondon : 1779.) 
 
 Cask LXIX. — Mr. Pinkstan, a surgeon of London in 1751, 
 reported the following case, of this species of malformation. 
 
 " Tuesday evening, May 7, 1751, I delivered M. K. of a 
 female child. Next mornino; the nurse told me that the child 
 had no stool, although she had used all the common methods 
 to procure one ; besides, she saw no fault at the fundament. 
 
 " On examining, I imagined the same ; but after introduc- 
 ing a probe about half an inch, I met with a firm and solid 
 resistance.
 
 170 THE FOURTH SPECIES OF MALFORMATION. 
 
 " I tlien told the mother the necessity there was for per- 
 forming an oj^eration on the child ; though not without ex- 
 pressing some doubt of its success. Having obtained her 
 consent, I cut about half an inch into the resisting substance, 
 and finding that none of the freces followed, I enlarged the 
 external orilice, and went about an inch deeper. 
 
 " Seeing at last nothing issue out but a little blood, I intro- 
 duced my finger, and found a resistance that made me despair 
 of succeeding in any further attempt of that kind, and I dres- 
 sed up the wound. 
 
 "The child had that night stercoracious vomitings, and 
 these continued till its death, which hapj)ened on the twelfth 
 in the morning. 
 
 " After much entreaty, I was permitted to open the child, 
 when I found the rectum callous and imperforate as far as the 
 last vertebra of the loins, which showed the defect was abso- 
 lutely incurable. 
 
 " In cases, however, of this kind, I think a cure should al- 
 ways be attempted." — [Smellie. ojp. cit. p. 464.) 
 
 Case LXX. — The following case was reported on the 20th 
 of May 1791, by Edward Ford, Esq., Surgeon to the West- 
 minster General Dispensary. 
 
 " March 6th, 1791, I was desired to see a male infant, two 
 days old, M'ho was supposed to have an imperforate rectum. 
 He appeared to be a strong healthy child, well formed in 
 every other i-espect, had taken nourishment the day before, 
 and as he exhibited externally no marks of mal-conformation, 
 when examined at his birth, it was not supposed that he 
 labored under this defect till it was found that no evacuation 
 had taken place through the intestines, that he rejected his 
 food, and vomited up every thing he had taken. 
 
 " When I saw the child he was continually vomiting ; the 
 matter thrown up was of a dark yellow color, and foetid, and 
 the abdomen was tense and swelled ; in other respects lie 
 looked healthy, had voided his urine properly, and the anus 
 was naturally formed as far as regarded its external appear- 
 ance. 
 
 " I endeavored to introduce my little finger through the 
 sphincter ani into the rectum, but found an uncommon 
 resistance in the first attempt, the parts not admitting of being 
 dilated as usual ; and when this difficulty was with some 
 force overcome, at the distance of an inch from the external 
 parts, there was an obstruction to be felt, which resisted 
 every effort I made to penetrate it, first with the nail of my 
 finger, and afterwards with the blunt end of a probe.
 
 THE FOUliTIi SPECIES OF MALFORMATION. 171 
 
 "Tlic first consideration which offered to inj mind, was to 
 ])erforate the obstruction with a small trocar; and in order 
 to do tiiis as safely as i)ossible, a small catheter was intro- 
 duced through the urethra into the bladder, which served as 
 a direction to avoid wounding those parts in the operation. 
 The canula of the trocar was then introduced into the anus, 
 under my linger, which defended the urethra, and was lixed 
 as well as I could against the obstructed part of the canal. 
 
 "The stilet was then carried up through the canula, and 
 pushed through the obstruction in a direction rather back- 
 wards towards the os sacrum. On withdrawing the stilet it 
 was followed by a discharge of fiBces, through the canula, 
 which continued for an hour so as to form rather a copious 
 stool. Upon taking out the canula, a bougie was attempted 
 to be introduced through the artificial opening, but without 
 effect. 
 
 " The child was now left an hour, and on my return I 
 found his belly more tense, and that his vomiting continued. 
 I therefore directed several clysters of oil and water to be 
 thrown up by means of a small pipe which was fortunately 
 conveyed through the artificial opening into the gut. These 
 clysters brought off a considerable quantity of faeces, but did 
 not seem thoroughly to empty the intestinal canal ; so that I 
 deemed it expedient to attempt an enlargement of the open- 
 ing, by means of the point of a blunt gorget carried up into 
 the groove of a common director. A farther discharge of 
 faeces ensued ; and the child was then put into a warm bath, 
 and castor oil was afterwards administered by the moutii. 
 llTotwithstanding these remedies, the vomiting continued, the 
 child became convulsed and died in the course of the follow- 
 ing night. Upon opening the body the next morning, I found 
 marks of considerable inflammation in the intestines, princi- 
 pally in the large ones, which were inflamed to a great degree. 
 There was no obstruction, however, to be found in any part 
 of tiie intestinal canal, except that in the rectum. 
 
 " The drawing which accompanies this paper will show the 
 manner in which the intestine terminated in a blind pouch, 
 at the distance of an inch from the anus, in the hollow of the 
 OS sacrum. The space between the intestine and the anus 
 was lined with an elastic ligamentous substance, which 
 would probably have produced much inconvenience to the 
 patient in retaining his stools, had the operation performed, 
 protracted his existence." \_Vlde PlateYl^ Figure 2.] {Med- 
 ical Facts and Ohservatlons. Vol. I. p. 102. London, 1791.) 
 
 Case LXXI. — ^William Adair, Esq., Surgeon General to
 
 172 THE FOURTH SPECIES OF MALFORMATION. 
 
 tlie garrison of Gibraltar, rej^orted the following interesting 
 case, on the 3rd of November, 1792. 
 
 " On the 7th of August, 1792, I was called to a child of an 
 officer of this garrison, which had been born thirty hours 
 without having had any evacuation by the anus. Upon an 
 examination, I found a j)assage of about two inches at the 
 usual exit of the rectum, but which beyond this was imper- 
 vious. There was an appearance as if nature had made an 
 attempt at another passage ; for at tlie end of the posterior 
 perinaeum, near the os coccygis, was a small sinus of about 
 half an inch in a direction towards the rectum. In both these 
 blind passages the cuticle w^as equally strong as on any other 
 part of the body. Tliere could be no hesitation from which 
 of the two we ought to attempt a communication with the 
 intestinal canal, and, therefore, after examining with a jjretty 
 thick bougie, the former and most natural of these passages, 
 I took a middling-sized trocar, and introduced it with the point 
 within the canula, till it reached the end ; then pushing it 
 beyond the canula, and finding that not sufficient, I pushed 
 the trocar forward, till it had completely overcome the resis- 
 tance. I then left the canula in, and drawing out the trocar, 
 observed the point of it tinged with meconium. This latter 
 circumstance seemed to be a very favorable appearance : but 
 after waiting some time nothing came away through the can- 
 ula, nor when this was removed did anything follow but a 
 few drops of blood. I now introduced a proper-sized bougie, 
 which was suffered to remain for some hours ; but when this 
 was drawn out, nothing followed but a few drops of blood. A 
 sponge tent of a proper size was also pushed up, and left in 
 for several hours ; but though it extended the passage more 
 considerably than the bougie had done, no stools followed on 
 its being taken out. The parts after this were left at rest 
 until next day, only a little warm milk was ordered to be 
 thrown up the passage ; and as the child (though its belly was 
 preternaturally full, but not hard, and it had now been fifty- 
 eight hours \vithout any passage by stool, which in this cli- 
 mate, and in the month of August, Avas very unfavorable,) 
 still seemed strong and hearty, we introduced another pretty 
 thick bougie up the passage, and left it there for twenty-four 
 hours. This, when withdrawn was followed by a copious black 
 stool, and that was succeeded by eight more in the course 
 of twelve hours. Xext day the evacuations were very fre- 
 quent, to the amount of sixteen stools, after which they dimin- 
 ished in number, and became of the natural color. Tlie cliild 
 now appeared to be going on very well, liut soon fell oft'; the 
 stools became sometimes dark, and sometimes yellow ; a
 
 THE FOURTH SPECIES OF MALFORMATION. 173 
 
 fevorislincss succeeded ; tlie ])elly coiitimied distended till two 
 days betorc it died, and then became suiullei". The child 
 lived only fifteen days. 
 
 I had no o])portunity of examining the body, so that the 
 cause of death cannot be ascertained ; but the history of the 
 case leads me to consider it as not immediately connected 
 Avitli the consequences of the operation. The child might 
 have been defective in other respects essentially coniu'cted 
 with the vital organs. The operation succeeded perfectly in 
 giving a passage for the contents of the bowels ; and so far 
 this case is deserving of notice, as it may give some informa- 
 tion to others who have this operation to perform under simi- 
 lar circumstances. It proves that although the contents do 
 not Immediately follow the instrument nor even the bougie, it 
 is not to discourage the surgeon from future attempts, as per- 
 severing in the use of the bougie may be attended by the 
 wished for success." {^Medical Facts and Ohservatiois, Yol. 
 IV., ■:p.'-2n. London: 1793.) 
 
 Case LXXII. — ^Tlie following interesting case of imperfor- 
 ate rectum, above a well formed anus, was reported by Mr. 
 William Chamberlaine, of London, on the 13tli of March, 
 1797. 
 
 " I was called to attend the labor of Mrs. Ashmore, No. 15 
 King Street, Compton Street. She had a good natural labor, 
 and was safely delivered of a male child. On my visiting 
 the next day, the nurse informed me the child had had no 
 evacuation either by stool or urine, and that it appeared very 
 uneasy. I found the pulse feverish, and a great degree of 
 tension and hardness of the abdomen. 
 
 " On examining the anus, I found it in a natural state ; how- 
 ever, supposing it possible there might be an obstruction 
 higher up, I introduced a probe into the rectum and found a 
 firm resistance at the distance of somewhat less than an inch 
 and a half. Withdrawing the probe, I then introduced a 
 very small glyster-pipe, well oiled, which stopped at the very 
 same place ; then examining the obstruction by means of the 
 probe, the glyster-pipe serving as a canula or director, I had 
 not the satisfaction to find anything like reaction, or any sen- 
 sation as if the faeces were forcing down sorae thin obstructing 
 membrane. However, as the case was desperate, and a most 
 miserable and perliajis lingering death was inevitable, unless 
 something should be done, I determined at all hazards, to 
 attempt a perforation. Having represented the case and its 
 consequences to the parents, and obtained their permission, I 
 determined to perform the operation with a small trocar ; and
 
 174 THE FOURTH SPECIES OF MALFORMATION. 
 
 introducing the canula first, well oiled as liigh as the obstruc- 
 tion, I pushed the perforator through the obstructing sub- 
 stance until I found no farther resistance ; then withdrawing 
 it and the canula together, I had the pleasure to see the 
 instrument followed by a very copious discharge of the meco- 
 nium slightly tinged with blood. I then thought it advisable 
 to inject a common glyster ; the pipe, in passing, stopped at 
 the place where the obstruction had been, but the resistance 
 was soon overcome, and a very mdoerate degree of force 
 enabled me to get it all the way up. None of the glyster was 
 returned, and the child seemed perfectly easy. On my 
 return, however, in about two hours, I found we had still 
 another difficulty to combat witli. He had not made urine, 
 and in consequence of this, convulsions, shrieking, fever, ten- 
 sion of the abdomen, and other alarming occurrences, had 
 come on. I took a coach and went to Evans's, but could not 
 
 fet a catheter of a size small enough for a new born infant, 
 took with me, however, one of the smallest gum elastic 
 catheters I could lind ; but even this on trial, was too large, 
 and would not enter the urethra. No time was to be lost ; 
 but having no proper instrument, I bent my probe into the 
 form of a catheter, and having, previously to my attempt to 
 introduce the hollow bougie, divided with a lancet the small 
 membrane that closed up the exrernal orifice of the urethra, 
 I passed the probe without difficulty, as far as the neck of the 
 bladder ; having got thus far, its passage seemed opposed by 
 some obstructing substance ; nevertheless, by a little persever- 
 ance, and gentle management of the probe, I was fortunate 
 enough to find the probe at last move forwards, until I could 
 perceive it to be fairly in the bladder, and the urine making 
 its appearance at the external orifice of the urethra. I then 
 withdrew the probe, which was followed by a j^lentiful dis- 
 charge of urine, and the child became for a time easier. 
 
 " Next day, however, a message was sent to me early, that 
 the child was worse ; I found all the symptoms of the preced- 
 ing day much aggravated, with inflammation (which the 
 nurse mistook for mortification) of the abdomen ; I ordered 
 the warm bath, fomentations, and emollient glysters, to be 
 prepared, and passed the probe as the day before, with the 
 same success. By the help of these aj)plications, and a few 
 aperient and carminative medicines, the child recovered, and 
 is now perfectly well." {Memoirs of the Medical Society 
 of London. Vol., V. Art. XXIII., p. 206. London: 1799.) 
 
 Case LXXIII. — Mr. Copeland, assistant surgeon to the 
 Westminster General Dispensary, had the good fortune to
 
 THE FOURTH SPECIES OF MALFORMATION. 175 
 
 treat with success two cases of tliis species of niullunuutiun ; 
 one of which lie reports as follows : 
 
 "I was desired by the late Dr. Tliynne to see a male child, 
 wlio was born with an ini|)erforate amis, [recturii.) The form 
 of the amis was perfect externally, but on introducing a bou- 
 gie it was stopped in its progress about an inch from the ex- 
 ternal aj)erture. The abdomen was very tumid. 
 
 " After some consideration, I passed a flat trocar on my 
 finger into the anus, with the point drawn into the canula ; 
 and when it would pass no further, I projected the point 
 through the impediment; no fluid followed; but when the 
 instrument was withdrawn, I thought I felt the tumid ex- 
 tremity of the gut ; and b}^ forcing it on I came in contact 
 with the OS sacrum. I had then no great hope of the recovery 
 of my little patient, and still less on the follow^ing day ; but 
 desired, that if any faecal evacuation took place, I might be 
 sent for. I was called on the fourth day, and found that a 
 considerable alvine evacuation had passed, and the belly 
 much gone down. When 1 examined with iny little finger, I 
 found the extremity of the gut with a small perforation so 
 very high up in the pelvis, that I was fearful to introduce an 
 instrument to enlarge the opening, if it could with safety be 
 avoided. 
 
 ""The next day, the fifth, the child had taken some castor 
 oil; the surrounding parts were considerably swelled and in- 
 flamed, and the abdomen again tense, though some faecal 
 evacuation had passed ; he seemed easy, and had slept. 
 
 "The sixth day, but little of the contents of the abdomen 
 had passed, and the child was still swelled and uneasy, until 
 the bowels were evacuated by castor oil. There was a con- 
 siderable purulent discharge from the anus. I had a great 
 objection to the repeated introduction of instruments, or my 
 finger, lest an interruption should be given to the adhesions 
 which I hoped were forming between the gut and tJie sur- 
 rounding parts ; but so great w^as the difiiculty of passing the 
 fifices, that the following day I introduced a large elastic 
 catheter, and the fseces flowed freely through it. The catheter 
 was used as often as was necessary, for a considerable time, 
 and to this I chiefly attribute the recovery of my patient, for, 
 during its use, the purulent discharge ceased, and the gut de- 
 scended nearer to the anus. 
 
 "When, after some time, I introduced my finger, the aper- 
 ture at the extremity of the gut was felt, hard and contracted 
 close to the anus, it was dilated by the use of bougies, which 
 were continued for some time, and the child performs his 
 functions with but little interrui^tion, and is otherwise in per-
 
 176 THE FOURTH SPECIES OF IVIALFOEMATION. 
 
 feet hecaltli." — {Ohservations on the Principal Diseases of the 
 Rectum and Anus. p. 174. London : 1814.) 
 
 Case LXXIV. — A case is recorded by Mr. Wayte, in whicli 
 tlie membranous septum was felt by the finger above an incli 
 from the verge of the anus. It was pierced with a pointed 
 probe, which was followed by a hydrocele trocar, and after- 
 wards by a bougie of large dimensions. On withdrawing the 
 latter, much meconium mixed with fiBces escaped, and con- 
 tinued to be frequently discharged. In a week, however, the 
 opening closed, and a fresh puncture was made, which was 
 maintained by the frequent introduction of bougies. Tlie 
 child proceeded tolerably well, until the end of another week, 
 when the passage was again much contracted, and the abdo- 
 men proportionally distended. On the twentieth day from 
 birth, a full-sized trocar was used for restoring the opening, 
 which, however, again had a tendency to close, but was after- 
 wards dilated by introducing twice a day bougies which were 
 increased in size, until a rectum bougie of middle size could 
 be jjassed. The boy now rapidly improved, and every liope 
 of a perfect recovery was entertained, but disease of the os 
 coccygis ensued, and at the end of six months the little pa- 
 tient died hectic. [Edhiburgh Medical and SurgicalJournal, 
 Vol. XVIL, 1). 232. April: 1821.) 
 
 Case LXXV. — A. Copeland Hutchison, Esq., relates the 
 case of an infant which presented a normal anus, but some 
 distance above, the rectum was found impervious. Tlie oper- 
 ation in this instance failed, and it is especially on this account 
 that the case is worthy of notice. 
 
 "I was called upon by Mr. Cullen, of Sherness, to operate 
 
 on an infant son of Mr. H , at Queensborough. The child 
 
 was otherwise well formed, and the anus marked so distinctly 
 that a small bougie was passed upwards in the apparently 
 natural passage for nearly half an inch, when it met with a 
 total obstruction ; even the smallest probe could not pass ; in 
 fact, there was a total closure of the gut above the external 
 well-marked anus. 
 
 "In the presence of my friend, Mr. Cullen, I made an in- 
 cision of proper length and depth, wnth the^ scalpel, and then 
 introduced a small sized trocar with great caution for fully 
 three inclies ; but no meconium, only a very little blood es- 
 caped on withdrawing the stilette. 
 
 "The patient died in a few hours afterwards; and on ex- 
 amination after death we found, by the introduction of a bou- 
 gie, that the gut was grazed by the cutting instrument, which
 
 TIIK KOURTII SPKCIKS OK M AM'oKM ATK ..V. 177 
 
 had it ]uMietrnt('(l, there was eveiy chance tliat tlic child 
 would have survived." {Op. cit. p- ^Ti.j 
 
 Cask LXXVL— D. O. Edwards. Esq., of Westminster, 
 Eiii;'laiid, reported, on the 28th of Jaiiuaiy, 1S.^)0, the follow- 
 iu^i' ease of an infant havin<jj a normal anus with an ini])erf >- 
 ration of the rectum some distance ahove. 
 
 "Ann Aldridge, residinii; in Castle Lane, Westminster, a 
 delicate woman, about thii-ty-seven years of age, was at the 
 full ])eriod of gestation delivered hy natural efforts, on the 
 17th instant, of a male, her sixth child. The two preceding 
 children were still-born, and the mother had suffered nnich 
 from grief and anxiety, having been deserted by her husband, 
 and obli<;:ed to maintain the surviving children bv her exer- 
 tions as a laundress. The infant was full o;rown, havino: 
 nothing jDeculiar in its external form, except the continuance 
 of the sagittal suture downwards to the nose. The integu- 
 ments were rugose and sodden, plaiidy indicating a decrease 
 of substance since the consummation of its growth. Its cries, 
 respiration, and other muscular efforts, were unusually feeble. 
 
 " On inquiry, twenty-four hours after birth, it appeared that 
 no discharge whatever had taken place ])er anum; the infant 
 seemed to have no power of suckling, and rejected every kind 
 of aliment. The abdomen was distended and painful on pres- 
 sure, the lower limbs rigidly contracted on the pelvis, respira- 
 tion difficult, and a constant moaning existed. The form of 
 tiie bladder also, notwithstanding a discharge of urine had 
 taken place, was distinctly manifest in the hypogastrium. 
 The anus was apparently well formed, in its projjer site, and 
 of the usual size, and during the strenuous attempts at dejec- 
 tion, which the little sufferer was constantly makiuir, the 
 retractive efforts of the levator ani were particularly evident. 
 
 " The introduction of a bougie detected an obstruction 
 about an inch above the external orifice, and which the finger 
 ascertained to be impeneti-ably strong and fibrous. At each 
 endeavor to expel the excrement, an impression was commu- 
 nicated to the finger similar to the pressure of a quantity of 
 impending fluid. 
 
 "• Having consulted my friends, Messrs. Chapman, Weight, 
 and Blakeney, the penetration of this adventitious membrane 
 was considered to be the most rational and indeed only pro- 
 bable means of saving the child from imminent death. An 
 incision was therefore made, forty-eight houi's after birth, 
 from the anus to the coccyx, and as far up as the cul-de-sac, 
 which formed the obstruction. A sharp-pointed bistoury w^as 
 then introduced, shielded by the index finger, and three 
 12
 
 178 TnE FOURTH SPECIES OF MALFORMATION. 
 
 incisions, commencing at one point, and directed towards the 
 sacrum, made completely through the membrane; no fluid 
 esca{)ed ; the knife was withdrawn, and the finger again 
 passed up, but no indication of the situation of the rectum 
 could be found, and the near neighborhood of the perito- 
 neum, bladder, vessels, etc., was tangibly evident. It was 
 thought prudent, for these reasons, to desist from the further 
 use of the knife, and the usual palliatives were resorted to 
 during the remainder of the ciiild's existence, which termi- 
 nated on the following day, with all the symptoms of strangu- 
 lation. 
 
 " AibUrpsy six hours after death — Conducted in the pre- 
 sence of Messrs. AVeight, Chapman, Blakeney, and Jenkins. 
 Abdomen much swollen, and slightly discolored. On making 
 the first incision, a small quantity of dark-colored blood 
 escaped, and the alimentary canal was found distended to the 
 utmost. The liver was of ordiiuvry size, color, and consistence ; 
 the gall-bladder elongated, deeply imbedded in the paren- 
 chyma of the liver, peculiarly curved near the fundus, and 
 filled M'ith dark-colored bile. The stomach and small intes- 
 tines were filled with flatus, and contained mucus mixed 
 with bile. Into the coecal portion of tlie ileum, a quantity of 
 meconium had escaped through the ileo-coecal valve, but 
 which was of perfectly natui'al formation. Nearly the entire 
 peritoneum was inflamed, and particularly tiiat which envelops 
 the large intestines. The ccecum, colon, and rectum, were 
 completely filled with thick and viscid meconium. The mus- 
 cular and mucous tunics were pretty healthy in the stomach, 
 duodenum, and jejunum, but a large portion of ileum was in 
 a p-aiio-renous state, and all the laro;e entrails indicated a state 
 of intense inflammation. Sigmoid flexure remarkablj^ large, 
 vith a long mesenteric attachment. The reditui termhiated 
 vn a cul-de-sac at the nnddle of the sacrum,, having a meso-rec- 
 tuni ill its whole length, and a complete peritoneal covering / 
 the mucous lining a'ul inuscular tissue equally contributed to 
 form the sac. Tne peritoneum was reflected laterally and 
 dov;nward, from tlie meso-rectum to the sacrum and sides of 
 the pelvis, and wa^^, as usual, continued forwards over the 
 bladder, giving a covering in its passage to the tliird portion 
 of the rectum, which was thus completely detached from the 
 main gut. This membrane being raised, the recto-vesical 
 fascia was seen passing backwards from the neck of the blad- 
 der, and ('ompletely closing up tlie inferior opening <»f the 
 pelvis. Under this, the levatores ani lay, stretching from the 
 sides of the bhidder directly backwards to the sacrum, and 
 becoming blended with the muscular fibres of the spliiucLui*
 
 THE FOURTir SPECIES OF MALFOIlMAnON. 17J> 
 
 and tlie loiinitiuliiial lihrcs, whicli constituted tlio insulated 
 anus. The Sj)hincter was iicrfectly well fornied, and attached, 
 as usual, to the coccyx and centrum tcndiiKJsuni perinei ; its 
 fibres were intimately connected with th'ose of the levator 
 ani, and contrihuted to form the adventitious harrier. 
 
 "It is evident from the dissection, that the cavity of the 
 peritoneum intervened between the blind pouch of the rectuin 
 and that of the anus, and consequently no operation could 
 have availed ; a distance, too, of half an inch existed between 
 the termination of the rectum and that of the anus, 'ihe 
 bladder, urethra, and their ap])eudages, were perfectly well 
 formed, and in their proper position; tlie peh'ic arteries 
 obeyed the ordinaiy laws of their distribution, regardless of 
 the disorder extant around them. In the thorax, the viscera 
 and their coverings were perfectly natural, and, indeed, the 
 whole economy seemed perfectly well adapted to sustain the 
 development of life, but for the fatal lusus just described. 
 
 "One of the three incisions had penetrated the cavity of 
 the peritoneum, hut no intestine had been wounded." {Lou- 
 don Lancet. Vol. I. Feh. 6, 1830. p. 637.) 
 
 Case LXXYII. — M. de Lens related the following case to 
 the " Medical Society of Paris''' in February, 1835. 
 
 "In a young child which M. de Lens saw in company with 
 M. Moreau, and which had not passed meconium for twenty- 
 four hours after birth ; the examination of the anus, showed 
 an imperforation of the rectum several lines above the ana! 
 orifice. The cul-de-sac could be very clearly perceived with 
 the finc-er. When the fino^er was introduced to the bottom 
 of this external cul-de-sac no impulsion was perceived. 
 
 "The operation was performed with the trocar, and a con- 
 siderable quantity of faecal matter followed by the canula. 
 A tent of charpie was introduced into the opening, but grave 
 symptoms jjresently manifested themselves, and the child died 
 next day. 
 
 "No autopsy was had." {Revue MSdicale de Pari^. Mai. 
 1835. p. 285.) 
 
 Case LXXVIII. — M. Sandras also related to the " Jledical 
 Society of Paris^"* at the same time, a somewhat similar case 
 to that of M. de Lens. In this case the following peculiarity 
 presented itself: Whenever the child cried, the anus formed 
 a clearly marked protuberance. M. Sandras performed the 
 operation with a bistoury, which he conducted upon a director 
 to the extent of about three lines. After the passage of the 
 meconium, he uiade the usual dressings adopted in the opera-
 
 180 THE FOURTH SPECIES OF MALFORMATION. 
 
 tion for fissure of the anus, and the little patient was cured. 
 {Log. cit.) 
 
 Case LXXIX. — M. Forget reports the following case : 
 Being called to an infant affected with an iniperforation of 
 the anus, he found the rectum obliterated about ten lines 
 from the anal orifice. The obstacle presented to the finger 
 the form of a cul-de-sac, resisting and corrugated as if ]>ro- 
 duced by a ligature, or an interruption of the intestine. The 
 cries of the child and the pressure upon the abdomen gave no 
 sign of fluctuation to the finger. M. Forget considered the 
 case a grave one : as the condition of the child was not imme- 
 diately dangerous, notwithstanding the tension of the abdo- 
 men, vomiting, &c., he advised the friends to take the child 
 to M. Roux, who would decide the kind of operation to be 
 performed, not daring himself to make a puncture through an 
 obstacle whose limits were not at all indicated. The parents, 
 frightened at the idea of an operation, removed their child, 
 without being Avilling to show it to any one, not even to the 
 usual attending physician, who wished to watch the state of 
 the obstacle. It w^as not till ten days after, that another 
 physician, having asked to see the child, recognized a fluctu- 
 ating tumor in the anus, which he immediately incised with 
 a lancet, and the child was saved. {Revue Medicals de Paris. 
 Mai. 1835. 2^' 283.) 
 
 Case LXXX. — M. Billard reports the following case of 
 imperforation of the rectum, in which the anal orifice 
 existed. 
 
 " Leblond, aged one day, of a robust constitution, entered 
 the infirmary of the Ilosjpice des Enfans Trouves on the luth 
 of July. To the night of the eleventh, he liad passed no 
 meconium ; yet the orifice of the anus appeared free ; the 
 abdomen had become swollen and very painful ; the respira- 
 ration was difficult ; the extremities cold ; the pulse small ; 
 the cries were without intermission. Towards evening, the 
 child after having throw^n up a quantity of yellow mucus, 
 vomited the meconium. 
 
 " It was placed in a bath for half an hour without having 
 any evacuation. The anal opening appeared to exist exter- 
 nally, and a catheter could be introduced to the depth of one 
 inch, but then met with an insurmountable resistance. I 
 caused a suppository of soap to be passed in the rectum, and 
 let it remain half an hour without any evacuation. I then 
 passed a bistoury, the point of which was directed by means 
 of a grooved probe in the direction of the sacrum ; the edge
 
 THE FOUIiTII SPECIKS OF MALFORMATION. 181 
 
 of the iiistrninoiit turned backward, and tlie hack .if it 
 forward. Tlie feelinii; that the resistance was overcome, 
 indicated that the peribration had hcen made. I withfh-ew 
 the instrument, tlie point of which was covered witli meco- 
 nium ; a small quantity of blood flowed. An injection was 
 then o-iven which was soon returned, brin<j;in<r with it some 
 g-rumous blood. The child was again placed in the })ath, 
 without experiencing any relief. The cry became more 
 feeble ; the abdomen swelled more and more ; the respiration 
 was (juick and suflfocating. Death took place about the 
 middle of the night, 
 
 " Pod mortem Examination. — Mouth and oesophagus 
 healthy ; the stomach contained some meconium ; it was also 
 found in the small intestines, which were distended M'ith gas. 
 The large intestines were considerably dilated by thick meco- 
 nium ; the dilatation commenced at the cjECum. The rectum 
 terminated by a cul-de-sac the extremity of which was 
 (Corrugated ; it adhered to the neck of the bladder, and did 
 not descend to the anal orifice in the skni. The incision 
 made in the cul-de-sac by the bistoury was found filled with 
 a i-ecently formed clot of blood, which seemed to havu 
 resulted from a haiinorrhage from the ha^morrhoidal arterie-s. 
 All the organs of the abdomen were perfectl}^ healthy. 
 
 The lungs were goi-ged wnth blood at their posterior 
 border ; the foetal openings were free ; the sinuses of the 
 cranium were filled M'ith blood." {A Treatise on the Diseases 
 of Infants. English Translation, by James Stewart^ M. D. 
 p. 280. mw York : 1839.) 
 
 Case LXXXI. — The following case of imperforate rectum 
 accompanied with a normal anus, occurred in the practice of 
 Dr. James Stewart of the city of New York, who reports it 
 in the Appendix of liis English version of Billard on tlie 
 Diseases of Infants. A narrative of the same case was read 
 to the " Kappa Lambda Society of JYeio York''^ by the 
 operator, Ricliard K. Hoffman, M. D. In this instance Dr. 
 Hoffman operated with a trocar used for paracentesis, with 
 complete success. 
 
 "The lady of Mr. J. P , of this city, (Isew York,) was 
 
 delivered, on the 12th of June, 1839, of a male child. He 
 was to all appearance in perfect health, and it was not until 
 the next day that any disordered state of liis system was 
 manifested. The nurse then stated that he had passed no 
 meconium and appeared to be much distressed with nausea. 
 Laxative enemata were directed to be used ; a teaspoonful of 
 castor oil had previously been given by the nurse and
 
 183 THE FOUKTH SPECIES OF MALFORMATION. 
 
 rejected ; on making a visit in tlie evening of the same day, 
 it was ascertained that great difficulty liad been experienced 
 in giving the injection. Tlie nausea and vomiting liad 
 increased, no meconium had been voided ; and on examining 
 the abdomen it was found swelled and tense. Suspecting 
 that there existed some obstruction in the intestinal canal, an 
 examination was made of the condition of the rectum ; the 
 anus was found perfect, but an obliteration was discovered 
 about three quarters of an inch from the sphincter ; various- 
 sized elastic bougies were introduced to ascertain the exist- 
 ence of a passage and to dilate it if one could be found, but 
 not the slightest opening could be detected, even with a 
 small probe. 
 
 On ascertaining this condition of the part, the nature of 
 the malformation was explained to the parents and its inevit- 
 able consequence, the death of the child, announced, unless 
 relieved by an artificial opening, which at the same time it 
 was told them was uncertain, from the impossibility of ascer- 
 taining the extent of the obliteration. Dr. Richard K. 
 Hoffman was requested to visit the patient; who upon a 
 careful examination, coincided in the opinion previously 
 expressed, and recommended an operation, as affording the 
 only chance of saving the child's life. Having obtained the 
 consent of the parents, he immediately introduced a common 
 trocar into the rectum, and passed np to the obliterated 
 portion ; this was found to be tough membrane, and some 
 force was required to pass the instrument through. The 
 meconium immediately flowed out on withdrawing the 
 instrument, accompanied with a quantity of thick purulent 
 fluid. Injections were given, and the bowels kept open by 
 their use. He continued to liave offensive discharges for a 
 week afterwards. At the time of writing this (July 26th,) he 
 is perfectly well and in a thriving condition." {A Treatise 
 on the Diseases of Infants, hj C. M. Billard. English 
 Version, hj James Stewart, M. D. p. oil. New York : 1839. 
 Also — New York Journal of Medicine and Surgery. No. 
 in. Jaiiuary, 184:0. J). 212.) 
 
 Case LXXXH. — Dr. George Bushe, of New York, wit- 
 nessed in a new-born infant brought into the dissecting room, 
 that the rectum above a well formed anus, was intercepted 
 by two membranous partitions. They were both quite thin 
 and friable and about three quarters of an inch apart, the 
 h)wer one being about half an inch above the anus. The 
 r(!ctum above these membranous sejita, was loaded Avitli gas 
 and meconium. (A Treatise on the Jfalfor mat ions, Injuries
 
 THE FOUUTII SPECIES OF M AI.KOUMATKJN. 183 
 
 and Diseases of the lieduni and Anus. Chapt. TIT. p. 40 
 
 New York: 18;}7.) 
 
 Case LXXXIII. — M, Voilleinier, reports tlie case of an 
 infjint ])resentiii<^ a iioriiuil anus, bnt the rectnni was divided 
 by nuMiibranons partitions, into four distinct conipjirtnients, 
 of M'hicli the superior one only contained ineconinni and gas, 
 the otliers enclosing a tliick mucus. {Gazette des Ilopitaux 
 de Paris. J?m(?<?'l84().) 
 
 Case LXXXLV. — Dr. Herman Friedberg mentions a case of 
 this species of malformation, in the pathological portion of 
 his able essay on Artlfic/ial Anus. 
 
 The case was that of a new-born female child, whose anus 
 was well formed, but the anal canal was closed a little above 
 the sphincter. The attempt made to open it by puncture 
 produced no evacuation of meconium, and the child died six 
 days aft^r birth. 
 
 At the autopsy, the walls of the intestine were found 
 adhering to each other and closely united in two different 
 places. Dr. Friedberg was of opinion that this cohesion was 
 canned by inflammation of the rectum during foetal existence. 
 
 Case LXXXV. — The following interesting case of imper- 
 foration of the rectum above a well-formed anus, is reported 
 by M. Amussat. 
 
 ■^ ''On the 22d of December, 1842, M. le docteur Schuster 
 sent me a new-born male infant who had passed no meconium 
 since his birth. The child well-formed and developed in all 
 other respects, w\as born on the 20tli at seven o'clock, P. M., 
 and as the anus perfectly well-foiuned pi-esented an opening 
 of the usual size, there was no immediate suspicion of an im- 
 perforate rectum. But after administering purgatives for two 
 days they sought to account for the condition of the child, who 
 vomited all that he received upon his stomach, and whose 
 abdomen was becoming sensibly larger. Upon introducing 
 the finger and a sound, imperforation was discovered. 
 
 "When ^ve saw the child, liis abdomen was swollen, his skin 
 presented the violet hue common in cases of obstruction of the 
 venous circulation, and he cried incessantly. 
 
 " A sound introduced by the anal opening penetrated M'ith- 
 out difficulty a distance of about seven eighths of an inch. 
 At this Inuglit it encountered an obstruction which it could 
 not overcome. The little finger was likewise arrested at the 
 same height, and there was no perceptible fluctuation indicat-
 
 184 THE FOUKITI SPECIES OF MALFOEMATIOlSr. 
 
 iiig that tlie upper })art of the rectum, distended by meconi- 
 um, terminated immediately above the closure. 
 
 " By percussion of the regions of the perin^eum and coccyx, 
 verv considerable fluctuation was perceived just behind tlie 
 anus. This fluctuation, particularly evident when the child 
 cried and made any straining effort, or when pressure was 
 nuide upon the abdomen, was clearly recognized by all the as- 
 sistants. Was it an indication that the upper part of the rec- 
 tum, deviating from its ncirmal course, terminated near the 
 skin of that region? It was quite probable, but hj no means 
 certain. Besides, on examinat-ion, the coccyx was found not 
 to be as much curved as is customary with well-formed child- 
 ren, indicating that the intestine developing itself in its inferi- 
 or portion, had pushed back the coccyx in order to make 
 room for itself. At all events, so unusual a circumstance as a 
 fluctuation extremely perceptible behind the anus, and alto- 
 gether unperceived by examining the anal aperture with the 
 linger, was sufficient to embarrass the operator, and render him 
 undecided about the proper course to take. Should he incise 
 the closure, making use of the anal opening, or would it ])e 
 better to form an artiticial anus between the normal c»])ening 
 and the coccyx, at the precise point where the evident fluctu- 
 ation indicated almost surely that the upper end of the rec- 
 tum, imperforate, had reached by its distension within a very 
 small distance of the skin ? 
 
 '•After reflection, I decided on the latter operation. The 
 fluctuating tumor was incised with a bistoury, plunged deeply, 
 upon the withdrawal of which gas and meconium were voided. 
 The opening having been enlarged, a sound and the flnger 
 were introduced into the artificial anus. A great quantity of 
 meconium flowed. Satisfied with the haj^py result of the op- 
 eration thus far, I reflected on the means necessary to restore 
 a part, if not all its functions to the natural anus. M. Vidal, 
 of Poitiers, one of the assistants, proposed enlarging the open- 
 ing on the side of the anus, in order to make one cavity of the 
 two which existed. A grooved sound soon perforated the thin 
 memljranous obstruction which separated the two ends of the 
 rectum. It was incised with the scissors after catching it with 
 the finger and brin^ino- it down. The intestinal mucous mem- 
 Itrane was smooth and soft, and the finger was covered as by 
 a hood with the anterior portion of the partition. The child 
 was bathed and cleaned. Emollient injections were recom- 
 mended for the wound, and sitz Ijaths were advised. The 
 child was brought to us daily, and his condition gradually 
 improved. 
 
 " An elastic canula was introduced from time to time dur-
 
 THE FOURTH 8PKCIES OF MALFORMATION. 185 
 
 ing the dny, into tliu anal upenino;, to dilate it and j)r('vcnt 
 contraction. 
 
 "At this date, February IStli, 1843, the child seeins as well 
 as tliough it had never endured so grave an <»[)eration. 
 
 '■'•Ileflectunus. — The diagnosis has been ])eri'ectly justified 1)V 
 the operation. My ideas formed at the time of the oj)eration 
 and leading me to this diagnosis were as follows: When 
 fluctuation was not ])erce])tible to the little finger introduced 
 into the cul-de-sac of the I'ectum, (Hie would hardly have im- 
 agined that it would be discovered behind and lower down : 
 it would naturally be supposed that the other end of the in- 
 testine was higher up ; but on reflection we see the thing is 
 possible, and the fact proves it. It is very probable that in 
 all analagous cases it must be so, but in a variable degree, ac- 
 cording to the distention of the upper end. 
 
 " The operation in the rear of the cnl-de sac of the rectum, 
 was perfectly successful. After incision into the meconial 
 pouch the gas and meconium were immediately evacuated. 
 I enlarged the opening, and introduced a sound and the little 
 finger without any difficulty. I subsequently enlarged the 
 opening yet more at its lower part, in order to make the anus 
 servicable, and finally with a grooved director, I penetrated 
 the thin mucous membrane which formed the obstruction. I 
 cut it entirely through, and the normal anus consequently 
 now communicated with the artificial opening made behind it. 
 W^ith the little finger I recognized the mucous membrane, 
 as well as a part of the separating membrane covering the 
 finger like a hood ; finally, I removed this portion of the ob- 
 struction with the scissors, and then the finger could be easily 
 introduced into the rectum without encountering any other 
 obstacle. 
 
 " From the description of the operation it is easy to infer 
 the pathological condition of the intestine. It is evident that 
 the rectum M'as closed, or strangulated about one inch and a 
 quarter from the anus ; in this state the other end of the intes- 
 tine was distended and extended back, having displaced the 
 coccyx, taking its position between the inferior extremity of 
 the coccyx. 
 
 " We must perceive that the same disposition of parts exist 
 when the pathological condition is the same. 
 
 " It would be higldy interesting to examine an anatomical 
 specimen of this kind, in order to see the cause of imperfora- 
 tion, and the adhesion of the cul-de-sac in front. 
 
 " Although it was impossible to recognize the fluctuation at 
 the bottom of the cul-de-sac, if we had operated there with 
 the trocar or the bistoury in the ordinaiy manner, we should
 
 186 THE Fouirni speciks of malfokmation. 
 
 undoubtedly have completely evacuated the meconiuui ; but 
 ■\ve know the difficulty of keeping the opening sufficiently 
 dilated. The cul-de-sac of the upper end would have inter- 
 posed a serious obstacle to the flow of the fgecal matter. 
 
 " Previous to this case I have always endeavored to bring 
 down the upper extremity to the anus, after having cut on 
 the inferior end in the rear. 
 
 " It is evident that the oj^eration on this last child is far pre- 
 ferable and more simple in execution. It is like a grand op- 
 eration for fistula in ano. 
 
 " The diagnosis being the same, would it not be preferable 
 to cut the anus behind, in order not to ascend too high by the 
 side of the coccyx. With a small straight-bladed bistoury, 
 the point covered with a small wax ball, we might at first en- 
 large the anus towards the rear, in order to explore and direct 
 for the rest of the operation." — {L* Examinaieur Medical d^ 
 Paris. Atinee 1843. tome III. No. 17. ]). 216.) 
 
 Case LXXXYI. — Dr. Condie reports a case as follows — 
 "We have lately seen a case of this species of malformation, in 
 wliicli the obstruction, consisting of a transverse membrane, 
 existed about an inch and a half within the anus, the lower 
 ]>ortion of the rectum being in all respects perfectly formed. 
 The cl)ild lived four days, and until within a few hours pre- 
 vious to death, presented no indication of the existence of tlie 
 obstruction, excepting the absence of all discharges from the 
 bowels. Shortly before death, great tumefaction of the abdo- 
 men from the development of gas took place, with evident 
 ])ain upon pressure of any portion of the abdomen. No 
 operation was permitted by the parents. 
 
 " An examination of the body revealed the nature of the 
 obstruction — a firm membranous partition existing about one 
 and a half inches above the termination of the gut, and 
 forming a complete obstacle to the furtlier passage of the 
 contents of tlie bowels. The small intestines were perfectly 
 empty, greatly contracted, and free from the least trace of 
 disease ; the colon was enormously distended with gas, and 
 tlirough its whole extent, injected with blood. The upper 
 portion of the rectum was likewise greatly distended, and 
 contained nearly eight fluid ounces of meconium, and thick 
 ropy mucus; its mucous coat presented very decided marks 
 of inflammation." [A PmotiGol Treatise' on the Diseases 
 of Childi'en.i?. 191. Philadeljyhia : 1814.) 
 
 Case LXXXYII. — The f )llowing case oi imperforation, or
 
 THE FOURTH SPECIES OF MALFORMATION. 187 
 
 rntliei* absence of the rectum, ahovc a normal anus, is 
 reported l).y Pn^tiessor James Jones of New Orleans. 
 
 "The iirst case in my )>ractice," says Dr. Jones, '• occurred 
 in February, 1846. I delivered a lady of a fine boy on the 
 morning of tlie 13tli, and as she lived two and a half miles 
 fn>m my residence, left her in charge of a very experienced 
 nurse, who now practises with some re])utati()n as a midwife. 
 Next day she informed me that the child had as yet no pas- 
 sage from the bowels, notwithstanding the exhibition of olive 
 and of castor oil, and also of two enemata. The child was 
 very restless and fretful, vomited and had a very tense belly, 
 I took the syringe which had a long ivory nozzle, and using it 
 as a sound fur the examination of the anus and rectum, found 
 to my regret that it would only penetrate about half an inch, 
 and that the anus [rectum) was imperforate. I immediately 
 made an incision with my lancet to the depth of half an inch 
 more, and finding by the introduction of a cataract needle an 
 inch and a half, that neither air nor liquid of an}' kind made 
 its appeai'ance, I called Dr. Stone into consultation, who dis- 
 approved of further incisions, and dilated that already made 
 to the depth of an inch and a half unsuccessfully. The abdo- 
 men became more tense, the child gave evidences of great 
 suffering and died on the next day." 
 
 " The post-mortem was made on the 17th, by my friend 
 Dr. Lemonnier. The intestines were all greatly distended, 
 and the surface of the peritoneum covered with coagulable 
 lymph. The lower portion of the colon, which was the ]iart 
 most enlai'ged, terminated at the promontory of the sacrum, 
 in a cul-de-sac, tilled with meconium. There was a complete 
 absence of the rectum, and the end of the colon had two 
 little punctures made by the needle, from which, apparently, 
 nothing had escaped. If {\\Qy had been larger, the contents 
 would have been emptied into the cavity of the pelvis." 
 {New deans Medical and Surgical Journal. Vol. XY. ^y. 
 98. 1858.) 
 
 Case LXXXYIII. — M. Baudelocque mentions the case of 
 a child two days old, presenting a natural anus, but having 
 voided no meconium. On passing the little finger of his left 
 hand into the rectum, he found that organ terminated in a 
 cul-de-sac, about one inch above the anus. He made an inci- 
 sion through the occluding membrane with a sharp-pointed 
 probe through a canula, and the meconium immediately found 
 a passage, and the child was relieved. 
 
 Baudelocque subsequently performed the same operation in 
 apparently a similar case, but it completely failed. He then
 
 188 THE FOURTH SPECIES OF MALFORMATION. 
 
 successfully perfonned colotoiny after the method of Callisen, 
 modified by Amussat. [Memolre de VAcadeinie Roy ale des 
 Sciences. Paris : Aout et Octobre. 1844. Also^ London 
 Lancet. Vol. I. Fehtniary, 1845.) 
 
 Case LXXXIX. — John Pikcop, Esq., a London surg-eon, 
 reports the folh)\ving case of imperforate rectum above a nat- 
 ural formed anus. 
 
 " On the 13th of Jul}', 1849, I attended Mrs. M- , in 
 
 labor of her first child, a female. During my visit, the fol- 
 lowing day, I was informed that the child's bowels had not 
 been moved; but, hoping they might be during the day, I 
 took little notice of the remark. 
 
 " Julv loth. — -The bowels still unmoved, thoucrh castor oil 
 had been given. The child would not take the breast, and 
 vomited an}- fluid almost as soon as taken. Bowels much dis- 
 tended. Retching, hiccough, and other symptoms of severe 
 enteritis. Ordered a calomel powder immediatel}^, and a tea- 
 spoonful, every three hours, of a mixture, containing a saline 
 laxative, with tinctures of cardamoms and henbane. 
 
 "16tli. — Vomiting abated. Belly still as usual, without 
 any evacuation. I proceeded to inject a little warm water 
 per anum, but was surprised to find it instantly returned, un- 
 altered. This induced me to introduce my fino-er, as I ima- 
 gined there might exist some imperfection in the passage. On 
 doing so, I found, that when my finger had passed about an 
 inch and a half, the bowel was closed, precisely like the end 
 of the fino-er of a glove. I could not detect any distended 
 portion of bowel to correspond. This condition of parts fully 
 disclosed the nature of the case. I explained to the mother 
 the immediate necessity of an operation, to afford the child 
 any chance of life, to which she consented. 
 
 "17th. — In the presence, and with the advice, of Mr. Grime, 
 surgeon, and Dr. Irvine, I introduced a sharp-pointed bis- 
 toury, against my finger, to the seat of obstruction, and 
 pushed it on about an inch. On withdrawing, nothing 
 escaped but a little venous blood. I then passed through the 
 opening a small bougie, on M'hich being removed, there fol- 
 lowed a copious discharge of meconium and other matter. 
 From this time the child became easier, and on the following 
 day began to take the breast. The mixture was continued 
 for a few davs, and also the introduction of the bougie. The 
 bowels are regularly moved, and the child is in perfect 
 health. 
 
 "The removed extremities of the rectum appeared to be 
 connected bv a short band of fibrous membrane. I have be-
 
 THE FOUKTII SPKCIKS OF MALFORMATION. 189 
 
 fore Hi'c'ii cases ul' iiiu)L'rli)riite iuius, I)iif, not of iiii[)crvi()us roc- 
 timi." {London Lancet^ Vol. 7., Maij: 1S50. 2>. 510.) 
 
 Cask XC. — Von Sclileiss, of Muiiicli, iv])()rt.s the (^iise of ii 
 male infant in whom the rectum was imperforate about one 
 inch above a well-formed anus. JJeyoiid the point of im])er- 
 foration, the rectum was absent, and the colon terminated in 
 a cul-dc-sac. Schleiss, by a very lucky phuii^o with a trocar, 
 readied and penetrated the blind end of the inferit)r extremity 
 of the colon, without wounding the Ijladder or any of the pel- 
 vic viscera. Success, under numerous difficulties, finally 
 attended the operation. 
 
 On the 11th of October, 1850, Mrs. J. St , a healthy 
 
 wonuin of Munich, aged twenty-two years, was delivered of 
 her second child, a boy, like her first still living, healthy and 
 well-formed ; no appearance extermdly whatever of any de- 
 formit}'. The child seemed quiet, had passed urine, but had 
 taken no nourishment, neither had it evacuated any meconiuui 
 for twenty-four hours. The midwife in charge of the case ad- 
 ministered an enema, but it iinn)ediately returned without 
 producing any effect. Late in the evening of tlie 12th of Oc- 
 tober, Von S'chleiss was called, and the midwife made him 
 acquainted with all the circumstances of the case, so far as 
 she knew. He observed that the child made strange move- 
 ments with its mouth and tongue, being between those of 
 licking and those which precede vomiting. Upon examina- 
 tion of the perinseal region, he found the aims normal, but on 
 introducing his little finger he found the canal completely ob 
 structed about an inch above the anal orifice. The cavity of 
 this portion of the rectum was empty, and no trace of mecn- 
 nium could be perceived, he therefore became assured that its 
 continuity was interrupted, and that it ended in a blind sac; 
 and that there was actually before him a case o^ atresia recti. 
 In consequence of the lateness of the hour in which he made 
 this discovery, he postponed further proceedings till next 
 morning, remindful of the advice of Diefi'enbach, to defer op- 
 eratino; in such cases till the second day. The child remained 
 quiet during the night, except the movements of its mouth and 
 tongue, which were increased in violence, without, however, 
 resulting in real vomiting ; but then it had taken no w\ater 
 nor any nourishment, and had passed no meconium. On the 
 morning of the 13th of October, he made a more thorough 
 exploration of the parts, by introducing a small silver cathe- 
 ter into the bladder, and his little linger as well as a small 
 probe into the rectum. This examination resulted in the con- 
 viction, that between the point of obstruction in the rectum.
 
 190 THE FOURTH SPECIES OF MALFORMATION. 
 
 and the inferior extremity of the colon, tlie former was defi- 
 cient, and that no communication whatever existed between 
 the two ; that the bladder which, in this case, was wide and 
 deep, had advanced as far as to the sacrum, to the anterior 
 surface of which it was adherent, was lying between these 
 two points — that is, between the blind end of the rectum, and 
 the blind end of the inferior extremity of the colon. 
 
 Von Schleiss was of opinion that this was a case sui generis^ 
 and that no method of operating heretofore recommended 
 was at all applicable to it. He however determined on this 
 occasion to use the trocar usually employed for paracentesis 
 abdominis, the child being placed on its right side with its 
 thighs drawn up and nates separated. Presuming that the 
 blind sac of the inferior extremity of the colon would be 
 situated more to the left, as in its normal place, Schleiss 
 introduced the trocar through the anal orifice into the rectum, 
 and pressed it to the left of the rectum by the side of the 
 false vertebra of the sacrum, and between the latter and the 
 posterior wall of the bladder into the cellular tissue which 
 united them ; and then pushing the stilette strongly in the 
 direction indicated, he experienced the sensation of having 
 traversed five or six lines of cellular tissue, and then having 
 penetrated a cavity. On witiidrawing the stilette he found 
 the point soiled with meconium ; and upon pushing the 
 canula still further upwards through the wound which had 
 been made, into the cavity, meconium immediately flowed 
 through it. The child at once improved in every respect, and 
 for the first time took the breast. The silver canula of the 
 trocar was allowed to remain in place for nine days, when it 
 was replaced by elastic tubes of gradually increased sizes ; 
 and at last after four weeks these were laid aside altogether. 
 The faecal matter now passed easily through the newly made 
 canal. 
 
 AVhen the child began to pass more solid faecal matter, 
 occasional difficulties occurred, which increased until it was a 
 year old. It seemed compelled to make, at different times, 
 two distinct efforts to accomplish the evacuation of its bowels. 
 At the first efibrt its uneasiness and cries only ceased after 
 tlie faecal matter had passed the newly formed passage from 
 the colon, and had become lodged in the cavity of the rec- 
 tum. At this effort no fcBcal matter whatever would pass by 
 the anus. At a subsequent period, however, when to all 
 aj)pearance no marked efforts were being made to defecate, 
 manifestly limited to the rectal region, they were nevertheless 
 followed by evacuation. The child often remained several 
 days without stooling, and made useless and painful efforts.
 
 THE FOURTH SPECIES OF MALFORMA.TI()N. 191 
 
 On examining tlie rectnin with the tinger, tlic rectal cavity 
 was found to bo lilled with scybala; it was sonieliiiies neces- 
 sary to exti'act them with the linger. After regular inJectioUH 
 of cohl water had been used for some time, evacuation became 
 easier ; however, dithculty of evacuation occurred from time 
 to time. Twenty-live months after the operation, tiie child 
 was healthy ; the artilicial caual between the colon and the 
 rectum, passing behind the bladder, was three or three and a 
 half lines in diameter. Yon Schleiss hoped tliat it would be- 
 come yet larger as the child grew older, lie encountered 
 much trouble and dithculty in the treatment of this case, in 
 consequence of the occurrence, lirst of und)ilical, then of 
 inguinal hernia on each side, douhtless the result of the 
 straining efforts of the child to evacuate its bowels, together 
 with its constant cries. {ZeltscJirift fiir Rat'ionelle Medicin. 
 Ncue Folije. Band. III. S.Zm. lleidelberg : 1^^)^.) 
 
 Case XCI. — ^The following case was communicated to the 
 editor of the ^''Boston Medical and Surgical Jouraal^'' by Dr. 
 A. Bryant Clarke, in a letter dated llolyoke, Mass., February 
 10th, i852. 
 
 "I attended a lady, the mother of several healthy children, 
 in her coniinement on the 5tli of April last, who was delivered 
 of a tine, plump-looking boy, and to all apj^earance perfectly 
 developed. On calling the next day, the mother and child 
 appeared to be doing well. To my inquiries, however, the 
 nurse stated that nothing had passed its bowels. A slight 
 laxative was ordered, with directions to use injections by 
 evening if nothing passed. The second day, nothing having 
 passed, and the nurse not being able to inject anything, I was 
 led to examine the rectum. I could pass my little finger into 
 the anus without difficulty, but after passing about three- 
 f )urths of' an inch it met with firm resistance, appearing to 
 terminate in a cul-de-sac. The nature of the case was now 
 made known to the mother, and the only means of relief, an 
 operation, was proposed ; but as her husband was absent, she 
 declined having it done until his return. Circumstances pre- 
 vented this until the evening of the seventh day. He at lirst 
 declined an operation, but seeing how w^ell the child continued 
 to be, and after consultino- a neio-hborino; surgeon, he consented 
 to have an operation performed on the morning ot the ninth 
 day. I made use of a trocar and canula. After passing the 
 trocar through the canula, I withdrew it, but no meconium 
 followed. Raving pushed up the canuUx into the opening 
 made by the trocar, I again inserted the latter and withdrew 
 it, when the meconium followed in abundance. The child
 
 192 THE FOUKTH SPECIES OF MALFORMATION. ' 
 
 made no cries, and seemed to be relieved by the operation. 
 But very little blood was lost. Yet the child died in about, 
 twenty-tbur hours. 
 
 "The parents being very intelligent and well-informed, 
 kindly consented to an examination, which was had the next 
 day. On laying open the cavity of the abdomen, the colon 
 was found adlierent throughout its course uj^on the left side 
 to the internal walls of the cavity of the abdomen. The 
 abnormal state of the rectum was now seen to consist of a 
 fleshy-looking mass, interspersed with fat and cellular sub- 
 stance, which made it resemble the muscular tissue of other 
 parts, and to close up the rectum for the space of about an 
 inch and a half. Upon examination it was found the trocar 
 had gone directly through the centre of the mass, and was 
 perfectly successful, so far as the operation was concerned. 
 It was observed that there was a fetid smell to the urine the 
 day before, and there is no doubt that the means of relief 
 were too late." {Boston JSLedical and Surgical Journal. Yol. 
 XL VL p. 100. Boston : 1853.) 
 
 Case XCIL — Groeschler, of Prague, reports the following 
 interesting case of imperforation of the rectum, the anus, in 
 the meantime being normal. In this instance the rectum 
 was obstructed at two points, first, by a membranous septum, 
 at half an inch above the verge of the anus ; then again at 
 two inches. Beyond this second obstruction the rectum was 
 entirely wanting, the colon terminating in a cul-de-sac. 
 
 Mrs. A. S , aged thirty-nine years, the wife of a shoe- 
 maker, was delivered on the 10th of July, 1854, of a vigorous 
 and to all appearance a healthy and iine conditioned boy. 
 The child urinated regularly, but could not evacuate its bow- 
 els. On tlie next day, after giving it some mai'sli-mallow tea, 
 vomiting ensued, and the midwife in attempting' to adminis- 
 ter an enema, met an obstruction within the anus, which 
 induced her to call in the aid of Goeschler. 
 
 On the 30th of July, at eleven o'clock, A. M., Goeschler 
 arrived, and upon percussing the child's abdomen, he discov- 
 ered a clear full tympanitic sound ; its respiration was hur- 
 ried ; and its hands and feet were of a violet hue. The local 
 examination of the perinanim, which he made, resulted in 
 finding a well formed anus, surrounded ])y a sphincter capa- 
 ble of contraction ; but an ivory sound which he attempted 
 to introduce, entered onh' about half an inch, being obstructed 
 by tlie closure of the intestine at that p(^int. This obstacle 
 ha\'ing been incised by means of a pointed bistoury, he suc- 
 ceeded in introducing the sound about two inches ; but at
 
 TIIF, FOUKTir SPECIES OF MAI.FOKMATIOX. 193 
 
 this point there was fouii<l a second ocehision as complete as 
 the first, and allowing neither evacuation of the meconium, 
 nor li(|ui(l injection, (loesc^lih'r pert'oi-utcd this second obsta- 
 cle 1)}' means of a trocar, and inunediately two lai'ge spoon- 
 fuls of meconium ])assed out. The swellino; of the abdomen 
 at once diminished ; the sound and the l)ipe of the syringe 
 were easily introduced, and an eiu'iua of cold water was 
 administered. A large elastic catheter was now placed in the 
 newly made canal. At the end of two hours the infant grew 
 pale, the tension of the abdomen returned, the extremities 
 became l)luo, and respiration was hurried ; the evacuation of 
 meconium ceased by degrees, and death occurred about six 
 o'clock P. M. 
 
 The autopsy was made by Professor Engel, and gave the 
 following results— The anus was well formed, but from a short 
 distance above it to the promontory of the sacrum, the rectum 
 was com})letely wanting : the bladder was normal. The 
 blind end of the colon was about the hight of the promontory 
 and attached to the anterior surface of the sacrum by a con- 
 tinuation of the peritonaeum. The sound introduced into the 
 anus, passed into the artificial canal, and thence into the 
 opening made wdtli the trocar in the closed extermity of the 
 colon. The canal thus formed passed along the line usually 
 occupied by the rectum, in this instance filled up with a firm 
 cellular tissue. The abdominal cavity was filled with licpiid 
 meconium ; but there was no appearance of peritonitis, nor 
 was there any trace of internal hemorrhage." ( Yiertel- 
 jalirseht'ift far die praktlsdie Ilellkunde^ XII. Jahrgang^ 
 1855. ///. Band. &\ IS!. Fracj.) 
 
 Case XCIII. — Mr. Bird, translator of M. Bouchut's treatise 
 on the diseases of children, reports a case as follows : — ■ 
 
 '' Through the kindness of my friend Mr. Tapson, I have 
 had the opportunity of witnessing the follovring case ; a 
 female child was born nearly dead, with feeble respiration, 
 blue surface, and deformity of the left hand. On the second 
 day, no meconium having jjassed, an examination was made ; 
 the anus was well formed, but on introducing the finger an 
 obstruction was discovered about half an inch from the anus ; 
 it gave the sensation of a membrane, which, on the feeble 
 effort of the child became more tense ; the child continuing 
 in a state of cyanosis, with feeble respiration, any operative 
 proceeding was deemed useless and cruel ; it died on the fifth 
 day, having taken only a few teaspoonfuls of nourishment ; 
 there was no vomiting with the exception of a single effort, 
 
 18
 
 194 THE FOUKTH SPECIES OF MALFOKMATIOISr. 
 
 on the second day, when a little fluid tinged with bile 
 escaped ; the abdomen became much distended before death. 
 " Autopsy. — Lungs free from congestion, collapsed, but 
 restored by insufllation; it was evident, however, that air had 
 never entered some portions, which required strong efforts of 
 insufllation to distend them. Both auricles, espcially the 
 right, were distended with clots ; the foramen ovale was only 
 two-thirds closed by a thin membrane, the free edge being 
 directed anteriorly ; the ductus arteriosus Avas widely open. 
 The peritoneal cavity contained much gas and faecal matters, 
 but there was no trace of any inflammatory products. About 
 three inches from the appendix vermiformis, a long rent in 
 the peritonseal covering of the colon was observed, showing 
 the mucous membrane beneath ; this was softened and thin- 
 ned and presented a circular opening less than half an 
 inch in diameter, the edges of which were irregular 
 from small shreds of mucous membrane ; the vessels were 
 much congested in tlie neighborhood of the rent, but no signs 
 of inflammation were observed, the rent being apparently the 
 result of mechanical distention. The rectum terminated in a 
 perfect cul-de-sac, the distended ha3morrhoidal vessels ramify- 
 ing over the extremity, all the coats of which were jDcrfect, 
 and not the slightest trace of any opening was observed ; the 
 vessels of the mucous membrane were considerably injected ; 
 the large intestines contained no meconium but a large quan- 
 tity of Arm bright colored faeces." {Practical Treatise on the 
 Diseases of Children. By M. Boucliut. Bird's English ver- 
 sion. Booh X. Chap. I. p. 615. London, 1855.) 
 
 Case XCIV. — Mr. Ashton reports a case of this species of 
 malformation. 
 
 " I have," says he, " in my possession a preparation given 
 me by my friend Dr. Qnain, namely, a case of malformation 
 of the rectum, in which tlie intestine terminated in a closed 
 sac. The prepai-ation was presented to the Pathological 
 Society, and the particuhirs of tlie case are published in the 
 Society's Transactions. ( Vol 1. p. 280.) The anus was 
 perfect, throngh which an incision was made by the surgeon 
 in attendance; but he was unsuccessfnl in opening tlie 
 bowel, and the child died on the ninth day." {A Treatise on 
 the Diseases., Lijuries and Mcdformations of the Rectum and 
 Anus. By T. J. Ashton, M. D. Chap. XIX. p. 333. 
 London : 1854.) 
 
 Case XCY. — S. Parkman, M. D., reported the following 
 case to the Boston Society for Iledical Lnprovenient, on the 
 13th of February, 1854.
 
 TUE FOURTH SPECIES OF MALFORMATION. 195 
 
 " The patient was fifty-two lioiirs old ; anus ])orfcctly 
 formed; obstruction of rectuni nearly two inches within the 
 anus. Dr. Parkuuin waited eighteen hours, until the septum 
 became distended by collected meconium, and then punctured 
 the ])ouch with a trocar ; injecting afterwards, and washing 
 out the bowel. This process was repeated, the opening not 
 remaining free, a director was passed into the anus and 
 through the opening made by the trocar, and the sphincter 
 ani and the septum were divided, from before backwards, l>y 
 a free incision ; the linger could then be passed, and went 
 into a large cavity. After the operation the child took the 
 breast readily, and is now doing well, three months after the 
 operation. l)r. Parkman directed an attendant to pass a well- 
 oiled finger wnthin the opened intestine daily. [Records of 
 the Boston Society for Medical Iraprovement. Vol. W. p. 
 55. Boston : 185(>.) 
 
 Case XCVI. — S. Cabot, M. D., of Boston, Mass., reported 
 the following case of imperforatioii of the rectum, to the 
 " Boston Society for Medical Improvement^'' on tlie 28tli ol 
 September, 1857. 
 
 Dr. Cabot saw the patient on the fourth day after birth in 
 the evening, at which time it was reported that no discharge 
 had taken place from the bowels. Castor oil had been given, 
 but was rejected. An injection had also been ordered. The 
 abdomen was now found distended. On examination per 
 rectum, the finger passed in about one inch. When the child 
 strained, the intestine could be felt pushing downward, 
 the central portion of the part thus pushed down feeling 
 considerably thicker than membrane. A trocar was thrust 
 in, and a large quantity of fseces and meconium discharged. 
 
 On the following morning, two probes were passed in 
 through the opening, into the intestine, as was supposed, the 
 largest being left in, and a piece of gum elastic catheter 
 pushed down upon it. In the evening it was reported that 
 nothing had passed through the canula. The child had also 
 vomited foeculent matter. The opening was now eidarged 
 by the knife and the intestine punctured ; this being followed 
 by the discharge of a small quantity of gas and meconium. 
 Death took place on the following day. 
 
 It was found on examination, that the internal and external 
 cul-de-sac approached to within about a half an inch of each 
 other, and that the probe and catheter, instead of passing 
 through the original opening into the intestine had made a 
 false passage in the cellular substance by the side of the gut.
 
 lOG THK FOURTH SPFXIIiS OF MALFORMATION. 
 
 [Bonton Medical and Surgical Journai. Yul. L YII. p. 238. 
 Boston : 1857.) 
 
 Case XCVII. — The following case is reported by Dr. G. 
 S. Jones. It was read before the Suffolk District Medical 
 Society, of Mass., on the 31st of October, 1857. 
 
 "Tlie subject of this case was a line, phinip, male child, 
 apparently otherwise in a liealthy condition. 
 
 ••' The day after its birth, the nnrse directed my attention 
 to the fact that it had had no discharge from its bowels, 
 although efforts had evidently been made to effect that object. 
 I ordered castor oil to be given, and if it failed in producing 
 an evacuation from the bowels, then injections of warm water, 
 until tlie object desired was obtained. At my next visit, I 
 was informed that neither the oil nor injections had acconi- 
 plislied the purpose for which they were intended, and that 
 the little patient continued to have a " bearing down," which 
 seemed to be accompanied with much suffering. A paroxysm 
 of this effort to unload the bowels coming on Mdiile I was 
 present, induced me to make a more thorough examination 
 of his condition, than I had done at my previous visit. The 
 abdomen was found quite tense and tympanitic ; as he passed 
 urine immediately after his birth, there was no anxiety or 
 uncertainty respecting the functions of the bladder. The 
 anal opening was normal, and freely admitted my oiled 
 linger, but in attempting to pass it up into the bowel,! found 
 that it could not penetrate further than to the second joint 
 (about one and a half inches,) in consequence of some obstruc- 
 tion. While the linger was in the passage, tlie little fellow 
 would strain and bear down violently, and I could distinctly 
 feel the blind or pouched extremity of the bowel distended 
 with meconium. The case was evidently a clear one, and 
 after rej)resenting its condition to the parents, they were 
 exceedingly anxious to have me operate upon the child, if 
 there was the least chance of saving its life. 
 
 "Having decided to operate, I had the child placed upon its 
 back in the lap of its nurse, with its legs flexed upon tlie 
 abdomen, I then passed a very small bi-valve speculum, 
 through the anal opening up to the point of obstruction, when 
 I dilated the passage to "its fullest extent, and by the aid of 
 light, I was now able to see, what I had only previously felr, 
 the termination of the impertbrate bowel. The child now 
 straining quite hard, forced the gut down very tensely ; I 
 then, with a spear-pointed stilette, made an opening into it, 
 and copious discharges of gas and meconium followed the
 
 TIIK FOURTH SPECIES OF MALFORMATION. 197 
 
 withdrawal of the iiistrmiicut. The ojxMiiiii;- was riirthcr 
 C'nlari>:e(l by ;i crucial incision across the end of the pouch, 
 and i)y the use of gum-elastic bougies ; commencing with 
 one, one fourth of an inch, and at the terminatifni of six 
 weeks, leaving off with one, half an inch in diameter. It is 
 now nearly two and a half years since the operation, and the 
 child appears well and hearty, and suffers no inconvenience 
 from the malformation or operation. No dr)ul)t the successful 
 result of this operation was in part due to the speculum, by 
 the aid of which a view of the parts could be fully obtained, 
 and a wrong direction could hardly be given the instrument, 
 in perfin'ating the bowel ; and also to the persevering use of 
 the bougies several times during the day and niglit, for a 
 period of six or seven Aveeks, in dilating the ojiening." 
 {Boston. Medical and Sargioal Jonrnal. Vol. LVI/.j?. 293. 
 Boston : 185T.) 
 
 Cases XCVIII. — XCIX. — ^The two following cases of im- 
 perfo ration of the rectum, accompanied by a normal anus, were 
 reported to the '' Suffolk District Iledical Society,'''' by Doctor 
 Ayer. 
 
 First Case. — The first case was a male child. The anus 
 was perfectly formed. On introducing the linger a few hours 
 after birth, its passage was obstructed a short distance from the 
 anus, but the upp)er portion of the intestine could not be felt 
 piressing down upon the finger as usuall}' happens in these cases. 
 The child was left for two or three days, when Dr. H. J. Bige- 
 low was called in consultation. At this time a distended pouch 
 could be felt by the finger pressed into the rectum. There 
 was also feecal discharge through the urethra. It was decided 
 not to do any operation, and the child died, in eight days from 
 its birth. — {Boston Medical and Surgical Journal. Vol. 
 L VII. 2>- 510. Boston : 1S58.) 
 
 Second Case. — The second case reported by Dr. Ayer, oc- 
 curred in a female child, and what was most remarkable, of 
 the same mother. In this case as in the first, the anus was nor- 
 mal and there was a passage of meconium through the ure- 
 thra. Dr. II. J. Bigelow was also called in consultation in this 
 case. The child was not operated upon and died in a few 
 days. 
 
 Dr. Ilodgcs made the autopsy of this case. On opening 
 the abdomen, which was greatly distended, the rectum pre- 
 sented itself and seemed to fill the whole cavity. The pelvis 
 and contents, with the external organs, were removed toge- 
 ther. The rectum terminated in a round cid-de-sac, and was
 
 198 THE FOURTH SPECIES OF MALFOEMATION. 
 
 •iilated by gas and meconium in a fusiform shape for six 
 inches or more above its termination, being largest just above 
 the brim of the pelvis, wliere its diameter was an inch and a 
 half at least. The anus jjenetrated about half an inch, and 
 the septum between it and the rectum was three -sixteenths of 
 an inch in thickness, consisting of loose celluar tissue. There 
 was no communication between the vagina or uterus and rec- 
 tum, though before death the color of the urine had led to its 
 supposed existence. No other malformation than that of the 
 rectum existed. — {Op. cit. p. 511.) 
 
 Case C. — In the case of a new-born infant which died six 
 days after birth, M. Littre found the rectum normal both be- 
 low and above an obstruction composed of a fibrous mass an 
 inch in length. This obstruction divided the rectum into two 
 portions, each terminating in a cul-de-sac. 
 
 ISTo operation had been performed in this instance. — {His- 
 toire de VAcademie Royale des Sciences de Paris. Annee 
 1710. 2>- 36.) 
 
 Tliis was the case that suggested to M. Littre the idea of 
 creating an abdominal artificial anus. [ Vide Chapter Xl.'\ 
 
 In addition to the authors already named, the following 
 may be referred to, as having also witnessed cases in which 
 the rectum was imperforate at a greater or less distance above 
 a well formed anus. 
 Courtial. Nouvelles Ohservatlons Anatomiques sur les Os. 
 
 p. 147. Leide: 1704. 
 Fourcade. Revue Medlcale de Paris. Anfiee 1830. tome 
 
 IV. p. 52. 
 Cruvielhier. Revue Medicale de Paris. Annee 1833. to7ne 
 
 II. p. 422. 
 Dupuytren. Journal Hehdornadaire de Medicine de Paris. 
 
 Annee 1829. tome II. p. 421. 
 Colson. Journal Hehdomadaire de Medicine de Paris. 
 
 Annee 1829. tome II. p. 150. 
 Bonn. Papendorf. op. cit. p. 253. 
 Griraaud. Journal GenSrale de Medicine, tome XXIV. 
 
 p. 238.
 
 THE FOURTH SPECIES OF MALFOltMATION. 199 
 
 Tlic following cases all belong to this the tV)urth species, 
 and should be so classed. Their history and description, for 
 obvious reasons, will be given in the chapter on Ahdombial 
 Artificial Anus. [ Vide Chapter XI.'\ 
 
 Casks — CCLXIII— CCLXVn— CCLXVIII -CCLXXVII 
 — CCLXXXIV— CCLXXXY— CCL XXXVII.
 
 THE FIFTH SPECIES OF MALFORMATIOK 
 
 S E C T I O X I . 
 DESCRIPTION. 
 
 1. In this species, the anus being generally either absent, 
 occluded by a membrane, or existing only in a rudimentary 
 state, the rectum near its interior extremity, sends off ajnpe- 
 lihe prolongation which terminates externally in a preter- 
 natural orifice at some point in the perinseum, or at various 
 points beneath the urethra, as far up as the frsenum prceputii ; 
 at the labia pudendi, or at some point in the sacral region. 
 
 2. The rectum sometimes terminates in two extremities in 
 the perinaeal region, each one by an abnormal anus, both per- 
 forming the functions peculiar to the natural anus, and situa- 
 ted more or less distant from each other. The one niay be 
 larger than the other, and give egress to the greater portion 
 of the contents of the bowels. Dr. Bushe has mentioned such 
 a case. [ Vide Case CXIII7\ Dr. Green also relates a sin- 
 gular instance of the same kind. [ Vide Case CXIV.^ 
 
 3. These adventitious canals of the rectum differ from the 
 ordinary fistulous passages only by being more perfectly 
 organized ajid being entirely free from induration. They 
 remind me verv much of the fistulous sinus which the rectum, 
 in order to relieve itself sometimes sends off from beyond a 
 permanent stricture of that intestine, when the contraction 
 exists a few inclies above the anus. Tliey may be regarded 
 
 in the character of supplementarv conduits, and cannot be 
 
 (200)
 
 TIIK Firm SPECIES OF MALFOKMATIOX. 201 
 
 considered Jis either lui arrest of development, nor a-; an 
 excess of development, but as a purely i>atliolo<^ical tV.ruia- 
 tion. 
 
 4. In some of these instances tlie conjjenital eloniration of 
 the rectum in the form of a fistulous sinus is covered merely 
 1)}' the thin skin of the perinreum^ so that the meconium can 
 be seen throuirh it, and the course of the canal traced to its 
 termination. The celebrated M. Cruveilliier reports a very 
 interesting case which 1 have presented in fnll translated 
 from the original. [Vide Case CV.'] 
 
 5. A few instances are recorded in which the sacrum was 
 found to be so congenitally malformed, so very deficient as to 
 permit the extremity of the rectum to perforate it, and open 
 externally in an abnormal anus. M M. De La Faye and 
 Lacoste mention cases of this character. [ Vide Cases CX- — 
 
 cxi—Gxn:\ 
 
 6. Papendorf, as well as others, has classed all such cases, 
 I am here considering, with those of his species which he 
 denominates — " Atresia Ani Vesicalis — UrethraUs — Vagi7i- 
 alis,''^ but as the rectum in these cases terminates externally, 
 and has no communication whatever with the genito-urin- 
 ary jiassages, they cannot therefore be so classed with propri- 
 ety. I will, however, have occasion again to refer to these 
 accidental canals of the rectum in the next chapter, in whicli 
 I will show, that they, instead of opening externally, by an 
 abnormal anus as in these cases, do sometimes open internally 
 into the genito-urinary passages by an abnormal anus. 
 
 7. The prognosis in these cases is generally favorable. 
 Should the accidental canal be tolerably large with a corres- 
 ponding orifice, the little patient may live for some time in 
 comparative comfort, if the other requisites of life are pres- 
 ent, but as soon as the diet of the child is changed, and the 
 stools become more consistent or hard, and are voided with 
 greater difficulty, the troubles commence which, unless 
 relieved by an operation, must sooner or later end in death.
 
 202 THE FIFTH SPECIES OF MALFORMATION. 
 
 8. Ill those cases whicli the anus is occluded by a simple 
 membrane only, the operation almost always succeeds. On 
 the contrary wlien this membrane is very thick, or when 
 there is no trace of an anus, and a considerable portion of the 
 inferior extremity of the rectum deficient, the operation of 
 course is much more difficult, and the result more uncertain. 
 
 SECTION II. 
 
 THE TREATMENT. 
 
 The indication to be observed in the treatment of those 
 cases of this species which occur in the male subject, is to 
 isolate completely the accidental canal from the end of the 
 rectum, and to establish the artificial anus in the perinseum 
 at the normal site of the anus. The jyijpe-like passage being 
 separated from the rectum should now be treated as an ordin- 
 ary anal fistula, by inserting into it a fine silk ligature and grad- 
 ually destroying its wall ; or by incising it with a small nar- 
 row sharp-pointed bistoury, guided by a flexible, grooved 
 director. 
 
 I will now give the method which Professor Dieffenbach 
 proposes for the treatment of those cases which occur in the 
 male subject. 
 
 The Process of Dieffenhach. At the place of the normal 
 anus a small oval flap of integument is incised, being held 
 wnth the bull-dog forceps, the skin is dissected away with a 
 small sharp scalpel. After its removal, the wall of the rec- 
 tum becomes visible, whicli must not be incised. One quar- 
 ter of an inch in front of this longitudinal wound and towards 
 the commencement of the scrotum, a vertical incision is made 
 in the raphe by means of a fold, about one-quarter of an inch 
 long and deep enough to reach the prolonged rectum at this 
 point. The cellular tissue is now separated from each side of
 
 THE FIFl'n SPECIES OF MALFOUMATFOX. 203 
 
 the rectiun, or a large probe is introduced beneath the rectal 
 prolongation, and mIiIcIi is completely divided \\i\]\ scissors 
 in a direction vertical to its axis. Then by the crucial wound, 
 the free end of the rectum is seized with the bull-dog forceps 
 and is drawn into the oval wound designed for the Jiiud open- 
 ing ; after having completely separated it IVom its cellular 
 adhesions, the end is brought througli the opening, and by 
 means of six points of suture the edges of the intestine are 
 united with the cutaueous edges of the oval wound. Tlie 
 fsecal matter having been expelled, there is passed into the 
 isolated and now abandoned end of the intestine, by means of 
 a large eyed probe, a coarse cotton thread, the ends of which 
 are tied with a knot, and the wound is then covered with lint. 
 The formation of the anus is now perfect, and is soon followed 
 by healthy cicatrization of the wounds. The useless anterior 
 extremity causes indeed some trouble by means of its mucous 
 lining, but it requires little attention until the effects of the 
 first operation are overcome. A caustic crayon may be passed 
 througli the canal, or a large meche of lint covered with some 
 irritating ointment may be introduced, and after remaining in 
 some time, it may be removed and perfect compression estab- 
 lished, by means of lint and strips of adhesive plaster. If 
 after all this the obliteration of the canal is not effected, it 
 may be incised, and in this way the object attained. {Opera- 
 tive Chh'urgle. Band. I. S. 675. Lipzig : 1845.) 
 
 Dieffenbach successfully executed this operation upon two 
 male children. [ Vide Cases CIII^CIVJ] 
 
 Dr. Friedberg has also projDOsed a method of operating in 
 such cases, which differs somewhat from that of his illustrious 
 coimtryman Dieffenbach. This operation he successfully exe- 
 cuted in the highly interesting case of the child Albert M . 
 
 As this case fully illustrates Dr. Friedberg's method of 
 operating, I have given it entire, translated from the French, 
 being, as I remarked before, unable to obtain a German copy 
 of his valuable essay. [Vide Case CJlVII.]
 
 20 i THE FIFTH SPECIES OF MALFORMATION. 
 
 Witli regard to tlie operation of Dieifenbacli, Dr. Friedberg 
 says: 
 
 " In the case of Albert M , I thought best to adopt a 
 
 method somewhat diflt'erent from that of Dieffenbach, and 
 which attains the end w'ith greater simplicity, and may be 
 employed in cases of union of the rectum to the bladder, ure- 
 thra and vagina ; but as the method of Dieffenbach is distin- 
 guished by the tiict that when the skin and cellular tissue are 
 removed, the rectal wall is visible, it w^ould not answer in 
 
 cases such as that of Albert M , in which the closed 
 
 extremity of the rectum is very high up, and since this fact 
 cannot always be determined before the operation, it is 23refer- 
 able to perform it in such a manner as will be adapted to any 
 possible condition. AVhen the rectum, interrupted in the 
 cavity of the pelvis, sends oiF a canal-like prolongation open- 
 ing into the bladder, or the vagina, or is prolonged tOM^ards 
 the exterior, passing above the position of the normal anus, 
 
 and opens near the scrotum, (as in the case of Albert M ) 
 
 or in the penis, I should perform the operation as I have 
 already stated above in ordinary cases of anal imperforation. 
 
 I shouhl cut the canal as I did in Albert M , if it were 
 
 found in the viciuity of the perinseum ; in a contrary case I 
 should not trouble myself about the formation of the anus, but 
 rather atteud to the obliteration of the canal, which object we 
 may hope to effect by diverting from it the passage of faecal 
 matter. The obliteration may be rapidly effected from the 
 point of departure from the rectum, as the post-mortem of 
 
 Albert M clearly showed, but if it should be attended 
 
 with considerable delay, I should attempt cauterization by 
 means of a "wire heated to a red heat by electricit3^" iOp. cit.) 
 
 Ill the formation of the artificial anus in those cases in which 
 the rectum terminates by an abnormal orifice at the labia 
 pudendi, the vulva, &c., tlie short accidental passage should, 
 if possible, be obliterated without dividing the septum sepa- 
 rating the artificial from the abnormal anus, as the division 
 of the circular fibres of the sphincter going to the vagina, 
 and perhaps the incontinence of the fseces consequent upon 
 the section of the canal, might be of serious consequence ever 
 after. Friedberg, however, does not at all fear any evil con- 
 se(piences to follow the complete incision of the canal. He 
 says that if it is cut and projjerly treated, it will granulate and
 
 TiriC FIKTII Sl'KCIKS OK MALFOItMATK >\, 205 
 
 ciciilrizc, and this will the more ivadilv Im11..w if th(; knees of 
 tlie chikl lire honnd together; and if the divided halves of 
 tlie external spliincter tini muscle are united l)y a Jiealthy 
 cicatrix, tliere is no cause for fear as to the functions of that 
 muscle. 1 confess, however, that I should have fears, ant I 
 would decidedly prefer to ohliterate tlie canal hj the " Gal- 
 vano-Causiiti''' method of Middeldorpfi*, of Breslau. This would 
 be attended with no danger, and would most certainly succeed. 
 Dr. Friedberg himself recommends this method in otlier 
 cases, in which, in my opinion, it is not as applicable as in 
 these. 
 
 In cases of this character some surgeons recommend tlie 
 practice of M. Yicq d'Azyr in the instances in which the rec- 
 tum opens into the vagina. His operation is certainly vei-y 
 simple and easy of execution, but is liable to the objection 1 
 have already stated. 
 
 The Process of Vicq D^Azyr. A straight bistoury guided 
 by a grooved sound introduced through the fistulous opening 
 and passage into the rectum, and directed from before back- 
 ward, or from the peringeum to the coccyx, or from above 
 downward, would divide all the tissues which had caused the 
 deviation. A canula fixed in the rectum near the posterior 
 angle of the wound, would enable the solution of continuity 
 in front to cicatrize, and the matters to re-acquire their nor- 
 mal direction. {MoWs Velpeau. Vol. III. p. 1087. New 
 York: 1817.) 
 
 In those cases in which the rectum terminates by two 
 abnormal apertures in the peringeum at the same time, differ- 
 ing in size, and more or less separated from each other, Mr. 
 Asliton, of London, says — " Surgical interference will not be 
 required if either opening be of suflicient size for the free dis- 
 charge of the fseces ; but if both be so small that the process 
 of defecation cannot be properly performed, the septum 
 between them must be divided, or that which corresponds
 
 206 THE FIFTH SPECIES OF MALFOKMATION. 
 
 most clearly to tlie natural position of tlie anus must be 
 dilated by pressure, and by incision if necessary. (A Trea- 
 tise on the Diseases, I)ijuries, and Malforinations of the Rec- 
 tum and Ames. Chapter XIX. p. 337. London : 1854.) 
 
 In tliose cases in wbicli the rectum terminates by an abnor- 
 mal anus in the sacral region, I am not aware that any treat- 
 ment has ever been proposed. 
 
 SECTION III. 
 
 CASES AND REMARKS. 
 
 Case CI. — Fabricius of Ilildanus mentions the case of a 
 child which had an abnormal anus situated at the root of the 
 penis, the orifice of which was about the size of a pea, and 
 from which meconium and gas escaped. In this instance there 
 was no trace of an anus, a thick, strong, and hard membrane 
 covering the place it should have occupied, and extending 
 itself forward to the abnormal opening at the root of the penis. 
 The operation of incising this membrane, was performed on 
 the sixth day, and the result was a cure. — {Ohservationum et 
 Curationum Chirurgicarum. Centuria. Centur. I. Ohserv. 
 76. J). 54. Basil : 1606. JPolia.) 
 
 Case CII. — Dr. George Tobie Durr, a physician of Augs- 
 burg, relates the case of a male child having an imperforate 
 anus, in which the membrane that closed the anus was pro- 
 longed forward to the anterior part of the perinoeum, in which 
 was a small opening through which the meconium drained ofi". 
 Two months after the birth of the child, Durr performed the 
 operation of incising this membrane up to the natural place 
 of the anus. The faeces were voided in abundance and the 
 cure was ultimately completed. — {Miscellanea curiosa, sire 
 ephem.. acad. natur eurlosor. decur. II. ami. VI. ohserv. 62. 
 p. 3. 1668.) 
 
 Cases CIII. — CIV. — Dieifenbach mentions the two follow- 
 ing cases of imperforation of the anus attended with a prolong- 
 ation of the rectum opening in the perinreum. 
 
 He observed this elongation of the rectum in two male
 
 THE FIFTH SPECIES OF MALFOUMATIOX. 207 
 
 cluldren, one a few weeks, and tlic otlier two munilis old. 
 In the first, the somewhat siiiull unal orifice was lui'iucd in 
 the posterior part of the scrotum, lii tlie second it opened on 
 the anterior face of the scrotum. In tliis last case tlie (■lonji:- 
 ated portion of tlie rectum, conti"actin<^ t(.»wards the anterior 
 part, was nevertheless hirge enou<2;h to admit an elastic cathe- 
 ter of medium size. In both children the tVbces were voided 
 throug-h the fistulous canal and ahnornuil anus with ]>ut little 
 dilliculty, and in each case iJieffenbach operated with com- 
 plete success. — {Operative Chirurgie. Band. I. S. 676. 
 Ze/j)2i(/: 1845.) 
 
 Diefi'enhach was the first surgeon who proposed '■[Anap- 
 lasty " by lengthening the rectum in the male subject. 
 
 Case CY. — Tlie celebrated M. Cruvielhier gives the details 
 of a highly interesting case of a male infant who presented a 
 congenital imperforate anus, with a prolongation of the rectum 
 in the shape of a narrow fistulous passage formed in the very 
 substance of the raphe scroti, and terminating in an abnormal 
 oj)ening immediately below the meatus urinarius. 
 
 " A woman twenty -nine years of age, who was pregnant 
 the second time, and who w^as an invalid and considerably 
 a3dematous during the second montli of her pregnancy, was 
 delivered on the sixth day of July, 1828, at the Lying-in 
 ilospital, of a male child at full time — living and presenting 
 the following peculiarities. The child was poorly developed, 
 and afflicted with marasmus ; it was besides reduced to a 
 purely vegetative life ; its body was cold ; its skin discolored ; 
 its limbs contracted ; it uttered nothing but dull groans, and 
 with the exception of some slight spasmodic contractions, it 
 was nearly motionless. 
 
 " There was no anus, but at the situation which the normal 
 anus should occupy, there was an elevation of the skin caused by 
 an accumulation of the meconium. Tlie raphe was prominent 
 and knotty, and it was easily observed that a narrow canal 
 penetrated it, as it was distended with meconium which could 
 be seen through the thin skin which covered it. This canal 
 ultimately terminated under the glans penis in an abnormal 
 opening which gave issue to meconium. 
 
 " An incision was made into the raised portion of skin cor- 
 responding to the anus ; a great quantity of meconium es- 
 caped ; nevertheless the child remained in the same condi- 
 tion ; cold, motionless, discolored, and voiding by the nose, 
 the milk and sweetened water which were introduced by the 
 mouth. It was momentarily expected to die, and yet its life
 
 208 THE FIFTH SPECIES OF MALFORMATION. 
 
 ^vas prolonged to the fii\eentli of Julj, nine days after its 
 birth. 
 
 " Autopsy. It was found that the rectum terminatecl in a 
 cul-de-sac, that it was distended by meconium and gas, and 
 of sufficient size to admit the index finger. Near its termin- 
 ation it gave off an accidental canal, very narrow and lined 
 with a mucous coat. This canal at first directed its course 
 from behind forward, and from above downward across the 
 fatty tissues of the perinaium, rea<?hed the posterior extremity 
 of the raphe through the body of which it continued, and 
 finally opened under the glans penis. This opening readily ad- 
 mitted a slender probe, allowing it to pass the whole length of 
 the canal. There was no communication between the rectum 
 and the bladder, between the rectum and the urethra, nor be- 
 tween the rectum and vagina. [ Vide PlateVIII. Figs. 1,2,3,] 
 
 '•■The extraordinary symptoms that presented themselves in 
 this case could not properly be attributed to the malformation 
 just noticed. Tliere must have been a remarkable deformity 
 of the organs of circulation and respiration. There was a per- 
 ceptible defect in the formation of the blood, but it was diffi- 
 cult to define exactly what it was. An injection made by the 
 left carotid artery filled the whole circulatory system, arteries 
 and veins, and returned through the mouth and the nostrils." 
 — {Anritomie Pathologique du Corps Ilumain. tome I. 
 Livraison I. Planche VI. Figs. 6, 7, 8. Bruxelles : 
 1833, 1831.) 
 
 Case CVI. — Mr. J. F, South, one of the surgeons to St, 
 Tliomas' Hospital, London, reports the following case : 
 
 " I had under my care, very many years ago, a case of im- 
 perforate anus similar to that mentioned by M. Cruvielhier. 
 {Anat. Pathol. Uvr. I. pi. V.fig. 6.) At the time of birth 
 there was not any opening, but a slight puckering marked 
 the place of the anus, and this was protruded each time tlie 
 child cried. In front of the scrotum, and in the track of the 
 raphe, as it passed on to the prepuce, was a small aperture, 
 just large enough to admit the entrance of a probe, and from 
 it, when the child cried, a small quantity of meconium passed, 
 I cut upon the puckered skin, but it was full an inch before 
 the rectum could be reached, and I then opened it sufficiently 
 to admit a large urethral bougie, and the meconium readily 
 escaped. A probe introduced at the opening before the 
 scrotum, passed along a canal, beneath the urethra, through 
 the }>eriuaeum, becoming larger and larger as it approached 
 the rectum, in which it terminated. No bougie, or au}^ thing 
 else, was left in, as I thouglit keeping the bowels loose, would
 
 THE FIKTII 8PKCIES OF MALKOUMATIOX. 2<)0 
 
 have l)oen snffici(Mit to ])rov(Mit union ; Iiowcnht, in tlu; courBe 
 of a fortiiig'lit the wound had closed, and no motion was 
 passed except hy tlie aperture in front of the scrotum. 1 
 therefore luid to cut into tlie rectum a<i;ain, and a ])ioc^^ of 
 l)oui;-ie was then introduced, to he woi-n consfantiv, l)Ut 
 removed three or four times a (hiy, for emptjiiii; the l)owels. 
 This went on very well for a short time, hut proha])ly from 
 iiei;li2;ence, the scar contracted, and at tlie end of three 
 nutntlis, the anal openin<>; wonhl not a(hnit, even the end of a 
 prohe. The scar was therefore again di\ick'd, and a hirger 
 bougie introduced and worn for a fortnight ; after which 
 a sliort pew^ter pipe, about the thickness of the little ^nger, 
 with a circular sliouldei" to pi-event it slipping entirely into 
 the gut, was introduced, so that the motions might pass con- 
 tinually by it, and the opening be established. Two months 
 after, the pipe having slippecl out, and been neglected, the 
 opening had again closed, and again required enlarging with 
 the kiufe to re-admit the tube. The parent's negligence again 
 compelled the dilatation of the aperture with the knife, and a 
 large bougie was directed to be passed frecpiently. I did not 
 again see liim nntil he was seven years old, wdien he was a 
 well-grown boy, but with an enormously distended belly. 
 The anus continued open, though not very sufiiciently, and 
 the oiiiice before the scrotum was still open, and occasionally 
 motion passed by it. I was desirous of removing this unnatu- 
 ral canal, but the mother was averse to it, and the child's 
 unhealthy appearance did not lead me to expect that he would 
 live very long. I had entirely forgotten him, when eleven 
 years after, he being then eighteen years old, I was surprised 
 on seeing him a line healthy young man, who said he was 
 the" person on whom I had previously operated. The appear- 
 ance of the anus could be compared to nothing else than a 
 bullet-hole in a board ; he said he had no difficulty in passing 
 or retaining his motions ; but it was quite evident from his 
 linen, that there was a continued oozing. The opening in 
 front, instead of being near the frcenum prmputii, was now 
 close to the scrotum, and a small quantity of stool occasionally 
 escaped from it. On examining more closely, I found the 
 anal orifice completely tilled with a protruded portion of the 
 lining of the rectum ; it, however, offered no obstruction to 
 the linger, which readily passed up as far as the knuckle, and 
 was received into the large cavity full of feculent matter, and 
 running forward along the perinseum, beneath the membranous 
 part aiid bulb of the penis, to the back of the scrotum where 
 the canal narrowed, and w<:)uld only admit the linger ; wdth 
 this the opening before the scrotum communicated. It was 
 14
 
 210 THE FIFTH SPECIES OF MALFORMATION. 
 
 curious, in this case that, although there was an entire absence 
 of tlie sphincter muscle, the stools did not pass involuntarily ; 
 the protruded fold of the internal membrane seemed to form 
 a valve which prevented ordinarily the escape of the stool, 
 and compensated the deficiency of the sphincter. I proposed 
 to him the removal of the continuation of the bowel into the 
 perinffium, but he would not submit to any operation. I have 
 not seen him for the last eleven years." {Saint Thomas' 
 Jlosjoital Bejyorts^ p. 121. London: 1836. Also English 
 Translation of CJieliiCs System of Surgery^ Amer. Ed.^ Vol. 
 IILp. 39. 'Philadelphia: 1847.) 
 
 Case CVII. — M. Monad gives an instance of a male child 
 having an imperforate anus, the rectum being prolonged in 
 the form of a fistulous canal to within a short distance of the 
 glans penis, where it terminated in an abnormal anus. 
 {JVouvelle Bibliotheqice Medicale. tome II. 2>- 4-17. Paris : 
 ls29.) 
 
 Cases CVIII — CIX. — M. Fristo mentions the cases of two 
 infants having each an abnormal anus. In one the rectum 
 opened in the loins, and in the other it opened ujDon the dor- 
 sum of the penis. {Mott's Velpeau. Vol. Ill j;. 1086. JVev^ 
 York: 1847.) 
 
 Cases CX — CXI. — M. De La Faye gives the description 
 of two children, in both of which there was found an abnor 
 mal anus in the sacral region, the orifice in each being suffi- 
 ciently large to admit the little finger. In one of the cases a 
 portion of the rectum passed through the opening in the 
 sacrum, and formed a kind of hernia. {Principes de Chirur- 
 gie, p. 358. Paris : 1811.) 
 
 Cask CXII. — M. La Coste mentions the case of an infant 
 in whom the rectum perforated the sacrum and formed an 
 aljnormal anus, througli which the fteces passed. (Bulletin 
 de la Societe Medicale d'' Emulation de Paris. Octohre, 1822, 
 p. 417.) 
 
 Cask CXIII. — Dr. Bushe mentions a case in which two 
 anal apertures existed at the same time. He says : " About 
 four years ago, Dr. AVilliam Power very kindly allowed me 
 to examine a fine healthy child, a few days old, in whom the 
 rectum terminated by two extremities, one being placed a 
 little more anterior than natural, while the other, though also 
 on the median line, was situated nearly an inch further back.
 
 THE Firni species of mai.foumatiox. 211 
 
 Tliis last, which was tlie smaller of the two, did not discliar<^o 
 more than one-third of the fu'ct's, and as nearly as I could 
 ascertain with a probe, M'as about one inch and a half in 
 length." {A Treatise on the Mai for mat ions, Injuries and 
 Diseases of the Rectum and Anits, jp. 44. JSfew York: 1S37.) 
 
 Case CXIY. — Dr. W. A. Green reports the following sin- 
 gular case of extensive congenital deformity : 
 
 ''I was called to Mrs. L ■ on Monday, January 5th, 
 
 1858. She had been in labor with her second child. Nothing 
 nnusual occnrred during gestation or paturition. She gave 
 bij'th to a child, over the average size, which cried lustily, 
 seeming to indicate that every function was regularly and 
 properly performed. Upon a close examination, the following 
 deformities were found to exist : The spine began a curvature 
 at the snperior third of the cervical vertebrte, in a direction 
 toward the right hypochondrium, to the top of the sacrum. 
 The concavityof this curvature w^as filled with two or three 
 sac-like appendages, containing, apparently, a fluid and gas. 
 moveable and compressible. 'A want of the spinous pro- 
 cesses of three or four contiguous vertebrae, is not a very 
 uncommon species of monstrosity.' ' This constitutes spina 
 lifida^ 'There is usually a soft, fluctuating tumor, in the 
 malformed bones, caused by water contained within the sheath 
 of the spinal marrow.' [ Vide Ramshothani' s Obstetric--<. 
 {Keating.) Appendix J/, p. 622.] Below, upon each side 
 of the sacrum, were tw^o appendages, resembling the mamma' 
 of woman. In front, between the point where the umbilicus 
 was attached, and the symphisis pubis, was a protrusion of 
 intestines, within the peritoneal sac, reducible by pressure, 
 but returning wdien removed. Immediately under this 
 hernia, the urine trickled, continuously, from two or three 
 small openings, which could not be entered by the smallest 
 probe. Below this, and hanging pendant from the middle of 
 the symphisis pubis, were the testicles, perfectly formed. 
 There was no trace nor any portion of the penis. Behind the 
 symphisis pubis, in juxta-contact, and at the extreme anterior 
 portion of the perinseum, was an anus, well formed, through 
 which the faeces passed. About an inch and a half behind 
 this, at the point of the os coccygis, was another anus, which, 
 upon examination, proved to be imperforate — a cul-de-sac. 
 
 "The face of the inftrnt, when first born, was perfectly 
 black, but is changing to a mulberry hue. Numerous marks 
 are upon its body, such as are frequently seen upon children. 
 Every other portion of the child seems perfectly and synmiet- 
 rically developed. Its bowels are regular, it is healthy, and
 
 212 THE FIFTH SPECIES OF MALFORMATION. 
 
 rapidly growing. The complete, entire absence of tlie penis, 
 or any portion of it — the unusual, unheard-of positions of 
 the anus, testicles, and anomalous passage of the urine, are 
 extremely remarkable and interesting. The bladder has no 
 urethra, through which to pass its urine, so these apertures 
 must come in direct contact with, and even enter the fundus 
 of the bladder," (Southeni Medical and Surgical Journal. 
 Augusta, Ga., 1858.) 
 
 Case CXY. — M. Bouisson of IVIontpellier, relates a case of 
 this cono-enital vice of conformation which was observed in 
 the practice of Delmas. 
 
 A child was brought to Delmas, from seven to eight days 
 old, which was born with an imperforation of the anus, and 
 with a small corrugated opening, red and excoriated, which 
 existed about half an inch from the median line on the side of 
 the right nates. Through this opening the fsecal matters were 
 constantly oozing, the liquid state of which allowed their 
 rather easy escape. It constituted a true congenital listula of 
 the anus, on wdiich Delmas operated, at the same time he 
 remedied the imperforation by an incision. Tlie obstructing 
 membrane was cutaneous, mucous, with conservation of the 
 sphincter. M. Delmas incised it, introduced his linger into 
 the rectum, when he recoguized, at an inconsiderable height, 
 the end of a grooved probe introduced into the accidental 
 opening. The operation was performed as in the adult, and 
 followed by the rapid recovery of the infant. — {These de Con- 
 cours de Paris. Annee 1851.) 
 
 Case CXYI. — A similar case in every respect to that of 
 Delmas' was communicated to the Chirurgical Society of 
 Paris in 1850, by M. Denonvilliers. This surgeon operated suc- 
 cessfully both on the anal occlusion and the fistulous sinus in 
 this case. — {Practical Treatise on the Diseases of Children, 
 1)1/ M. Boiichut. Bird^s English Version, ]). 516. London : 
 1855.) 
 
 Case CXYII. — Dr. Friedberg reports the following highly 
 interesting case of imperf n-ation of the anus, accomjDanied by 
 a fistulous prolongation of the rectum opening into the pos- 
 terior wall of the scrotum. 
 
 " Albert M — , the fifth child of a healthy woman, was born 
 on the fourteenth day of Jnly, 1852, at nine o'clock P. M., 
 by natural labor. During the following night and day the 
 child look the breast with reluctance, even from the first. It 
 passed urine frequently, but without any mixture of faecal
 
 TIIK MI'JU SI'ECIKS OF MALFORMATION. 213 
 
 matter. Three days uWor birtli, the cliild liavuig as yet had 
 no reii;iihir stool, and excitini^ tlie anxiety of the niotlier l)y 
 its cries and restlessness, slie examined the perinanim and 
 found in the posterior wall of the scrotum a small (»peiiiii;;' in 
 ])lace of an anus, and thi'oui;-]i which a little meconiuiri passed 
 when the child made violent straining ett'orts. The physician 
 called in on the following day, in-escribed warm cataplasms 
 upon the abdomen, and syrup of rhubarb internally. From 
 lime to time the abdomen became distended, "the child 
 groaned and made efforts to stool, until fsecal matter passed 
 which soon became yellow. Although frequently put to the 
 breast, it sucked very little, but slept in a very unquiet man- 
 ner, and from the fourth week it began to waste away surpris- 
 ingly. Towards the sixth week after its birth, as the mother 
 said, there occurred a remarkable attack, during which it be- 
 came pale as a corpse, very restless, breathed almost imper- 
 ceptibly, drew lip its knees, and seemed to the mother as if 
 dying. This attack was repeated several times during the 
 two following weeks, and especially as the mother was con- 
 vinced, when the child had had no evacuation for several hours. 
 " The attending physician sent for me on the nineteenth of 
 September, 1852, to make a more complete diagnosis. The 
 examination gave me the following results. The child, for its 
 age, two months, was very small and reduced to the last de- 
 gree of emaciation. The saliva was of a yellow color, and so 
 was the wdiole body, especially the countenance ; the eyes 
 were sunken and surrounded by a greenish blue circle, the 
 voice was very feeble, and the cries replaced by feeble groans. 
 The abdomen was moderately distended, hard and sensitive. 
 There was a slight malformation of the penis ; in fact the in- 
 ternal orifice of the canal of the urethra, opened in the form 
 of a cleft about three lines from the end of the glans penis. 
 The genital organs w^ere quite in the rear of their normal posi- 
 tion. Three or four lines below the point where the rectum 
 terminated, there was found in the posterior wall of the 
 scrotum, an opening with its border turned inward, only large 
 enough to admit a small sound. I introduced such an instru- 
 ment half an inch, and had the sensation as if I had introduced 
 it into a cutaneous canal which extended no further in that di- 
 rection ; however, as I had seen a greenish colored matter 
 pass from the opening, I could not doubt the existence of a 
 continuation of this canal uniting it with the intestine. I in- 
 troduced a whalebone sound, at first directly upward, then 
 more towards the rear, in the direction of the middle of the 
 pelvis, as much as three inches, without meeting a dilatation of 
 this canal. At this depth the sound was arrested by an ob-
 
 214 THE FIFTH SPECIES OF MALFORMATION. 
 
 strnction sucli as caused it to bend. The tuberosities of the 
 ischium projected when compared with the remarkably wasted 
 condition of the child, and seemed to be pressed close to each 
 other, so that the space which separated them was much nar- 
 rower than usual. The coccyx was bent quite to the front ; the 
 perina3al raphe extended as far as the coccyx and was not well 
 marked ; and not even the slightest trace of an anus was 
 found. During the efforts made shortly after the use of the 
 catheter, and whilst the abdominal walls were in full action, 
 I could not feel any fluctuation in the perinsBal region. The 
 eftbrts were followed by an evacuation, lasting several minutes 
 and passing through the fistulous opening, and also by an ex- 
 cretion of urine of a natural color flowing by the external ori- 
 fice of the urethra. Whenever with my right fore finger 
 placed in the normal position of the anus, I pushed the perin- 
 eum towards the pelvic cavity, and with the left hand pressed 
 the intestines from the anterior abdominal wall towards my 
 fore-finger, I could not perceive the slightest fluctuation which 
 could induce me to suspect the vicinity of the terminal end of 
 the rectum. Little was discovered by auscultation of the per- 
 in^eum, during percussion of the walls of the abdomen. 
 
 " Some hours later, I undertook the formation of a perinaBal 
 anus. The child was placed on its back, upon the table, the 
 legs flexed and held asunder by two assistants, while a third 
 lield the small silver catheter which I had introduced into the 
 bladder ; then I introduced a silver sound into the opening to 
 the depth of half an inch and placed it in the hand of an assis- 
 tant. Starting at this point, I incised the skin along the per- 
 inseal raphe, to within three lines of the os coccygis, and then 
 divided the soft tissues, layer by layer. An artery was cut 
 and had to be tied. Presently the sound escaped from the 
 canal which could not again be found. I ceased the attempt 
 to introduce the sound because I feared I would injure the 
 bladder, and because the operation seemed to fatigue the child ; 
 I rather sought to penetrate the pelvic cavity as soon as pos- 
 sible, and whilst an assistant wnth the hand pressed upon the 
 abdomen of the child, pushed the intestines downward to- 
 wards the pelvis, with my finger which was introduced to the 
 depth of two inches, I discovered a moderately soft body situ- 
 ated between the bladder and the smooth promontory, its an- 
 terior portion having a round form, and adhering to the pos- 
 terior wall of the bladder, whilst its posterior fiice was consid- 
 erably extended along the promontory. By the touch it could 
 be slightly brought down, and this made me suppose that it 
 was the intestine filled with solid fk'cal matter. I seized it by 
 its inferior wall with artery forceps, and brought it down
 
 THE P^FTir SrKCIKS OF MAI,K(MiMATI()N. 215 
 
 C'fii'ofully, whilst with tlie end oi' my fini,^cr, T (lestroyc'd all 
 the luliiesions uttachin^- it to the nei^h])i»riiii^ parts. fii tVinit 
 I could not altogether succeed ill doin;^ this ; ])ut elsewiiere I 
 succeeded so completely that I was able (<• hrin*^ duwn the 
 ])osterior portion into the ])erina'al wound. Contii-iued in niv 
 suj)position that it was a ])art of the dilated rectum, 1 seized it 
 tirndy with a pair of forceps and a crochet, and between the 
 two instruments I made an incision longitudiiuilly, from fiont 
 to rear, about nine lines in len<i;th. There immediately ])assed, 
 by the increasing efforts of the child, some yellowish brown 
 matter, the evacuation of which I aided with a spatula. Yery 
 shortly, liquid faecal matter passed, of a green color and acid 
 odor. I then cleansed the wound with injections of cold 
 water. I divided the anterior wall of the canal, as far as I 
 could recognize it, and then nnited the edges of the intestine 
 with the lips of the perinieal wound by frequent points of su- 
 ture ; then I nnited the edges of the wound in front and rear 
 of the anterior and posterior angles, by means of suture, and 
 likewise between the ans-les of the intestinal wound and those 
 of the perinseal w^ound. The most anterior suture of the per- 
 inaium was placed in such a manner that it travei-sed the 
 mouth of the canal. I prescribed ap[)lications of cold water 
 to the perinaeum, and frequent lotions to the wound. During 
 tlie night the child slept tranquilly, but the next day it uttered 
 frequent groans, and drew up its legs as if suffering from pain 
 in the abdomen. It took the breast but seldom, but drank 
 cold water with avidity ; respiration was accelerated, and the 
 pulsations of the heart were unusually frequent. The lips of 
 the wound as well as the surrounding parts were red and 
 somewliat swollen ; yellow liquid fajcal matter of very acid 
 odor, was evacuated in small quantities every five or ten min- 
 utes through the newly formed anus. I prescribed rhubarb 
 and syrup of saffron, and caused warm poultices to be placed 
 on the abdomen, after a restless night ; the next morning, 
 however, the child was better. The redness and swelling of 
 the edges of the wound were lessened, and they seemed thor- 
 oughly united, except at the anterior angle. The condition 
 of the child improved daily ; suppuration continued in the 
 vicinity of the fistulous opening, without, however, presenting 
 any mixture with faecal matter. Evacuations occurred only 
 every hour, or half hour, and the faeces were yellow in color 
 and of the consistence of pap. 
 
 " The sixth day after the (Operation, the anus took an oval 
 form ; at the commencement of the excretion I observed dilat- 
 ing motions of the perinteum, and at the close the contraction 
 of the anus was made manifest by the gathering up of the su-
 
 216 THE FIFTH SPECIES OF MALFORMATION. 
 
 lure. Some of the needle punctures opened into each other, 
 and discharged a shght quantity of pus ; for this reason I took 
 away the points of suture in question, and the others, two days 
 after. The union of the edges of the wound, was eveiTwliere 
 complete. 
 
 " The needle punctures which had been open were now 
 closed, as was also the anterior angle, still suppurating, near 
 the scrotum. On the fourteentli day after the operation, tlie 
 cure was complete, tlie jaundiced discoloration had disap- 
 peared, and the child prospered in a remarkable manner. 
 From this time it had three or four healthy stools, during the 
 twenty-four hours ; the appetite was good,*so that besides the 
 breast, the child took other food, and none of the preceding 
 morbid phenomena reappeared. 
 
 " When in the month of December, 1852, I again saw the 
 child, it M'as suffering from dentition, and often carried its 
 hands to its mouth ; the gums were swollen and sensitive to 
 the middle of the lower alveolar edges. The child wasted 
 rapidly, it cried out all night long and began to cough. On 
 the twenty-third of Decemljer, I found in the upper lobe of 
 the left lung, and in the upper and middle lobes of the right 
 side, a rough vesicular murmur, respiration was obscure, as 
 also was the sound produced by percussion. Nevertheless 
 the child breathed a little, but with dithculty, and presented 
 a bluish color of tlie face. The pneumonia resisted treatment 
 and terminated fatally on the tAventy -fifth of December, 1852. 
 
 " The autopsy performed the next day, gave the following 
 results.^In the cavity of the cranium, there Avas nothing re- 
 markable ; in the large bronchia, a catarrhal secretion, but the 
 mucous membrane was not red. The posterior and lower 
 portion of the inferior right lobe was tilled with blood ; the 
 middle portion, and the lateral portions at their top on l;)eing 
 cut allowed a large quantity of sanguinolent and frothy serum 
 to escape, and the bronchia contained a viscid catarrhal i)ro- 
 duct. No portion was found to contain air. Tlie left inferior 
 lobe was studded with apoplectic kernels, from the size of a 
 lintel seed to that of a pea, and near them the pulmonary tis- 
 sue was filled with blood, partly extravasated, partly fluid 
 which the latter especially, was easily expressed. In these 
 places and around them, the pulmonary tissues contained no 
 air, and upon pressure gave out a stringy serous exudation. 
 In the pulmonary vessels, comprising the bronchial tubes, as 
 far as I could follow them, I found no blood nor any other 
 morbid matter. The right side of the heart was filled with 
 black liquid blood, and at the left posterior wall of the ventri- 
 cle there was found only a soft fibrous cord, passing into the
 
 THE FII'Tir SPECIES OF MALFORMATION. 217 
 
 I mlinonary arteries; the left sale of the licjirt coiitnincil no 
 l)h)od ; the f(i3tal conduits were closed. In tlic ulxloniinal 
 cavity, as soon as tlu^ oincntuni, luucli cniaciatod, had lici-n 
 raised up, a dilatation, tilled with i>;as, and conipi-jsini; the 
 eiul of the ileum, and tlie ui)i)er j)art of the descending;' colon, 
 jutted out. The rectum appeared very slutrt, and of unecpuil 
 size, the luirrowest portions, however, were of normal diani- 
 e'er. Ahout one inch above the anus there proceeded IVom 
 the anterior wall of the rectum, a cord, the size of a larg-c 
 knittinsj:; needle, directed towards the vesical triau<j:;lc, and at- 
 tached to the bottom of the bladdei* by cellular tissue. Thus 
 fixed and becoming-, smaller and smaller, it at last bent its 
 way to the middle surface of the prostate, towards the bulb 
 of the urethra, and having reached its posterior wall, was lost 
 beneath the fistulous opening. It was entirely filled up, 
 and it was only at its ui)per aiul larger portion, that the exis- 
 tence of a canal could be perceived, which had, hoNvever, no 
 longer any communication with the cavity of the rectum. The 
 interior of the canal no longer presented the appearance of 
 mucous membrane. W'here the cord left the rectum the lat- 
 ter presented on its internal surface a depression of a medul- 
 lary nature. The large intestine contained a yellow ftecal 
 nuitter, liquid and semi-fluid; the mucous membrane was 
 healthy throughout. The artificial anus could not be distin- 
 guished from a normal anus. At its upper portion the circu- 
 lar fibres of the rectum were so strongl y developed, that they 
 represented a real internal sphincter. The cicatrized needle 
 marks were clearly recognized. The liver was very laro-e, of 
 a nutmeg shape and poor in blood. The biliary ducts were 
 flexible, the gall bladder was full of yellowish brow^ii bile ; 
 the mucous membrane healthy. Several of the mesenteric 
 glands were much swollen and not free from tubercles. Be- 
 sides this the abdominal cavity presented nothing remarkable. 
 The muscles of the perineeum did not seem more feebly de- 
 veloped than usual." — {Recherches Cliniques et Critiques sur 
 V Anus Artijiciel. In Archives Generales de Medicine de 
 Paris. Jidllet., 1857. p. oL) 
 
 Case CXYIII. — M. Olinet relates the case of a female 
 child in whom the rectum opened within two lines of the 
 vulva, the rectum being prolonged to this point by means of 
 a canal. Through this abnormal anus the meconium was dis- 
 chai-ged. {,Tournal Universel des Sciences Medicales. Paris: 
 Fevrier, 1820.) 
 
 Case CXIX. — Burns thus describes the case of a female
 
 218 THE FIFTH SPKCIKS OF MALFORMATION. 
 
 child liaving an imperforate anus, accompanied with an ab- 
 normal anas: 
 
 '•The rectnm, instead of terminating at the usual place, 
 perforated the posterior -wall of the vagina; then occupying 
 the canal of the vagina, it passed through the vulva, and pro- 
 jected about an inch beyond the labia pudendi, bearing a 
 distinct resemblance to an imperfectlj'- formed penis. It was 
 of considerable size, possessing a writhing motion, and freely 
 discharged meconium by an orifice at its apex." {Edinburgh 
 Medical and tSurgical Journal^ Vol. I., 2^- 137.) 
 
 Case CXX. — M. Yelpeau says that M. Brachet published 
 the case of a little girl who had an abnormal anus situated at 
 the fourchette ^ the normal anus was imperforate. {MoWs 
 Velpeau, Vol. TIL, p. 1087. JVew Tori: 1847.) 
 
 Case CXXI. — The following case of imperforate anus, with 
 an abnormal opening of the rectum in the posterior part of 
 the vulva, is reported by M. Caussade. The operation in this 
 case was followed by com|)lete success: 
 
 "The subject of this case was a female infant who, when 
 two months of age, was in an almost dying condition, taken 
 to M. Caussade. This infant vomited fcecal matters ; had hic- 
 cup ; the pulse was small, contracted; the face livid, and 
 covered with sweat ; the voice almost extinct ; and the abdo- 
 men much distended. She had been placed out to nurse im- 
 mediately after her birth ; her clouts were observed to be wet 
 and slightly soiled, but the nurse never observed any alvine 
 evacuation as in other children. As the little one was, how- 
 ever, in gopd health, and even grew fat, the nurse continued 
 to suckle her without seeking the cause of the absence of 
 alvine evacuations. On examining the infant, M. C. found 
 that there was no anus, or trace of one. She passed through 
 a capillary opening at the posterior part of the vulva, very 
 iiear to the hymen, a thick and yellowish fluid, which, M'hen 
 the intant cried and struggled, spouted out as if discharged 
 from the spent of a small syringe. During the straining of 
 tlie infant, a tumor projected in the perina^um, and in a part 
 of the breech. To relieve tlie perforation, M. Caussade made 
 an incision three or four lines in depth in the place which the 
 anus ought to have occupied. He found at the bottom of the 
 incision a mass of hard and yellow faical matters. It was 
 necessary to break them up, and they were removed by 
 means of a scoop. Several injections were administered, 
 which brought away a large quantity of yellow liquid matter. 
 The wound was kept open by a lint tent. The next day the
 
 TIIK Finn Sl'i:CIK8 OF MALFORMATION. 219 
 
 fecal matters were readily (Kscliartiicjd, ;ill the unpleasant 
 symi)tonis ceased, and the health of the little patient was re- 
 stored." {Gazette des Il6pitaux de Paris^ Mars 29, 1S34.) 
 
 Case CXXII. — George Hay ward, M. D., of Boston, Snrgcon 
 to the Massachusetts General lIos{)ital, reports the fol lowing 
 interesting case of imperforate anus, tlie rectum terminating 
 in the labia pudcndi by a small abnoi-nial opening, which 
 performed the functions of an anus. The operation in this 
 case was attended with complete success. 
 
 " About eighteen months since, I was desired to examine a 
 female infant, three or four days old, in consequence of a mal- 
 formation about the anus. On inspection no external opening 
 of the bowel could be discovered ; but in separating tlie labia, 
 it was found that the urethra and vagina were perfect, and at 
 two or three lines behind the vagina, there was a small ori- 
 tice, sufficient to admit the large end of a prolje, through 
 which the faeces were discharged. 
 
 "The child did not seem to suffer at all, and I heard noth- 
 ing of it for more than a year, though I visited frequently the 
 famil}' to which it belonged. A few days after it was 
 weaned, which was in January last, I was called to visit it, 
 and was told, that since the change in its diet, it had appa- 
 rently suflered very much in its eltbrts to discharge the con- 
 tents of its bowels. These eftorts were violent, almost con- 
 stant when tlie child was awake, and afibrded scarcely any 
 relief. Since it had ceased nursing, it liad become emaciated 
 and very feeble, and had but little continuous or quiet sleep, 
 
 " After it was weaned, its diet consisted of milk and barley 
 flour, and the fseces, no doubt in consequence of the change 
 in the food, had become of much greater consistence. The 
 contents of the bowels were forced out by violent straining in 
 small pieces, quite solid, about the size of a duck shot. 
 
 " On examining the parts, I found that the outlet of the 
 bowel w^as but little, if any larger than when I saw it before, 
 and the large end of a probe did not pass very readily into it. 
 The moment, however, that it was introduced, strong convul- 
 sive efibrts followed, and it was evident that there was a 
 great accumulation of ftecal matter in the intestine, lying in 
 ilie hollow of the sacrum. 
 
 "As it was apparent that the child would not live long in 
 this way, I suggested the expediency of attempting to relieve 
 it by an operation ; though i confess that I was not very san- 
 guine as to its success, nor did I give a very favorable prog- 
 nosis to the parents as to the result. They consented, how-
 
 220 THE FIFTH SPECIES OF MALFORMATION. 
 
 ever, and on the following day. Jan. 26tli, 1853, I performed 
 it in the following way : 
 
 " The child, having been rendered insensible by the inhal- 
 ation of rectified snlplmric ether, was laid on a table. A 
 "iirector of the smallest size was introduced, thongh with dif- 
 ficulty, about an inch into the bowel, with the groove towards 
 the sacrum. With a very narrow knife passed into the 
 groove, I enlai'ged the external opening of the bowel suffi- 
 ciently to admit my fore-linger, and continued the incision 
 upwards nearly to the end of the director; I then found that 
 I could pass my finger readily into the bowel, which aj^peared 
 to be of the usual size, till within about an inch of its outlet, 
 where it had been contracted into a small canal, certain! v not 
 one fourth as large as the bowel above. 
 
 " I did not consider it necessary to carry the incision any 
 farther ; nor did I deem it safe ; partly from the fear of hem- 
 orrhage, and in part from an apprehension that if I did so I 
 sliould destroy the retentive power of the bowel, as sometimes 
 happens from an operation for fistula in ano, where it has 
 been found necessary to divide the parts high up. 
 
 " Lint was applied to the edges of the wound, and a cloth 
 wet in cold water laid over it. There was no bleeding, ex-' 
 cept a slight oue at the time ; the child was evidently re- 
 lieved, though the fiiecal matter was not discharged till castor 
 oil was administered on the following day. 
 
 "In two days after the operation I introduced a moderate- 
 sized rectum bougie, of a diameter as large as that of the 
 bowel, and this has been done daily to the present time. In 
 a very few days the wound healed, and the child has appa- 
 rently sufi'ered no inconvenience since. It has regular evac- 
 uations of a proper consistence without the use of medicine. 
 It has the entire control of the bowel, and has regained its 
 health. It is now vigorous and active as female children of 
 that age nsuallv are. 
 
 " I examined the parts very recently, four months after the 
 operation. The anus can now be seen without separating the 
 labia ; but the perina?um is covered with the same delicate 
 mucous membrane that lines the vagina. Whether this will 
 ever be productive of inconvenience, it is not perhaps easy to 
 say ; it is probable that this membrane niay lose some of its 
 sensibility, but there is no reason to suppose, that it will 
 ac(piire the properties of the ordinary covering of the body. 
 
 " This case must be regarded as a favorable one of mal- 
 formation of this kind. In some that have been described, 
 the <»pening into the vagina was as large as the diameter of 
 the bowel, and there was no sphincter ; while here the lower
 
 THE FIFTH SI'KUIKS OF MA[,F(»K.\r Air< »N'. 2:^1 
 
 pjirf of the rectum was contmetiMl into a narrow canal, fiir- 
 iiislu'd with lunscuhir power sulHcieiit to prevnit the invohiii- 
 tary (lisehari;-e of the fa'ces. WJiere there is no provision of 
 this kind, tlie nialfonuatiou must of course be oho of the most 
 (lisgustin<j^ character." {The Virginia Mcdiml and Sanjical 
 Jiiiu'ital, Vol. I., p. ^iy'^. Richmond: 1S53.) 
 
 Cask CXXIII. — Professor Nagel reUites the followiui!^ case 
 of imperforate anus, being the second, though of a ditferciit 
 species, M'hich he communicated to the " ^Society of Practical 
 Meilicinc of BerlinP 
 
 '' Tills second case of Dr. Nagel's occurred in a female child 
 six months old. There was imperforate anus and an abnormal 
 opening of the rectum at the entrance of the vagina, at the 
 point ol the lower commissure; a small tono-ue with its edire 
 l):-esented to the front completely closed this opening. A 
 sound could not only be introduced with ease into the rec- 
 tum, but could also be pushed against the perina^um, and IV-lt 
 in front. The child although doing well, often sutfered with 
 colic and tenesmus, especially when fruit-stones, green goose- 
 berries covered wath their skin, or similar bodies were re- 
 tained in the narrow anal aperture, or when impacted fieces 
 were collected in the false passage behind the orifice. Consti- 
 pation became more and more frequent, and the means 
 hitherto employed to obtain liquid stools continued ineffectual. 
 Nagel then decided upon an operation, which he performed 
 by the process of Dieftenbach. By means of a hollow bent 
 sound he easily formed the new anus ; the muc<ius coating of 
 the open intestine was joined to the skin. In the part of the 
 rectum situated in front of this new anus, that is to say, in 
 the canal which opened at the point of the posterior commis- 
 sure of the vagina, Nagel introduced, eight days after, a red- 
 hot iron, but without succeeding in obliterating it, A small 
 ([uantity of fsecal matter still continued to pass therefrom. 
 Nagel feared to divide the cutaneous bridge which separated 
 the artificial from the abnormal anus, considering the section 
 of the circular fibres of the sphincter going to the vagina, and 
 the incontinence of ffecal matter, consequent upon the section 
 of the canal, as a still greater inconvenience." [Recherches 
 Clinques et Critiques sur IJAnus Artijiciel. Par le Dr. 
 Ilerinann Friedherg. Archives Genercdes de Medicine de 
 Paris. Jfai, 1857. p. 581.) 
 
 Case CXXIY. — ^Tlie following case was communicated to 
 J. C. Lettsom, M. D., by Mr. T. Mantell, of Dover, England, 
 in a letter dated, Dover, May 25th, 1789 :
 
 222 THE FIFTH SPECIES OF MALFOKMATION. 
 
 " JVIrs. S was delivered of a female child in September, 
 
 1786. A few days after I was informed, that no proper 
 evacuation of meconium had taken place, and that some small 
 quantity of faeces had come away with the urine. On exam- 
 ination I found that a malformation was the cause, there not 
 being any anus, or the least appearance of one. The infant, 
 in other respects, was well formed : the vagina was perfect, 
 and the water passed naturally by the urethra ; the health of 
 the child was bad ; she appeared generally in great pain, was 
 very costive, and, by violent forcings, a little quantity of hard 
 fteces were driven out, in the form of small spiral strings, per 
 vaginam. 
 
 " On acquainting the parents with the danger of the case, 
 and proposing, as the only relief, to make an incision through 
 to the intestine, and by that means endeavor to obtain a natu- 
 ral mode of evacuation, they requested me to do whatever I 
 thought proper. 
 
 " As I had no direction by an impulse of the foeces against 
 the skiu, I chose the usual natural distance from the vagina, 
 and made a deep but small incision, and, by passing a curved 
 probe by the vagina, through the aperture into the rectum, I 
 soon felt it, and was guided by that to proceed till the dis- 
 charge of fieces came plentifully through the new aperture ; 
 the haemorrhage was not great, and tlie child was imme- 
 diately relieved. To prevent constipation, and avoid pain by 
 the expulsion of hard faeces, I gave laxative medicines, and 
 my young patient felt little inconvenience, though there still 
 continued some small discharge, as before, per vaginam. At 
 the month's end it removed with its mother to town, and I 
 saw no more of them till the spring of 1788, when I was 
 informed by Mrs. S that the child had been very un- 
 healthy, that it had sutfered from many disorders, and was 
 still troubled (particularly when costive) in voiding the faeces ; 
 and that the orifice I had formerly made had been so much 
 closed as to render it necessary for a surgeon to dilate it, and 
 yet it was now again very confined, which made such a con- 
 stant use of purging medicines necessary, as to debilitate the 
 constitution of the emaciated little subject. 
 
 " I had formerly been afraid of making the aperture large, 
 lest, if I did, the powers of retention would be lost ; but there 
 now being a kind of stricture at the part, induced me to think 
 the levatores and sphincter muscles were not deficient ; and 
 that no mischief would ensue, if I enlarged the orifice. 
 Accordingly I made a large incision, and afte*' this no further 
 difiiculties arose, the child became healthy, and I have the 
 satisfaction of finding, near a year since the last operation,
 
 TIIK FIFTH SPECIES OF MAI.lOIiMATIt iN. 223 
 
 tliat slio contiiinos perfectly well." (M' ntoirs <>f the Mxlical 
 fSocliii/ of London., Vol. I J I.., Art. XIX.., v. 389. London : 
 1792.) 
 
 Cask CXXV. — The late and lamented Dr. Miitter, lorinerlv 
 the able and distini»;uishe<l Professor of Surgery in tlie Jefler- 
 sou Medical Oolle<^e of Philadel])hia, conuuunicated to Dr. 
 Meigs the following interesting case, in a letter dated October 
 4th, 1844 : 
 
 " In compliance with your rerpiest, I send a Ijrief notice of 
 the case of Imperforate Anus, of which you s])oke the other 
 day. About the last of April, 1844, I was requested by Dr. 
 Jewell to visit, in consultation, the female infant (two weeks 
 old) of one of his patients. On examination, the following 
 condition of things was observed : The rectum terminated in 
 a cul-de sac, which extended to within three or four lines of 
 the natural position of the orifice of the gut, which spot was 
 occupied by dense cellular tissue and common integument, 
 and no trace of the anal opening could be distinguished. We 
 were told that the child was in the habit of passing its faeces 
 through the va'/ina, and that each evacuation was attended 
 with violent efforts, while the fiscal matter was moulded into 
 snuill threads. Separating the labia, an opening about the size 
 of a small duck-shot was discovered just withhi the fourchette, 
 and above it, a well-formed hymen. Through this opening a 
 probe was readily passed into the rectum, and also through 
 the hymen into the vagiiui, and both canals appeared perfectly 
 normal, with the exception, of course, of the defect already 
 described. The indication was obvious, and I at once pro- 
 posed the following operation. With the view of establishing 
 a proper channel for the faeces, and, at the same time, dispose 
 the orifice between the rectum and vagina to contract and 
 thus heal. Passing a small grooved director from the vagina 
 into the rectum, 1 forced out the tissues forming its lower 
 extremity, and then thrust a trocar down to the director and 
 directly tlirough the spot usually occupied by the natural ori- 
 fice of the intestine. Withdrawing both instruments, I next, 
 with a probe-pointed bistoury, enlarged the opening made by 
 the trocar, and as soon as this was accomplished, the child 
 passed an immense quantity of ftecal matter, apparently with 
 much relief. A sponge-tent was then introduced into the rec- 
 tum, and the nurse instructed as to its objects and use. 
 
 " Being on the eve of sailing for Europe, I did not see the 
 child again, but suggested the continued use of the sponge- 
 tent, until the opening made had lost all disposition to 
 contraction ; and, after this, if the orifice in the vagina did
 
 224 THE FIFTH SPECIES OF MALFORMATION. 
 
 not heal of its own accord, in consequence of the natural 
 channel for the fasces being established, that it should be 
 touched occasionally with tlie argent nitrat. 
 
 " I did not deem this a case in which the operation 
 of Aniussat was advisable, nor Avas it one that indicated 
 (ituu.noii of the tissues occupying the position of the anal 
 oritice, nor could any operation upon the fistulous open- 
 ing between the rectum and vagina be with propriety pro- 
 posed. I preferred the trocar to a sharp-pointed hisfoury^ for 
 performing the operation, for the simple reason that wounds 
 nuitle with the former instrument are much less prone to heal 
 by the first intention than when the latter is em^^loyed ; 
 and as it was one object, of course, to prevent the close of the 
 gut again, an event by no means uncommon, when a simple 
 conical incision is made with a bistoury, I adopted the plan 
 of operating described. I have not seen the child since 
 my return, but understand from Dr. Jewell that there is some 
 contraction of the orifice, and that, in all prol)al)ility, it will 
 be necessary again to divide its margins."' {^A Treatise on tlm 
 Diseases and Special Hygiene of Females. By Colomhat De 
 Vlsere. Translated from the French., hy Charles D. Meigs., 
 M. D. p. 116. Philadelphia : 1845.)
 
 CHA^r^TER VII. 
 
 THE SIXTH SPECKS OF MALFORMATION. 
 SECTION I. 
 
 DESCRIPTION. 
 
 1. This species is recognized by the rectum terminating by 
 an abnormal anus, either in the bladder, the urethra, the 
 vagina, the uterus, or in a cloaca in the perinseum with 
 the urethra and the vagina. There is generally neither 
 a natural anus nor the sign of one present ; yet sometimes, 
 though rarely, a small contracted orifice indeed exists, at the 
 natural situation, simulating the normal anus, which permits 
 the introduction of the end of a small probe for a few lines. 
 Mr. Cooke and Mr. Lucas have each seen and reported a case 
 of this description. [ Vide Oases CXXXYI—CXG F/.] 
 
 2. This preternatural alliance of the digestive, the urinal 
 and the generative systems, which is analogous to the normal 
 formation of some animals, comprises that division of the con- 
 genital malformations of the anus and the rectum which 
 Meckel very appropriately denominates — " Cloaca Congenital,'''' 
 and which is the ^''Atresia Ani Vesicalis, Urethralis and 
 
 Yaglnalis''' of Papendorf. 
 
 3. The variety of this species of congenital vice in which 
 
 the rectum opens into the bladder, is much more common in 
 
 the male than in the opposite sex. Tliere are indeed but few 
 
 cases of the latter on record, and even those few are by no 
 
 means well authenticated. Tlie celebrated Morgagni reports a 
 
 case from mere hearsay. [ Yide Case CXXIX.^ 
 15
 
 226 THE SIXTH SPECIES OF MALFOKMATION. 
 
 Aristotle gives the singular instance of a cow wliicli pre- 
 sented not tlie slio-htest trace of an anus in situ naturali. He 
 sa3's, in this case, that "Me excretnentitious jmHs of the food, 
 heing attenuated., were discharged through the bladder^ {De 
 Generatione Animalium. Lib. IV., C. 4, in Jin,) 
 
 4. There are but few cases on record of the variety of this 
 species of malformation, in which the rectum oj^ens into the 
 female urethra. Licetus and Delesalle report each a case. 
 [ Vide Cases CLI—GLIIL ] 
 
 5. Some of the instances in which the rectum communi- 
 cates with the bladder in the male, are accompanied with an 
 imperfect development of the penis, especially occlusion of 
 the prepuce and urethra. M. Desgenettes records a case of 
 this charactei-. [ Vide Case CXXXII?\ 
 
 6. The rectum, in the majority of instances, instead of com- 
 municating directly with the bladder by simply an orilice, 
 terminates obliquely in this viscus, between the insertion of 
 the ureters, by a short conical canal, the vesical orifice of 
 which being sometimes so small in diameter as scarcely to 
 admit the end of the smallest sized probe. This narrow con- 
 ical duct or rectal extremity, the base of which corresponds 
 to the superior extremity of the rectum, or inferior extremity 
 of the colon, and which is observed, in these cases, to connect 
 the rectum and the l>ladder, is said by Dr. J. B. S. Jackson, 
 of Boston, to resemble very much the ductus arteriosus. 
 {Recoi'ds of tlie Boston Society for Medical Iinprovement, 
 
 VoK III., J)' 158. Boston: 1859.) 
 
 7. The rectum, wlieu it terminates in the urethra, does so 
 by a narrow conical canal, and quite small orifice, as it does 
 in the bladder, and in the largest number of instances opens 
 into the membranous portion of the urethra. 
 
 8. When the rectum terminates in the vagina the recto 
 vaginal orifice is generally mucli larger than when it opens 
 into the urinary passages. In some few instances, however, 
 it terminates by a canal which becomes gradually narrowed
 
 THE SIXTH STKOIES OF MALI-UlCMATloN. 227 
 
 as it approaches tlio vagina, luilil it is quite small. The va- 
 ginal anus will nsiuilly be found situated htw down in some 
 part of tlie posterior or lateral parietes of the vaginal canal. 
 [ Vide Plate IX, Figure 1.] 
 
 Papendorf reports a case in which the rectum terminated at 
 two [)oints in the vagina. S. F. Ainsworth, M. D., of our own 
 country, records a similar case. [ Vide Cases CLXXXVl— 
 CCIIL] 
 
 9. Physical Signs — Diagnosis. Should the abnormal open- 
 ing of the rectum be vesical, its existence will be manifested 
 by the thickness of the urine, and by its greenish appearance, 
 which it acquires from being blended and tinged with the 
 meconium previous to its expulsion from the bladder; and 
 by its passing only at the time of urinating. These evidences 
 are sufficient to show that the abnormal opening is entero- 
 vesical, but they are not sufficient to indicate the direction, or 
 the precise point of the termination of the rectum. This is 
 often quite difficult, if not impossible to determine. When 
 the urine is so much mixed with the meconium as to become 
 semi-fluid, it is an evidence that the recto-vesical opening is 
 large ; when on the contrary it merely tinges the napkins, it 
 is evident that the abnormal opening is small. Besides the 
 passage of the meconium through the bladder and urethra, 
 gas is also often expelled through the same medium. 
 
 Should the abnormal opening of the rectum be urethral, 
 the meconium will often escape unmixed wath the urine, 
 either constantly in small quantities, or at intervals, or a 
 small jet will always precede the passage of the urine. The 
 meconium is sometimes also forced out in small cylindrical or 
 spiral bodies. It is also difficult in these cases to determine 
 at what point the rectal opening enters the urethra, wliether 
 at a short distance from the glans penis, or deeper down near 
 the perinseum. 
 
 10. Prognosis. The prognosis in those cases in which the 
 rectum communicates with the bladder or the urethra of the
 
 228 THE SIXTH SPECIES OF MALFORMATION. 
 
 male is always very unfavorable, and unless such cases are 
 relieved by prompt surgical measures, as a general rule, they 
 soon end in death. In these instances the great danger and 
 difficulty are at once obvious, when we take into considera- 
 tion the smallness of the recto-vesical opening generally, and 
 the length, narrowness and flexure of the male urethra. The 
 extremely delicate and highly sensitive mucous lining too, of 
 the bladder and the urethra, is not capable of sustaining for a 
 length of time, without imminent danger of fatal cystitis, the 
 immediate contact of the highly irritating stercoraceous mat- 
 ters ; and when the recto-vesical orifice is so small that noth- 
 ing but the thinnest portions of the meconium can pass 
 through it, the great danger then is from the accumulation 
 and the retention of the excrementitious matters. Should the 
 child even under these unfavorable circumstances continue to 
 survive for several months, as soon as the fseces increase in 
 quantity and acquire a certain degree of consistence, and ac- 
 cumulate, the life of the unfortunate little patient could no 
 longer be sustained. 
 
 11. Much the same difficulties and dangers attend those 
 cases in which the rectum terminates in the male urethra. 
 
 It was declared by M. Bertin, many years ago, that this 
 particular malformation — that is, that in which the rectum 
 opens either into the bladder or the urethra of the male — 
 uniformly resulted in death. {Memoire de V Academic des 
 Sciences. AfinSe 1Y71. j:). 496.) This opinion is still held by a 
 number of surgeons of the present day, but it is not altogether 
 tenable, for it will be seen that several cases have been 
 reported in which life has been prolonged for months and 
 even for years. M. Bravais mentions the case of a i)oj four 
 years old. [ Vide Case CZIL] Flajani reports an interesting 
 case of a child four months old. [Vide Case CZIV.] M. 
 PouUetier saw a boy three years old, who passed all his fseces 
 through a preternatural opening of the rectum into the ure- 
 thra. [ Vide Case CL Vin.~\ Professor Gross, of Philadel-
 
 THE BIXTII SPECIK8 OF MALKOltMATION. 229 
 
 pliia, luinies two cases. One a very reinarkaljlc one. [ Vide 
 
 Case aZ.] 
 
 12. The prognosis is somewliat more favoraLle wlicii tlic 
 rectnm communicates with the bUidikM- or tlio urethra of the 
 lemale, in consef|ueuce of the shortness and the straightness of 
 the uretlira, and its great susceptibility of diUitation. 
 
 13. The prognosis is much more favorable when the rectum 
 communicates with the vagina than when it opens into the 
 urinary passages, in consequence of the greater amplitude of 
 the recto-vaginal aperture generally in these cases, and the 
 width and the straightness of the vaginal canal which tluis 
 affords an ample passage for the easy egress of the ficcal 
 dejections. The vaginal anus wdien large, as is usually the 
 case, does not give rise to fatal results, does not compromise 
 the life of the patient, neither does it in after life interfere 
 with, nor prevent the functions of the vagina and the uterus. 
 Several instances have been recorded of such patients having 
 grown up to womanhood, and even of having been capable of 
 becoming pregnant and of bearing children, without any very 
 serious impediment to life or inconvenience, excej)t the very 
 disgusting nature of the infirmity itself. M. Fournier cites 
 the case of a woman who became a mother, who had a con- 
 genital imperforate anus with an abnormal opening of the 
 rectum in the vagina. [Vide Case CXCIII.] Kicord 
 reports the singular case of a courtesan twenty-two years of 
 age, who presented a congenital imperforation of the anus 
 with an abnormal opening of the rectum in the vagina. A 
 similar case to this in almost every respect, is related 
 l)y Switzer. [Vide Cases CCI—CCII.] Morgagni records 
 the cas© of a woman who from birth was afflicted with this 
 infirmity, and who attained the extraordinary age of one 
 hundred years. [ Vide Case CZXXVII.] 
 
 14. Although we have shown that the unfortunate subjects 
 
 of this affliction are generally in no immediate danger of 
 
 death, yet the imperfection is one of a peculiarly delicate 
 9
 
 230 THE SIXTH SPECIES OF MALFORMATION. 
 
 cluaracter, and one that, should life be spared and prolonged, 
 would only entail miseiy upon the unfortunate victim of it. 
 The manner in which such a malformation would operate 
 upon the mind, should the patient thus afflicted arrive at the 
 age of reflection, can well be imagined, when we take into 
 consideration the disgusting and the repulsive nature of the 
 deformity itself. 
 
 ' 15. All the cases in which the rectum opened into the 
 vagina were until of late years considered liopelessly incura- 
 ble, and even many surgeons still consider them so. They are 
 the opprobrium medicoruTn. Surgery, however, must remedy 
 this repulsive infirmity hereafter, and thus wipe out this dis- 
 grace. This she has already to a considerable extent accom- 
 plished. 
 
 16. In some of the cases under consideration, however, the 
 mucous membrane of the vagina sooner or later becomes 
 excoriated, indurated and fungated from the neglect of clean- 
 liness, and abscesses often form in the adjacent cellular tissue. 
 Such cases generally, are deplorably hopeless. 
 
 17. With regard to the prognosis of those extremely rare 
 cases in which the rectum, together with the genito-urinary 
 organs terminates in a cloaca in the perinseum, as observed 
 in the monotremata, in birds, in reptiles and in many fishes, 
 it is useless to conjecture. Such cases would seem, as a mat- 
 ter of course, to be beyond all hope of remedy. Only one 
 such case in the human subject, as far as my reading extends, 
 is recorded, and that one was observed by Saviard, and which 
 I have presented entire. [ Vide Case CCIY.^ 
 
 Martin saw a malformation of this nature in a full-grown 
 bitch. {Annates de Societe Natur. tome XII.) 
 
 Hartmann observed a lusus of this character in a heifer. 
 {Miscellanea curiosa sive ephem. acad. natur. curiosor. decur. 
 II. ann. VII et VIII p. 59.) 
 
 18. The operation for the establishment of an artificial anus 
 in the perinseum in all these cases in which there is an outlet
 
 TIIK SIXTH KPECII2S OF MALFORMATION. 231 
 
 for tlie mecoiiiimi, gas and l-occs, even tlioiiol, it l.e- Hiiall, is 
 much more favorable than if \u> outUi whatever existe(h Tlie 
 operation can therefore be always iiiulertakeii with bli-on-a-r 
 ] lopes of success in these instances. 
 
 SECTION II. 
 THE TREATMENT. 
 
 1. The treatment for the relief of that variety of this spe- 
 cies of congenital malformation in which the rectum termi- 
 nates in the bladder or in the urethra, is by no means void of 
 dithculty and danger, and not well calculated to inspire the 
 surgeon with confidence. 
 
 2. Tlie indication in these cases is to establish an artificial 
 aims in the peringeum, if the end of the rectum can be found, 
 and thus open a new route for the free exit of the fsecal mat- 
 ters which may all in course of time be diverted from the 
 abnormal route, and in this way enable it to become gradually 
 obliterated. 
 
 3. Should the rectum open either into the bladder, or into 
 the urethra, and the child be threatened with speedy death, 
 the surgeon should at once proceed to search for the end of 
 the rectum, as advised in cases of imperforation of the anus 
 and rectum, and if possible, form an artificial anus in the 
 natural situation, capable of giving free egress to the accumu- 
 Lited meconium, excrement and gas. Afterwards the newly- 
 formed passage should be maintained pervit)us in the manner 
 already advised. 
 
 4. Although this operation may not obviate all the incon- 
 veniences of this infiiTiiitv, it w^ill nevertheless at once relieve 
 the urgent symptoms, and give ample time to put into requi- 
 sition other measures, if necessary. Tlie new passage may 
 neither altogether prevent the fseces from following the other
 
 232 THE SIXTH SPECIES OF MALFOEMATION. 
 
 route, yet it will certainly divert the largest portion of them 
 and in this way very materially improve the condition of the 
 unfortunate little sufferer, and enable the abnormal j^assao-e 
 and orifice finally to become obliterated when the fteces 
 acquire more consistence and become less frequent. 
 
 6. M. Amussat advises that in case the rectum opens into 
 the bladder or the urethra, that only the posterior wall of the 
 rectum should be drawn down, because if the oj^ening could 
 not be closed, an extravasation of urine might ensue. lie re- 
 ports an interesting case upon which he operated, but unfortu- 
 nately without success. In order to give his method of 
 operating and his reflections on the subject, I have presented 
 his case in full, translated from the French. [ Vide Case 
 CXLIV.] 
 
 I have also presented two highly encouraging cases, success- 
 fully operated on by two of our own talented countrymen, 
 Drs. Buckingham and Gilman, These two cases reflect great 
 honor upon those two surgeons. [ Vide Cases CXL V— 
 CXL F/.] 
 
 All other methods afiforded by surgery for the relief of this 
 defective variety of organization are imperfect, and their use 
 often completely powerless. 
 
 6. M. Martin, Jr., a surgeon of Lyons in France, proposed 
 in such cases the operation of incising the perinseum through 
 the neck of the bladder, as in lithotomy, for the purpose of 
 establishing a large and common orifice for the free egress of 
 both the urine and the faeces which might pass into the blad- 
 der and become mixed there. The orifice he expected to be 
 kept open by a oanula constantly worn. [Dlctionnaire des 
 Sciences Medicales. tome XXIV. p. 127.) 
 
 This proceeding of M. Martin should, in my opinion, never 
 be adopted. If it is not as dangerous, it is at least more 
 revolting than the infirmity itself. The greatest objection, 
 however, to the operation is, that in the largest number of 
 cases it is impossible for it to succeed, indeed it has not even
 
 THE SIXTH SPECIES OF MALFORMATION. 233 
 
 tlie advantage of prolonging tlie life of tlu; little patient for 
 one hour, for it leaves the chief difficulty untouched, wliidi is 
 neither in the bladder nor in the urethra, l)ut in the naiiuw 
 conical rectal canal and orifice beyond them. I have already 
 shown that the rectum in the majority of instances, for a 
 greater or less distance before entering either into the bladder 
 or the urethra, becomes (juite small and narrowed, often to 
 such an extent as scarcely to admit the end of the most slen- 
 der probe. This canal in its congenital state of constriction, 
 together with its recto-vesical or recto-urethral opening, would 
 not perhaps be touched by the operation. Even should the 
 opening be urethral and be divided in the passing of the knife 
 into the bladder, yet the difficulty beyond would still remain 
 untouched. 
 
 M. Cavenne performed this operation, but was so unfortu- 
 nate as to lose his patient in the course of several hours after- 
 wards. As his case is interesting, I have presented it in full, 
 translated from the French. [ Vide Case CXXXYIII^ 
 
 It is not to be understood, however, that this oj^eration is 
 never successful, for in cases in which the rectum communi- 
 cates directly with the bladder or the urethra by a large ori- 
 fice, it might succeed. 
 
 As I observed before, this operation should be repudiated, 
 for besides its other numerous inconveniences, it would also 
 add those of rendering the patient impotent, and leaving him 
 with a stercoraceous and urinary fistula. 
 
 7. When the rectum opens into the vagina the indication 
 is the same, as in the other cases — that is, the artificial anus 
 should be established in the natural situation, by opening a 
 new route from the end of the rectum, and cutting ofl* the 
 communication with the vagina, thereby placing these two 
 passages in a condition capable of carrying on their respective 
 functions, independently of each other, as they should do in a 
 normal state of the parts. 
 
 There are two very distinct methods of operating for the re-
 
 234 THE SIXTH SPECIES OF MALFOEMATION. 
 
 lief of tliis peculiar deformity, with very ingenious modifica- 
 tions. One of these proposes the division, and the other the 
 preservation of the perinseum and septum. Both methods find 
 advocates in eminent surgeons. 
 
 8. M. Yicq d'Azyr, as I have shown in the sixth chapter, 
 has recommended the division of the posterior wall of the 
 vagina, below the opening, together with as much of the sub- 
 jacent tissues as would admit of the introduction of a canula. 
 This method has been improved by Martin, who advises that 
 after having incised the entire septum from above downwards, 
 and from before backwards, as recommended by Yicq d'Azyr, 
 and after having placed a canula in the wound to form a con- 
 tinuation of the rectum, that the flaps of the vagina should be 
 united in front of the canula, by points of suture. M. Vel- 
 peau is, however, of opinion that this last stage of the opera- 
 tion, which is the most difiicult, is unnecessary — that if the 
 tube is properly adjusted, the reunion of the divided tissues 
 in front will be effected without the points of suture. He 
 advises that an instrument curved backwards in the form of a 
 blunt hook, should be introduced through the recto-vaginal 
 orifice, into the cul-de-sac of the rectum, and its extremity 
 rendered prominent in the perinseum, that the parts covering 
 the extremity should be divided, and that a tube should be 
 introduced into the opening thus formed. {Nouveaux Me- 
 ments de Medicine Operatoire. tome HI. jp. 979. Paris: 
 1832.) 
 
 By this method recommended by M. Yelpeau, the division 
 of the recto-vaginal septum would be avoided, which would 
 make it decidedly preferable ; but it would not be practica- 
 ble in those cases in which the rectum opened directly into 
 the vagina without terminating in the form of a cul-de-sac. 
 
 9. Our own able and distinguished fellow-countryman. 
 J. Ehea Barton, M. D., of the city of Philadelphia, was, how- 
 ever, the first surgeon who, so far as my knowledge extends, 
 proposed and executed a new method of operating in such
 
 THE SIXTH SPECIES OF MALFOKMATloN. 235 
 
 cases. This operation, peculiarly liis own, lie sncccssfully 
 executed in 1823, upon a female child a few moiillis did. Jn 
 order to give a complete exposition of his operation, 1 have 
 presented a full report of his case. [ Vide Case CXC VII.\ 
 
 Dr. Barton's operation in a similar case was successfully 
 executed within a short period subsecpiently, by tlie late able 
 and highly esteemed Dr. Parrish, of the same city. I have 
 presented the case of Dr. Parrish in full, as reported hy Dr. 
 Satchell. [Vide Case CXCVIII.] 
 
 10. Professor Dieifenbach has proposed two methods of ope- 
 rating in these cases, one of which diliers but little from that of 
 Dr. Barton. {Operative Chiruryie. B. I. .8. 676. Leipzig : 
 1845.) He successfully executed one of his methods of opera- 
 ting upon a female child three months old. I have presented 
 this case entire in order to explain fully his ingenious method. 
 [ Vide Case CXCIX.-] 
 
 11. Should it be deemed advisable not to remedy the 
 deformity at once, by the establishment of an artificial anus, 
 on account of the feeble condition of the patient, or from some 
 other cause ; the recto-vaginal orifice not being of sufficient 
 size, might, for the time being, be dilated by proper bougies, 
 if not situated too far back. In the majority of instances, 
 however, the recto-vaginal opening is sufficiently ample for 
 the easy evacuation of the ffeces, and should the circular 
 fibres of the vaginal orifice of the rectum exercise to some 
 extent the functions of a sphincter muscle, as they sometimes 
 do in these cases, the surgeon could still with greater safety 
 and propriety postpone all active measures until the patient 
 had attained a more mature age, or until the cause which 
 contra-indicated the operation, in the first instance, was re- 
 moved.
 
 236 THE SIXTH SPECIES OF MALFORMATION. 
 
 SECTION III. 
 
 CASES AND REMARKS. » 
 
 Many of the following cases, reported by the older surgeons 
 and authors, I have presented as briefly as possible, inasmuch 
 as they are very similar in character, and as no treatment for 
 their relief had either been proposed or adopted. 
 
 The very careless and indefinite manner in which some of 
 the following cases are described and reported by their 
 authors, makes it quite difficult sometimes to determine posi- 
 tively whether the rectum terminated in the bladder, or the 
 urethra. 
 
 (1.) Cases in which the Rectum Terminated in the 
 Bladder. 
 
 Case CXXYI. — Holtzach relates the case of a male child 
 in whom the anus was imperforate and the rectum opened 
 into the bladder by an abnormal orifice. i^Schenckii. Obser- 
 vationum Medicoimm^ novarum, admirdbilium et tnonstrosa- 
 ram. Lib. HI. Sect. I. Ohs. CCXXVII. p. 387. Fra7wf. 
 1609. Folia.) 
 
 Case CXXVII. — A description of the case of a new-born male 
 child is given by Osiander, in whom an imperforate anus 
 existed, and the fieces were passed by the urethra. The child 
 died. At tlie autopsy it was found that the rectum commu- 
 nicated with the bladder by a short canal the size of a goose- 
 quill. {Denkwurdichheiten. Band. II. 8. 470.) 
 
 Case CXXVIII. — Murray saw a male child who presented 
 an imperforate anus, and in whom the rectum communicated 
 with the fundus of the bladder. The child lived four months, 
 and passed fneces and gas by the urethra. The fiscal matter 
 could not be passed through this small channel in sufficient 
 quantity, which finally gave rise to inflammation and mortifi-
 
 THE SIXTH 8PKCIE8 OF IIALFOKMATION. 237 
 
 cation, and rcsnltcMl in doatli. {Dh^ertatlo Atresia A/ii 
 Vcisicalib; sinyulari obaei vatione llLaatrata. Upsal : 1704.) 
 
 Cask CXXIX. — Morgagni relates tlie case of a <,nrl wlio 
 had l)e6n seen at ])()l()<;-iic, wlio liad an impertin-att' anus with 
 an ahnornial opening of the rectum into tiie l)la(hler, as all 
 tlie fa3ces passed by tlie uretlira completely mixed with the 
 urine. 
 
 No operation is said to have been performed in this case. 
 {Loc. eit. Epist. XXXII. Art. 4.) 
 
 Case CXXX. — Vollgnad saw a new-born male infant pre- 
 senting an imperforation of the anus, in whom the faeces were 
 passed by the urethra, both in drops and in large (juantities. 
 The child only lived a few days, no operation having been 
 performed. 
 
 At the autopsy it was discovered that a communication be- 
 tween the rectum and the bladder existed, {Miscellanea 
 natur. curiosa. decur. I. arm. I. Ohs. 2.) 
 
 Case CXXXI. — Yan Sanden mentiouB the case of an infant 
 of the male sex in whom the anus was imperforate and the 
 rectum communicated with the bladder by a narrow canal 
 the length of the thumb. {Miscellanea natur. curiosa. decur. 
 Ill ann. IX. Ols. 194.) 
 
 Case CXXXII. — M. Desgenettes reports the case of a male 
 child in whom the anus was imperforate and the rectum ter- 
 minated in the bladder. In this case, in addition to the mal- 
 formation already named, there existed imperforation of the 
 prepuce and occlusion of the mouth. {Gazette Salutaire.) 
 
 Case CXXXIII. — The following case is related by M. Ber- 
 lin, and translated from his memoir in the Academy of 
 Sciences by Mr. Thomas Coj^eland, who published it in his 
 own work. {Ohsei'vcdions on the Prineipcd Diseases of the 
 Hectum^p.ll^. Second Edition. London: 1814.) 
 
 " In the montli of April, 1769, an infant, five days old, 
 was brought to me from the parish of Sens, in the bishojjrick 
 of Rennes, who evacuated the meconium by the penis ; and 
 having no anus, the rectum evidently terminated in the blad- 
 der. I saw the importance of the complaint, and the danger 
 of the infant, who had been vomiting three or four days, and 
 the abdomen was tense. I first desired the parents to call in 
 M. Thouin, a neighboring surgeon : when he arrived, I pro-
 
 238 THE SIXTH SPECIES OF MALFOEMATION. 
 
 posed to make an incision at the place where the anus should 
 have been, which was farther marked out by a bluish spot. 
 We hoped to open the natural passage for the faeces, and 
 give tliem a more free exit than through the bhidder ; and 
 tiiat eitlier the opening in the bLadder would close, or that 
 the child would void his faeces mixed with some urine by the 
 new anus. 
 
 "The abdomen being very hard, and the child vomiting 
 the milk, and even its excrements, M. Thouin made the 
 incision immediately, in the presence of M. Guiot, a surgeon 
 in the neighborhood, wlio told us, he had performed the ope- 
 ration twice with success. 
 
 " But the two cases related by M. Guiot, were different 
 from the present one, as there was no communication with 
 the bladder ; and another diversity from the cases he de- 
 scribed was, that in this case, the meconium did not follow 
 the incision, nor could the rectum either be found with the 
 instrument, or the finger, the best of instruments. ^ We 
 judged it necessary to plunge the trocar through the incision ; 
 i't was passed deep, but without success ; which was the more 
 disconcerting, as we were as certain of the existence of the 
 rectum, by the evacuation of the meconium through the 
 bladder, as if we had seen it with our own eyes. A tent w^as 
 introduced into the wound, to ])reserve the opening for fur- 
 ther trials which might suggest themselves on reflect! ou. 
 We had done all that was advised by authors, in cases in 
 which the rectum does not descend to the anus, and also as 
 much as the debilitated state of the child would bear. The 
 child was taken away at six in the evening, proposing to_my- 
 self to make some farther attempts the following day, if the 
 condition of the child would permit it. 
 
 " I requested M. Tliouin to see him early in the morning. 
 He told me on his return, that the child was so ill, that he 
 did no more than examine it ; but that the meconium had de- 
 scended on the tent. 
 
 "The child died." {MSmoire de VAcademie Royale des 
 Sciences de Paris. Annee 1771.) 
 
 M. Eertin remarks in relation to such cases, that a free in- 
 cision should be made into the bladder, in order the more 
 effectually to evacuate the faeces, and reproaches himself for 
 not having resorted to such an operation in the preceding 
 case. From this it is evident that the operation of M. Mar- 
 tin, which I have already noticed, was proposed by M. 
 
 i
 
 THE SIXTH SPECIES OF MALFORMATION. 239 
 
 Bertin as early as 1769, consequently M. Martin could not 
 liave been the originator of it, as ho claims to be. 
 
 I would also remark here, that the blue or livid spot which 
 is oftcMi observed at the normal situation of the anus in 
 imperforalion, is not always a positive evidence of confined 
 meconium tliere, or the presence of the end of the rectum, as 
 is generally believed. Dr. Gay reports a similar case in this 
 respect to that of M. Bertin. [ Vide Case CXLIXi\ 
 
 Case CXXXIY. — Wreisberg mentions the case of a male 
 infant in whom the anus was imperforate and the rectum 
 opened into the posterior part of the bladder, by a small 
 aperture. [ Yide Plate ZZ, Figure 2.] . . . . {Dlssertatio 
 de PrcEtematurali et raro Intestini Recti cwm lotii Vesica 
 coalitu^ et independente Ani Dcfectu — Comment^ Societat, 
 lieg. Scientiar. Gotthigens. Vol. I. p. 1. 1779. Also — Com, 
 m.e7itationum, Medici Physiologlci Anatomlci et Obstetrlci 
 Argumentl. p. 172. Tah. VII. Gottingens : 1800.) 
 
 Case CXXXY. — Casimir de Chonski relates an interesting 
 case of a male child in whom the anus w^as imperforate, the 
 rectum absent, and the colon, after descending with a con- 
 siderable curve, passed down behind the bladder, between 
 the ureters, and terminated in its fundus by a large orifice. 
 In this remarkable case, there also existed bilobation of the 
 bladder, an umbilical hernia formed by a portion of the small 
 intestines, together with a preternatural anus, or rather a 
 faecal fistula, situated in the umbilical region. The ureters 
 were very much dilated, except immediately at their junction 
 with the bladder, where they were of the normal size. [ Vide 
 Plate IX., Figure 3.] .... {Dlssertatio. I. de vitio quodavi 
 primcB formationis inferioreitTh j^otissiinwn tubi intestinalis 
 partem et vesicam urinariam spectante. c. ted). Berol: 
 1837. Uo) 
 
 Case CXXXYI. — The following very curious, interesting 
 and unique case was communicated to Mr. Costello, editor of 
 the Cyclopfiedia of Practical Surgery, by Mr. Bennett Lucas. 
 
 "A. B., a male infant five days old, presented in the situa- 
 tion of the anus, a red fl.eshy-looking tumor about the size of 
 a pea, which concealed an opening only capable of admitting 
 a small tube, about to the depth of from three to four inches. 
 Nothing had ever been passed in this channel, the child dis-
 
 240 THE SIXTH SPECIES OF MALFORMATION. 
 
 clmrffinff both Its urine and feces tlirouiih tlie nrethra. Botli 
 testicles had descended, and a congenital hernia existed on 
 either side. With these exceptions the infant was otherwise 
 well formed, healthy and of the ordinary size. I proposed to 
 Mr. Kenii}^, in company with whom I saw the case, to perform 
 an operation, with a view to establish a connection between 
 tiie rectum and anal aperture ; but as no very great hope, 
 much less decided success, could be held out from its per- 
 f)rmance, the parents objected to the operation being at- 
 tempted, and the little patient died on the evening of the 
 ninth day of its birth. Two days before the infant expired, 
 its scrotum became extended, and evidently contained a fluid. 
 An incision was proposed to be made into the tumor, but it 
 would not be permitted. 
 
 " From the haste attending the removal of the parts, I lost 
 sight of the termination of the ureters, as also the termiiui- 
 tion of the vassa deferentia. I have, however, since the 
 accompanying sketch of the parts was taken, slit up the 
 remaining portion of the undivided urethra, and with the 
 greatest care examined its mucous surface, and also the 
 mucous surface of the bladder, but 1 could not detect any 
 openings besides those already mentioned. 
 
 '•As the child passed urine through its urethra, there can 
 be no doubt but that this secretion was received into the 
 bladder ; and as no trace of any opening, except the recto- 
 vesical, tlie ano-vesical and the urethro-vesical, can be de- 
 tected, the urine must liave been conveyed, in the first 
 instance, into the large intestine, and thence into the bladder 
 by means of the recto-vesical opening. 
 
 " I am unable to say at wliat point each ureter entered the 
 large intestine, having brought away only the length of tlie 
 intestine shown in the engraving, which includes all the rec- 
 tum, such as it is, and a portion of the sigmoid flexure of the 
 colon ; and so far as this much of the gut is concerned, the 
 only opening it presents is the recto-vesical. Tlie ureters 
 probably opened into the corresponding ascending and de- 
 scending portions of the colon. But this can be only con- 
 jecture. 
 
 " The course of the vassa deferentia was also destroyed in 
 the liurry of removing the parts ; but there is no opening in 
 the urethra, bladder, or the portion of large intestine, to indi- 
 cate that they terminated in any of these organs. 
 
 "The urethra does not present a trace of the veru mon- 
 tanum. I also looked most carefully fur the prostate gland 
 and vesicufe seminales, without success. 
 
 " The appearance revealed by the dissection of this, I
 
 THE SIXTH SPKCIKS OF MALFOKMATION. 241 
 
 believe, unique conJitic f parts, was very tliflerent fioiii 
 
 what was anticipated. Although tlie infant passed both 
 fajces and urine throiii;li its urethra, it was a reasonable infer- 
 ence that tlie anal orilice conununicated with the rectnni, in 
 consequence of the depth whicli the i)robe passed ; the 
 extreniity of tlie probe on being withdrawn, being sullied 
 with faices, and this being the natural ontlet of the alimen- 
 tary canaL The usual orilice, also, and the canal leading 
 from it, being so uneven, as to offer a serious inii)ediment to 
 the passage of the faices in this direction. Notwithstanding 
 it was evident during life that a communication must have 
 existed between the bladder and the rectum ; yet under the 
 su])position that the anal orilice communicated with the rec- 
 tum, all hope of success from an operation which had for its 
 object the restoration of the lower portion of the intestinal 
 canal, was not shut out, particularly when we recollect the 
 rai)idity with which abnormal openings in children close, 
 wiien once the cause which tends to keep them open, is 
 removed. 
 
 "In this case, however, 1 doubt, if any operation, even were 
 the state of the p;irts beforehand ascertained, would have 
 been attended with a favorable termination." [Vide 
 Plate X, Figure 1.] {CydopcBdia of Practical Sur- 
 gery. Vol. 1. Article. Bladder, p. 472. London, 1841.) 
 
 Case CXXXVII. — The following interesting case of imper- 
 forate anus with the rectum terminating either in the bladder 
 or in the urethra, is reported by Mr. Miller, of Methven. 
 This case was allnded to in the fourth chapter of this work, 
 when speaking of the difficulty of nuiintaining a perinatal 
 artiticial anus, previous. 
 
 " In the nKmth of January, 1821, Mr. Miller delivered a 
 yonng woman of a male chdd. Thirty hours after birth it 
 was discovered that the child had no anus, and there was no 
 indication of the place which the anal orifice should have 
 occupied. The niecanium passed by the urethra. Dr. 
 Miller made an incision in the peringeuin, at the normal sit- 
 uation of the anus, of an inch long and an inch deep ; and 
 then introduced a large trocar, such as is commonly used in 
 abd aninal paracentesis ; and upon the second attempt, after 
 having pushed the instrument to the guard, the end of the 
 rectum was penetrated, which at once gave exit to its 
 contents." 
 
 '' What ordinarily occurs," says Dr. Miller, " presented itself 
 here also. There was great difficulty in keeping the anus 
 open, and before the cliild was eight months old, it was 
 16
 
 2-i2 TUE SIXTH SPECIES OF MALFORMATION, 
 
 necessary to make ten incisions with the bistomy. Hardly 
 had the boy begun to walk than he showed a fondness for 
 eating cinders, whicli lodging in the rectum, obliged fre- 
 quent operations for his relief. In one of these the bladder 
 was wounded, and from that time the urine passed in small 
 quantity from the rectum, but the larger portion still followed 
 the course of the urethra. Laxatives and frequent injections 
 enabled the stools to be made with tolerable ease." 
 
 The child was four years old when one day the mother 
 found difficulty in introducing the beak of the syringe into 
 the rectum ; she thought she felt a hard, resisting body. She 
 did not mention tliis to Dr. Miller ; but three years after, a 
 complete obstruction of the rectum occurred, accompanied 
 with the most severe pain. They then discovered the presence 
 of a large calculus in , the rectum. The anus Avas so much 
 contracted that it would hardly admit a goose quill. — 
 Dr. Miller enlarged it sufficiently to introduce his finger, and 
 he found the concretion was large enough to fill the hollow of 
 the sacrum. The hardness of this calculus made him think it 
 only possible to extract it in fragments. For this reason he 
 constructed a drill, by the aid of which he could easily make 
 a hole five-eighths of an inch in diameter. To hold the stone 
 during the drilling, he introduced forceps in separate parts, 
 and afterwards united them when in proper jjosition. The 
 amis was then enlarged in the antero-posterior direction to a 
 sufficient extent, and the drill was worked until the stone was 
 completely traversed. Into this opening a strong pair of poly- 
 pus forceps was placed, and forcibly separating the blades 
 the stone was broken into several pieces, each of which was 
 also in its turn, drilled, broken and extracted. The operation 
 lasted two hours and three-quarters. All the fragments being 
 removed, the patient was put to bed. At the end of ten days 
 he was able to rise and the anus had returned to its normal 
 dimensions. The calculus was of the size of a very large tur- 
 key Qrfi:!;, quite hard, and very rough on the outside, and 
 seemed formed of earihy matter. 
 
 Dr. Miller, having left the country for several years, lost 
 sight of his patient, but hearing mention made of two cases 
 of malformation of the anus, (one of which presented an anus 
 opening into the bladder,) and upon which no operation was 
 ]>erformed, being considered useless, he caused inquiry to be 
 made to learn what had become of his patient. He was still 
 alive, and Dr. Miller had an interview with him. He was hi 
 good health, and had never complained since the stone was 
 removed, and is to day a strong and active farmer. At the 
 age of twelve years, a second soft stone, the size of a chesnut,
 
 THE SIXTH SPECIES OF MALFORMATION. 248 
 
 passed M-itliout pain, but he had h»st it. The functions ftf iho 
 bladder and tlie rectum were performed with perfect re^uhir- 
 ity." {Edlnbur(jh Medical and Surgical Journal. No. 
 XCVIII, p. r.i 1S29. Also— Gazette des Uopitaux de 
 Paris. No. VL, 10 Septemhre, 1857.) 
 
 Case CXXXVIII. — M. Cavenne, a physician of Laon 
 (Aisne,) reports the following case of a male child who pre- 
 sented an imperforation of the anus and rectum, the latter 
 terminating in the bladder by means of an abnormal cana-l 
 and orifice. 
 
 " Celine Plainou, 38 years of age, wife of Pierre Cordevan, 
 of the Commune of Brie, Department of C'Aisne, gave birth, 
 on the 22nd January, 1824, at eleven o'clock, A. M. to a male 
 child, seemingly healthy and well formed ; for up to the 24th 
 January, the second day after its birth, the parents had not 
 discovered the infirmity with which it was afflicted. The 
 cliild sucked well, and hitherto the urine passed, was 
 unmixed with any foreign matter. 
 
 "Soon the abdomen became swollen, the child cried out, 
 and appeared to suffer much ; it also vomited meconium sev- 
 ei'al times. The health officer of the place being consulted, 
 prescribed a bath into which the child M'as placed for some 
 minutes. The same symptoms continued, and as it had had 
 no evacuation of the bowels, it was resolved to administer an 
 enema ; but they were not a little surprised to discover no 
 trace of an opening at the normal place of the anus, nor even 
 in its vicinity. On leaving the bath a little urine was passed, 
 mixed for the first time with meconium. The passage of this 
 foreign substance through the urethra caused swelling of the 
 entire penis, which was temporarily remedied by emollient 
 applications. 
 
 "I was called in on the mornino-of the 25tli to examine the 
 cliild and employ suitable means to remedy the malformation. 
 The abdomen was distended, slightly tinged with green and 
 sensitive to pressure. In the perinseum I discovered only a 
 line of depression extending from the end of the coccyx to 
 tlie point where the skin of the scrotum unites with that of 
 the penis, so that the scrotum instead of affording a single 
 envelope to the testicles, formed two very distinct ones ; tlie 
 prepuce adhered also to the lower half of the gland. I 
 caused the child to lie on its abdomen so that the pressure 
 caused by this position might render the place ordinarily 
 occupied by the extremity of the intestine more prominent, 
 if it was not too far distant. I discovered no sign of its exist- 
 ence. During this manoeuvre the child vomited meconium,
 
 24: i THE SIXTH SPECIES OF MALFORMATION. 
 
 whicli also passed by the penis mingled witli tlie uriiie, tiiitr- 
 iiig the diapers a dee]j green since its exit from the bath. 
 
 " Presuming then that there was a communication between 
 the intestine and the bladder, forced to act promptly, since 
 the abdomen was rapidly swelling, while the meconium was 
 passed by vomiting, it became necessary to choose a method 
 and to put it into execution. To establish an artificial anus 
 after the advice of M. Dumas would only j^artially remedy 
 the malformation, at least on the supposition of the oblitera- 
 tion of that portion of intestine below the new amis, for want 
 of which a part of the meconium must continue to pass into 
 the bladder. I therefore gave the preference to the process 
 recommended by M. Martin, Junior, a surgeon at Lyons. 
 
 " To perform the operation the little patient was placed on 
 the border of a sufficiently elevated table, furnished with a 
 cushion, and a cloth folded several times ; a very small staff 
 was introduced into the bladder by the urethra ; the thighs 
 were flexed upon the abdomen a little apart, the scrotum was 
 raised with the left hand, and the perineum rendered promin- 
 ent by pressure exerted by the assistant to whom the staff was 
 confided. A longitudinal incision in the perinasum, about an 
 inch long, allowed me to pass the point of a long straight bis- 
 toury over the finger nail of the fore-finger of the lefc hand, 
 into the groove of the staff" which I raised towards the pubis, 
 whose direction I followed in order to penetrate the bladder 
 and incise its neck by the withcb-awal of my bistoury. 
 
 Instead of the great quantity of meconium which I ex])ected 
 to see gush out, there only flowed a little urine mixed with 
 blood. I introduced a female catheter by the opening just 
 made, to make sure of having penetrated the bladder ; it pen- 
 etrated in fact to a greater depth than the blade of my bis- 
 toury had done, and passed around the cavity of the organ 
 very freely, always arrested by the resistance of its walls. A 
 silver canula, two inches and a half in length, surrounded 
 with fine linen, well greased, was introduced into the opening 
 for the purpose of dilatation and to arrest the hemorrhage ; 
 nothing passed the canula and the child died at six o'clock, 
 P. M., on the 25th of January. 
 
 " Upon opening the abdomen there flowed out several ounces 
 of serous fluid of a greenish color, apparently caused by the 
 great quantity of meconium which distended the large intes- 
 tines, as well as the greater part of the small intestines. 
 
 '■' The end of the colon cut longitudinally brought to view the 
 cavity of the rectum very short, terminating in a cul-de-sac, 
 from which there issued a narrow canal, about a half inch
 
 THE SIXTH SPECIES OF MALKOUMATION. 245 
 
 long coininuiiic!itin<i; witli tlie bladder, Ix'liiiid tlic iiccl< of that 
 organ by an opening of very small diameter. 
 
 riirough an opening made in the anterior j)art ol" tlu' \\;dl 
 of tlie bladder uliieli contained no ilnid, was seen the incision 
 of the neck, abont tlwee lines in length, and at the right of 
 this, the vesical oju'iiing of the canal commnnicating between 
 the intestine and the bladder, surrounded with a slight border 
 which seemed to perform the ottice of a Sj)hincter. I conld 
 only ]>enetrate tlie (bict from the cavity of the intestine to that 
 of the bladder, by the aid of a blunt stvlet a little larirer than 
 those used for sounding the lachrymal ducts. {An'hicefi Gen- 
 erales de Medecine de Paris, Annee 1824. tome Y. p. 63.) 
 
 Case CXXXIX. — The late Dr. John 11. Steel, of the Sara- 
 toi:;a Sprinf>;s, New Yoi'k, reported the following case. 
 
 ^"On the 13th of April, 1833, Mrs. C, a strong, healthy 
 woman, was delivered of her tenth child, a fine, fat boy, who 
 weighed between eight and nine pounds. He was dressed, 
 and placed in bed with his mother, and nothing unusual was 
 observed about him until the succeeding day, when he 
 became restless and exceedingly fretful, and although he was 
 nursed freely, his attention to the breast was frequently 
 interrupted by fretful stai-ts, accompanied at times by pierc- 
 ing shrieks and noisy crying. His diapers were observed to 
 be frequently wet, and when removed were found to contain 
 portions of feculent matter, of a natural appearance, and in 
 about the usual quantity; liis restlessness however continued 
 to increase, and his crj-ing became more constant and 
 alarm in o;. 
 
 '' On the second or third day after birth, it was discovered 
 by the nurse that the usual aperture for the evacuation of 
 the contents of the bowels was entirely wanting, and that 
 the feculent matter which had appeared, was voided through 
 the urethra along with the urine. It was at this period that 
 I Hrst became acquainted with the case. 
 
 " On removing the diaper, about a spoonful of faeces and 
 urine, of the consistence of thick gruel was voided at once, 
 apparently with some effort, troni the extremity of tlie 
 urethra; the glans penis was considerably inflamed, and the 
 child cried as if in great agony. Several other and stronger 
 eflforts were evidently made, wdien smaller portions of fffices 
 of the same appearance and consistence as the first were 
 excl'ided and the little sufferer then became more quiet. 
 
 " The parts behind the scrotum were perfectly natural in 
 every respect, except the want of an anus, of wdiich there 
 was not the slightest vestige, the spot where it should have
 
 2J:6 THE SIXTH SPECIES OF MALFORMATION. 
 
 been was smooth, and of a uniform color with the adjacent 
 parts, the sphincter muscle was evidentl>^ wanting, and there 
 was nothing to indicate an accumulation of fseces in the 
 
 vicinity. 
 
 ''The examination resulted in the conviction that the 
 intestine did not extend to the perinseum, but probably ter- 
 minated in the bladder or some of its a])pendages ; under 
 this view of the case any attempt to form an artificial anus 
 would have been useless, if not absolutely injurious. The 
 parents, therefore, were instructed to keep the parts clean, 
 to use a little sweet oil about the glans penis, and by all 
 means to keep the bowels loose should any tendency to con- 
 stipation occur. 
 
 " For the first three or four weeks the child continued 
 fretful, and evidentlfy to decline in vigor and growth ; but 
 from tliat period to a short time before its decease it suffered 
 but little apparently, nor did its growth or strength seem to 
 be at all impeded. The only peculiarity observable was the 
 appearance of two large front teeth in the upper maxilla, 
 which at the age of seven months were as large and fully 
 grown as those of an adult ; they, however, in the course of 
 two or three months became loose, and finally dropped out. 
 In the latter part of the month of March ensuing its birth its 
 bowels became obstinately obstructed, the scrotum enlarged, 
 and became extremely tender, and on the 30th of the same 
 month its sufferings were terminated in death. 
 
 " At the antopsy, on removing the integuments from around 
 the body of the penis, which were considerably swollen, two 
 ap2?le seeds of a large size, which had passed through the 
 intestines, together "with a portion of the capsule or hull 
 which surrounds the seed in the core of the fruit were found 
 lodged in the urethra about three-fourths of an inch from its 
 termination ; they were so situated as to completely obstruct 
 the passage, and a small opening had been formed immedi- 
 ately behind them in the urethra through which some of the 
 contents of the bladder had been infused into the cellular tis- 
 sue, and extended to the scrotum. Inflammation and conse- 
 quent gangrene was the result, and to this may undoubtedly 
 be imputed the immediate cause of the child's death. 
 
 " Tlie contents of the abdomen appeared perfectly natural, 
 excepting that portion of the intestinal canal termed the colon 
 sinistrum or descending colon, which was found to be entirely 
 destitute of the sigmoid flexure ; the gut passed along the 
 left lumbar, and through the iliac regions in nearly a straight 
 line to the neck of the bladder, into which, after an abrupt 
 but imperfect curve, and being suddenly contracted in its
 
 THE SIXTH SPECIKS OF MALFOUMATION. 247 
 
 (iiiiU'iisions, it was inscrtoil just hi'liind the hasc of tlicyy/vAv- 
 tate {/land. The ajK'rture wiiicli iinit,i.'(l the gut and hhuhler 
 of urine into (»ni' conmion receptacle for their respective con- 
 tents, was of suiliciont (•aj)a('ity to a(hnit a iarti:;e si/.i'd gonse- 
 (|uill ; throug'li tliis a[)erture the urine found a rea<ly egi-ess 
 into the intestine, where becoming united with the contents 
 of that receptacle it was forced back to the bhidder, and 
 finally expelle<l through the urethra. About half a pint of 
 urine and l\eces of the consistency of that whicli was usually 
 voided, was found to occupy the cavity of these two organs, 
 and was readily excluded by means of a slight pressure on the 
 parts. The space between the ])erinaHim and the termination 
 of the intestine was occupied by a sofr, fatty substance, but 
 there was not the slightest vestige of a gut." [ Vide 
 
 Plate X, Figure 2.] (Atnerieafi Journal of tJie 
 
 Medical Sciences. No. XXX. p. 40-4, Philadelphia ., l^elru- 
 ary, 1835.) 
 
 Case CXL. — M. Cruvielhier gives a very interesting in- 
 stance of a fully matured male ftetus, in which was presented 
 an imperforation of the anus, with the rectum terminating in 
 the bladder by a very small canal, at the posterior extremity 
 of the vesical uvula. In this case, besides the malformation 
 already mentioned, there existed a very remarkable deformity 
 of the pelvis with congenital luxation of the femur, club-foot, 
 &c. The perinasum was enormous in its antero-posterior 
 diameter. There was not the slightest trace of an anns and 
 no median raphe, but all was smooth in the ano-perinteal re- 
 irion. At the extremity of the coccyx a small depression 
 coidd be observed, resulting from adhesion of the skin to that 
 point. The genitals were well formed but were pressed to 
 the front, and the scrotum was destitute of testicles. [ Vide 
 Plate Xi, Figures 1, 2, 3.] {Anatomic Pathologique du 
 Corpes Humain. Tome I. Livraison, II. Planche, II. 
 Figs. 1, 5, 6. Bruxelles : 1833, 1834.) 
 
 Case CXLL — Baillie saw a child in which at birth, the rec- 
 tum opened into the bladder. The deformity was of such a 
 character, he observes, as neither to admit of a remedy by 
 art, nor to allow of life being continued. {Morbid Anatomy^ 
 p. 165. London: 1833; hj Wardrop.) 
 
 Case CXLII.— Dr. Dorsey remarks, that a very interest- 
 ino- case of imperforate anns in a male child, is related by 
 his friend Dr. J. A. Smith, in the second volume of tlie 
 "- Xcw Yorl: Medical anl Philosophical Journal?' In fjiis 
 case the rectum terminated in the urethr;i, through which
 
 248 THE SIXTH SPECIES OF MALFORMATION. 
 
 canal its contents were evacuated. An unsuccessful oi)era- 
 tion was performed tor tlie relief of the patient; the wound 
 healed, but M'ithin a month the child expired. No dissection 
 was |)ermitted, consequently tlie mode and place of commn- 
 nication between the rectum and the urethra or bladder 
 remained uidvnown. {Elements of Surgery. Vol. 11. Chap. 
 LXIV. J), ttfjy, Zrd Edition, Pfiiludelphia : 1823.) 
 
 Case CXLIIL— The following case was communicated to 
 the " Boston Medical and Sargioal Journal,^'' by Dr. L. W. 
 Houghton, of Waterford, Maine, in a letter dated July 8tli, 
 1847. 
 
 "I was called on the 20th of last month to see an infant 
 child, who, the messenger said, 'seemed to have no passage 
 from the bowels.' The child was some eight or ten liours 
 old, the mother having been attended during lier confine- 
 ment by a midwife, there being no physician within some 
 eight miles of her residence. With the following exceptions 
 the appearance's of the child were healthful. ' The lower 
 extremities were not well developed, and the cuticle M'as 
 wanting in considerably large portions, while in other parts 
 it appeared dry and horny. Tlie spine also terminated from 
 t\yo to four inches higher up than natural ; the sacral portion 
 of it, if no more, being wanting. The rajyhe along the perin- 
 aeinn extended only a short distance back of the scrotum, and 
 there was no appearance of the anus. I came to the conclu- 
 sion, that from the external appearance of the child, there 
 was malformation of the pelvic viscera, or that some portions 
 were wanting, and did not therefore attempt the operation 
 for artificial anus. A few hours after I left, the child com- 
 menced voiding meconium ]>er urethra, and continued to do 
 so till death, which occurred forty-eight hours from its birth. 
 " Post-mortem Examination. — I found, on examination, a 
 termination of the rectum into the neck of the bladder, by a 
 very small opening, barely sufficient to admit an ordinary- 
 sized probe. The rectum, besides the opening already de- 
 scribed, terminated against the lower lumbar vertebra." — 
 {Boston Medical and Surgical Journal. Vol. XXXVI., 
 p. 520. Boston : 1847.) 
 
 Cask CXLIV. — M. Amussat reports the following case of 
 imperforation of the anus and rectum in a new-born infant 
 of the male sex, in which the rectum opened into the 
 bladder : 
 
 " On the seventh of May, 1842, MM. les docteurs Miquel 
 and Devilliers sent a child to me, about forty-eight hours old.
 
 THE SIXTH SPECIES OF MALFORMATION. 249 
 
 We were intonucd tlioro was no unus, that tlic cliild |>assc(i 
 mecouiiiiu with the uriiu', and that on account of tli is cii-ciiin- 
 Btance, the diapers Leui<^ stained yeUo\v, they had onlv jii-t 
 discovered tlie nialt'orniatidii. 
 
 ''1 examined the chihl in tlie ])resencc of ^1^[. L. lioyci, 
 Fillios, Grabowski, Kontsoscki, Silvestrc Dii Perrt)n and I.e 
 Vail hint. 
 
 *' No anal oj^enino; existed ; the raphe, stroni;-ly niarki-d, 
 extended beyond the coccyx, and tlie perliueal reg-iun was 
 everywhere uniformly developed. Tlie abdomen was n^xuch 
 distended, and the lower part tilled with seroslty. The urine 
 was of a yellowish hue, thick, and coIojxhI the linen. Press- 
 in<;' Urmiy on the abdomen with the lingers placed on the 
 ])erinix.'uui, it was impossible to discover any kind of fluctua- 
 tion. Although the conviction existed that the rectum termi- 
 nated in the bladder, there was reason to suppose that the end 
 of the intestine descended to the lower part of the pelvis, 
 either directly opening into the fundus of the bladder, or by 
 dilatation approaching the floor of the perina3um and coccyx. 
 lleasoning from this supposition, we should operate from 
 below, and endeavor to establish the anus in the region of 
 tlie coccyx, before attempting to make an artificial opening 
 in the left lumbar region by incising the descending colon. 
 
 " An incision was first made in the median raphe, of suffi- 
 cient depth, extending about a half an inch from before 
 backward. No fluid escaped. Searching under the coccyx 
 nothing was found. To aid the exploration, we amputated 
 the cartilaginous extremity of the coccyx and explored with 
 the index finger introduced into the wound. In the u^jper 
 part of the pelvis, a protuberance was seen wdiich seemed to 
 us to be the end of the large intestine. We now hoped to 
 reach the end of all our eftbrts ; but this protuberance having 
 been incised, furnished no liquid, and yet a sort of mucous 
 membrane was seen, and a stilette could be inserted into its 
 cavity. It was really a cavity, as it seemed, but a cavity con- 
 taining neither gas nor fluid. Finally, after many useless 
 endeavors to recognize the fluctuation which should be sensi- 
 ble, if the intestine had been in the upper portion of the 
 wound, as we had hoped at first, the operation was abandoned, 
 by reason especially of the feebleness of the child, and from 
 the same cause we deemed it advisable to operate in the left 
 lumbar region by opening the descending colon. 
 
 "The cluinces of life in this child were very small, even 
 before the operation ; lor there w^as an infiltration of the 
 lower part of tlie abdomen, an Infilrratlon announcing already 
 existing disorders of that region, and perhaps of the respira-
 
 250 THE SIXTH SPECIES OF MALFORMATION. 
 
 tion. Its condition became still more disturbed after so lonij 
 and fruitless an operation. A gleam of hope jet remained 
 frum the idea that the end of the intestine might become 
 c'liiraored in the wound by the cries and efforts of the child, 
 and that then we might open it and tix it to tlie edges ot 
 the wound. But we were disappointed even in this hope, 
 and the child died thirty-six hours afterwards without our 
 perceiving through the opening which we had kept open 
 with a tent of charpie, any species of fluctuation indicating 
 that the rectum terminated in the pelvis. 
 
 " At the autopsy, performed in the presence of MM. 
 Piett, Filhos, L. Boyer and Le Vaillant, the following was 
 observed. 
 
 "The large intestine was distended by meconium and gas. 
 It jn-eserved its ordinary relations and it was demonstrated 
 that the left lumbar colon was fixed to the posterior abdom- 
 inal M'all and that the peritonseum did not come at least one 
 third of its extent. The rectum, M'liich was very much dis- 
 tended, formed a voluminous sac, terminated by a conical 
 extremity opening into the bladder between the two ureters 
 hy h narrow strait half tlie size of the opening of the neck 
 of the bladder. 
 
 " By the perinseal incision which was made in order to 
 reach the end of the lai'ge intestine, we arrived within a very 
 short distance of the rectum. Had we persisted in this effort, 
 it is })robable that Ave should have reached it." {Troiseme 
 Memoire sur la Possibilite d''etablir une ouverture aitifciSUe 
 sar la Colon lomhaire gauche sans oavrier le Peritome, chez 
 les Enfans imperfores. Paris : Annee 18^2. Also L'Ex- 
 aminateur Medical de Paris^ Annee 1843, tome^ III. p. 
 215.) 
 
 Case CXLY.— C, E. Buckingham, M.D., of Boston, Mass., 
 communicated the following case to the " Boston Medical 
 and Surgical Journal ;" 
 
 " William, the son of William Lund, was born on the 6th 
 of December, 1851, and on the morning of the following day 
 the nurse reported that there was an obstructed anus. On 
 examination, the cleft of the nates was found sufficiently 
 imirked, but there w^as no evidence of an anus, either by pro- 
 trusion or discoloration. During the night there had been 
 r>ccasionally bilious vomiting, and latterly straining, as if to 
 eviicuate the bowels. There had been no discharge of urine. 
 Ilad taken no food of consequence, but had tried to nurse, 
 'the countenance looked badly, and there was lividity about
 
 TIIIC SIXTH SPECIES OF MALFORMATION. 251 
 
 the inoutli and ejos. Was somewluit stuj.i.l ; did noi cry, Init 
 was constantly nioaniiiiij. 
 
 "O])oration tliirty-two and a half lioiirs after l)irt]i, with the 
 assistance of Dr. IJenry Osgood Stone. Tiie child was licld 
 upon the lap of the nurse, its nates resting over the right 
 knee, and the knees raised as for lithotomy. I made an 
 incision in the centre; of the cleft of the nates from the scro- 
 tum to the coccyx, and crossed this with another, at right an- 
 gles, from the tuberosity of one ischium to the other. The 
 dissection was carried on with a sharp-pointed, straight 
 bistoury, backward and a little to the left, for two inches. 
 No evidence of the neighborhood of the rectum being 
 obtained with the linger, I passed a hydrocele trocar into the 
 wound, in the same direction, a half inch further. On with- 
 drawing it, meconium was found upon it. The wound was 
 then enlarged with the knife, and a female catheter M'as intro- 
 duced, through which an enema of warm water was adminis- 
 tered. There was immediately a fair discharge of meconium, 
 and a slight discharge of urine. 
 
 " The child cried but little, and the whole loss of blood was 
 not much more than two drachms. A few spoonfuls of milk 
 and water were given, and it was dressed in the usual manner, 
 no application being made to the wound. Half an hour later, 
 the moaning had ceased, the child looked brighter, and there 
 was a profuse dejection. 
 
 "5, P.M. — Has had two full evacuations, but has not vomited 
 nor passed urine. At 5, P.M., on the 8th, I introduced a 
 sponge tent two and a half inches, with some little difticulty. 
 During the attempt at introduction, the eftbrts of the child to 
 evacuate the bowels produced an audible passage of air 
 through the penis, which was rendered visible by the spatter- 
 ing of urine, and perceptible to the hand, which was laid 
 above the pubes. 
 
 " Dec. 9th. — Removed the tent, immediately after which, 
 he passed a large amount of almost colorless urine in a jerking 
 stream. No passage, either fluid or solid, by the anus at the 
 time. 
 
 " I have the regular reports of each visit, but select only 
 such as are of particular consequence. 
 
 " Dec. 1 4th. — Tried unsuccessfully to introduce a bougie of 
 more than one-fourth of an inch in diameter. Umbilical cord 
 has not yet separated. 
 
 " 16tli. — Introduced a female catheter with difficulty. 
 
 "25th. — Free dejection. Passed a bougie of ebony, seven- 
 sixteenths of an inch in diameter. 
 
 " 27th. — In pain all night. Tumor in left side just over
 
 252 Tiir: sixth species of malformation. 
 
 short ribs, size of a small walnut. ISTurse says, she discovered 
 it last night. 
 
 u 29th. — Tumor increasing in size. Passed bougie of 25th 
 again with case. Some bloody pus followed it. 
 
 ''Jan. 1st, 1852. — Opened tumor, which discharged an 
 ounce of pus. 
 
 " 7th. — For several days the left side of the scrotum has 
 
 been swelling. 
 
 a 13tb. — Opened small abscess in front of scrotum. Child 
 weighs nine and a half pounds, an increase of two and a half 
 pounds since birth. 
 
 " 22d. — Bouo-ie has not been introduced since the 16th. 
 Has two dejections daily, and sometimes more. The scrotal 
 abscess is well ; there has been a slight gathering again on 
 the left side, which broke yesterday, and does not discharge 
 to-day. 
 
 "Feb. 13th. — ^N"o bougie since Jan. 16th. Three dejections. 
 Weighs eleven and a half pouiids. 
 
 " March lltli. — Gains daily. Nurses well. Bowels open 
 freely every day without medicine. No bougies since Jan. 
 16th. Has gained another pound. 
 
 " Soon after this last report, the child left town for Gardi- 
 ner, Maine, and returned on the 28th of May. Saw it tliat 
 afternoon. Looks well and is fat and hearty. About the 
 1st of May, discharged urine and fasces mixed, by the urethra ; 
 but has not since. For several days last week, had diarrhoea, 
 which stopped on the 21st. No instrument has been passed 
 into the anus, which is red and shining about its edges, and 
 bled a little on separating the nates. 
 
 " Aue. 5th. — lias six teeth. For several weeks has had 
 diarrhoea, and feecal matter passes by the uretlira, as much as 
 by the anus. 
 
 " In the fall the family removed to Maiden. 
 ' Oct. 21st, 1857. — Saw Mrs. Lund, the mother, at 36 Lev- 
 erett Street. She informs me that her boy upon whom 
 I operated is still living, and is generally in good health. He 
 occasionally has ]:)ain in the pubic region, but she considers 
 him well. There is, however, at times, difficult micturition. 
 The family still reside at Maiden." {Boston Medical and Sur- 
 gical Journal, Vol. LVIL, J). Z'd4:. JBonton : 1S57 .) 
 
 Case CXLA^L — The following case was communicated to 
 the " BodiJii Medical and Surgical Journal^'' by Noah Gil- 
 man, M. D., in a letter dated. South Deerfield, August 23rd, 
 1853. 
 
 " While residing in Frankfort, Maine, about three years
 
 THE SIXTH Sl'i:ciK8 OF M.M.IOJi.MATIoX, 2o3 
 
 since, T uttendcd Mrs. W. in her first coiifiiicineiir. Slio \v:is 
 (U'liveriMl of Ji lurj^^c, ii])]>;uviitly iu'iiltliy, uiid well-devcloiuMl 
 male cliild, in wliich 1 could perceive no detect whatever. 
 Twenty -four liours afterwards, was notified by the nurse that 
 the child had passed neither urine nor fieces. On examina- 
 tion, it proved to bo a case of imjierf >rate anus, of a very 
 unusual character. The rectum liad terminated in a <al de 
 sac, high up in the pelvis, and communicating with the 
 bhidder. There was not the slightest rudiment of an outlet 
 to the gut, nor any mark to indicate where it should be. JS'o 
 distension of the integuments denoted a pressure of the fieces 
 within. The genital organs were somewhat deformed. The 
 testicles well developed, but there was a mere apology for a 
 j»enis, with the urethra ternjinating near its root, just above 
 the scrotum. 
 
 *' Having introduced a bent silver probe into the bladdei-, 
 its removal was followed by a jet of urine and thin fieculent 
 matter. The probe was also covered with meconium. In 
 deciding upon an operation, I reasoned thus : — As it is uncer- 
 tain how far it will be necessary to dissect in order to reach 
 the rectum, the danger of wounding arteries beyond the reach 
 of the ligature will be very great. Should it be necessai-y to 
 carry the dissection any great distance, the patient will prob- 
 ably die in my hands. And then, should he survive the 
 operation, the fact of the connnunication between the gut 
 and the urinary organs, would render the ultimate success of 
 the operation quite uncertain, to say nothing of the difficulty 
 of preserving a proper opening. On the other hand, the 
 child must die. 
 
 '- With the advice and asssistance of Drs. Edmund ami 
 Charles Abbott, I made an incision through the skin and 
 cellular membrane, from the extremity of the coccyx, along 
 the perinseuni, about tw^o and a half inches. No muscular 
 fibres were divided. Dissected carefully up the natural 
 course of the bowel about one and a half inches, where the 
 rectum presented itself, terminating in a cul de sac and enor- 
 mously distended with fseces. This was freely laid open, and 
 a copious evacuation ensued, giving entire relief to the little 
 sufterer. No blood-vessel requiring ligature was wounded. 
 The divided parts were kept from adhering together, at lirst 
 by tents well-oiled, and afterwards by a tube with a button 
 on the end, which was made to order. Much trouble was at 
 first experienced in retaining the tube, as its introduction 
 would produce violent straining and evacuation, but the parts, 
 after a while, became accustomed to the irritation. In a few 
 weeks the parts were entirely healed, and an artificial anus
 
 25^ THE SIXTH SPECIES OF MALFORMATION. 
 
 established, to all appearance as good as natural. Fortun- 
 ately, after the operation, no faeces ever appeared in the 
 urine, nor was there any reason to believe that the urine ever 
 passed into the rectum. 
 
 " The child, at the age of one yeai-, was remarkably large 
 and vigorous. The family removed from the place, and 1 
 liave not heard from the child since. As the sphincter 
 muscle is wanting, he must necessarily experience some 
 inconvenience on that account. It is a circumstance worthy 
 of remark, that this patient, scarcely twenty-four hours old, 
 never cried during the operation, thus putting to shame those 
 robust persons, of mature age, who cannot bear the extraction 
 of a tooth without the use of ether." {Boston Medical and 
 Surgical Journal. Vol. XLIX. p. 115. Boston: 1853.) 
 
 Cases CXLVII-CXLVIII.— M. Yelpeau says, that he met 
 in his practice, with two male children, in whom the anus 
 was imperforate and the rectum opened into the bladder. 
 {3fott, Op. cit. I). 1086.) 
 
 Case CXLIX.— G. H. Gay, M. D., of Boston, Mass., on the 
 23d of November, 1857, reported the following case to the 
 '-'•Boston Society for Medical Improvement.'''' 
 
 "The child was first seen, says Dr. Gay, on the 14th No- 
 vember, 1857, about sixty hours after birth. By the mother's 
 account, it had passed nothing from its bowels, and only a 
 slight quantity of urine from the penis, and was in nearly 
 constant distress, with occasional nausea and the vomiting of 
 a greenish fluid, it was also restless and crying most of the 
 time. 
 
 " On examination, there was the brownish discoloration and 
 puckering of the skin where the anus ought to be, but no 
 opening could be found. On pressure with the flnger, active 
 contraction and retraction of the skin followed, indicating a 
 strong muscular power. A moderately firm, bluish mem- 
 brane, completely closed up the anal aperture. During the 
 longest straining, there was no forcing down nor protrusion 
 of this membrane. The abdomen was swollen, but apparently 
 not tender to the touch. The skin of the face and upper ex- 
 tremities was yellowish. 
 
 " A probe passed through the penis into the bladder could 
 not be felt in the perinseum. 
 
 " The parents urged an operation. 
 
 " Operation. — The membrane being freely divided, the point 
 of the little finger was passed through the opening, but no ob- 
 struction was met with, no cul-de-sac could be felt, nor was
 
 TIIK SIXTH SPECIES OF MALFOliMATloN. 255 
 
 there aiij impression on the finger, during the most vioh-iit 
 straining. While the finger was in the opening there was 
 strong contraction upon it. Tiie finger parsed easily to the 
 toj) of the sacrum. A i)robe was then passed into the blad- 
 dei", and traced to the upper part of the sacrum with nothing 
 intervening but the thin coat of tlie bladder. This was appa- 
 I'cntly closely attached to the bone, as notiiing would })ass be- 
 tween them. The bladder was not distended. As far as the 
 fore-finger could reach, nothing was felt but the probe in the 
 bladder, and the sacrum. 
 
 "Under the circumstances, nothing further was attempted. 
 The parents would not permit an operation in the iliac or 
 lumbar region, 
 
 " During the operation, some good-colored urine ^vas passed. 
 All the symptoms that weie present before the operation, now- 
 increased, together wntli feecal vomiting, hiccough, and great 
 yellowness of the skin. The child died about two days and a 
 half from the operation. No autopsy was permitted. 
 
 " Befoi'e death, there was evidently meconium mixed with 
 tlie urine, from the appearance on the cloths. The mother 
 said that there was the same greenish color, though not sn 
 marked, once before the operation. As there was nieconium 
 evidently mixed with the urine, the intestine, whether it was 
 the lower part of the colon or the commencement of the rec- 
 tum, in all probability terminated at, and communicated Mitli. 
 the upper posterior part of the bladder, and was out of the 
 reach of any operative procedure at that point." {Records 
 of the Boston Society for Medical Improvement^ Vol. III.,]). 
 156. Boston: 1859.) 
 
 Case CL. — Professor Gross, of the Jefferson Medical Col- 
 lege, Philadelphia, reports the case of a male child in whom 
 the anus was imperforate, and the rectum terminated in the 
 urethra or the bladder. Dr. Gross, in this case, made the at- 
 tempt to reach the rectum through the perinteum, by a very 
 deep incision, but failed to reach it. The child survived six 
 weeks, passing daily a little fsecal matter by the urethra. 
 
 What is very remarkable, the Professor says that an uncle 
 of this child had lived in a similar condition for upwards of 
 thirty years. {A System of Surgery, Vol. II, Chaj). XIII^ 
 I). 765. Philadelphia: 1859.)
 
 256 THE SIXTH SPKCIKS of ilALFoEMAXIO^". 
 
 (2.) Cases in which the Rectum Tcrm'matedin the Vnthra. 
 
 Cask CLI. — Licetiis relates tlie case of a woman who luul 
 from birth an imperforate aims, with an abnormal opeiiiniz; 
 of the rectnm in the urethra, through which her faeces were 
 voided. {De Moni^troruiii Causis, JSfatura^ et Differeniiu. 
 L',h. 11. cap. f3. Patavii: 161G. Uo) 
 
 Case CLII. — M. Bravais mentions the case of a little boy 
 about four years old whom he dissected, who had been born 
 with an atresia ani and whose excrements had altogether 
 been passed by the urethra. The rectum curved round 
 the bladder and opened into the urethra by a narrow prolonga- 
 tion. {Actes de la Societe de Sante de Lyon. Amiee 1801, 
 tome 11,^. 97.) 
 
 Case CLIII. — M. Delesalle mentions the case of a female 
 child with an imperforation of the anus, who passed gas and 
 fluid meconium through the urethra. After a bougie was 
 passed in for live days, the child could pass a few drops of 
 urine. It died on the tenth day. 
 
 At the autopsy the rectum was found very much distended 
 and so full of gas and meconium that the bladder was 
 crowded out of its natural situation. When the rectum was 
 opened and washed, it was found that it lu\d passed down and 
 terminated in the urethra by a small orifice. {Bulletin de la 
 Soelete Medlcale d'' Emulation de Paris, Jui7i, 1824.) 
 
 Case CLIY. — Flajani gives the description of the case of 
 a child four months old, which presented no trace of an anus, 
 and in which the fsecal matter passed out by the urethra. 
 Otherwise the child was well formed and the perinaeuin and 
 scrotum were entirely normal. Occasionally there was swell- 
 iuij; of the hvpogastrfum, and the child seemed to suffer much 
 from the attempts it made to evacuate its bowels. VVlien it 
 had readied the ajje of seven months, search was made 
 in vain for tlie rectum by two punctures m the normal 
 position of the anus. Tlie child died a month after, jn-esent- 
 ing sym])toms of retention of faecal matter, considerable and 
 painful tumet'action of the abdomen, ci'amps, &c. 
 
 At the autopsy, the colon and the greater portion of the 
 intestines were found filled with solid excrement, and very 
 much distended, 'ilie rectum was deficient about three 
 inches, and terminated in a canal about four inches long, 
 which passed under tlie prostate gland, and opened into the 
 membranous portion of the urethra. Tiie recto-urethral canal
 
 TiiK SIXTH si'i:('ii;s of M.\r,KOKM.\Tr(>x. 25" 
 
 was r(tni)(] (•(.iiiplcU'lv ohsti-iiclcd Ky a clierfy stoiio, lod^'cd 
 ill it, which hati hceii swallowed hy the chiM, mid w liich \va> 
 the imnu'diaro cause of its death. [CollrzloiK' (P Ossrrrd.-inni 
 (' lilll'fisilone di C/tinmjla. tome I V. OKnerc 3l>. Itomti 
 1798-1803.) 
 
 Cask CLY. — Zacutus Lusitauns, of Lisbon, inoiitioiis the 
 case of a male cliikl which had an iiiipeii'orate anus witli an 
 abnormal opening of the rectum into the uretlira, as the treces 
 made their exit altogether tlirough tliis passage for three 
 months. The anus was closed by a membrane, which was 
 incised when the chihl was three months old, and a com- 
 plete cure was the" result. {Prax. Med. Admir. lib. III. 
 Ohserv. 72.) 
 
 Case CLYI. — Ilochstetter reports the case of a male infant 
 who presented an imj^erforate anus with an abnormal open- 
 ing of the rectum in the urethra. {In Med. WochenUatl 
 
 JVo. 18, 1780, J^o. 19, 1788.) 
 
 Case CLYIL— Kretschmar records a case of a male infant 
 in whom the normal anus was absent, and the rectum opened 
 into the uretlira. {Ilorn^s Archiv far die Medicinsche 
 Erfah'uiuj. Band. 1. S. III. Par Ud.) 
 
 Case CLYIII. — Poulletier saw a boy three years old who 
 had an imperforate anus with a preternatural opening of the 
 rectum in the uretlira. {Dictionnairedes Sciences Medicales. 
 tome IV. p. 157.) 
 
 Case CLIX. — Schenck reports the case of a new-born in- 
 fant in whom the anus was imperforate and the rectum opened 
 into the uretlira. {Obseroatlonum Medicorxim, rai^arum, no- 
 V(frt/./n, adniirahiliiitii^ et rnonstrosarum. Lib. lY. Obs. 
 XXIV. p- 55. Framf: 1609. Folia.) 
 
 Case CLX. — Somraering cites the case of a child in whom 
 the normal anus did notexisr, and in whom the rectum opened 
 into the urethra. (Abildungen und Beschreibuncjen eingiger 
 MlmgiJjarten. S. 53. Mainz : 1791. Folia.) 
 
 Case CLXI. — Lauremberg also relates a similar case to 
 that of Sommering. (Procrest Anat. lib. I. cap. 16.) 
 
 Case CLXIL— M. Bonnet reports the case of a child who 
 presented an imperforate anus with an abnormal opening of 
 17
 
 258 THE SIXTH SPECIES OF MALFORMATION. 
 
 tlie rectum in tlie urethra. {Archives Generales de Medecine 
 de Paris. Annee 1829. totne XX. p. 576.) 
 
 Case CLXIII. — M. Willaume relates a similar case to that 
 of M. Bonnet. {Journal des Progress, tome VIII. 2?. 238.) 
 
 Case CLXIY. — Randolphe records the case of a child who 
 with an imperforation of the anus had an •abnormal opening 
 of the rectum in the urethra. {Ency eloped ie des Soience 
 Medicales de Paris. Annee 1839. jt?. 195.) 
 
 Case CLXV. — Dumas saw a child two days after birth, 
 which had no anus, but in place of the anus had two fissures 
 of the skin. The space wdiicli they enclosed was thick and 
 filled with hard tissue. The urine was mingled with fsecal 
 matter. They searched in vain for the rectum by the perin- 
 eum. The finger introduced by the periiiasal wound struck 
 the ischium. The cavity of the pelvis was, therefore, very 
 naiT'Ow. The chikl died. At the autopsy the lower part of 
 the colon was found distended with gas and fciecal matter, and 
 jutting against the abdominal muscles. The rectum seemed a 
 straight sac, movable and directed towards the left side of tlie 
 neck of the bladder, and opening into the posterior part of the 
 urethra. {Recueil per'iodique de la iSociete de Medecine de 
 Paris, tome III. p 46.) 
 
 Case CLXYI. — M. Williams communicated a case of im- 
 perforation of the anus and rectum in a male infant in whom 
 the rectum opened into tlie urethra. The great difiiculty of 
 passing the fteces • by this canal, compelled the surgeon 
 to form an artificial anus in the perimeum at the nor- 
 mal ])lace of the anus. It was necessary to penetrate to 
 a considerable depth before, the end of the rectum could be 
 reached. The fseces now pass equally through the urethra 
 and by the newly-formed anus. {Revue Medicale de Paris, 
 Antice 1S-2C). tome III^p- !"''"•) 
 
 Case CLXYII. — The following highly interesting case was 
 reported by M. Iloux de Brignoles, and fully illustrates his 
 peculiar method of operating in such instances. The ditficul- 
 ties, though formidable, were all overcome, and complete suc- 
 cess crowned the operation. 
 
 " The case was that of a new-born male infant in whom 
 there was an atresia both of the anus and of the urethra. No 
 trace of an anus could be discovered in the perina?um either 
 by the ^ight or the touch, and the urethra was closed
 
 TI1I% SIXTH SPKCIKS OF MALFORMATION. 259 
 
 by :i lliiii iiicinhniiu at the huso of the <i;lanK, coiistitiitIii«r a 
 kind of hypospadias. Tlie chikl had heeii ahnost wliolly m'<r- 
 lected for nearly two (hiys, the hibor liavini^^ l)een '8Ui)er- 
 ititciidcd by an iji;n(»raiit midwife. M. Deveze, a iiei^ldx.rin^j; 
 [)hysician, was first ealled, who after liaviiifij aseertained 
 the real nature of the case, and finding that tlie urethra m-jls 
 closed, and tliat the penis was in a state of erection, at once 
 perforated the occluding membrane with a stilette, and 
 the urine was voided, lie, however, did not venture to 
 search for the anus. On the loth of May, 1833, two days al- 
 ter the birth of the child, M. Koux was called in consultation. 
 The countenance of the infant exhibited signs of great suffer- 
 ing, the skin was dry and yellow, the abdomen tympanitic 
 and painful, and the convolutions of the intestines could 
 be distinctly traced upon its surface ; there was frequent hic- 
 cup, with vomiting of milk and sugar-water which had been 
 given. Notwithstanding the difficulties of the operation under 
 such unfavorable circumstances, M. Roux determined to haz- 
 ard the performance of it, in order to save the child's 
 life. This he did in the following manner : — He placed 
 the little j^atient on the lap of an assistant, in the same 
 manner as for the operation of lithotomy, and with a 
 scalpel divided the skin to the extent of about an inch, 
 in the exact line of the raphe, or in the situation which the 
 anus ought to have occupied. On separating the lips of the 
 incision, the fibres of the elliptic muscles of the sphincter 
 could be seen and were carefully dissected aside, and on 
 arriving at the levatores ani muscles, their fibres were also 
 separated towards the coccyx for fear of wounding the blad- 
 der. Tlie incision at the depth of an inch, and just above the 
 last layer of muscles, terminated in a mass of cellular tissue, 
 in which a soft and fluctuating tumor was perceptible to the 
 finger. The scalpel was now laid aside and a straight bis- 
 toury was directed to the spot of this indication of tlie 
 rectutn, the point being turned obliquely upwards and down- 
 wards, in order to avoid the bladder, and soon entered a 
 cavity which proved to be the rectum. For the purpose of 
 enlarging the intestinal opening thus made, the handle of tlie 
 bistoury was then raised and the blade withdrawn in this 
 position, which at once gave exit to a large quantity of meco- 
 nium, and announced the success of the operation. Injec- 
 tions of marsh-mallows water were now thrown up to wash 
 out the intestine, and a roll of lint smeared with cerate was 
 introduced into the wound and maintained there. This kind 
 of dressing was con*tinued for two weeks, after which on two 
 (•ccasions, granulations sprouted up from the borders of the
 
 2(30 THE SIXTH SPECIES OF MALFOEMATION. 
 
 wound, and narrowed and obstructed tlie newly made pas- 
 sa<>-e to such an extent that the f«cal evacuations became 
 much less frequent, and were voided with much greater tlitti- 
 culty, and what was very remarkable at the same time, a 
 small quantity of fsecal matter was discharsjed through the 
 urethra after each passage of urine. In the first instance, 
 these difficulties which seriously threatened, the success of 
 the operation, were for a short time entirely overcome by 
 simply enlarging the newly made opening towards the coccyx 
 with "the bistoury. In the second instance however, when 
 the granulations again returned causing the same difficulties, 
 they were destroyed by the nitrate of silver, and the artiti- 
 cial aims was kept open and enlarged by the frequent intro- 
 duction of bougies, until complete cicatrization took place, 
 and the faecal matter no longer came by the urethra. After- 
 wards the artificial anus fulfilled completely all the functions 
 of a natural one. The child lived and enjoyed good health. 
 [ Vide Plate X, J^igure 3.J 
 
 M. M. Capuron, Eoux de Saint Maximin and Moreau, to 
 whom this case was referred by the Royal Academy of Med- 
 icine, in their report highly extol the method pursued in it, 
 by M. E.0UX de Brignoles. {Gazette MeJioale de Parin : 
 juin 28, Annee 1834:.) 
 
 Cases CLXYIII— CLXIX— CLXX.— M. Yelpeau says, 
 that he met three cases in children of the n^de sex, in which 
 the rectum oj^ened into the excretory duct of the urine. 
 {Molt, op. cit. I). 1086.) 
 
 Case CLXXI. — The following case was communicated to 
 the " Bostm Medical and Surgical Juurnal^ 
 
 " This case occurred recently in the practice of Dr. J. II. 
 York, of South Boston, and the subject of it was a male child. 
 Intestine punctured on the third day, with a trocar, and 
 about two ounces of meconium drawn off. Canula left in for 
 a week; and the opening being then dilated with a sponge, 
 the fffices passed tolerabi}' well. At the end of six or eight 
 weeks, the opening having been still further enlarged with a 
 knife, a silver tube, three eighths of an inch in diameter was 
 introduced and kept in for about a year ; the faeces mean- 
 while passing ofi:' well. Occasionally the instrument was 
 removed and cleansed; but once or twice it became corroded 
 and obstructed, and then it was observed that the fieces 
 passed through tlie penis ; this last fact being first noticed 
 when the child was about six months old. 
 
 '' Three or four months before its death, the parents removed
 
 TIIK Sixril 9PKCIES OK MALFOUMATION. 2f>l 
 
 the tube, without, the sanction or kno\vh'(l«r(', of Dr. V. ; and 
 sooii after tliat time the t;ecc8 l)e<,^iu tc^piis-s thi-oiif,'h tlie 
 penis, and continued to do so ever afterwards. For a lime 
 they passed also throun-h the artilicial openini,^ hut for the 
 hist two months not at aih The general health of the cliild 
 was quite ii-ood, and it died at last from the eilects of a fall 
 that it received a few days before its deatii. 
 
 " Aulopxi/. — On dissection, tlie rectum was found to be very 
 much enlarged and moderately thickened ; containing some 
 liquid fjxices, besides a quantity of foreign matter. The oi)en- 
 ing into the urinary |)assage was direct, perhaps two lines in 
 diameter, and, upon cutting open the urethra, found to be 
 Justin front of the verumontanum. The opening that had 
 been made during life luid so nearly closed, that, \hough air 
 could be forced through before the parts wqyq cut open, the 
 head of a very small pin could not be made to pass. Other- 
 wise the rectum presented no unusual appearance, excepting 
 a soft, fleshy growth, about one and a half lines in dianieter, 
 projecting from the inner surface, situated upon the anterior 
 face of the intestine, a few inches above its termination, and 
 divided into two equal parts as if cut with a knife. The 
 bladder contained some liquid faeces, but no foreign substan- 
 ces such as were found in the intestine ; inner surface per- 
 fectly healthy, and organ otherwise not remarkable." {Boston 
 Medical and Surgical Journal. Vol. XLIL j>. 273. Boston : 
 1850.) 
 
 Case CLXXII. — Mr. Fergusson records the case of a male 
 child in whom the anus was imperforate, and the rectum 
 opened into the membranous portion of the urethra. 
 
 " An opening was made into the neck of the bladder, as 
 was supposed, and the operation was, in as far as circum- 
 stances would admit, perfectly successful. The boy lived 
 and throve till he was six years old, when he died of disease 
 of the lungs. Although it may be doubtful if there was a 
 sphincter or levator muscle here originally, he had the com- 
 mand over the aperture and the urinary apparatus that chil- 
 dren usually^ possess. Occasionally when his bowels were 
 loose, a few dro]3s of faeces would come by the urethra, and 
 he w^as wont also to discharge part of the urine by the artifi- 
 cial opening. On several occasions, small hard urinary de- 
 posits were discliarged from the anus, and I had to extract 
 one about the size of a hazel-nut. Often his mother had to 
 remove small seeds and barley pickles from the orilice of the 
 urethra, and once she extracted a small j)ortion of a bone 
 which he had swallowed in his food.
 
 262 Tin-: bixth species of malfokmation. 
 
 " On inspecting the parts after deatli, I found that the 
 bowel terminated in the membranons portion of the nrethra 
 by an aperture, about the size of a lancet puncture, and not 
 in the upper end of the bladder, as was originally imagined," 
 {A Sy stein of Practical Surgery. 4:th American JEdit.,p. 545. 
 Philadelphia : 1853. Also., Edhiburgk Medical and Surgi- 
 cal Journal. Vol. XXX VI., p. ^Q'd. 1831.) 
 
 Case CLXXIII. — Dr. Nagel, Professor of Surgery at Clau- 
 senbourg, communicated, on the 25th of August, 1855, to the 
 " Society of Practical Medicine of Berlin,''^ the following 
 case of imperforate anus, with an abnormal opening of the 
 rectum in the urethra. 
 
 " This was the case of a male infant in whom no anus 
 existed. A small tumor a little elevated above the skin was 
 the only indication of an anus. The meatus urinarius was 
 immediately in front of the scrotum. Hypospadias and 
 imperforation of the anus therefore existed at the same time. 
 Through the meatus urinarius small cylinders of fsecal matter 
 passed from time to time, mingled with the urine, which 
 sometimes however passed unmixed. A curved sound intro- 
 duced by this passage could easily be so turned that its ter- 
 minal extremity was felt in the normal position of the anus. 
 An incision was made upon the sound, the wound was 
 dilated, and a pasteboard cylinder was introduced into the 
 rectum. During severral days a small quantity of fgecal 
 matter passed by the urinary meatus, and of urine by 
 the anus. At the end of some months the child was doing 
 well, the anal opening M'as sufficiently large, and the urine 
 passed by the urethra alone, and the Isecal matter by the 
 anus." {liecherches Cliniques et Critiques sur VAnus Artifi- 
 ciel. Par le Dr. Hermann Friedherg. Archives Generales de 
 Medecine de Paris. Mai, 1857,^. 580.) 
 
 Case CLXXIV. — M. Godard, a resident Hospital student 
 of Paris, presented to the " Societe de Biologie de Paris^'' in 
 July, 1855, three anatomical preparations and six drawings, 
 relating to three cases of congenital imperforation. of the anus, 
 which came under his observation at the Hospital Necker, and 
 at the Hospital des Enfants Malades, wathin the year 1855. 
 These cases are highly interesting in several respects. They 
 all occurred within a short period of each other; they were 
 all male children ; the rectum in each terminated very smgu- 
 larly in the urethra by a narrow, pipe-like prolongation, and 
 the operations in each were soon followed by death. I have 
 presented these cases almost entire, translated from the origi-
 
 THE SIXTH 8PECIKS OK M.M.I ( (UMATION. 203 
 
 rial. Tlie iolldwinoj is M. (iodunrs tliiid case; his fust aiul 
 second cases will he touiid in tlie chapter on yl/^Aw//?*^//? yl/'//- 
 ficial Anus. [ Vide Cases CCLXXIX—CiJLXX XI 1 1.^ 
 
 " Charles rr(isj)er Drcel was Ixini on the 2Tth of June, IS.");'). 
 On ihe day after his birth tlie midwife discovered that he had 
 no anus, and tluit tlie mcconiuni jiassed by the nrethra willi 
 the urine. Tiiis child was admitted into the hall Saint Come 
 of the Hospital des Enfanis MahiJcs^ on the 21>th of June; 
 on this day, as well as on the i)recedin<i;, it had several times 
 vomited a peculiar matter, having the odor and the ai»j)ear- 
 ance of meconium. Pressure upon the al)domen caused the 
 meconium to be discharged in jets from the urethra. M. 
 Guersant, the surgeon of the hospital, made an incision in the 
 pcrinaium, three-eightlis of an inch long, and then pushed in 
 a trocar in the direction of the sacrum, and at once the meco- 
 nium flowed through the camila. This opening was erdarged 
 and an elastic sound was inserted. On tlie 3Uth of June the 
 vomiting ceased and the intestinal matters passed both by the 
 nrethra and by the canula. On the first of July there was no 
 change in the condition of the child, and on the third it died, 
 
 "•Tlie autopsy was made on the fourth of July, and gave 
 the following results: — The peritoneum was slightly vascular, 
 and in the pelvic cavity at the left of the rectum it presented 
 a wound, apparently owing to the puncture of the trocar. 
 The su])erior extremity of the rectum was normal, and passed 
 obliquely from above downward, and from left to right; it 
 adhered behind to the sacrum and coccyx, and in front was 
 directed towards the bladder and to the prostate, both of 
 which it touched. <,)n the left, the rectum was adjacent to an 
 abscess, which, as in the first case, was the result of the punc- 
 tures of the trocar ; the wound in the peritonaeum proves this. 
 On the right there was nothing in the rectum w^orthy of no- 
 tice. The inferior extremity of the rectum terminated in a 
 sack-like dilatation, and presented on its left side an oldong 
 openins:, whose greatest axis was directed from before back- 
 wards. "" At the circumference of this orifice a fibrous cylinder 
 was sent off, which extended as far as the anal region. This 
 cylinder was formed by a condensation of the cellular tissue 
 of the part, and was the result of the operation. Around this 
 canal the external sphincter could be dissected ; tlie fibres 
 composing it were in layers and very distinct. This muscle 
 was three-eighths of an inch in height. The dilated portion 
 of the rectum being laid open, a funnel-shaped orifice was 
 observed on its ant'erior wall, which led into a small canal 
 which passed under the prostate and opened in the urethra 
 just in front of the urethral crest. The peritonaium descended
 
 264 TiiK SIXTH srivCiES or malformation. 
 
 as usual along the niiterior face of- the rectum, flexed upon 
 the bladder, and at the point of reflection was seven-eigliths 
 of an inch distant from the cutaneous surface of the perin- 
 aeum." {Oazette MedicaU de Par'is. A7inee l^bh. No. 44. 
 p. 700.) 
 
 In relation to the cause of the formation of i\\Q filjrous cylin- 
 der mentioned in the preceding case, M. Friedberg, of 13erlin, 
 in the pathological pait of his invaluable Essay on Artificial 
 Anus, makes the following comment: " M. Godard considers 
 this cylinder the result of the operation. I contest this opin- 
 ion for two reasons — First, a flbrous cord could not form, by 
 condensation of celluhir tissue, in four days after a wound. 
 Second, M. Godard says that he found the external sphincter 
 very clearly developed around this cylinder, as well as fibres 
 covering it to the height of three-eigiiths of an inch. It evi- 
 dently follows that this fibrous cylinder descending from the 
 corrugated part of the rectum, was actually the end of this 
 intestine which had been obliterated, and upon which the 
 movable intestinal canal was extended, when it was dilated 
 with the accumulation of meconium." 
 
 Friedberg is doubtless correct. 
 
 (3.) Cases in which the Rectum Terminated in the Yagina. 
 
 Cask CLXXV. — Benivenius describes tlie case of a girl 
 who had an imperforate anus wdtli an abnormal opening of 
 the rectum. This girl, two days after her birth, commenced 
 to discharge her faeces per vaginam, and continued to do so 
 until she died, which event took place in her sixteenth yeai'. 
 She died with most excruciating colic pains, doubtless in con- 
 sequence of obstinate constipation and induration of the fieces, 
 tor she usually had but one alvine evacuation in eight days. 
 {Lihellus de Ahditis nonnvllis ac tniixindis Morhorum Sana- 
 tionum Causis. cap. 86. Basil: 1529.) 
 
 Cask CLXXVI. — Van Swieten relates the case of a young 
 woman who was afflicted with the same disgusting malforma- 
 tion as the one mentioned by Betiivenius. There was in this 
 case an iniperforation of the anus with an abnormal opening 
 of the rectum. 
 
 No surgical operation is said to have been performed either 
 in the case of Benivenius nor in this of Van Swieten. {Com-
 
 THE SIXTH SPKCIES OF MALFORMATION. 20; 
 
 m 
 
 enla/'id in Ihnnainu Boerhaave Aphorisinos do cognoHccuilis 
 et curandis MorVis. Lib. IV. Aph. 1340, p. 575. Ludo. But. 
 1785.) ^ •" 
 
 Cask CLXXVII. — Mcrcuriulis reliUcs the rciiKirkiiMc c.-isc 
 of a ytHiiiiJj Jewess, the diiir'^litcr of a i\-si<KMit of I'adiia, 
 iiaiiUMl Teiitouicus, who was born without an anus, and (lis 
 chai'iiX'd tlie feces altogether through the vagina. i^De Mor- 
 huH Pnerot'iun. Lib. 1. c. 9, Ve)ietu.s\ 178.3. 4:(<t.) 
 
 In this curious and fai--faini'(l ease of that day, there was 
 an iiu]ierforate anus with un abnormal opening of the rectum 
 into the vagina, tlirough which tlio fiecal matter was dis- 
 chai'ged ; yet strange to say, that tliis remarkable patient, 
 with this great affliction, attained to the extraordinary age of 
 a whole century, as Morgani testifies. lie also says that Mer- 
 curial is pei'formed no o])eration himself in this case, and ad- 
 vised the father of the girl never to suffer one to be perfoi'med 
 bv any one. {De Sidlbus et Causls Morborxim Epist. 
 XXXII. Art. 3. Venellis 1761. 2 (o)n. Folia.) 
 
 Case CLXXVIII. — De Jessieu mentions the case of a girl 
 seven years old, whom he knew, who had an imperforate 
 anus with an abnormal opening of the rectum. Tiiis girl 
 from infancy had always discharged her fiEces per vaginam. 
 No operation is mentioned as having been performed. {^Ilis- 
 toire de V Academic des Science. AnnSe 1719. p. 42.) 
 
 Cask CLXXIX. — Htesbart says that he saw a .young 
 woman, twenty years of age, who passed her faeces altogether 
 per vaginam, the anus being imperforate. She always had 
 excellent health. No operation was performed. (Jfiseel- 
 lanea curiosa svm ephem. acad. natur curiosor, decur. II. 
 anil. X. Observ. 1^. p. 132. 1691.) 
 
 Case CLXXX. — Dodonpens records the case of a child in 
 whom the anus was imperforate and the rectum opened into 
 the vagina. [Anjiotationes ad jBeneviuin, cap. IX.) 
 
 Case CLXXXI. — Amatns Lnsitanus records a case of a 
 female infant in whom no natural anus existed, and the 
 rectum communicated freely with the vagina. [Ouratlonum 
 Medicinalium. Cent. II. curat. 10. Venet : 1653.) 
 
 Case CLXXXII. — Schenck also reports a case of a female 
 child in whom no normal anus was ]^resent, and in whom the 
 i-ectum opened in the vagina. {Opus ciiatum. Lib. III. 
 Sect. I obs. 258. p)- 458.)
 
 266 THE SIXTH SPKCIKS OF MALFOKMATION. 
 
 Case CLXXXIII. — Peteriiiann observed a child in wlioin 
 iu> imtnral anus existed, and in whom the rectum opened 
 into the va<2;ina. {Observationes Medlcm, dec. II. Ohs. 2. 
 Lipsm : 1707.) 
 
 Case CLXXXIV. — Ilartmann saw a child that was in 
 excellent liealtli and growing rapidly, who presented an 
 imperforate anns, and who passed the faeces altogether per 
 \ aginam, {Miscellanea curiosa she ephem,. acad, noiur curi- 
 osor, decur. II. ann. 1691. />.279.) 
 
 Case CLXXXY. — Alix saw a chikl in whom no anus 
 existed naturally, who by an abnormal anus, discharged the 
 feces through the vagina. [Ohservat'iones ChirurgiccB, tome 
 III p. 203. Altenhurg : 1774.) 
 
 Case CLXXXYI. — Papendorf observed a female infant in 
 M-liom no normal anus existed, whose rectum communicated 
 with the vagina by two abnormal orifices, and through which 
 all the fsecal matter was passed. {Abhandlung von der angeh- 
 ohrnen Yerschlicssung des Afters hey Kind r en. Leipzig: 
 1783.) 
 
 Case CLXXXYII. — ^Wandermonde saw a female child in 
 whom all the faeces were passed by the vagina, there being 
 no natural anus. {Recueil Periodigue de la Societe de Medi- 
 cine de Paris, tome VI. p. 128.) 
 
 Case CLXXXYIII. — Arand relates the case of a female 
 child in whom there was an imperforate anus and a communi- 
 cation ol the rectum in the vaginal canal, through which the 
 fiEces were passed. {Ohservat. Med. Chirurg. obs. IV. jp. 28.) 
 
 Case CLXXXIX. — Fiirst re2:>orts the case of a female child 
 who presented an imperforate anus, with the rectum opening 
 into the vagina. {Miscellanea curiosa sive ephcTn. acad. natur 
 curiosor. decur. II. arm III ohs. 112.) 
 
 Case CXC. — Bonn records a case in which the anus was 
 imperforate and the rectum opened into the vagina. (Papen- 
 dorf. Opus citatum.) 
 
 Case CXCI. — Kirsten saw a child whose anus was imper- 
 forate and the rectum tei'minated in the vagina. {Act nat. 
 vur, Llh. IX. ohs. XI. p. 24.)
 
 THK SIXTH SPKCIKS OF MALKcjltMATION. 267 
 
 Cask CXCII. — Ilocliard oLsorvt'd the cnno of a fcinalo 
 iuttint in whom tlie {uius was iinpcrfonitc aii<l tin; rL-ctuiii 
 coimnuiucated with tlie vagina, {Jtmrnal de Medicine, Ch'ir- 
 xirgie, Pharmacie. tome LXXXV. p. 3 TO.) 
 
 Case CXCIII. — M. Fournier relates a very interesting case 
 in which he was called to consult, of a woman who had been 
 five days in lal)or. On making an examination, he discovered 
 no trace whatever of an anus in its natural situation, it l)ein'>- 
 congenitally imperforate ; the rectum he found tilled with 
 foeces, compressing the uterus, and tliat the abnormal opening 
 of the rectum which M^as large, entered the vagina. He 
 administered an enema, after which the fieces were evacuated, 
 and the acconchement safely terminated. {Dictlonnaire des 
 Sciences Jledicales. tome IV. p. 155-6.) 
 
 Case CXCIY. — Mr. Cooke, whilst attending a woman in 
 labor, who was nearly forty years of age, discovered that with 
 the descent of the foetal head, excrementitious matters escaped 
 per vaginam ; and also that a congenital communication 
 existed between the vagina and the rectum, sufficiently large 
 to admit two fingers. {English Translation of Moryagni. 
 Vol. II. I). 110. Boston : 1824.) 
 
 Case CXCV. — Mr. Cooke reports the case of a female 
 infant wdiich was brought to him, in which the rectum com- 
 municated with the vagina, through wdiicli all the faeces Avere 
 discharged. An anus indeed existed at the natural situation, 
 but so rigidly contracted that a small probe could scarcely be 
 introduced. {Opus citatum.) 
 
 Case CXCVI. — Mr. Howship reports the following case of 
 imperforate anus with an anormal opening of the rectum in 
 the vagina. 
 
 " In 1815, I was requested by my friend, Dr. Samnel Merri- 
 man, to examine the body of a young woman, aged seventeen, 
 who had died of a scrofulous disease, and who from birth had 
 evacuated her stools by the vagina ; although there Avas in 
 this case no w^ant of power of retention. 
 
 '■'- Post-Mortem Examination. There was an external mark 
 in the natural situation of the anus, but no opening. Upon 
 laying open the abdomen, the intestine rectum was traced 
 down to the posterior part of the vagina, to which it was 
 adherent. 
 
 "The vagina being removed and laid open, the intestine was 
 found to open upon its surface, by a very vascular and prom-
 
 268 Tii;<; sixth species of malformation. 
 
 inent sort of papilla, situated witliin the vagina, near the os 
 externum.'" {^Practical Ohservatlons in Surgery and Morhid 
 Anatomy. />. 321. London: 1816.) 
 
 Cask CXCVII. — The following liighly interesting case in 
 whicli the rectum terminated, by an abnormal opening, in 
 the vagina, was communicated to the ''Medioal Recorder'' by 
 the able and distinguished surgeon, J. Rhea Barton, M.D., 
 formerly surgeon of the Pennsylvania Hospital, and of the 
 Philadelphia Alms-House Infirmary. 
 
 "Tiie subject of this imperfection was a female infant, 
 already six weeks old. Upon examining the part, not the 
 slicjhtest trace of an anus was to be seen ; but I soon observed 
 tiie faeces, says Dr. Barton, with much suneringto the patient, 
 simultaneously voided with the urine jy^'r vaginam. A minute 
 inspection of this part, led to the discovery of a fistulous 
 aperture through the recto-vaginal septum, and communicat- 
 ing with some part of the intestine. The mother evinced 
 that degree of distress at the unhappy deformity of her off- 
 spring, and commiseration for its sufferings that might be 
 expected from a tender parent, and was extremely solicitous 
 for its relief. Accordingly, the operation, as is usually 
 directed in cases of imperforate anus, was performed ; 
 namely, by making an incision through the parts where the 
 anus should be, tt:c., &c. The instrument passed into the 
 rectum, and upon withdrawing it, fffices esca])ed freely. The 
 part was then plugged with patent lint dipped in sweet oil, 
 to prevent re-union. Not many days before the wound be- 
 gan to granulate and rapidly cicatrize ; to prevent, therefore, 
 its closure, a piece of bougie was introduced, and brouglit 
 out of the vagina through the original opening into it. Tliis 
 tent caused much irritation and suffering; but as it was 
 deemed advisable, its use was persisted in for several weeks. 
 The mother, wiio in the meantime had left the city with her 
 infant, findino; it productive of no good effect removed it ; and 
 the part soon closing up, rendered the opei'ation abortive. 
 
 "When the infant had attained the age of nine months, the 
 father called upon me, and announced the increased sufferings 
 of his child, owing to the still existing defect, and greater re- 
 tention of faeces, from their becoming more consistent as the 
 patient grew older, stating also, that without tlie effect of 
 aperient medicines, there would be an evacuation not oftener 
 than once in four or five days, and sometimes prolonged to a 
 period threatening death. 
 
 " In taking the case into further considei'ation, the following 
 mode of operating suggested itself to me, as one promising
 
 TIIK SIXTH SPKCIES OF MALFORMATION. 2(^9 
 
 SUCC0S8. To tak(^ tor 1113' i^Miido into tlio n-ctniii tliu ojx'iiiii:,' 
 coniiuunicatini^ witli the v;i<,Mnu; to iiitroducu into it adinjctor, 
 and with a bistoury to lay open the vagina and inti-^runu'iits 
 as far l)ack as the pai't where the amis should he ; ihcic in 
 remove! a small pt»rtion of the inte:^'uments, if necessary, and 
 to dissect down until I came to the tei-minatiou of the i;ur, 
 and to open it freely. By this operation the antei-ior houndary 
 of the incision would be the listulous openini>; in the vaL;'ina, 
 and posteriorly it would terminate where the natural outier. 
 ou^ht to be found. The subsequent ti'eatment t(^ consist in 
 endeavorini; to ])romote granulations and the cicatrizinir of 
 the original opening, and so much of the anterior ])ortion of 
 i'.utislon as rendered the vagina incomj)lete ; in the mean time, 
 to keej) the remainder open until this shall have been etfected. 
 This plan was pursued, and I had the pleasure to succeed 
 most ])erfectly in all my views. The integuments around the 
 incision retracted, and thereby obviating the necessity of re- 
 moving them. The original aperture closed up with that 
 ])art of the incision connected with it. The vagina became 
 complete, and a route direct from the rectum was established, 
 havino; no communication whatever with the vaii-ina. 
 
 " In this case there was no sjjlimcter ani muscle ; in conse- 
 quence of which I had nearly been deterred from the 
 operation, by the opinion of some of my medical friends, wlii> 
 nuiintained that even thouii-h I should succeed in establishin<^ 
 a direct outlet from the rectum, the patient would throughoiir 
 life, labor under the lamentable misfortune of being uiuible 
 to control the evacuations, tor want of a sphincter muscle. 
 Reflecting, however, upon cases of fistula in ano, where this 
 muscle had been divided by the bistoury, I recollected that 
 the patients even there were enabled to exercise a limited 
 degree of restraint over the part by the action of the general 
 muscular coat of the rectum, or, as it is sometimes described, 
 the internal sphincter muscle. Under a belief, therefore that 
 this part of the structure, from continued use, would in time 
 assume the functions of a proper sphiircter, I operated with 
 confidence of success, and was not disappointed. The little 
 patient never found any difficulty from that source." {Med- 
 ical Recorder, Vol. V'lLp.2,bY. P/u7. 182i.) 
 
 Case CXCYIII. — The following interesting case, similar 
 to that operated on by Dr. Barton, was communicated to the 
 ~" Medical Recorder,^^ by Dr. Satchell, then House Surgeon to 
 the Pennsylvania Hospital. The late and lamented Di'. 
 Parrish, of Philadelphia, was the successful operator in this 
 case.
 
 270 THE SIXTH SPECIES OF MALFORMATION, 
 
 " Jane Dimraick, aged about fifteen montlis, was admitted 
 into the Pennsylvania Hospital on the 6th of February, 1823, 
 durin£:; Dr. Parrish's tour of duty. Slie was afflicted with 
 imperforate anus, the fseces being passed per vaginam 
 through a small opening situated about lialf an inch from the 
 OS externum. The depression in wliich the anus should have 
 existed, was quite smooth, and exhibited no mark whatever 
 of the proper structure. The child passed her faeces with 
 considei-able pain, at intervals of ten days or two weeks, 
 which were fluid or of a very soft consistence., 
 
 " Under the impression that the rectum terminated in a cul- 
 de-sac, Dr. Parrish, on the 18th of February, performed the 
 following operation. A probe, having a curvature suited to 
 the purpose, was introduced into the vagina, thence through 
 the orifice of communication into the rectum, so as to pro- 
 trude the integuments in the place where the anus should 
 liave been. An incision was then made upon the point of 
 the probe with a small scalpel through tlie integuments, and 
 the opening thus formed was freely enlarged both anteriorly 
 and posteriorly, by means of a bistoury, until it was supposed 
 that the intestine was opened, no discharge of fseces being 
 the only circumstance of evidencing tlie contrary. Presum- 
 ing, however, that the rectum was freely opened, a silver 
 tube somewhat in the form of a nipple, with a curvature 
 adapted to the bowel, and with shoulders, anteriorly and 
 posteriorly, for the purpose of confining it in its situation by 
 means of tape, was introduced with the view of obviating a 
 closure of the wound, and at the same time of allowing the 
 evacuation of the faeces. But in the course of two or three 
 days, it was positively ascertained that tlie rectum had not 
 been opened, and that even if it had been opened, it would 
 have been utterly impossible to have prevented a reclosure 
 of the gut. 
 
 " The disease, or rather the malformation being unique in 
 the practice of the institution, it elicited a good deal of atten- 
 tion and interest, and it was ultimately agreed to attempt a 
 mode of cure, which had proved entirely successful in a very 
 similar case that had occui'red to Doctor J. R. Barton. Encour- 
 aged by the success of this case. Dr. Parrish performed a like 
 operation upon his little patient, and liad the pleasure of 
 succeeding to the extent of bis wishes. A very large quan- 
 tity of impacted faeces was found to occupy tliQ rectum, and 
 by means of the handle of a teaspoon, enemeta, and repeated 
 doses of the Olei Picini, the bowels were thoroughly emptied. 
 
 " On the 6th of March, two days after the last operation, the 
 child voided an unaltered water-melon seed, which must hav
 
 TIIR SIXTH SPKCIKS OF MALKOUMATK >X. liTl 
 
 been in the bowels since tlie ]»recc(lin<; full ; and inilccij 
 there is reason to believe that she never passed jmy solid 
 excrement. The faeces were at first of a dark color, and 
 very offensive, bnt soon acquired the natural yellow appear- 
 ance. The wound healed; and on the 'JTtli of March, three 
 weeks and two days after the second operation, the child was 
 discdiarii'ed cured. At the time of her disciiar<ije, she 
 appeared to possess considerable jjowcr over the anus, and 
 indeed she could retain or discliari^e her faeces at pleasure. 
 
 '• We have every reason to believe, that the rectum termin- 
 ated in this case, in the vagina, and not in a cul-de-sac, as 
 was at tirst presumed. I will merely add, that no dressings 
 were used, but the linger lubi'icated with simple cerate was 
 introduced every day or two, in order to do away any ten- 
 dencv which the opening mii^ht have to heal." {Medical 
 Recorder, Vol. VII. p. 359. PA^/. .' 182J-.) 
 
 Cask CXCIX. — Pi-ofessor Dieifenbach reports the case of 
 a female child three months old, in whom there was not the 
 least trace of an anus visible external I3", the rectum termin- 
 ating in the vagina in its posterior wall, by an abnormal 
 opening. In this case Dieffenbach performed the following 
 operations at two different times. He first introduced a 
 grooved director considerably curved, through the vagina 
 into the recto-vaginal orifice ; thrust a pointed bistoury imme- 
 diately below the fossa navicnlaris, out-side of the vagina, 
 into the groove of the director, and divided all the cellulai- 
 and muscular tissue between the point of the puncture and 
 coccyx. He then dissected off the end of the rectum from 
 the abnormal opening, and isolated it for some distance 
 from the surrounding parts, which enabled him to draw 
 down the freed end of the bowel and attach it to each edge 
 of the cleft perineum. The cut edges of the rectum united 
 to the skin, and the recto-vaginal aperture closed very com- 
 pletely, after having been occasionally touched with the 
 nitrate of silver. 
 
 Three weeks after the first operation, and after complete 
 union of all the wounded parts had taken place, he attempted 
 the formation of an artificial perina3um. He commenced by 
 finishing the separation of the superior wall of the rectum 
 from the vagina with a bistoury. This portion of the rectum 
 thus set free in the centre, contracted considerably, and 
 receded about half an inch. The deep-seated soft parts were 
 brotight together by a needle-stitch, whilst the edges of the 
 wound were united by two short hare-lip pins and the twisted 
 suture. The cure was completely successful. {Oher die
 
 272 THE SIXTH SPECIES OF MALFOKMATION. 
 
 VerseJiUessung des Afters. In Ileckers literarischcn Anva- 
 len. January., 1826. 8. 31.) 
 
 Case CC— AslibcU Smith, M.D., of Salisbury, IS^ortli Caro- 
 lina, reported tlie following case : 
 
 "This was the case of a female infant. Tlie accouchement 
 of the mother was at the end of the ordinary period ; of the 
 lir;;t child, easy, and presenting nothing worthy of record. 
 The child was of the usual size, healthy, and exhibited no 
 malformation except the one which I am about to describe. 
 Some time after its birth, it was discovered that an anus was 
 wanting, and that the excrements were voided through the 
 vagina. The patient continued to void her fteces, in this way, 
 till she was four months old, lacking five or six days, when an 
 operation for artificial anus was performed. 
 
 " At the time of the operation, July 7, 183-1, the general 
 health of the little patient was good, unless we except a some- 
 what costive habit. It has been raised partly by the bottle, 
 in consequence of a deficient secretion of its mother's breasts; 
 but the derangement of its health was not greater than 
 almost invariably accompanies imperfect nourishment, in the 
 way instituted by nature. Tlie genital organs, on careful 
 examination, did not present eortcriiallij anything remarkable 
 or abnormal. The clitoris, the labia, the fourchette, the 
 meatus urinarius, were of the usual size and well formed. 
 The hymen existed, but was small. Whether the os tinea?, 
 and of course the womb, existed, I could not conveniently 
 discover. The rectum terminated in the posterior and upper 
 portion of the vagina. The perinoeum offered no trace of 
 anus, except it were that the place it should have occupied 
 w'as thought to be marked by a very slight brownish discolor- 
 ation. 
 
 " The operation was performed in the usual way. Assisted 
 by my friend. Dr. E. R. Gibson, I made an incision in the 
 place commonly occupied by the anus, and continued it along 
 the direction of the coccyx until I arrived at the rectum. 
 The depth of this incision was from nine to twelve lines. 
 The rectum was thus opened to the extent of two-thirds or 
 three-fourths of an inch, and some fffical matter was discharged 
 through the incision. A transverse incision was made, and a 
 tent smeared with sweet oil, was placed in the wound to keep 
 it open. No untoward symptom succeeded the ojxn-ation ; 
 the inflammation was moderate, and did not extend beyond 
 the wound, nor in any degree complicate the general health. 
 
 '• About seven months after the operation, February, 18^."^, 
 I again saw the patient. The artificial anus was perfectly
 
 THE SIXTH SPECIK8 OF .AIAhroKMATlON. 273 
 
 healed, :in<l wuild then easily admit an iirelhni! I.un^noof the 
 lai-<,a'st size, beiii_j;- of less dimensions ihan the ()ri^ri„arincisi..n 
 in consequence, as i.s pi-obabk-, of tiie ditlicuhy in maintainin-r 
 the tent in its phico._ The tent had been for a lon^- time- di" 
 used, and the artificial anus showed no disposition t(:) conliact 
 further. Its parietes were covered with a smooth and ai)i)a- 
 rentlj or<j:anized membrane. The fieces were discharn-Jd 
 partly through the recto-vaginal canal. It was intended to 
 enlarge, at some future time, the artificial anus, but the 
 patient died of an acute disease some weeks subsecpientlv to 
 the last date, or more than eight months after the operation. 
 No cadaveric examination, I understand, was made." {Ainer- 
 lean Journal of the Medical Sciences. No. XXXIV.. p 341 
 Februarxj, 1836.) 
 
 Case CCI. — The celebrated M. Eicord, of the Hospital du 
 Midi of Paris, relates a very interesting case of a courtesan 
 twenty-two years of age, in whom the rectum terminated in 
 the lower and back part of the vagina by an orifice which 
 permitted the introduction of the index finger without pain, 
 who had come, at the request of one of her lovers, to consult 
 him as to whether or not she had a Mennorrhagia. 
 
 " M. Ilicord introduced the speculum easily, and at first 
 nothing abnormal was seen. The depth, however, to which 
 the instrument was carried without meeting the neck of the 
 uterus, began to excite some astonishment, when a lump of 
 fiBcal matter was brought into view, simulating to the touch, 
 the OS uteri ; and also some grape seeds, at first taken for 
 vegetations. Some malformation being now suspected, a 
 more careful examination was made. Tlie external organs 
 were natural, but there was no anus, the place where it ought 
 to be being marked by a brown spot, irregularly radiated and 
 of the size of a shilling. The ring of the vulva did not pre- 
 sent any carunculiB myrtiformes, had eccentric folds of mu- 
 cous membrane, and possessed a much greater contraction 
 than the natural constrictors of the lower part of the vagina, 
 but less than the sphincter ani. Beyond this vulvar ring, the 
 finger passed easily into the recto-vaginal canal. No trans- 
 verse rugse were found as usual in the vagina, and the specu- 
 lum, when introduced to its full length, was arrested by fiecal 
 matter. No trace of the uterus could be seen or felt. By her 
 account, the fseces were always passed by the vulva, and 
 were perfectly under the command of volition, but flatus 
 sometimes escaped involuntarily. When the faeces were at 
 the vulvar ring, she felt a desire to go to stool, and when this 
 desire was satisfied, the finger, introduced as far as possible, 
 18
 
 274 THE SIXTH SrECIES OF MALFOKMATION. 
 
 no longer met with any obstacle. An injection was always 
 used ini mediately after, and she was careful in keeping her- 
 self clean. Menstruation had never shown itself under any 
 form, and no trace of blood was ever found in the urine or 
 fffices. Although she had lived with one of her lovers for 
 three years, he never, in the least, suspected any malforma- 
 tion. She never had been subjected to any operation." 
 {Journal Universel et Hthdomadaire de Medecine, etc. tome 
 XII., p. 167. Faris: Octobre, 1833.) 
 
 Case CCIT. — Switzer mentions the case of a public girl 
 whom he knew, who had a congenital imperforate anus, and 
 in whom the rectum opened into the vagina. This girl 
 informed him that she suffered no pain in passing the fneces, 
 or was in the least troubled if she washed herself well with a 
 sponge after each evacuation. If her words are to be believed, 
 says Switzer, she had numerous lovers. {Annotationes in Co- 
 lotomiam^p.l'i). IlafnicB : 1826.) 
 
 Case CCIH.— On the 12th of October, 1857, C. G. Page, 
 M.D., read to the " Boston Society for Medical Improve- 
 ment^'''' the following very interesting account of a case of im- 
 perforate anus, with the rectum terminating in the vagina. 
 Tlie case was that of Dr. S. F. Ainsworth. 
 
 " Mrs. K was delivered of a female child, mature and 
 
 of average size, early on the morning of Monday, July 20th, 
 1857. On examination, two openings w^ere found in the 
 vagina, one occupying the place of the urethra, the other sit- 
 uated between the internal labia and surrounded by a small 
 red tumor, the size and shape of a common bean. Both these 
 openings barely admitted a common probe, and from both, 
 while under examination, a small quantity of yellow meco- 
 nium and urine was expelled. TheTe was no external trace 
 of the anus, the skin over the entire perina^um being smooth, 
 and the raphe extending to the coccyx. At each expulsion 
 of the meconium or in-ine by the vagina, a slight motion was 
 observed in the perinasum, as if some fibres of the levator ani 
 were inserted into the fascia. On exploring the openings in 
 the vagina, it was found that a probe carried upward close to 
 the pubis passed into the bladder, and could be felt on the 
 abdomen ; but directed backward and upward, it passed in 
 half its length and then encountered a firm body which was 
 supposed to be the upper part of the sacrum. When passed 
 downward, the point could be carried a few lines below the 
 orifice and indistinctly felt in the perinjeum. The child being 
 quiet and apparently liealthy, it was decided to cut down on
 
 THE SIXTH SPECIES OF MALI'OKMATION. 275 
 
 the pcrinn3nm, and, if possible, bring down the rectum. On 
 Tuesday, assisted by Drs. C. (r. Page and C. II. Stetbuan, the 
 operation was commenced by introducing a probe into the 
 lower opening in the vagina, and passinf^ it downward as far 
 as possible. An incision was then matle along the raphe of 
 the perinroum, and continued in the track of the rectum 
 about an inch and a half; the point of the ])robe M'as then 
 distinctly felt, the tissues wefe carefully separated from the 
 cul-de sac, and the intestine easily drawn down to the exter- 
 nal opening, where it was laid open, the serous surface 
 everted, and confined by sutures to the edges of the extermJ 
 w^ound. A quantity of flatus escaped at the moment of open- 
 ing the intestine. A small tent was placed in the wound, a 
 wet compress on the perinreum, and a T-bandage a])])lied. 
 The patient, until the following Sunday, w^as attended by i)r. 
 Page. During that time, the child did well. On visiting 
 the child on Sunday, the wound was looking w^elL The 
 nurse, for the first time stated that there had been, since the 
 birth, intervals of great distress of breathing, accompanied 
 by a purple discoloration of the face, neck, lips and ears. 
 These twrns increased in frequency, and the child died on 
 Tuesday, having lived eight days. 
 
 " The following is the account of the autopsy : 
 " The heart was found malformed, there being but one ven- 
 tricle into which the aorta opened directly at its summit ; the 
 only auricle was situated on the right posterior aspect, com- 
 municating obliquely with the ventricle. The pulmonary 
 artery was very small, given off below the point where the 
 aorta enters the heart, and on the left side passing upward 
 and backward and bifurcating behind the aorta. An imper- 
 fect valve projected into the ventricle, attached by two short 
 and firm columnse carnese, and by two slight cordae tendinee 
 to the upper and lower left sides. The pulmonary veins 
 opened into the auricle. The rectum terminated in a cul-de- 
 sac about an inch and a quarter€rom the perinseum, and com- 
 municated with the vagina from its upper borders. The 
 uterus was bifid. Ko other abnormal appearances were 
 observed." {Boston Medical and Surgical Jommal. Vol. 
 LVIL,p.22>^. Boston: 1S51.) 
 
 (4.) Case in which the Becttim, together u'ith the Urethra 
 and Vagina^ terminated in a Cloaca hi the Perinmum. 
 
 Case CCIV. — ^The following case, reported by M. Saviard, 
 is the only one on record as far as my reading extends, in
 
 276 THE SIXTH SPECIES OF MALFORMATION. 
 
 which this extraordinary anomaly was observed in the human 
 enbject. 
 
 " On tlie 6th of January, 1692, a woman was delivered of 
 a child at the Hotel Dleu, in Paris, which M' as very defective 
 in its conformation, both internally and externally. This 
 child having only lived a few days, I carried its body to my 
 room to examine it with M. de Verney, who had desired me 
 to show him all the subjects that were remarkable. 
 
 " The hands were alike externally, down to the knuckles, 
 very even on the outside, and on the inside such folds as are 
 common ; there were no fingers at the extremity, but they 
 terminated in a large lump ; its feet were like the hands, 
 without toes, and terminated in the samg manner. 
 
 " We discovered by the dissection of the extremities, that 
 the bones of the carpus and metacarpus, of the tarsus and 
 metatarsus, were complete in number and order ; the whole 
 difference consisted in this, that it was observable there 
 appeared at the end of each bone of the metacarpus and 
 metatarsus, a small elongation that seemed to be disposed to 
 form the phalanx of a finger or a toe, but it seemed as though 
 the formation was incomplete for want of matt er. 
 
 " Tliere was nothing extraordinary in the structure of the 
 thorax ; but when we came to examine the remainder of the 
 umbilical vessels, we observed, that beside the umbilical vein, 
 tliere was only one artery instead of two, which are branches 
 of the iliac or hypogastric, and that this artery was formed 
 from the trunk of that artery which ought to have produced 
 the left iliac. When I penetrated into the cavity of the abdo- 
 men we observed the capsulm atrabilares thrice their natural 
 dimension and their vessels of the ordinary magnitude. At 
 length, not finding in the regio lumbaris, either on the right 
 or left side, neither kidneys, emulgent vessels nor ureters, we 
 began to doubt whether the capsulfe atrabilares, being of un- 
 common size, had not supplied the defect of those organs that 
 were wanting ; which induced us to examine carefully whether 
 these capsulae had no excretory ducts that might serve for that 
 purpose. Meeting with no success in this enquiry we prose- 
 cuted our dissection to a tumour upon the os sacrum, at the 
 place where it begins to be curved in order to form the^;«Zt'/.9 
 of the hypogastrium. Having opened the membrane covering 
 this tumour or protuberance, we perceived the two kidneys at 
 a quarter of an inch distance from each other, but fastened 
 together, notwithstanding, by means of a small ureter proceed- 
 ing from the left canal ; and this common canal discharged 
 itself into a large Hole^ which we call the Cystis Communis. 
 
 After we had examined the irregular disposition of those
 
 TlIK SIX'lII SPKCIKS OF MALKOIIMATION". 277 
 
 oi-o;ans mentioned, we endeavored to discover the sex (A' tliis 
 ijifunt, which lind no ;ip}»areiit marks of either externally, by 
 which a male could be distino-uishcd from a female. To this 
 end we made nse of a blow-pipe, and blew into tlie ci/.siis 
 roimmmis, whose aperture was the only one external. Tlie 
 blow-pipe introduced into this ef/si/6', aitbrded us tlie oj)por- 
 tuiuty of observing the inflation of those two small canals, 
 which were perceived to rise above a Anger's breadth, so that 
 l)ursuing this inflation, we found two small wombs, each of 
 them having a spermatic vein and artery distributed on their 
 proper side to a small testicle, which according to custom, was 
 lixed to the lif/amcntiun latum. These two wombs had each 
 their ligamenta lata and rotimda., near their trunks and bor- 
 ders, their vasa dtfereniia^ and a short vagina ; nevertheless the 
 right, somewhat longer than the left, emptied itself a little 
 lower into the cysth communis, and the small left vagina was 
 pierced to receive what was discharged from the common canal 
 of the uretlu-a, which evacuated the serum separated by the 
 kidneys into that cystis., and this, to speak truth, was only the 
 extremity of the rectimi a little dilated. 
 
 " It is very probable by the description of these organs that 
 if this child had lived to be adult, it would have been incapa- 
 ble of generation, from the mixture of the seed with the ster- 
 coral and urinary excrements. i)esides,'both these excrements 
 would have had an involuntary exit." {Ojpus citatum., Ohser- 
 V at ion, XGIY^ 
 
 Tlie ffllowing cases all belong to this the sixth species, and 
 should be so classed. Their history and description, for obvi- 
 ous reasons, will be given in the chapter on Abdominal Artifi- 
 cial Anus. — [ Vide Chapter XI.^ 
 
 Cases CCLYII— CCLIX— C CLXII— CCLXX V 
 — CCLXXIX— CCLXXXm.
 
 CH^I>TER VIII. 
 
 THE SEVENTH SPECffiS OF MALFOEMATION. 
 
 SECTION I. 
 
 DESCRIPTION. 
 
 In this singular species of malformation, the rectum, together 
 with the anus, is usually normal, hut either the ureters, the 
 vagina or the uterus, may terminate in it, hy an abnormal 
 orifice, and the urine and the menstrual fluid be discharged 
 by this unnatural route. 
 
 In these instances there often exist other malformatioDS 
 at the same time — such as the absence of the bladder, the 
 absence of the urethra in the female. 
 
 Fortunately cases of this deplorable infirmity are compar- 
 atively rare. 
 
 When the ureters terminate in the rectum, they generally 
 enter at a short distance below the line of reflection of the 
 peritonseum. (Oberteufer. Nexies Archiv. de Sta?'7c, tome 
 II.) 
 
 "When the vagina terminates in the rectum, the urethra 
 usually occupies its natural position, and the menstrual 
 evacuation passes out by the anus. What is very remarkable 
 in such cases, is the fact that through the anal orifice impreg- 
 nation has been known to have taken place, and that even 
 parturition has been safely effected by more or less laceration, 
 however, of the perinjeum. Barbout says that he delivered 
 two women per rectum. Professor Rossi mentions a singular 
 case. [Vide Cases CCXII—CCXIII—CCXVIII] M. 
 
 Louis also mentions a highlv interesting instance of the same 
 
 (278)
 
 THE SEVENTH SPECIES OF MALKOUMATION. 279 
 
 diameter. [Vide Case CCXIV.] Tliis famous case of M. 
 Louis was made the subject of bis celebrated thesis, in which 
 lie established the fact, not only of the possibility of concep- 
 tion, but also of a successful accouchement in such cases : (De 
 paituim externaram generatioiii inserventium in mulieribus, 
 naturali, vitiosa, et morbosa dispositione. Theses AnatomiccB 
 Chu'Hrgic€B^ Paris : 1753.) 
 
 This thesis of M. Louis was delivered to the schools of 
 surgery over which he presided, aud caused him to be prose- 
 cuted by the Parliament of Paris ; and the Doctors of the 
 Sorboiine interdicted him, for addressing to the casuists the 
 following question : — " In uxore^ sio disposita, tiii fas sit • 
 vel non f Judicent theologi morale?, V [Let moral theologians 
 judge, whether in a wife thus formed, the action was lawful 
 or not.] » 
 
 The Pope, however, being much more philosophic than 
 the Parliament or the Sorbonne, gave M. Louis absolution, 
 and his thesis was published in 1754. 
 
 The uterus also has been known to terminate in the 
 rectum. Yallesnieri describes such a case. [ Yide Case 
 
 ccxxi.-] 
 
 In such a case as Yallesnieri mentions, as in those already 
 named, coitus per anura, would doubtless also, be followed by 
 conception. 
 
 This species of congenital malformation does not necessa- 
 rily result in early death, as we perceive from the cases 
 reported, yet the unfortunate victims of any one of its 
 varieties, are rendered deplorably miserable for life. 
 
 SECTION II. 
 THE TREATMENT. 
 
 The powers of nature and of art combined, seem altogether 
 inadequate to remedy so serious a defect, as is presented by
 
 280 THE SEVENTH SPECIES OF MALFORMATION. 
 
 some, if not all tlie cases of this species of congenital malfor- 
 mation. Althongli surgery may be out of the question in 
 these cases, nevertlieless, they are still highly interesting in 
 a pbysiologico-pathological point of view. 
 
 SECTION III. 
 CASES AND REMARKS. 
 
 (1.) Cases «Vi lohich the Ureters Terrtiinated in the Rectum. 
 
 Cases CCV.— CCYL— CCVII.— CCYIir.—CCIX.— Cam- 
 per mentions five cases in M'hich the ureters terminated in 
 the rectum, the bladder being absent in each ; one of M"hich 
 was that of a female. {^Memoires sur les Svjets proposes jyour 
 les Prix de V Acaderaie de Chirurgie. tome V. p. 9. 
 Paris: 1775.) 
 
 Case CCX. — Klein speaks of a case in which the ureters 
 terminated in the rectum. {Rachit congenit. Hova Acta 
 Acadcmie Naturw Curiosuni. Ann. I. Observ. 38.) 
 
 Case CCXI. — Richardson relates the case of a Yorkshire 
 boy seventeen years old, in whom the nreters terminated in 
 the rectum, and who never voided his urine but by the anus. 
 Doubtless, in this case, the bladder was wanting. The contin- 
 ued passage of the urine through the anus, gave rise to much 
 irritation and diarrhoea, which did not, however, impair his 
 general health. {Philosophical Transactions of the Royal 
 Society of London. Vol. VII.) 
 
 (2) Cases in which the Vagina Terminated in the Rectum. 
 
 Cases CCXII. — CCXIII. — Barbout mentions two instances 
 of delivery by the rectum, which occurred in his practice be- 
 tween the years 1739 and 1775. In both cases the catamenia 
 flowed by the anus, there being no vulva. In one of these the 
 mother of the woman contended that her daughter could not 
 become pregnant, because the lochia was passed by the anus. 
 In one case the perinseum was torn ; in tlie other it was cut 
 with a bistoury. {Suite da Cours d'Accouchemens. tome II. 
 2?. od. Paris: 1775.)
 
 Till': SEVENTH SPECIES OF iMALF'OUMATION. 281 
 
 Cask CCXIV. — M. Louis relates the foUowiiifij hii>;]ily iiitcr- 
 estiiif:; case of a youiii;; lady m'Iio had a coiiifciiital iinjx'rtora- 
 tioii of the external ori;-ans of generation. This girl menstru- 
 ated per anuni. She was solicited in marriage by a y<»ung 
 man to whom she was much attached. After much resistance 
 she confessed to him the secret. In the height of his passion, 
 he besc»ught her to allow him to unite in the only way which 
 was practicable. She consented to everything, and became 
 pregnant. The delivery of an infant took place at the proper 
 time, causing a la(;eration of the sphincter ani. {llieses Ana- 
 toiiiicoi Chh'uiylcm. Paris: 1753.) 
 
 Case CCXV. — Portal speaks of a girl, who having no vulva, 
 the vagina o]->ened into the rectum, through which medium 
 she passetl her catamenia. She became pregnant, and at the 
 moment of delivery, the perina^um became so distended that 
 it was ruptured. {Precis de Chirurgie Pratique, tome II. 
 p. 745. Paris: 176S.) 
 
 Case CCXVI. — Engel mentions a case of a woman who 
 having no vulva, the vagina opened into the rectum. [Dis- 
 sertatio de Utero dcjicieiite. apud. Schlegel. tome I. p. 259.) 
 
 Case CCXVII. — M. Orfila mentions a similar case to that 
 of Engel. {Medeoine Legale, tome I. p. IhO. Paris: 1821.) 
 
 Case CCXVIII. — Professor Rossi has recorded a curious 
 case of a woman in whom there was complete absence of the 
 vulva, yet notwithstanding, pregnancy and natural delivery 
 took place. This woman was married, but as the malform- 
 ation of the genital organs was known, it was not suspected 
 that pregnancy could have occurred, and. consequently, that 
 the pains she felt at the approach of labor, were supposed by 
 her friends to be arising from an attack of colic. 
 
 Upon examination, it was ascertained that there was no 
 trace of the external organs of generation. Tlie pubis was 
 void of hair. It was thought that the pains might result from 
 retention of the menses. M. Possi examined the rectum, and 
 determined on making an incision of three fingers' breadth 
 in length in the natural direction of the vulva and vagina. 
 He was much astonished at feeling with his finger, which he 
 introduced into the wound, the membranous sac containing 
 the waters laying over the opening of the neck of the uterus. 
 The membranes ruptured after frecpient and violent pains. 
 The head of the fa?tus presented, and the labor was completed 
 by the natural efforts. The child lived six hours. — The incis-
 
 282 THE SEVENTH SPECIES OF MALFORMATION. 
 
 ion which had been made in the direction of the vagina was 
 kept oj^en by means of a tube which was distended with air 
 after its introduction, so that in future the canal might be of 
 Bufhcient dimensions to receive the penis. That this intention 
 was accomplislied, is proved from the fact of tlie woman liav- 
 ing become pregnant a second time, and in two years after- 
 wards she was delivered by this new passage. The inform- 
 ation which was gained from her husband led to a more care- 
 ful examination of the rectum, and an orifice was found within 
 the anus, wliich would only admit a siixall probe. This orifice 
 communicated Math the artificial canal which had been made 
 by the surgeon, and was no doubt the channel by which 
 impregnation had been efl:ected. 
 
 The reflections which were suggested to M. Rossi upon 
 considering this case, are not devoid of interest. Such was the 
 malformation of the parts, that the os uteri had no other 
 external communication but by the small hole within the 
 anus. This aperture was so small that it would not have been 
 seen, had the parts not been very carefully examined. It did 
 not pass in the direction of the opening of the cervix uteri, 
 but formed an angle with that part. It is difficult, therefore, 
 to conceive that the male semen could possibly have pene- 
 trated the uterus. He therefore imagines that " m quodam 
 spiritu, quddam. aura, exGiijus 'prcBsentla organorwm genita- 
 lium imilierum vis peculiaris modo ahsoj'hens excttaUirT 
 {Hlstoire de la Societe de Medicine de Montjpellier, tome I^jj. 
 39.) 
 
 Cases CCXIX — CCXX. — A case of absence of the vulva, 
 with the vagina terminating in the rectum, is recorded in the 
 " Meinoires de Berlin^'' for the year 1774. A similar case in 
 every respect is found recorded in the " Journal des Savants^^ 
 for the year 1777. 
 
 (3.) Case in which the Uterus Terminated in the Rectum. 
 
 Case CCXXI. — ^Yallesnieri dissected a female in wliom 
 were found two uteri ; the orifice of one opened into the va- 
 gina, whilst that of the other into the rectum. M. Fournier 
 says, in relation to this case, that there is no doubt but that 
 coitus per ajium would liave been followed by conception. 
 He founds this opinion upon the case related by M, Louis. 
 {Dictionnaire des Sciences Medicates de Paris, tome IV.)
 
 CHAPTER IX. 
 
 THE EIGHTH SPECIES OF MALFORMATION. 
 
 SECTION I. 
 
 DESCRIPTION. 
 
 This species of congenital malformation is characterized by 
 the entire absence of the rectum, or by the comj)lete oblitera- 
 tion of its whole cavity, and constitutes one of the most seri- 
 ous vices of conformation, pertaining to these parts, infallibly 
 leading to death in a few days unless the patient is relieved 
 by surgery. In these instances the colon generally ends in a 
 cul-de-sac, and either floats unattached in the abdominal cav- 
 ity, is suspended in the pelvic cavity, or fastened down to the 
 top of the sacrum. The absent rectum, in case of complete 
 obliteration, which occasionally though rarely occurs, is re- 
 presented by a fibro-ligamentous cord attached to the blind 
 end of the colon, and sometimes passing down along the sac- 
 rum and becoming blended with the cellular tissue behind 
 the prostate gland and the neck of the bladder. The pelvis 
 in these cases is sometimes abnormally small and contracted, 
 and there is generally no sign whatever of a normal aims pre- 
 sent, yet occasionally a preternatural anus does exist. 
 
 This is comparatively a very rare deformity, being by no 
 means as common as that in which a portion only of the rec- 
 tum is wanting. Some authors, however, confound these 
 cases ; they arrange under the head, ahsence of the rectum, 
 
 cases in which there is only a partial absence of the rectum, 
 
 (283)
 
 284 THE EIGHTH SPECIES OF MALFOEMATION. 
 
 thus making no distinction whether the rectum is partially or 
 wholly wanting. 
 
 This species of malformation is usually attended by some 
 other deformity, especially by a contraction of the pelvis. 
 MM. Martin, L'Eveille, and Meckel report such cases. 
 [Vide Cases CCXXXY1I^-CCXXXYIII—CCXXXIX:\ 
 
 These authors have made the important observation, that 
 in cases in which the rectum is wholly wanting, the pelvis is 
 usually very narrow, and that the nates approximate closely 
 to each other. This is doubtless the result of an early arrest 
 of development of the pelvis in its evolution. 
 
 As there is no positive or pathognomonic sign by which the 
 absence of the rectum may certainly be known, we can only 
 establish our diagnosis in the usual manner, by a thorough 
 exploration, as advised in the fourth chapter, and by search- 
 ing for, and endeavoring to reach the rectum through the 
 perinaeum with the knife. Should we fail thus to find it, we 
 conclude that it does not exist. Some surgeons in these cases, 
 recommend making an exploratory puncture over the normal 
 position of the anus ; when the rectum or some portion of it is 
 present, there will be a flow of meconium follow the with- 
 drawal of the instrument ; when the rectum is absent, no issue 
 of meconium will follow the puncture. This proceeding, 
 however, is too hazardous and too uncertain, and should never 
 be adopted. 
 
 SECTIONII. 
 
 THE TREATMENT. 
 
 The only treatment that holds out any prospect of success 
 in cases in which the rectum is wholly absent, is the creation 
 of an abdominal artificial anus. [ Vide Chapter on Abdom- 
 inal Artificial anus.'}
 
 THK I.IGIITII SrECIEb OF MALFORMATION. 2S5 
 
 M. Amnssat, I tlihik it is, wlio asks tlie question — SliouM 
 the suri^eon, in searching tor tlie rectum through the perin- 
 a3uni, l';ii! to find it, hut find tlie end of the colon or some 
 other intestine, should he bring this down in the perinatal 
 region and form an artificial anus there, in preference to one 
 in the abdomen ? I would answer 3'es — provided the intes- 
 tine met with, was long enough, had no adhesions, and could 
 be brought down easily without violence being used. 
 
 SECTION III. 
 CASES AND REMARKS. 
 
 Case CCXXII. — Binninger saw a child who presented no 
 trace of an anus, and the attempt to reach the rectum 
 through the perinseum failed. The child died ten days after 
 birth. 
 
 At the autopsy it was found that the colon terminated in a 
 cul-de-sac, and was further on, changed into a slender cord. 
 The rectum was completely absent. {Ohsero. et Curat, M<i(J. 
 ccntur. II. Olserv. ^l,p. 222, Ilontbdg : 1673. Also, Dlctlon- 
 naire des Sciences Medicates, tome XXIV. jp. 129.) 
 
 Case CCXXIII.— Bonet records the case of a child in 
 whom no rectum existed. {Sepulcretum Anatomicum. Sect. 
 XVII) 
 
 Case OCXXIV. — Morgagni records the case of a child in 
 whom the entire rectum was " solid like a ropeJ^ {Ojym 
 citatmn, lih. Ill Epist. XXXII. Art 3. et 5.) 
 
 Cases CCXXV — CCXXVI. — Ruysch mentions having 
 seen two new-born children, in whom there was no trace 
 whatever either of an anus or a rectum. No operation was 
 performed and death was the result. {Adversaria Anatorii- 
 ica, decad. 11. c. 10. p. 43.) 
 
 Case CCXXVII. — Beauregard relates the case of a child 
 in whom the colon terminated in a cul-de-sac and the rectum 
 was wanting. {Backer Journal de Medicine, Janvier, 1786. 
 p. 90.)
 
 286 THE EIGHTH SPECIES OF MALFOEAIATION, 
 
 ^ Cases CCXXYIII— CCXXIX.— Meiy relates the curious 
 circumstance of two male infants {twins) whom he saw, and 
 who were destitute of the anus and rectum ; and in both of 
 whom the colon terminated at the umbilicus in a nipple-like 
 projection, in the centre of which was an opening a line 
 and a half in diameter, through which the faeces passed. 
 Both cases terminated fatallj^ no operation having been per- 
 formed. {Historu de VAcacUjnie Royale des Sciences, Aiinee 
 1700.^. 40.) 
 
 Case CCXXX. — Henkel relates a case in which no rectum 
 existed. {Mem. Med. Clvirug. Amnerkungen, 11. 17T2.) 
 
 Case CCXXXI. — Estero mentions a case in which the rec- 
 tum was absent. {Listit. Chirurg. tome 11. Sec. V. cap. 163. 
 
 m. 1.) 
 
 Case CCXXXII. — Bonn reports an instance in which 
 there was a complete absence of the rectum. (Papendorf. 
 OjMs citatum.) 
 
 Case CCXXXIII. — Ludov^icus gives an instance of a child 
 in whom no rectum existed. {Miscellanea curiosa sive 
 ephem. acad natur curiosor. ami. III. decur. I. ohserv. 257.) 
 
 Case CCXXXI V. — Huber reports a case in which the 
 rectum was wanting. — {Acta Physco-Medica. tome VII, 
 Ohserv. 24:. _p. 64:.) 
 
 Case CCXXXY. — Matani cites the case ot a child in 
 whom the rectum was wanting. {Orteshi Giornal di Medi- 
 cini. tome III. p. 250. Padoue.) 
 
 Case CCXXXVI. — Mr. Jamieson, surgeon in Kelso, relates 
 the following interesting case of imperforate anus, and ab- 
 sence of the rectum. 
 
 "Some years ago, Mrs. Hannah, midwife in this town, was 
 called to one Mrs. Stevenson, in Plowland, five miles distant 
 from this place, whom she delivered of twins, the one female, 
 the other male ; and discovering in the latter no appearance 
 of an anus, came home, and sent me to see the child, whom 1 
 found otherwise sprightly, and seemingly in perfect health, 
 but not the least vestige of an anus to be seen or felt, but 
 equally firm and solid from the coccyx to the scrotum : where- 
 upon I told the grandmother, who only was acquainted there- 
 with by the midwife, that it was preternatural, and that,
 
 THE EIGHTH SPECIES OF MALEORMATION. 287 
 
 though I liad twice seen the anus covered by a membraiie, 
 which was easily cured, I conhl not projiose to do the like in 
 this ; but, if she pleased, I should try to reach the gut by in- 
 cision, which she, with the mother's consent, fondly agreed 
 to: whereupon I made an incision pretty deep in the most 
 reasonable })art, then introduced my little linger into the 
 wound, to tind the gut, but in vain. 
 
 " 1 afterwards tried the trocar, which penetrated, but nothing 
 followed but some gutts of blood ; so was obliged to leave the 
 patient without |)rospect of further help from me, only desired, 
 that when he died, I might be allowed to open the body, 
 which 1 did next day. 
 
 '• Upon opening the child, I saw the rectum entirely wanting, 
 and the colon was a perfect intestinam caecum^ suspended 
 loosely in the abdomen, and full of meconium ; all the other 
 parts being in a natural state." {Edinburgh 31edical Essays 
 and Ohseroations, Vol IV., Art. XXXIII,]^. 354, 1771.) 
 
 Case CCXXXYII. — Martin de Lyon saw a case in which 
 the rectum was entirely wanting. In this instance the tuber- 
 osities of the ischia approached so near each other, that the 
 pelvis was almost closed. {Meriioires de la Societe de Sante 
 de Lyon, tome I, p. 185.) 
 
 Case CCXXXVIII. — Meckel reports a case in Mhich tlie 
 rectum was absent, and the pelvis quite small and contracted. 
 {MeiVs Archivfur die Physiologic, Band IX., Heft I.) 
 
 Case CCXXXIX. — M. Leveille reports the case of a child 
 in whom the rectum was entirely wanting, and the pelvis so 
 small and contracted that it presented quite a deformity. 
 {y)Ki^-A\\\\, Journal de Chirurgie, tome IV., sur V imperfora' 
 tlon d\mus.) 
 
 Case CCXL. — Giering mentions an instance of a child in 
 whom no rectum existed. {8el Med. Francqf. tome IV., 
 p. 137.) 
 
 Case CCXLI. — Fitteau reports the case of an infant in 
 whom the rectum was entirely absent. (Sedillot, liecueil 
 Periodiqiie. tome II., p. 101.) 
 
 • Case CCXLII. — Carvenon cites the case of a child in whom 
 the rectum was w^auting. (Sedillot, Eeoaeil Periodique. tome 
 II., p. 36.)
 
 288 THE EIGHTH SPECIES OF MALFORMATION. 
 
 Case CCXLIII. — Oosterdyke reports the case of an infant 
 ill wliom no rectum existed. (Papeudorf. Opus citattiin.) 
 
 Case CCXLIY. — Fleisclimann reports tlie case of a male 
 child in whom both the anus and the rectum were wanting, 
 and the colon terminated in a cul-de-sac and hun^ looselj in 
 the abdominal cavity. [ Vide Plate XIII, Figure l.J 
 (2>« Vitiis Congenitis Circa Thoracem et Abdomen. Tab. 
 IV. ErdargcB 1810. Uo>, 
 
 Case CCXLV. — Otto cites the case of an infant in whom 
 the rectum was absent. {PatJiologische Anatomie. Bres- 
 lau: 1813.) 
 
 Case CCXLYI. — Dr. Palmer dissected the body of a child 
 in whom the colon, after reaching the vicinity of the left kid- 
 ney, began, as it descended, to form a sigmoid flexure, but 
 previously to its arrival at the concavity of the left ilium, 
 made a sudden turn to the right, and crossing the psoas mus- 
 cle, reached the projection of the sacrum, where it terminated 
 without at all entering the ])elvis. With this malformation 
 was combined an imperforate meatus urinarius and other con- 
 siderable deviations of the genital organs from their natural 
 structure. [Medico- Vhirurgical Journal. Vol. I. London : 
 1816.) 
 
 The case of Dr. Palmer was that of a female child who 
 lived four days, and upon whom the operation for imperforate 
 anus had been performed without success. 
 
 Case CCXLYII. — M. Jacquemin witnessed the following 
 case of this species of malformation : 
 
 " Several years since, an intant was brought to the consult- 
 ation of M. Dupuytren, at the Hotel Dieu, who had not yet 
 passed meconium. A bistoury was introduced about an inch 
 without giving issue to any faecal matter. The parents 
 refusing permission to make any further attempt, the child 
 shortly died. At the autopsy it was discovered that there 
 was an entire absence of the rectum." {Revue Medicals de 
 Paris. Mai, 1835. p. 286.) 
 
 Case CCXLYIIL— Mr. AYcst says that Mr. Arnott commu- 
 nicated a case to him in Avliich the child lived seven weeks 
 and three days, the rectum being entirely absent and the 
 colon terminating in a blind sac, and floating loosely in the
 
 TIIK KIOIITII SPKCIES OF MALFOKMATIOX. 28^ 
 
 abdominal cavity. {Lectures on the Diseases of Infancy and 
 Childhood, p. 376. Philadelphia : 1854.) 
 
 The following case belongs to this the eighth species, aiul 
 should be so classed. Its history and description will be 
 given in the chapter on Abdomitial Artifoial Anus: 
 
 Case CCLXXIL 
 
 19
 
 THE NINTH SPECIES OF MALFOKMATION. 
 SECTION I. 
 
 DESCRIPTION. 
 
 In this species of malformation the rectum and the colon 
 are both absent, and generally some other portion of the 
 intestinal canal terminates externally in a preternatural anus, 
 at some extraordinary part of the body — such as at the 
 umbilicus, left iliac fossa, the lower part of the abdomen just 
 above the symphysis pubis, below the scapula, and at the 
 side of the face, as it has been known to have occupied each 
 of these situations. No normal anus ever exists. 
 
 Writers generally in describing these cases remark that it 
 is the rectum which terminates externally in an abnormal 
 anus, at these distant and unusual situations of the body. 
 This is, however, a great mistake, for in these instances th« 
 rectum and the colon are absent ; indeed, the rectum when 
 present has never been known to have terminated at any of 
 these extraordinary points of the body. I have already 
 shown, in the sixth chapter, the various abnormal situations 
 at which the rectum has been known to have terminated 
 externally in a preternatural anus. 
 
 This species of malformation is but seldom met with, and is 
 usually attended by other aberrations of structure. Tlie preter- 
 natural anus or faical fistula which generally attends it, is a most 
 disgusting infirmity, and unfortunately one, which in the ma- 
 jority of cases, can be but little, if any, benefited by a surgical 
 
 operation. It does not, however, always necessarily at once 
 
 (290)
 
 THE NINTH SPECIES OF MALFORMATION. 291 
 
 prove mortal, as would be the case if no opening at all 
 existed, but on the contrary the miserable patients have been 
 known to have lived for months and for years. Happily such 
 cases are not common. 
 
 Sometimes this malformation is not accompanied by an 
 abnormal anus, and then it is truly formidable, there being 
 no rectum, no colon, and no outlet whatever for the passage 
 of the excrementitious matters. 
 
 By a proper exploration, the existence or non-existence of 
 the colon, can be very easily ascertained, and the diagnosis 
 established accordingly. 
 
 SECTION II. 
 
 THE TREATMENT. 
 
 "When the absence of the rectum and the colon is not 
 accompanied by a preternatural anus, the case, as before 
 observed, is desperate, and demands immediate treatment. 
 Nothing but the formation of an abdominal artificial anus, 
 either in the caecum, or in the ileum, holds out any hope of 
 saving the life of the patient. 
 
 M. Yoisin, in a case in which the rectum and colon were 
 absent, but which was accompanied by an abnormal antis 
 situated in the hypogastrium, established an artificial anus in 
 the abdomen, according to the method of Littre. Instead, 
 however, of opening the colon as he thought, which in this 
 case was absent, he opened the ileum. [ Vide Case CCLX.'] 
 
 Should the abnormal anus which usually attends this mal- 
 formation, or this absence of the rectum and colon, be of sirffi- 
 cient size to admit of an adequate discharge of fseces, it ought 
 not to be interfered with. Should it not be large enough, 
 eflforts should be made to enlarge it, either by dilatation or 
 incision. The inconvenience of the infirmity, however, shoul d
 
 292 THE NINTH SPECIES OF MALFORMATION. 
 
 always be preferred to an uncertain operation wliich might 
 be attended with more or less danger, and should only be 
 j^erformed in case of the most urgent necessity. As 1 
 remarked before, in a large number of these cases, surgery 
 can afford no aid, so far as the preternatural anus is concerned. 
 In all such cases, therefore, as do not admit of a surgical 
 operation, the efforts of the surgeon should be directed to the 
 use of palliative measures for the alleviation of the suffer- 
 ings of the patient, and for rendering him less offensive to 
 himself and others. This may often be accomplished by 
 various mechanical contrivances. 
 
 SECTION III. 
 
 CASES AND REMARKS. 
 
 Case CCXLIX. — 'M. Littre records the case of a child in 
 whom both the rectum and the colon were absent. In this 
 instance the ileum opened into a fleshy pocket the size of a 
 hen's egg. From the inferior extremity of this pocket was 
 a canal three lines long and tw'o thick, wliich terminated in a 
 circular opening a line and a half in diameter, situated just 
 above the symphysis pubis. This abnormal opening served 
 the child as an anus. Tliis case resulted in death, no opera- 
 tion having been performed. {Meinoire de V Academie Royale 
 des Sciences de Paris. Annee 1709. p. 9.) 
 
 Case CCL. — M. Petit reported to the Academy of Science, 
 the history, in the case of a child who had neither a rectum 
 nor a colon, and only a portion of the cfficum. In this case 
 the extremity of the ileum terminated at the left side of the 
 has-ventre in an abnormal anus. {Memoire de V Academie 
 Royale des Sciences de Paris. Annee 1716. p. 89.) 
 
 Case CCLI. — An extraordinary case is related by Bils, in 
 w^hich the intestine ascended from the pelvis, througli tlie 
 chest, into the neck, and opened on the face by a very small 
 orifice. {Specimina Anatomica et Varia Opuscula, p. 10. 
 Roterod: 1661. 4^o.)
 
 TIIK NIMH SrKCIES OF MALFORMATION. 293 
 
 Cask CCLII. — Dr. l)Uslio suj^s tliat Dinmorc rnoitions a 
 remarkable instance of jiu iiifjuit iu Avliom the inferior i)or- 
 tion of the abdomen was badly (leveh.)i)ed. In this case some 
 portion of the intestinal canal tnrncMl upward and opened 
 niider the border of the right scapula, (^Malformations^ 
 Injuries and Diseases of the Itectuin and Anus, p. 46. 
 JVew York : 1837.) 
 
 Case CCLIII. — Professor Samuel D. Gross, of the Jefferson 
 Medical College, dissected a fostus in which both the rectum 
 and the colon were wanting ; the ileum terminating iu a capa- 
 cious cul-de-sac two inches and a half in length, and floating 
 loosely in the abdominal cavitv. {Pathological Anatomy, ]). 
 628. Pliiladel])hia : 1845.) 
 
 Case CCLIY. — The following case of imperforate anus, 
 M-itli absence of the rectum and colon, is given by Dr. Loh- 
 mann : 
 
 " The author was called to a child who had been born five 
 days, and who up to that time had passed nothing from its 
 bowels. It was a boy of mature but weak development. From 
 the account of the mother, vomiting of a thickish green fluid 
 had occurred several times. The raphe of the scrotum was con- 
 tinued to the point of the os coccygis, and in its centre, in the 
 place where the anal opening is usuallj' found, were two 
 strong folds of skin united together. The abdomen was dis- 
 tended, and hard, like a drum, and the windings of the small 
 intestines were visible below the skin. A puncture an inch 
 deep was made between the folds with a lance, and kept open 
 with charpie ; the following day a trocar was introduced, to 
 the depth of two inches. It seemed, by the sensation commu- 
 nicated, that the instrument had been pushed into an empty 
 space. No fa3ces came away, and the child died on the day 
 after, the seventh from birth. 
 
 On opening the body, the small intestines were found dis- 
 tended with gas, and in many places filled with meconium, and 
 with yellowish- colored fseces. The colon and rectum were 
 altogether absent. The ileum went to the place where tlie 
 colon should have comhienced, and there terminated in a 
 blind sac, distended with meconium. There was no commu- 
 nication between the sac and the neck of the bladder. The 
 puncture had perforated the cavity of the abdomen, without 
 reaching the blind sac described. {Medicinisohe Vercins 
 Ziitung. Berlin : 1845. iVo, 8.) 
 
 The following case belongs to this, the ninth species, and
 
 294 
 
 THE NINTH SPECIES OF MALFORMATION. 
 
 should be so classed. Its history and description will be 
 given in the chapter on Ahdo7ninal Artificial Anus : 
 
 Case CCLX. 
 
 SECTION IV. 
 RECAPITULATION. 
 
 The following table will exhibit at one view the whole 
 number of cases of congenital malformation of the rectum 
 and anus, collected from various sources which are reported 
 in this work. It will give the number of each species ; the 
 number treated or operated on, and the result ; the number 
 not operated on, and the result ; and the number of those cases 
 in which neither the treatment nor the result are reported. 
 It will be seen that it comprises by far the largest number of 
 cases ever before published in a single work. 
 
 TABLE. 
 
 
 
 
 RESULT. 
 
 o 
 
 KESCLT. 
 
 O 
 
 
 
 
 
 
 
 Q 
 
 
 
 
 
 
 
 is 
 
 
 
 U 
 
 
 
 r, 
 
 
 
 
 o 
 
 
 
 <l 
 
 
 
 
 
 SPECIES. 
 
 i 
 
 H 
 
 
 
 O 
 
 
 
 
 « 
 
 H 
 
 
 tK 
 
 0. 
 
 
 
 
 O 
 
 
 
 
 ^S 
 
 n 
 
 
 o 
 
 o 
 
 U 
 
 
 !5 
 
 H 
 
 
 ta 
 
 D 
 
 
 n 
 
 n 
 
 > 
 
 O 
 
 o 
 
 
 
 
 O 
 
 d 
 
 
 1.) 
 
 
 u 
 
 s 
 
 b) 
 
 
 & 
 
 H 
 
 
 Id 
 
 O 
 
 
 T? 
 
 10 
 
 8 
 
 S 
 
 1 
 
 a. 
 
 1 
 
 z 
 
 1 
 
 12 
 
 First Species, 
 
 Second Species, 
 
 16 
 5« 
 
 14 
 
 49 
 
 8 
 23 
 
 6 
 
 26 
 
 2 
 
 1 
 
 .... 
 
 2 
 1 
 
 ":V 
 
 16 
 53 
 
 Third Species, 
 
 Fourth Species, 
 
 45 
 
 25 
 
 36 
 14 
 
 20 
 43 
 
 16 
 1 
 
 8 
 1 
 
 "i 
 
 8 
 
 1 
 in 
 
 45 
 
 25 
 
 Fifth Species, 
 
 Sixth Species, 
 
 85 
 17 
 
 27 
 
 15 
 
 12 
 
 22 
 
 11 
 
 11 
 
 36 
 
 17 
 
 85 
 17 
 
 Seventh Species, 
 
 Eighth Species, 
 
 ?« 
 
 5 
 
 
 ft 
 
 6 
 
 
 6 
 
 17 
 
 28 
 
 Ninth Species, 
 
 6 
 
 1 
 
 
 1 
 
 1 
 
 
 1 
 
 4 
 
 6 
 
 
 287 
 
 156 
 
 87 
 
 69 
 
 42 
 
 12 
 
 30 
 
 89 
 
 287
 
 CHAPTER XI. 
 
 ABDOMINAL AllTIFICIAL ANUS. 
 SECTION I. 
 
 GENERAL REMARKS. 
 
 The term aTtificial anus^ from having been indiscriminately 
 extended or applied to the preternatuial^ the accidental^ or 
 abnormal anus, has occasioned more or less confusion among 
 surgical authors. This term is strictly applicable only to such 
 an anus, as is designedly established by the surgeon. 
 
 The first, or rude idea of the formation of an artificial anus, 
 was doubtless the result of suggestions occasioned by having 
 witnessed and contemplated the accidental or preternatural 
 anus ; the difiference, however, between the two, compared 
 as an affliction, is very considerable, the latter being a mere 
 faecal fistula, located in the small intestine, is a most disgust- 
 ing and revolting infirmity, whereas the former, approaching 
 so much nearer the normal anus in character, is far less often- 
 sive, and consequently quite easy to tolerate. 
 
 Two operations have been devised and proposed by sur- 
 geons for establishing an abdominal artificial anus, for the 
 relief of insurmountable obstruction of the inferior extremity 
 of the intestinal canal. The principles upon which these 
 operations are conducted vary considerably, according to the 
 difterent localities in which they are practised. It is there- 
 fore necessary to consider them separately and distinctly, as 
 performed either in the iliac or the lumbar region, which I will 
 presently do. [ Vide Plate XV. Figs. 1, 2.] 
 (295)
 
 296 ABDOMINAL ARTIFICIAL ANUS. 
 
 Tlie operation for abdominal artificial anus should by no 
 means be undertaken until the surgeon shall have first failed 
 to recognize the end of the rectum through the perineum, 
 and after having exhausted all the measures for disco verino- 
 it which are recommended for this purpose. Then, and not 
 till then, should he consider the propriety and the necessity 
 of forming an abdominal artificial anus, which at best, is a 
 poor substitute for a jDcrinseal artificial one. 
 
 Some very able and distinguished surgeons, however, have 
 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 
 relation to this operation, says — " I am inclined to think that 
 a proposal to cut into any portion of the left side of the colon 
 without injuring the peritonaeum, either in the young or the 
 old subject, must have been made from a very limited 
 anatomical experience ; for from what I have seen, I am 
 positive that not one case in twenty would have admitted of 
 an operation of the nature proposed. I make this statement 
 as to numbers, however, merely at random, not having kept 
 any exact account." {Edinhurgh Medical and Surgical Jour- 
 nal. 1831. j^. 366.) There never were at any time but a few 
 surgeons who were in favor of Callisen's method. M. Allen, 
 who alone as it were in 1780, was of the opinion that it was 
 well worthy of further consideration. {Recueil Periodique de 
 la Societe de Medicine de Paris, tome I. p. 123.) 
 
 This was the estimation in which Callisen's operation was 
 held, when M. Amussat, in 1839, took the first step towards re- 
 viving and improving it ; whether for the real benefit and 
 advancement of surgery, is a question not yet decided. This 
 step was taken on the first day of October, 1839, by reading 
 and defending, before the Royal Academy of Medicine, 
 a paper which I have already noticed in this work, entitled : 
 " Memoire sur la PossibilitS d'' etablir un Anus artifidel 
 dans la Pegion lonibaire sans penetrer dans le Peritoine^ 
 This paper was soon followed up by two others on the same 
 subject ; one on the sixth of September, 1841, and the other 
 on the fourth of July, 1842, 
 
 This able and distino-uished suro:eon in the series of mas- 
 terly papers on this subject, read before the Royal Academy 
 of Sciences, investigates most critically, in highly chaste and 
 beautiful language, the diff'erent methods heretofore existing 
 of forming an artificial anus ; gives their history ; points out
 
 ABDOMINAL ARTIFICIAL ANUS. 309 
 
 their numerous defects; endeavors to establisli flx('(l rnlo^ of 
 practice, founded upon accurate anatomical investif^ations, 
 instead of the vague and uncertain ones existing, and endea- 
 vors to substitute impi-ovcd methods of operating, &c. 
 
 M. Amussat was therefore the first surgeon wlio had tlie 
 courage and the ingenuity to revive, to modify and to execute 
 Callisen's operation, of opening tlie left lumbar colon Avithout 
 wounding the peritonfeum. If he has no claims to originality 
 of conception in doing this, he certainly can claim the whole 
 merit of reviving, improving and re-introducing an operation 
 which was universally condemned and consigned to oblivion, 
 in consequence of the unavoidable and insurmountable diffi- 
 culties and dangers which were believed necessarily to attend 
 it in all cases. 
 
 SECTION III. 
 
 THE PROCEEDING OF LITTRI^, 
 
 The different steps of the method of forming an abdominal 
 artificial anus in the left iliac region, attributed by universal 
 consent to M. Littre, are as follows : 
 
 The little patient should be placed on its back on a pillow, 
 Math its thighs extended, and supported in this position 
 by one or two assistants. The surgeon being conveniently 
 situated, should make an incision in the left iliac region of 
 from one and a half to two inches in length, between the 
 antero-superior spinous process of the ilium and the pubis, a 
 little above and almost parallel to Poupart's ligament. He 
 should then successively divide the skin, fascia superficialis, 
 aponeurosis of the obliquus externus, the lower fibres of 
 the obliquus internus, and the fascia transversalis ; pro- 
 ceeding, however, more cautiously as he approaches the peri- 
 tonaeum, which after being reached and well exposed, should 
 be pinched up and perforated, and then divided w'ith a bis-
 
 S10 ABDOMINAL ARTIFICIAL ANUS. 
 
 touiy, on a grooved director, to tlie same extent as the 
 incision in the integument. Tlie sigmoid flexure of the colon, 
 distended with meconium, usually siDontaneouslj presents it- 
 self at the back part of the opening, and may generally be 
 recognized by its livid or its greenish color, by the aspect of 
 its external envelope, and arrangement of its fibres. It may 
 also be distinguished by the resistance of the mesentery 
 which comes from the right side, whilst the resistance of the 
 iliac meso-colon is felt from the left. It sometimes, but rarely 
 ever happens that immediately after the peritongenm is 
 opened, that a portion of small intestine protrudes ; and from 
 its great distention and its dark color, caused by inflamma- 
 tion, might lead to some doubt ; a very slight examination, 
 however, will enable the operator to distinguish it from the 
 sigmoid flexure of the colon. The surgeon should now intro- 
 duce into the incision the index finger of his left hand and 
 seize the intestine and bring it outwards as far as possible, 
 the finger acting as a hook for this purpose ; whilst with the 
 right hand a larcje soft ligature should be carried throuorh its 
 mesentery by means of a curved silver needle, in order to re- 
 tain it in this position. A longitudinal incision should now 
 be made into the intestine, and its contents evacuated. BotJi 
 ends of the bowel should be well washed out by injecting 
 warm flax-seed tea, or warm milk and water, and the thread 
 in the mesentery should be fastened to the parietes of the 
 abdomen ; after which a tent of lint besmeared with simple 
 cerate should be carefully introduced to prevent adhesion of 
 the lips of the wound, and a fold of linen dipped in cold 
 water, or a warm poultice applied to the lower part of the 
 abdomen. Care should be taken for some time after, that 
 the new anus should not contract too much. 
 
 It has been proposed to unite the edges of the intestinal 
 wound to those of the external by four or more points of 
 intercepted suture, and the extremities of the external v/ound 
 closed by the twisted suture. This would be decidedly pre-
 
 ABDOmNAL AKTIMCIAL ANUS. 311 
 
 fci'iible to the other methud, uiid iiuike ii much more comj)leto 
 jind handsome operation. [ Vide Plate XV. Fiys. 3, 4.J 
 
 Should any htemorrluige occur durhig tlie early stai^e of 
 tlie operation, the bleediii;^ vessels should be immediately 
 tied, to prevent the subsequent stages from being obscured. 
 
 SECTION I Y . 
 
 CASES AND REMARKS. 
 
 The following are all the cases, so far as my knowledge ex- 
 tends, in which the operation of M. Littre was executed for 
 congenital malformation of the rectum and anus, and are all 
 the data upon which surgeons are at present proceeding in 
 such cases : 
 
 Case CCLV, — Professor A. Dubois was the first surgeon 
 who in a case of cono-enital malformation of the rectum and 
 anus, put into execution the operation which M. Littre Iiad 
 proposed so many years previously, namely, the establish- 
 ment of an iliac artificial anus. In this instance the child 
 was three days old, presenting an imperforation of tlie anus 
 and rectum, no trace whatever of an anus being visible. M. 
 Dubois performed the operation in December, 17S3, but 
 unfortunately the child died ten days afterwards. 
 
 At the autopsy it was observed tliat the edges of the intes- 
 tinal wound were consolidated with those of the abdominal 
 wound. Tills appears to be all that is known in relation to 
 this case. {Recueil Periodique de la Societe de Medicine de, 
 Paris, tome HI. p. 125. Also, Dictionnawe de Medicine et 
 de Chirurgie Pratiques, tome III. ]). 128.) 
 
 Case CCLVI. — A male infant thirty-eight hours old was 
 brought to M. Duret, a distinguished naval surgeon at Brest. 
 In this case there was not the sliglitest trace of an anus visi- 
 ble ; no swelling in the anal region took place whilst the child 
 made efforts to defecate. The scrotum was divided into two 
 parts along the median line, having a testicle in each. The 
 glans was in the perina^um with its meatus, from which the 
 urine passed freely.
 
 312 ABDOMINAL ARTIFICIAL AKUS. 
 
 M. Diiret made a fruitless attempt to establish an artificial 
 anus in the periuajum, and through the incision which he had 
 made, lie introduced a sound, but no rectum could be felt. 
 Twenty-four hours afterwards the case w^as considered des])e- 
 rate, the cliild's abdomen was distended, its extremities ci)h], 
 and there was constant vomiting, and every thing indicating 
 that unless soon relieved, it must inevitably perish. Duret, to 
 save the life of the child if possible, determined to establish 
 an^ artiticial anus in the abdomen. But before performino; 
 this operation on the living ease before him, he practiced 
 Calliseii's method on tlie dead body of a child two weeks old ; 
 observing, however, that he W(mnded the peritonfeum, as the 
 ascending colon was attached to the mesentery, he at once 
 determined to abandon Callisen's and adopt Littre's method 
 on the case in hand. When the child was seventy-two hours 
 old, on a certain day in October, 1793, Duret performed Lit- 
 tre's operation. An incision was made in the abdominal 
 cavity above the iliac region, in the situation where the sig- 
 moid flexture of the colon formed a swelling. This portion 
 of the intestine was drawn out by the finger, and a ligature 
 was passed through the meso-colon to retain it out of the ab- 
 domen. An incision was then made into it, an inch and a 
 half long. The meconium escaped in abundance. The vom- 
 iting at once ceased, together with all the other alarming 
 symptoms. On the fifth day the sutures uniting the intestine 
 to the abdominal wall were removed. On the sixth day, 
 however, the opening in the intestine an inch in length, was 
 jiartially closed by the extrusion of the mucous membrane ; 
 but on the seventh day the child was well enough to be re- 
 stored to the care of its parents. Twelve years after this the 
 patient with his iliac artificial anus was doing well. [Recueil 
 Periodique de la Societe de Medicine de Paris, tome IV. 
 p. 45.) 
 
 What is remarkable, this patient, according to M. Amussat, 
 was still living in 1839, having then survived the operation, 
 fortv-six years. {Memoir e sur la Possihilite d'etaUir mi Anus 
 artificiel dams Region lombaire sans penetrer dans le Peritoine. 
 Paris: 1839.) 
 
 Cask CCLVII. — M. Leveille reports the following case in 
 the Journal of Desault. 
 
 In the month of April, 1794, M. Desault performed the op- 
 eration of Littre upon a male infant forty-eight hours old. In 
 tins child tliere was no trace of an anus, and the ischia closely 
 approaching each other, seemed to be placed, one upon tli'c 
 other. Tills eminent surgeon, previous to performing colotomy,
 
 ABDOMINAL AKTIFHTAL ANUS. 313 
 
 satisHed liiinsclf that it would be iiupo.ssil)le to estaldisli tlie 
 artificial anus in the pcriniieal region. The child dird tniir 
 days after tlie operation. In tins instanct; Desuidt niudc; the 
 artificial anus in the bigniuid tlexture of the colon. 
 
 At the autopsy, nieconiutn was found in the bladder; in 
 the posterior wall of which, and between the mouths of the 
 urett'rs an oix'uing was soon, about the diameter of a nicdinm 
 sound, leading to the lower end of the intestine which was 
 closed in every direction. What distance this was from the 
 ])erimTeum we are not told. {Journat de Chinorgie. tome 
 IV. p. 2iS. ParU: 1794.) 
 
 Case CCLVIII.— M. Yoisin, of Versailles, in 1789 per- 
 formed the operation of Littre upon a child having an imper- 
 forate anus. The result of this case is not known, never hav- 
 ing been published. It w^as doubtless fatal, or it would have 
 been reported. {Fine's Memolre de la tSocietede Medicine de 
 Montjjellier. tome VI.) 
 
 Cask CCLIX. — M. Desgranges in 1800 performed colotomy 
 after the method of Littre, in the case of a little girl four years 
 old, in which the rectum opened into the vagina. Eight 
 months after the operation, Desgranges wrote to Fine that he 
 had been perfectly successful, and that his little patient was in 
 good health, but that a part of the faeces still passed by the 
 vaginal anus, and that the artificial anus in the abdomen had 
 to be constantly dilated with a plug to prevent it from com- 
 pletely closing, which it had the strongest disposition to do. 
 ( Voir le second memoire sur V enterotomie par Fine^ dans leQ^ 
 ■volume des Annales de la Societe de Montpellier.) 
 
 In this instance Desgranges to avoid, as he thought, the dif- 
 ficulties attending the vaginal anus, determined to establish 
 at once the artiticial one in the abdomen, intead of in the per- 
 inseum, imagining that by this proceeding he could the more 
 easily get rid of the vaginal one, as all the fsecal matter would 
 necessarily pass through the abdominal anus ; consequently 
 that the vaginal one would soon close voluntarily. 
 In this, however, he was much disappointed, for the 
 faces continued to pass through the vaginal opening. Indeed 
 his case was anything ^'- hid perfectly successful" as he inti- 
 mated in his letter to Fine. The abdominal anus was entirely 
 useless, and to say the least of it, not any less inconvenient 
 than the vaginal one. It is supposed that the artificial anus 
 in this instance Avas made in the sigmoid flexure of the colon.
 
 Sli ABDOMINAL AJtTIFICIAL ANUS. 
 
 Case CCLX, — The following singular case of supra-pubic 
 abnormal anus is mentioned by Voisin of Yersailles. It oc- 
 curred in a male child in whom there was an entire absence of 
 the rectum and the colon, the ileum terminating in an abnor- 
 mal anus in the h_ypogastrium. 
 
 This child was seen bj M. Voisin some time within the year 
 1802. It had no perinj^nm, the perinseal raphe terminated in 
 fi-ont in two cutaneous folds which seemed to represent the two 
 halves of the scrotum, but as they had no depth, they might 
 have been regarded as the labia majora. Voisin finding no 
 trace of a j^enis, was at that time at a loss how to decide the 
 sex of the child. The abnormal anus commenced to contract 
 on the seventh day, and on the tenth, symptoms of retention 
 of fajcal matter were so evident that Voisin determined to 
 perform Littre's operation. Tlie child survived the operation 
 four days. 
 
 At the autopsy it was found that the j^ortion of the intestine 
 drawn towards the outside for the formation of the artificial 
 anus, was not the colon, but the ileum which turned from the 
 artificial anus towards the posterior wall of the bladder, into 
 which it opened with a short dilatation. Tlie vesical opening of 
 the ureters was closed in the form of a figure 7. During the 
 life of the child the urine had been constantly voided by 
 numerous very small openings. The two testicles were found 
 in the abdominal cavity, but both the rectum and the colon were 
 absent. {liecueil Periodique de la Societe de Medicine de 
 Paris, tome XXI. p. 353.) 
 
 This was the second case upon w^hich M. Voisin practiced 
 colotomy after the method of Littre, the first being in 1798. 
 This liis last operation, however, cannot be called colotomy., as 
 the ileum was the intestine opened, the colon being absent. 
 
 Case CCLXI. — In the case of a male child, two days old, 
 brought to M. Billaunt for an imperforate anus, that operator 
 nuide a puncture in the periufeum, at the point where the anus 
 ought to be, but ftiiled to reach the rectum. M. Duret was 
 called in immediately and practiced colotomy according to the 
 method of Littre. The artificial anus in this instance, was 
 nuule in the sigmoid flexure of the colon. The child only 
 lived four or five days after the operation. 
 
 At the autopsy, the closed end of the rectum was found ad- 
 herent to the posterior wall of the bladder, but having no 
 communication with it, and about one inch from the place 
 where the normal aims should have been. 
 
 M. Duret performed this o|)eration in 1809, and it was the 
 second case upon which he practiced Littre's operation, the
 
 ABDOMINAL AKTIFICIAL ANUS. 315 
 
 first, [Vide Case CGLVIi\ bein^ iu 1793. {These inaugur- 
 ale de Mlrieljeune.) 
 
 Case CCLXII. — M. Legris, a distinguislied surgeon in the 
 navy at Brest, in January, IS 13, performed tlie ()])eration of 
 Littre on a child having an imperforate anus with an abnor- 
 mal opening of the rectum into tlie urethra. In this instance 
 it was supposed that the artificial anus was established in the 
 sigmoid tlexure of the colon. Death occurred seventeen days 
 afterwards from ])eritonitis, the result of injury of the parts 
 through the carelessness of the parents. {These inaugurale de 
 Serrand. Montpellier : 1814.) 
 
 Case CCLXIIL— In 1813 M. Serrand de St. Malo observed 
 in a female child sixty hours old, a well formed anus, but the 
 rectum was found closed one inch and a half above the anal 
 orifice. The solidity of the substance forming the obstruction ; 
 the uncertainty whether the superior part of the rectum would 
 be found in the vicinity ; the probability that the two parts 
 of the rectum had no commnnication with eacli other, and the 
 extreme weakness of the child, decided JVI. Serrand not to at- 
 tempt the formation of a perina3al anus. He therefore deter- 
 mined to practice colotomy according to the process of Littre. 
 Twenty-two months after this operation the child still lived, 
 but the fourteenth day after the operation it presented a pro- 
 lapsus of the incised portion of the intestine — " an inconveni- 
 ence beyond the power of art to remedy." Tlie prolapsus 
 increased more and more, and caused Serrand to fear that the 
 happy result was not of long duration. In this case the artifi- 
 cial anus was made in the sigmoid flexure of the colon. 
 {These inaugurale de Serrand. 3font2>eUier: ISl-l.) 
 
 Case CCLXIY. — In 1813, a surgeon of Lyons w^hose name 
 is not given by Serrand, performed Littre's operation on a child 
 having an imperforate anus. The artificial anus was estab- 
 lished in the sigmoid flexnre of the colon. The operation 
 proved successful. {These inaugurale de Serrand. Montpel- 
 lier : 1814.) 
 
 CasE CCLXV. — In 1813 a surgeon of Brest, performed 
 Littre's operation in the case of a female infant having an 
 imperforate anus. In this operation the ovary was included 
 in the ligature passed through the mesentery. The result was 
 death. In this instance the artificial anus was formed in the 
 sigmoid flexure of the colon. {These inaugurale de Ser- 
 rand.)
 
 316 ABDOMINAL ARTIFICIAL ANUS. 
 
 Case CCLXYI. — Mr. Freer, of Birmingham, England, in 
 1815, performed Littre's operation on an infant having an im- 
 perforate anus. An unsuccessful attempt was first made to 
 establish the artificial anus in the i^erinaeal region. In this 
 case the lower part of the descending colon was opened. 
 After confining the colon with one stitch at each end. of the 
 wound, a longitudinal incision two inches in length was made. 
 The child died, however, in three weeks, apparently trom 
 marasmus. 
 
 At the autojisj, it was observed that the opened intestine 
 was adherent to the wound in the abdominal parietes, and 
 there was not any appearance of inflammation. {London 
 Medical and Physical Journal^ Vol. XL V. j)- 9.) 
 
 Case CCLXVIL— MM. Miriel Senior and Duret, in 1816 
 saw a female child two days old, having a firm obstruction in 
 the rectum, half an inch above a well formed anus. They at 
 once abandoned the idea of attempting to open out the 
 obstructed canal, because, first it seemed to them a grave 
 operation to push the bistoury into so dangerous a region ; 
 second, the occlusion of the rectum seemed to them to be 
 thick, and they apprehended further difliculties, and especially 
 contraction of the new opening. On the next day, M. Miriel 
 practiced colotomy according to the process of Littre, the arti- 
 ficial anus being made in the sigmoid fiexure of the colon. 
 
 This patient was living, and in excellent health in 1835, 
 consequently being then nineteen years old. {These inaug- 
 urale de Miriel Jils. Paris: April 3, 1835.) 
 
 ^ Case CCLXVIIL— In 1822 M. Miriel Senior, for the second 
 time, performed Littre's operation successfull}^ The case was 
 that of a male child three days and a half old. In this case, 
 as in that of his first, the anus was found perfect, but the rec- 
 tum was occluded, one inch and a quarter above the anal 
 orifice. Miriel first made an unsuccessful attempt to open 
 out the rectum at the point of the obstruction. Tlie i^atient 
 was living thirteen years after the operation. In this case as 
 in the first, the artificial anus was established in the sigmoid 
 flexure of the colon. {TJiese citee.) 
 
 Case CCLXIX. — In 1823, M. Miriel Senior saw a male 
 child six days old, in whom the anus was absent, but at the 
 ])lace which the anus should have occupied, there was found 
 a cutaneous excrescence of firm consistency, inclining toward 
 the left side of the perineal raphe. The urine did not pre- 
 sent any mixture Avitli fyecal matter. Miriel first attemjjted
 
 ABDOMINAL AKTIFICIAL ANUS. 317 
 
 to ostablirtli the urtiiicial aims in tlie anal roii:;ion, hy attack- 
 in"^ the perin;enni, iirst witli the bistoury, and then with the 
 trocar, but without success. He tlien ])ert'ornie(l IJttre's 
 operation, and liis little i)atient survived it, two years and 
 three nionths. 
 
 At the autopsy, it was found that the rectum presented the 
 appearance of a funnel, with its brim u])permost, whilst the 
 narrow beak adhered to tlie left side of the posterior wall <»f 
 the Idadder, terminated in a luird aiul closed extremity, two 
 inches h)n<^, and united to the cutaneous wall of the 
 periimeum. 
 
 M. Miriel was of opinion that the death of this child was 
 independent of the artificial anus, but says himself, that at the 
 autopsy he found the colon intlamed. In this case tlie artifi- 
 cial anus was formed in the sigmoid flexure of tlie colon. 
 This made the third case upon which M. Miriel, Senior, per- 
 formed Littre's operation. {These inaugurale de Miriel jils.) 
 
 Case CCLSX. — In the case of a child, having an imperfo- 
 rate anus, as described by JA'^QY^{devitus fahriav primitivw^ 
 intestini ■recti et orlficu ani., these, inaugurcde de Wurtshourg, 
 1826.) Textor after having in vain attempted to establish tJie 
 artificial anus in the perinseum, made it in the abdomei 
 according to the method of Littre. Eight days after this oper- 
 ation the child died. 
 
 At the autopsy the blind end of the rectum was found 
 greatly distended with meconium, and projecting far to the 
 front part of the pelvic cavity. 
 
 Case CCLXXI. — Schlagintweit reports the case of a child 
 having an imperforate anus, and in whom there was, in the 
 vicinity of the closed anus, an elevation of the skin in tlie 
 form of a crest. In this case the rectum adhered to the bladder 
 and terminated in a closed and pointed extremity which rested 
 upon the cocyx. Schlagintweit first attempted to establish 
 the artificial anus in the periuseum, and only abandoned the 
 attempt after having penetrated in vain one inch deep through 
 an incision, extending from right to left, nine lines long. He 
 then established an iliac artificial anus in the sigmoid fiexure 
 of the colon according to the method of Littre. {La These 
 hiaugurale de Ottinger sur les Imperforations de Vanus. 
 Munich : 1826.) 
 
 Case CCLXXH. — M. Bizet, in 1830, saw a male child 
 having an imperforate anus. He made an incision in the per- 
 inceuni toward the rectum, but failed to reach that organ.
 
 318 abdom:inal artificial anus. 
 
 He then performed the operation of Littre, and formed the 
 artificial amis in the sigmoid flexure of the colon. The child 
 died one month after the operation, probably from the effects 
 of indigestion. 
 
 At the autopsy it was found that the rectum was com- 
 pletely wanting ; and that tlie inferior extremity of the colon 
 was continued by a fibrous cord attached to the posterior wall 
 of the bladder. {These inaugurale de Miriel jils.) 
 
 Case CCLXXIII.— M. Bizet within the same year (1830,) 
 again performed Littre's operation. 1 he case was that of a 
 cliild four days old, presenting an imperforate anus. The 
 child died on the day following the operation. M. Bizet in 
 this case, as in his first, made the artificial anus in the sigmoid 
 flexure of the colon. {These citee.) 
 
 Case CCLXXIY.— M. Ouvrard, of Angers, in 1830, per- 
 formed Littre's operation on a female infant two days old. In 
 this case no anus was visible. It is supposed that the artificial 
 anus was established in the sigmoid flexure of the colon. The 
 child died suddenly. {Lancdte Ft'ancaise^ tome 11., j>. 99. 
 Paris : 1837.) 
 
 Case CCLXXY. — On an evening in March, 1835, a male 
 child three days and a half old, was brought to Klewitz at 
 Colberg. This child since its birth had passed nothing from 
 its bowels, the anus being imperforate ; its abdomen was 
 greatly distended and painful upon pressure j it was very 
 feeble and jaundiced, nursed but little and passed a great 
 deal of dark colored urine. He at once attempted to form a 
 perinaeal artilicial anus, but without success, after having 
 penetrated with the bistoury two inches in depth in the per- 
 inteuin, and then plunging a trocar equally without effect, an 
 inch deeper still. Klewitz then without any surgical assistant 
 and by candle light, established an iliac artificial anus in the 
 sigmoid flexure of the colon, according to the process of Lit- 
 tre, which was successful. The child survived the operation 
 two years and ten months, having died of scrofula. 
 
 At the auto})sy it was discovered that the rectum passing 
 doA^n to the middle of the pelvic cavity, behind the bladder, 
 presented a dilatation about the size of a pullet's cgg^, in 
 which was enclosed a clayey concretion : this being removed 
 it was found that the rectum opened into the bladder close 
 behind the internal opening of the urethra. The left kidney 
 and the left ureter were absent. {Gazette de Berlin. April
 
 ABDOMINAL ARTIFICIAL AND8. 319 
 
 29, 1835. Also, Tiingel. Uher KanstUche Afterl'dduny. S. 
 62. Kiel. 1853.) 
 
 Cask CCLXXVI. — M. Roux in 1839 saw a child in wlioiii 
 there was not the slightest trace of an anns. In this case 
 Roux established an artificial anus in the siijinoid flexure of 
 the colon, after the process of Littre. Tiie child, however, 
 died in two hours after the operation. 
 
 At the autopsy they found the cul-de-sac of the rectum 
 distended with nieconiuni, and distant only half an inch from 
 the perinjiBum. [Gezette des Ilopltaux de Paris. Annee 
 ISll. No. IT.) 
 
 Cask C'CLXXVIL — Some tiiye within the year 1846, Dan- 
 zel of Hamburg was called to see a child three days old, 
 which had passed nothing from its bowels since its birth, an(l 
 which vomited occasionally. Otherwise the child a])peared 
 well. Its anus was normal, but in the rectum at the iieiglit 
 of the little linger appeared an obstrnctiun which resiste<] 
 both the linger and a small bougie. On the following day 
 the child vomited meconium, yet with this exception it still 
 did well. In order to overcome the obstruction, and if pos- 
 sible to open a passage for the fseces, Danzel introduced on 
 his linger a sharp-pointed bistoury up to the point of obstruc- 
 tion, and tirmly pushed it in the direction of the rectum as 
 high as tiie promontory of the sacrum. No meconium, 
 however, followed the withdrawal of the instrument. Dan- 
 zel now determined to establish an abdominal artilicial anus 
 in the left iliac region according to the method of Littre. 
 This operation he at once executed, establishing the artificial 
 anus in the sigmoid flexure of the colon ; but on the eighth 
 day tlie child died. 
 
 At the autopsy it was found that the rectum and the colon 
 were entirely empty and conti-acted, and that a complete 
 obstruction existed in the caecum which together with the 
 small intestines was greatly distended. No evidence what- 
 ever of inflammation was discovered. The rectum was not 
 closed as Danzel had imagined, but simply a fold of its 
 lining membrane had arrested the finger and the bougie, and 
 thus deceived him as to the true character of the case.^ The 
 cause of death was obvious. Had the artificial anus been 
 made in the csecum, the probability is that the child would 
 have 'been saved. {[laser's Archiv. Band. IX. Heft. 3. S. 28-1:.) 
 
 Case CCLXXVIII. — The following case of imperforate 
 anus and rectum is reported by Walter F. Atlee, M.D., of 
 Philadelphia. The infant was subjected to Littre's opera-
 
 320 ABDOMINAL ARTIFICIAL ANUS. 
 
 tion by tlie able and distingnisbed M. Nelaton, of the Clini- 
 cal Hospital of tbe Faculty of Medicine of Pai'is: 
 
 "In April, 1854, a cbild, new-born, was brougbt to tbe 
 bospital, as liaving no anus, from iniperforation of tbe rec- 
 tum, or absence of tbat intestine. 
 
 " M. JSTclaton establisbed an artificial anus in tbe left iliac 
 tossa. In performing tbe operation, tbe integuments were 
 divided, tben tbe muscles one after tbe otlier ; tbe perito- 
 naeum, tbus exposed, was opened, and tbe intestine was 
 drawn out by tbe linger, and fastened to tbe opening in tbe 
 abdominal walls by means of a tbread. Tbe intestine was 
 tben opened, freed of tbe matters it contained, and tbe 
 wound dressed by cbarpie, and a loosely-applied bandage 
 placed around tbe body. Tbe cbild, bowever, died in tbe 
 afternoon." {Clinical Lectures on Surgery. By M. Nelaton. 
 From Notes taken hy Br. Atlee. Chap. XIX. jp. 588. JPhila- 
 delphia: 1855.) 
 
 Case CCLXXIX. — Tbe following case is reported by M. 
 Godard, of Paris, France, as alluded to in Cask CLXXIV., 
 wliicb see. 
 
 "Alpbonse Eugene was born on tbe first of April, 1855, 
 and bis motber sbortly after observed tbat the cbild had wo 
 anus. On tbe third of April, when be was two days old, his 
 motber sent him to tbe Hospital Necker, hall of Saint Cecile, 
 under tbe direction of Professor Natalis Guillot. Tbe same 
 day M. Lenoir, es]3ecially called into this case, made an 
 incision in the perinseum, and tben plunged a trocar in tbe 
 direction of the rectum, hoping to reach and to open its dila- 
 ted extremity. As he did not succeed by this method, he 
 performed tbe operation of Littre. The child immediately 
 evacuated tbe meconium through tbe wound, and his con- 
 dition was greatly improved, ai-Td continued satisfactory dur- 
 ing five days. On the sixth day after the operation he ap- 
 peared worse, and on the eleventh of April, three days later, 
 he died. 
 
 Tbe urine showed a mixture of fgecal matter. 
 
 The autopsy was made on the tAvelfth of April, and gave 
 the following results. — Tbe peritonaeum investing the pelvic 
 viscei*a exhibited the most intense inflammation. At tbe left 
 of the bladder there was a large abscess, which had pushed 
 that organ out of its natural position. The inferior portion of 
 the sigmoid flexure of the colon and the superior portion of 
 the rectum, adhering and united by numerous false mem- 
 branes, were drawn into tbe artificial anus, which was situ- 
 ated just above Poupart's ligament. These portions of intes-
 
 ABDOMINAL AiniKICIAL ANUS. 321 
 
 tine presented u dark viok-t hue from wliicli ini^lit I)e liil'erred 
 great vjiscuhirity. The rectum descended from ;il>()ve <ht\vu- 
 wjird, and from left to right. Behind, it corresponded to fht- 
 suci'um, l)eing united to it l)y numerous librous adhesions; in 
 front it extended to the bhuhku-, l>eing separated from it by 
 the peritomeal cul-de-sac. On the left, the rectum touched 
 an extended abscess which separated it, like the bladder, from 
 the walls of the pejvic cavity and crowded it entirely out of 
 position. This abscess opened beneath the rectum ; it appeared 
 to result from the inilamniation of the cellular tissue of the 
 pelvic cavity, and was doubtless the effect of the punctures 
 made with the trocar in that region. On the right side of 
 the rectum there was nothing observed worthy of note. The 
 inferior extremity of the rectum terminated in the form of a 
 sack, situated on a level with, and behind the prostate, about 
 one incli and three eighths from the point of the perinaium in 
 which the puncture was made. On the anterior wall of the 
 rectum, this sack presented the oi'iiice of a small canal, three 
 eighths of an inch in length, which passed under the pros- 
 tate and opened into tlie urethra in front of the veru mon- 
 tanum. That part of the urethra situated in front of this 
 opening was dilated in bottle form, and of sufficient size to 
 contain a large pea, whilst the vesical end, or that part of the 
 urethra situated behind the abnormal opening, was on the 
 contrary singularly narrow. {Gazette Medicate de Paris. 
 Annee 1855. iV^o. U. p. 699.) 
 
 SECTION V. 
 
 COMPENDIUM. 
 
 The following table will present in a compendious and con- 
 venient form for reference, the twenty-five preceding cases 
 reported in this work, in which the operation of M. Littre was 
 performed, in consequence of congenital malformation of the 
 rectum. It will give the number, the operator, the date, the 
 sex, the age, the species of malformation, the situation of the 
 artificial anus, and the result ; so far as any or all these facts 
 are known to us.
 
 322 
 
 ABDOMINAL ARTIFICIAL ANUS. 
 
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 ABDOMINAL AKTIFICIAL ANUS. 323 
 
 SECTION VI. 
 
 THE PROCEEDING OF LITTRE, AS MODIFIED BY PILLORE. 
 
 The metliod of M. Pillore is a modification of that of M. 
 Littre, differiiiii^ in the intestine opened, and the artificial 
 aims being in tlie right side. He recommends the anterior 
 part of the caecum to be opened tln*ongh the peritonaeum, and 
 the lips of the incision in the intestine to be fastened by sev- 
 eral points of sutnre to the margins of th<3 divided integu- 
 ment. [ Vide Plate X F, Figures 5, 6.] 
 
 M. Pillore was induced to select the ccecum for the place 
 of the artificial anus, both on account of its situation, as well 
 as its forming a reservoir, and thus preventing, as he imag- 
 ined, the constant and involuntary escape of the fteces. 
 
 Case CCLXXX. — The following is an interesting case of 
 the success of M. Pillore's method, and the only one on record, 
 so far as my reading extends, in which the operation was per- 
 formed on account of congenital malformation of the rectum 
 and anus. I failed to obtain the German Medical Journal in 
 which the case was originally reported, and was compelled to 
 present the brief narrative of it, without names or dates, as I 
 found it in the London Medico-Chirurgical Review. {No. 
 LIII. p. 230. July, 1837.) 
 
 " An infant, three days and a half old, was found to have 
 no anal aperture. The raphe of the perineum extended from 
 the scrotum to the point of the os coccygis, without any inter- 
 ruption. — The child was jaundiced all over; the abdomen was 
 hard and distended, there had been no vomiting, and of course 
 no alvine evacuation. It had taken the breast repeatedly, and 
 had also voided urine several times. An incision was made at 
 the usual place of the anus, and a trocar was introduced for at 
 least an inch or more in the direction of the rectum ; but 
 without any effect. It was, therefore, deemed unsafe to pen- 
 etrate to a greater depth ; and a proposal was made to open 
 the caecum in the right iliac region. This was accordingly 
 done. An incision was made through the integuments imme- 
 diately in front of the anterior superior spinous process of the 
 OS ilii, and when the peritonaeum was opened, a portion of 
 small intestine escaped. This was replaced, and the caput
 
 32-4 ABDOMINAL AKTIFICIAL ANUS. 
 
 cneci being found, an incision was made into it. Several onn 
 ces of a consistent meconial matter immediately flowed out, 
 with great relief to tlie symptoms. The progress of the caso 
 was most satisfactory (der Fortgangwarganzerwiinsehat) ; co- 
 pious alvine evacuations began and continued to escape. On 
 tlie eighth day after the operation, the stitches of the abdo 
 minal woimd were removed." {Medizin Zeitimg fur He'd 
 hand, in the Preusse^i.) 
 
 SECTION VII. 
 
 THE PROCEEDING OF CALLISEN. 
 
 Callisen, in preference to the method of M. Littre, advised 
 the artificial anus to be formed in the left lumbar, instead of 
 the left iliac region, doubtless for the purpose of preserving 
 the integrity of the peritonaeum. What is, therefore, gener- 
 ally called Callisen's operation, consists in opening the des- 
 cending colon in the left lumbar region, without dividing the 
 peritonaeum. This distinguished surgeon, in order to accom- 
 plish this object, directed a vertical incision to be made 
 between the last false rib and the crest of the ilium, parallel 
 with the external or anterior margin of the quadratus lumbar- 
 nm muscle. 
 
 The surgical anatomy of the lumbar region in which the 
 operation of Callisen is to be performed, I will give in the 
 language of M. Malgaigne. " The left lumbar colon," says 
 this able. surgeon, " descends at first in front of the loins, from 
 wdiich it is separated by fat only ; then in front of the apone- 
 urosis of the transversalis abdominis and quadratus lumborum, 
 from which it is also separated by a thin layer of fatty tissue ; 
 below this aponeurosis it reaches the crest of the ilium, below 
 which it is no longer accessible to our instruments. It is tlien, 
 between the loins and the crest of the ilium that we must seek 
 it. It generally corresponds to the aponeurotic groove between 
 the quadratus lumborum and transversalis, which itself corres-
 
 ABDOMINAL ARTIFICIAL ANUS. 325 
 
 ponds to the external border of the comiuon mass of the sacro- 
 luinbalis and lon<^issinius dorsi, easily recognized in middling 
 fat subjects. Sometimes it is more internal, and is in great 
 part concealed by the quadratus lumborum. Yon see tliat in 
 any case it is on a level with the external edge of the sacro- 
 lumbalis, and more deeply under the external border of tlie 
 <[uadratiis lumborum, that you are most sure to find it. 
 
 The layers to be divided are the skin and fatty subcutane- 
 ous tissue ; beneath this the latissimus dorsi behind, the 
 obliquus externus in front ; more deeply the obliquus 
 interniis, and then the transversalis ; then the aponeurosis 
 of the transversalis, common also to the quadratus lumborum ; 
 then the adipose tissue that covers the intestine ; and lastly, 
 the intestine itself. But here we have the most important re- 
 lations. 
 
 Almost always both in the adult and infant, the left colon is 
 deprived of peritonasum in the posterior third of its circum- 
 ference, and especially when it is distended by gas and faecal 
 matters. But the space in which it is thus outside the serous 
 membrane is very variable ; and the more care must be taken 
 not to wound this membrane, because it is here very thin, and 
 ahnost adherent to the aponeurosis of the transversalis. There 
 is no certain indication of this limit. On the contrary, j>osi- 
 tion alone informs us that we have reached the colon instead 
 of some other part of the intestine covered by the parietal peri- 
 tonaeum. For, of the three longitudinal bands of the colon 
 which might have served us as a guide, one is in front, another 
 on the inside, and a third outside ; and it is the space between 
 these two last that w^e have to open behind. Yon see then 
 tliat the operation, to preserve its essential advantage, which 
 is the integrity of the peritonceum, demands a great firmness 
 of hand and great precautions." [Operative Surgery. Brit- 
 tail's translation^ p. 447. Philadelphia : 1851.)
 
 326 ABDOMINAL ARTIFICIAL ANUS. 
 
 SECTION YIII, 
 
 CASES AND KEMARKS. 
 
 The following are all the cases, so far as I know, in which 
 the operation of Callisen was performed for congenital malfor- 
 mation of the anus and rectum. 
 
 Case CCLXXXI. — M. Dupiijtren in his " Lecons Orales," 
 very bnefly alludes to the case of a male child having an im- 
 perforate anus, upon whom in 1818 he performed Callisen's 
 operation, somewhat modified by himself, and since then 
 greatly modified by M. Amussat. In this instance Dupuytren 
 established the artificial anus in the caecum without wounding 
 the peritonaeum. The result, nevertheless, was death from 
 peritonitis. {Lecons Orales de Clinique Chirurgicale^ tome 
 III,^. 663,2 Ed'd>^ 
 
 C^sE CCLXXXIL— On the eighth of December, 1828, a 
 male child thirteen days old was brought to the office of M. 
 Bougon. It was very small and remarkably thin. This child 
 since its birth had passed no ftecal matter by the anus ; it had 
 hiccup and continual vomitings. The skin of the abdomen 
 was bluish at several points ; an attentive examination having 
 discovered no trace of an anus, M. Bougon thought best to 
 plunge a bistoury into the place usually occupied by the anus, 
 in order to assure himself whether the rectum reached within a 
 short distance of that point, and if it might not be possible to re- 
 establish a natural opening thereby. A bistoury Avith a straight 
 blade was then cautiously pushed to the depth of seven or 
 eight lines ; no liquid flowed, except a little blood ; even the 
 cries of the child produced no sensation of fluctuation which 
 could lead to a presumption that the intestinal cul-de-sac was 
 in the vicinity. M. Bougon then abandoned the attempt to 
 make an artificial anus in the perinseum, and proceeded in 
 search of a portian of the colon to establish an artificial anus 
 in the left lumbar region. For this purpose he made a long- 
 itudinal incision in the left side a little more than an inch long, 
 between the last false rib and the crest of the ilium. Having 
 reached the peritonaeum, he detached it to a small extent, in 
 order to seize the intestine where it is not covered by the 
 serous membrane, but without success. He then decided to 
 open the peritonneum and seize a portion of the colon as is
 
 AIJDOMINAL AKTIFICIAL ANUS. 327 
 
 ordinarily done. That intestine was then bron^dit to flie sur- 
 face ; it was opened, and a guiu-elastic canuhi was introduced 
 into the cavity which u:;ave vent to o^as and a consicU'i-able 
 (juantity of fecuU^nt matter. A thread was used to maintain 
 the foreign body in the intestine. 
 
 Sliortly after the operation the liiccup and tlie vomiting 
 ceased ; tiie little patient was cahu during the day and i)art of 
 the nii»:lit. 
 
 On the ninth of December, about two o'clock, A, M., the 
 child made plaintive cries and vomited a sul)stance resem- 
 bling coagulated milk. At the period of visit the cries became 
 constant, the liiccup returned trom time to time ; the 
 patient sometimes vomited a yellowish liquid which 
 it scarcely had the strength to expel. The countenance 
 became altered since last evening, and already pre- 
 sented a cadaverous look. The condition of the child 
 became more and more serious ; the vomiting mori^ 
 frequent; little or nothing passed through the canula and 
 death occurred about three o'clock, P. M., twenty-eight hours 
 after the operation. 
 
 Post-mortem forty-two hours after death. 
 
 On opening the abdomen the small intestines were found m 
 their natural condition. The rectum was in its j^lace ; it des- 
 cended low down into the pelvis and terminated about one 
 inch from the natural situation of the anus, and the interval 
 which separated the inferior extremity from the point which 
 it ought to have reached, was occupied by a condensed cellu- 
 lar tissue ; all that portion of the intestine which formed th* 
 rectum was much distended with liquid yellow matter ; the 
 peritonneal surfjice had contracted several feeble adhesions to 
 the neighboring intestinal arches ; the mucous membrane was 
 inflamed ; the inferior extremity of the rectum terminated in 
 a cul-de-sac without any trace of an opening. {Lanoette Fran- 
 caise. toine I. j>, 78. Decemhre, 1828. Also, Gazette des 
 Jlopitaux de Paris. Annee 1828. p. 78.) 
 
 In this instance M. Bougon intended to perform the oper- 
 ation of Callisen, but as he not only opened the colon but the 
 cavity of the peritonaeum also, he performed that of Littre — 
 hence it is a question, whether this case should not have been 
 classed Avith those of Littre. 
 
 Case CCLXXXIII. — ^The following case is reported by M. 
 Godard, as alluded to in case CLXXIV, which see. 
 
 " Julien Francois Leflou was born on the 15th of June, 1855. 
 On the next day M. Grange, being consulted by the mother, 
 found only a slight depression of tlie skin in the place of the
 
 32S ABDOMINAL ARTIFICIAL ANUS. 
 
 amis. He made an incision in the perinpenm, and tlien plunged 
 in a trocar, but failed to reach the end of the rectum. On 
 the ISth of June the child was received into the hall Saint 
 Come of tlie Hospital des Enfants Malades. M. Guersant 
 the surgeon of the hospital, next day renewed the attempt to 
 iind the rectum, but equally without success. He then formed 
 an abdominal artificial anus after the method of Callisen. 
 Shortly after the operation the child voided the meconium by 
 the wound. On the 21st of June inflanunation of the cellu- 
 lar tissue of the pelvic cavity and of the extremities, super- 
 vened, and oii the 23d, at nine o'clock in the morning, the 
 child died. Up to this period no meconium wasj^assed inixed 
 with the urine. 
 
 Autopsy. The peritoufeum showed no trace of inflamma- 
 tion. The artilicial anus was situated a little below the spleen. 
 The open part of the intestine corresponded to the angle 
 Jbrmed by the transverse and descending colon. The rectum 
 at its superior extremity was of normal size, but as it descended 
 into the pelvic cavity, its diameter diminished, and at the 
 upper margin of the prostate, entirely disappeared ; however, 
 there was discovered at this point a pipe-like prolongation 
 Avhich passed behind the bladder and penetrated the prostate ; 
 making its way thence between the ejaculatory ducts, it 
 reached and penetrated the urethra in an opening covered by 
 a thin membrane. This prokuigation extended from the an- 
 terior wall of the rectum and was lined with a corrugated 
 nnicous membrane. The inferior extremity of the rectum 
 ^vas about one inch and a quarter from the skin of the perin- 
 a3um, which with the subcutaneous and fatty cellular tissue 
 beneath was five-eighths of an inch in thickness." {Gazette 
 Medicale de Paris. jVo. 44. p. 700.) 
 
 SECTIONIX. 
 
 THE PROCEEDING OF CALLISEN, AS MODIFIED BY AMUSSAT. 
 
 The principle upon which Callisen's operation is founded, as 
 has already been observed, is to establish an artificial anus 
 without wounding the peritoneum, by opening the posterior 
 third of the descending colon in the left lumbar region, at that 
 part of the intestine which is destitute of a serous investment.
 
 ABDOMINAL ARTIFICIAL AND3. 329 
 
 The aiuitoinj of the p;irts cuucenied is of the utmost impor- 
 tance mid must be the lirst tiling to en<^agc our attention. 'I'lie 
 most important point is tlio reUition which the desceiidiiii:: 
 colon bears to tlie peritonaeum in the left lundjar region. In 
 order to study and understand this well, iVccpuMit dissections 
 upon the dead body should be nuide ; and in making these the 
 body should always be opened from behind, and not from the 
 front, as is ordimirily done. If the dissection is made from 
 behind, the posterior third of the descending colon will be 
 found lying closely against the ccllulo-adipose lanunas, which 
 line the abdominal wall in this situation. It will be observed 
 to be uncovered by peritonaeum, and to have no loose or float- 
 ing meso-colon ; but the serous reflexion will be found to be 
 closely applied to the abdominal wall on ea«h side of the intea-f 
 tine. When, on the contrary, the dissection is made from the 
 front, the colon is always drawn forward, and in doing this, a 
 distinct and somewhat elongated meso-colon is formed which 
 does not normally exist, but is made by the traction of the 
 dissector in tearing off the reflexions of the peritonaeum. It is 
 of the greatest importance to observe that the extent of intes- 
 tine uncovered by peritonaeum varies, according as the colon is 
 contracted or distended. When it is empty and contracted, 
 the peritonaeal reflexions come into very close apposition, and 
 nearly overlay the naked portion of intestine ; but when this 
 is distended they are pushed aside, as it were, and a broad 
 expanse of colon will be seen to be uncovered by peritonreum. 
 To verify this it is only necessary to inflate the colon if it is 
 empty or contracted. The facility of exposing the uncovered 
 part of the colon, without wounding the peritonaeum, will be 
 in the exact ratio of its amount of distention. 
 
 M. Amussat attributes the failure of Callisen's operation 
 on the dead body, to the fact that in such cases the intestine is 
 most always empty. Those, therefore, who might wish to prac- 
 tice the operation on the dead subject should always flrst inflate 
 the intestine. In the cases of congenital malformation, how-
 
 330 ABDOMINAL AKTIFICIAL ANUS. 
 
 ever, in which this operation is required, this condition of the 
 colon does not obtain, as in sucli cases, it is nniversally dis- 
 tended to its ntmost capacity by meconium and gas, conse- 
 quently the layers of the peritonseum, forming its imperfect 
 mesentery, are so separated, as to allow of the intestine being 
 readily reached, without touching the peritonfeum. 
 
 The first step M. Amussat takes to improve Callisen's oper- 
 ation is to adopt the transverse instead of the vertical incision 
 of the integuments and muscles, the advantages of which he 
 maintains are, first, that it makes the operation easier and 
 more certain, and avoids the danger of dividing the lumbar 
 vessels and nerves ; second, that it greatly facilitates the dis- 
 covery of that portion of the intestine destitute of peritonaeum, 
 as well as the opening of it without wounding the periton- 
 aeum ; and third, that it enables the artificial anus to be estab- 
 lished more anteriorly. {Ojncs Citahtm.) 
 
 M. Amussat besides modifying this operation in various 
 resj)ects, has extended the applicability of it to the ascending 
 colon — hence by his method it may be performed either upon 
 the left or the right side, according to the situation of the de- 
 formity or obstruction. 
 
 Some authorities maintain that in early life it is by no 
 means unusual to find a kind of lumbar meso-colon, or the 
 colon floating and surrounded by peritonteum, like one of the 
 small intestines ; and that under such circumstances the serous 
 membrane would necessarily have to be opened, and the oper- 
 ation would present no advantage over that of M. Littre ; 
 consequently they contend that it is not applicable to, nor 
 should be performed on infants, but should be limited to 
 adults alone. M. Amussat on the contrarv, however, con- 
 tends that tlie disposition of the parts in early life is more 
 favorable for the operation than in adults ; first, because the 
 situation of the lumbar colon is more fixed or constant in 
 early life ; and second, because the kidney forms an unerring 
 guide to the colon which always lies immediately external to
 
 ABDOMINAL AUTIFICIAL ANUS. 331 
 
 that organ. lie says too, that the intestine seems more firmly 
 adherent to the parietes of the abdomen than in adults. 
 {Troialhne Memoir e^ ike. In UExaminateur Medical de 
 Paris. Annee 1843. p. 216, 229.) In only one dissection 
 out of twenty did M. Amussat find a lumbar meso-colon in 
 the infant, and in that instance the intestine was empty. 
 {Bulletin de V Academie Royale de Medicine. 30 Juin^ 1842. 
 p. 302.) 
 
 The Operation. — Every thing being made ready, bistou- 
 ries, forceps, scissors, crochets, tenaculum, sponges, small 
 curved silver needles, ligatures, and small canula, the little 
 patient should be placed upon its abdomen inclining to the 
 right side, with a pillow placed under the abdomen to ele- 
 vate it. The operator will observe that the region in which 
 the operation is performed, is bounded above by the last 
 false rib ; below, by the crest of the ilium ; behind, by the 
 lumbar spine ; and in front, by an imaginary mesial lateral 
 line. After marking with ink the three bony boundaries of 
 this oblong quadrilateral space, the operator should make a 
 transverse incision of from two to three inches in length, mid- 
 way between the last false rib and the crest of the ilium, 
 parallel with the crest, commencing at the external margin 
 of the sacro-lumbalis and longissimus dorsi muscles. This 
 incision must be continued down, so as to divide the poste- 
 rior margin of the three broad muscles of the abdomen, and 
 the anterior portion of the latissimus dorsi and quadratus 
 lumborum. These muscular layers should all be divided, 
 first across, then vertically, to aflford a crucial incision, if 
 necessary, and the better to expose the intestine. All the 
 posterior part of the incision, the cellular and adipose tissue 
 which envelops the kidneys and colon, may now be per- 
 ceived. This tissue should be divided vertically with caution, 
 when the colon will appear between the edges of the incision. 
 The colon thus being recognized and exposed, two threads, 
 one above and one below should be passed through its coats
 
 332 ABDOMINAL ARTIFICIAL ANUS. 
 
 with a needle, and by it should be drawn to the middle of 
 the external wound, and in the space between the threads, it 
 should be pierced with a trocar, and after some of the meco- 
 nium and gas has escaped, the opening thus made, should be 
 enlarged by a crucial incision. It is highly important that 
 the intestine should be well drawn forwards before it is 
 punctured, fully on a level with the skin, in order that its 
 contents may not be extravasated into the loose cellular 
 tissue around it. The intestine after being punctured, and 
 the orifice thus made, enlarged by a crucial incision, should 
 now be completely evacuated and washed out by injections 
 of tepid milk and water ; after which the margin of the intes- 
 tinal wound should be fixed by four hare-lip sutures to the 
 lips of the skin in the middle tract of the cutaneous wound, 
 for the purpose of preventing the escape of the faecal matters 
 into the loose cellular tissue of the region of the colon, as 
 before observed. Tlie anterior and posterior angles of the 
 cutaneous incision should also be closed by more or less 
 hare-lip sutures, according to their extent, for the purpose of 
 effecting union by the first intention. iVide Plate JCYI^ 
 Figures 1, 2, 3.] 
 
 The child should now be put to bed and a warm poultice 
 applied. About the fourth or fifth day after the operation, 
 if all goes on well, the sutures may be removed. 
 
 M. Amussat executed Callisen's operation as modified by 
 himself, in three instances of imperforate infants. His report 
 of these cases I have presented in full, translated from the 
 original. It will be found highly interesting and still more 
 fully illustrate his method of operating. [ Yide Cases 
 CCLXXXIV—CCLXXXV—CCLXXXVL'] 
 
 This operation requires considerable firmness of hand and 
 great precaution, in order to avoid wounding the serous 
 membrane, the preservation of which is its essential advant- 
 age. The most difficult and the most perplexing part of the 
 operation, however, is to recognize the colon. The signs
 
 ABDOMINAL ARTIFICIAL ANUS. 333 
 
 which M. Aimissat gives, whether taken separately or col- 
 lectively are by no means diagnostic. He says, for instance, 
 that the kidney forms an nnerring gnide to the coh)i), yet in 
 0})erating on his third case, {(JCLXXKVI) the kidney wa^ 
 actually mistaken for the colon, and the incision made into it 
 disclosed the mistake. lie himself admits that, '•'■ Even if 
 the colon is distended there are no sufficient means of ideniifij- 
 ing it, though it should he perfectly laid hareP {Detixiiime 
 Me moire, <]&c.) 
 
 The greenish color of the colon, as well as the greater 
 development of its muscular fibres, may aid the operator to 
 recognize it. Pressure and percussion with the fingers, on 
 account of its elastic tumefaction, are excellent means of 
 ascertaining its presence. 
 
 M. Baudens, chief surgeon of the Military Hospital of 
 Gros-Caillon, objects to all of M. Amussat's signs. Should 
 the colon be filled wnth faeces, says he, it would be hard, and 
 then liable to be confounded wath the kidney ; should it be 
 pliable and elastic, from being distended with gas, then it 
 could not, by the touch, be discriminated from the small 
 intestines. He recommends, as an infallible means the 
 employment of exploratory acupuncturation. Previous to 
 opening what he supposes to be the colon, he introduces an 
 acupuncture needle, furnished with a canula, and on with- 
 drawing the needle, eitlier gas escapes, or the canula is soiled 
 with fieces, if it has entered the colon. {Gazette des Ho])it- 
 aux de Paris, Annee 18i2. No. XX VII. p. 179.) 
 
 M. Baudens, however, with a much greater show of reason, 
 objects to the transverse incision proposed by M. Amussat in 
 Callisen's operation, in consequence of the liability of wound- 
 ing some of the large branches of the genito-crural and 
 inguino-cutaneous nerves, and also that it exposes too small 
 an extent of the intestine, which should be opened by an 
 incision at least one inch and a half long, as otherwise the 
 anus will contract. He says, that M. Amussat, moreover, is
 
 334 ABDOMINAL ARTIFICIAL ANUS. 
 
 obliged to make a crucial incision in the deep parts, which 
 perils the lumbar arteries, is painful, and augments the extent 
 of the wound. In order to combine the advantages of a 
 vertical and transverse incision without the disadvantages of 
 either, M. Baudens proposes an oblique incision. {Opus 
 Citatum.) 
 
 SECTION X. 
 CASES AND REMARKS. 
 
 Cases CCLXXXIY— CCLXXXV— CCLXXXVI.— In the 
 
 three following cases, M. Aiiiussat performed colotomy after 
 the method of Callisen, as inodiiied by himself. 
 
 First Case. — " On the 22nd of January, 1842, M. Hippolite 
 Larrey, sent me a male infant, born on the 20th January at 
 four o'clock, A. M. On the next day after its birth, seeing 
 no discharge of meconium, they discovered that the child 
 M-as imperforate. They attempted with sounds, and even 
 with trocars to give vent to the meconium, but without 
 success. 
 
 In other respects the child was strong and well made, 
 and the anus occupied the usual position. It allowed the 
 introduction of sounds and the fore-tinger, but at about one 
 inch deep the progress of the finger or instrument was 
 arrested by an obstruction, beyond which no fluctuation was 
 perceived indicating the presence of a distended rectum. 
 
 The urine was slightly affected, but with no mixture of 
 meconium ; the abdomen was distended hard and elastic, but 
 without inequalities or depressions ; the child was not ema- 
 ciated, and the yellow tint common to imperforate children 
 was barely perceptible. Notwithstanding the absence of 
 fluctuation above the closure at some distance from the anus, 
 I attempted to go beyond that, profiting by the small opening 
 already made with sounds or trocars. I forced this opening 
 with my finger, and sought to recognise the end of the large 
 intestine : but it was impossible either for myself or my 
 assistants to discern the least fluctuation. For an instant I 
 thought I felt an intestine ; but the sensation was vague, and 
 besides I had reached too great a height after rupturing the
 
 ABDOMINAL AJ4'1TFICIAL ANUS. 335 
 
 cellular tissue of the pelvis with my fore-finger, to dare to 
 attinn that 1 had to do with an intestine. 
 
 Reflecting upon the course to be taken in so embarrassing 
 a case, I proposed to establish an artificial anus in the left 
 lumbar region. Tin's proposition liaving been discussed and 
 ap|)roved, I immediately proceeded to the operation. 
 
 The child was placed on its abdomen, a little inclined to 
 the right side, so that the left flank was turned uppermost. 
 Some folded napkins were placed under the right side to 
 render the left flank more prominent. After closely exam- 
 ining the left lumbar region, and measuring the distance 
 from the crest of the ilium to the last false rib, I marked the 
 position of the vertebral column and the resistance and thick- 
 ness of the tissues of that region. My dimensions being 
 carefully taken, I made a transverse incision about two inches 
 in length, in the middle of the space comprised between the 
 last rib and the crest of the ilium. This flrst incision com- 
 prised only the skin and the cellular tissue. By another 
 incision I divided the thin muscles and came immediately 
 upon the cellular and adipose tissue which characterizes the 
 envelope of the kidney at this age. I cut this envelope and 
 saw the kidney perfectly naked, and filling almost the whole 
 interosseous lumbar space, which was very embarrassing. 
 My first transverse incision not being sufficient, I made 
 another, forming a T with the first. I pushed back the kid- 
 ney and sought for the colon. After nnich uncertainty, 
 thinking I recognized it, I determined to seize longitudinally 
 with a tenaculum, from above downwards what I believed to 
 be the colon, and I brought it towards the surface, after again 
 seizing it wdth another tenaculum which I inserted in an 
 opposite direction and a short distance behind the first. The 
 organ being thus firmly fixed and held, I made an opening 
 between the two tenacula with the scissors. Immediately we 
 perceived a greenish ball, being the meconium covered with 
 a jDellicle ; as soon as this was ruptured, gas and meconium 
 escaped. I then enlarged the opening a little above and below, 
 and I seized the edges w^ith spring forceps. I then introduced 
 into the intestine a canula through which, by means of injec- 
 tions, to dilate the meconium and to facilitate its evacuation ; 
 lastly, I cleansed the wound and attached the ed^es of the in- 
 testinal opening to the skin by three jioints ot interrupted 
 suture, taking care to draw the intestine well forward. 
 
 The child was very weak ; it had lost much blood and it 
 was exhausted with pain, and I must confess I had little hope 
 of it surviving, nor indeed did any of the spectators expect it 
 to live.
 
 336 ABDOMINAL AETIFICIAL ANUS. 
 
 I advised that it should be suckled and that its linen should 
 be frequently changed. 
 
 From day to day the condition of the child improved ; the 
 sutures were detached on the fourth day ; the agglutination 
 of the edges of the intestine was then complete, and the 
 opening afforded an easy exit to fiecal matter. 
 
 On the 10th day after tlie operation, on examining the ab- 
 domen which had diminished in volume, we observed in the 
 left iliac cavity, a swelling or tumor about three inches from 
 the artificial anus. We thought that this sort of sac was 
 formed by the end of the large intestine which terminated at 
 this point, instead of descending into the pelvis. 
 
 On the 14th or the 15th day the artificial anus, by the 
 tendency which it always had to contraction, was almost com- 
 pletely obliterated, and the child evacuated faeces with difli- 
 culty. It was very restless. I promptly dilated tlie opening, 
 and I recommended in future, tlie daily introduction of wax 
 bougies to keep the opening sufficiently large. In spite of my 
 recommendation, the artificial anus contracted to such a de- 
 gree, that on the 8th of March, I was obliged to force an open- 
 ing with sounds and dilute by injections the faecal matter 
 which liad accumulated. Afterwards the child was very sick. 
 Seeking to account for the obstacle which had formed a second 
 time to obstruct the passage of fsecal matter, I perceived that 
 the wax bougie hitherto used had become too short, and that 
 it dilated only one half of the i)a?sage ; the other half had 
 contracted on itself and only afforded vent to the more liquid 
 portion of the faeces. 
 
 After this dilatation was kept up by the introduction of 
 sounds the whole length of the artificial anus, and from time 
 to time with a sponge prepared with pack thread, and no fur- 
 ther accident occurred. 
 
 Tlie description of this case, which I do not read in full, in 
 order to spare the valuable time of the Academy, proves a 
 complete success attained by the establishment of an artificial 
 anus in the left lumbar colon, without ojjening the peritonaeum, 
 of a new born child. 
 
 In this child the normal anus was well formed, but it did 
 not communicate with tliat portion of the rectum coutainiiig 
 the meconium, and in spite of the attempts made to ascertain 
 the presence of this intestine above the closure, I could not 
 recognise it at all. I was therefore forced to make an anus in 
 the lumbar region. 
 
 1 would remark that the life of the child was twice endan- 
 gered by contraction of the lumbar anus. It is therefore in-
 
 AP.DOMINAL ARTIFICIAL ANUS. 337 
 
 dispensable in tliis and all similar cases, to keep up tliis artifi- 
 cial passai^e with Itoiio-ies of wax or _i;inn clastic. 
 
 It is probable that the intestine terniinatt's in the left iliac 
 cavity above the })elvis ; for when tlie cliild cries or makes 
 unusual effort there is seen au evident tumor in that re<;ioii. 
 Is this disposition favorable to the ]>lan of operation ]n-o])os('<l 
 by M. Klewitz of Colberg? This oj)eration would consist of the 
 repression toM'ards the perinajuin, throiig-h the artificial anus of 
 the lumbar region, of the terminal cul-de-sac of the large intes- 
 tine, and the establishing' an anus in the resfion of the 
 perin^euni or coccyx, in order to suppress that of the lumbar 
 region. I do not think such an operation practicable, for it 
 would expose the life of the child to the new changes of a 
 serious operation. 
 
 MM. Breschet, Magendie, and Larrey, who have seen the 
 child, have testified that it is strong and well developed. 
 
 To-day it is more than a year old; its health is as good as 
 its infirmity will allow. 
 
 Its life seems certain so long as the artificial opening is 
 kept well dilated and sufficiently open, and in fine, so long as 
 the retention of the foeces is avoided. 
 
 Let us consider, however, wdiether some new operation 
 might not be attempted to restore the normal passage, as M. 
 Hippolite Larrey has proposed, or to establish au artificial 
 anus in the tumor as proposed by Baron Larrey. 
 
 Without discussing the possibility of executing these two 
 propositions or the advantages they might secure, I tliink it 
 more prudent to attempt nothing, in order not to compromise 
 the life of the child. We have only to prevent the too great 
 development of the tumor, and especially the contraction of 
 the artificial anus. 
 
 In conclusion, this instance is remarkable in two respects, 
 the difficulty of the operation, and the difficulty of keeping 
 the artificial opening dilated. 
 
 From these observations, let us see what is to be done, and 
 what is to be avoided in such cases. First, in a similar or 
 analagous case, I would do what I did heloio, or rather, after 
 havino; introduced a sound or the little fino;er, if I did not find 
 a distinct fluctuation, indicating the upper end of the mtestme, 
 I would dilate the inferior end with a prepared sponge, to give 
 time to tlie meconium to distend the end of the large intestine 
 the better to explore it, and if the simple exploration, without 
 rent, discovered nothing, I w^ould immediately have recourse 
 to the operation in the left lumbar region. 
 
 But if I found the rectum distended with meconium, as 
 most frequently hapT)ens, instead of perforating the obstruc- 
 
 22
 
 338 ABDOMINAL ARTIFICIAL ANUS. 
 
 tion as is commonly done, I would make an incision on the 
 side of the coccyx, behind, and I would brhig down the rec- 
 tum to the skin and fix it there by several points of suture, 
 after opening it, in order to make an artificial anus in this 
 region, just as we do in the abdomen. 
 
 Ordiiiarily surgeons content themselves with making a 
 puncture with the trocar, and then enlarging the opening ; 
 but the child almost always dies. Almost every one that I 
 have seen operated on, or that I have heard reported, have the 
 same result. Death occurs in these cases, in consequence of 
 an effusion of ftecal matter in the cellular tissue of the pelvis, 
 and because it is very difficult to preserve proper dilatation 
 of the artificial opening. 
 
 Seco7id Case. — On Monday, May 2ith, 1842, a child was 
 brought to me, of the male sex, born on Saturday, 22d inst., 
 at midnight. Since birth it had passed no meconium, and 
 had vomited almost constantly. I examined the region of the 
 coccyx and found the anus well formed ; but on introducing 
 my little finger, it was arrested at about one inch and a half in 
 height, and I could find no fluctuation at the bottom of this 
 cul-de-sac, indicating that the rectuni distended by meconium, 
 terminated above the obstruction. The abdomen was not 
 much distended. The urine was clear and flowed from a very 
 small opening situated beneath the gland ; hypospadias there- 
 fore existed in this case as well as imperforate rectum. 
 
 Desirous of assuring myself in the most positive manner, 
 that the extremity of the intestine did not terminate immedi- 
 ately above the closure of the rectum, which I could hardly 
 reach with my little finger introduced by the anal opening, I 
 proposed to place a prepared sponge in the anus, in order to 
 facilitate future examination. Besides, the child was very 
 sti'ong and active, and I saw no inconvenience that could re- 
 sult from delaying the operation till the next day. 
 
 The next day, the 2.5th, the child was again brought to me. 
 It had continued to vomit greenish matter, and the sweetened 
 water which they had given it. The abdomen was much dis- 
 tended and elastic ; the urine had continued to escape freely 
 by the opening situated beneath the gland. It was now highly 
 necessary to determine upon some course. 
 
 I renewed the examination made the day before, and came 
 to the same conclusion, that is, that the end of the rectum 
 did not terminate above the closure. It was impossible to 
 perceive any fluctuation. 
 
 After conferring with those present, wlio had made the 
 same examinations, I did not hesitate to ])ropose an operation
 
 ABDOMINAL ARTIFICIAL ANUS. 339 
 
 ill tlie left liinihar rcf2:ioii in prcforcnoe to tliat wliicli T might 
 have perfoniied in the region of tlie coccyx ; and u[)oii a 
 review of all the reasons I adduced in favor of my opinion, it 
 was unaniniously decided to open the colon in tlie left lumbar 
 region and make no attempt in the region of the coccyx. 
 
 1 then proceeded to that operation in presence of MM. 
 Chains, physician at St. Maur, who had received the child, 
 Capuron, Bauni of Dantzick, Eydoux, Genouville, Du])re 
 Latoiir, Parnot, Marinier, Dufresse, Denouette, Porinet, L. 
 Poycr, Filhos, Le Vaillant, &c., &c. 
 
 The child having been placed on its right side, the head 
 supported on a cushion, I began by assuring myself of the 
 position of the last rib, the crest of the ilium, and the mass 
 of the sacro-lumbalis, and longissimus dorsi muscles ; then I 
 marked in ink the boundaries of the region in which I was to 
 operate. Finally, I made a transverse incision, about two 
 inches loner commencing witli the common mass of the sacro- 
 lumbalis and longissimus dorsi muscles. This incision 
 promptly extended to the muscles, which I was obliged to 
 cut crucially as well as the skin. Quite a large artery was 
 checked by torsion. I dissected the layers of the transverse 
 aponeurosis and reached the adipose tissue of the kidney. I 
 dissected back this tissue, and caught sight of the kidney 
 which was uncovered for a part of its extent both behind and 
 above: I then saw beyond and above this organ, another one 
 of a Iwown color, which seemed to be the intestine ; having 
 seized it with two tenacula, I incised it between the two 
 instruments ; but I found no cavity, it was a solid organ like 
 the spleen, or the supra-renal capsule ; it could not have 
 been the spleen which I cut, since that organ is within the 
 peritoufBum, and the peritonaeum had not been opened. I 
 therefore concluded that I had to do with the supra-renal 
 capsule, largely developed and projecting beyond the kidney. 
 I then sought for the intestine below, pushing the kidney 
 upward and backward, and soon after, having enlarged the 
 muscular incisions, pushed aside the kidney, the supra-renal 
 capsule and the anterior angle of the kidney, and having 
 sponged the bottom of the wound carefully, I perceived a 
 greenish organ : from its color, position, and form, and from 
 the sensation of fluctuation perceptible to the touch of the 
 finger, I thought, and so did some of my assistants, that it was 
 the descending colon, distended with meconium. A drawing 
 of the lumbar region which I had before me confirmed this 
 opinion, showing me the exact relation of the parts. 
 
 Examining then with minute attention the intestine in 
 question, I was almost sure it was the left lumbar colon with-
 
 340 ABDOMINAL AKTIFICIAL ANUS. 
 
 out the peritonseuin. I then fixed two teiiacula in the walls 
 of the intestine, a short distance apart, and between the two 
 instruments iirmly held, I cut the intestinal tunics with the 
 scissors ; gas immediately escaped with a prolonged whiz 
 and having a characteristic odor, and then meconium passed 
 in a continuous jet. To the great satisfaction of all present 
 tlie result of the operation was about to be attained. The 
 child seemed relieved by the escape of gas and fsecal matter ; 
 for it was remarked that it cried much less. After enlarging 
 the opening of the intestine, I introduced a cannla, which 
 penetrated deeply in the direction of the sigmoid flexure of 
 the colon : then to keep the incision open, I put on its edges 
 three artery forceps. Lastly, after injecting several times 
 with tepid water, to tliin the meconium and favor its evacua- 
 tion, I lixed the edges of tlie intestine to the anterior angle 
 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 
 Species. 
 
 De Jessieu, Case CLXXVIII., p. 205. Rectum terminated in the vagina. 
 Sixth Species. 
 
 De La Faye, George, Cases CX — CXI., p. 210. Abnormal anus in the 
 sacral region. Fifth Species. 
 
 De La Marre, vide case, p. 55. 
 
 De La Salle, Case CLIII., p. 256. Rectum terminated in the urethra. 
 Sixth Species. 
 
 De Lens, Case LXXVIL, p. 179. Occlusion of the rectum above a normal 
 anus. Fourth Species. 
 
 Delmas, Case CXV., p. 212. Imperforatioh of the anus, with an abnor- 
 mal opening at the side of the right nates. Fifth Species. 
 
 Denonvilliers, Case CXVI., p. 212. Imperforate anus, accompanied with 
 an abnormal opening in one of the nates. Fifth Species. 
 
 Desault, Pierre, Case CCLVIL, p. 312. Imperforate anus and rectum. 
 Third Species. 
 
 Desgenettes, R., Case CXXXIL, p. 237. Rectum terminated in the blad- 
 der. Sixth Species. 
 
 Desgranges, Case CCLIX., p. 313. Rectum terminated in the vagina. 
 Sixth Species. 
 
 Desormeaux, P., vide case, p. 45. 
 
 Devilliers, Case XI.,. p. 72. Abnormal contraction of the anus. First 
 
 Species. 
 ^ 23
 
 354 INDEX TO ILLIJSTKATIVE CASES. 
 
 Dewees, William P., vide cases, p. 39. 
 
 Dieffenbach, Johann Friedrich, Cases CIII. — CIV., p. 206. Imperforation 
 
 of the anus, with an abnormal opening in the scrotum. Fifth 
 
 Species. Case CXCIX., p. 271. Rectum terminated in the vagina. 
 
 Sixth Species. 
 Dodonaeus, Rembertus, Case CLXXX., p. 265. Rectum terminated in 
 
 the vagina. Sixth Species. 
 
 Dubois, Anton, Case CCLV., p. 311. Imperforate anus and rectum. Third 
 Species. 
 
 Duges, Anton, vide case, p. 45. 
 
 Dumas, Case CLXV., p. 258. Rectum terminated in the urethra. Sixth 
 
 Species. 
 Dupareque, Cases XX — XXI., p. 84. Simple occlusion of the anus. Second 
 
 Species. 
 
 Dupuytren, M. le Baron, Case CCLXXXI., p. 326. Imperforate anus and 
 rectum. Third Species. 
 
 Duret, Cases CCLVI. — CCLXI., pp. 311 — 314. Imperforation of the anus 
 
 and rectum. Third Species. 
 
 Durr, George Tobie, Case CII., p. 206. Imperforate anus, with an ab- 
 normal orifice at the anterior part of the perin^eum. Fifth Species. 
 
 (E.) 
 
 Edwards, D. 0., Case LXXYL, p. 177. Occlusion of the rectum above a 
 
 normal anus. Fourth Species. 
 Engel, H. T., Case CCXVI., p. 281. The vagina terminated in the rectum. 
 
 Seventh Species. 
 Engerran, Case LXYI., p. 168. Imperforate rectum above a normal anus. 
 
 Fourth Species. 
 Estero, Case CCXXXI., p. 286. Rectum entirelj^ wanting. Eighth 
 
 Species. 
 
 (F.) 
 
 Fabricius, Guilhelmus, Case CI., p. 206. Occlusion of the anus with an 
 Abnormal orifice at the root of the penis. Fifth Species.
 
 INDEX TO ILLUSTRATIVE CASES. 355 
 
 Fabricius, Ilieronymus, vide ease, p. 8G. 
 
 Fenerly, Case XXVIII., p. 123. luiperforation of the anus and rectum. 
 
 Third Species. 
 Fergusson, "William, Case VII., p. 71. Abnormal narrowing of the anal 
 
 orifice. First Species. Case CLXXII., p. 201. Rectum terminated 
 
 in the urethra. Sixth Species. 
 Fitteau, Case CCLXL, p. 287. Rectum entirely wanting. Eighth 
 
 Species. 
 Flajani, Giuseppe, Case CLIV., p. 256. Rectum terminated in the 
 
 urethra. Sixth Species. 
 Fleischmann, S., Case CCXLIV., p. 288. Rectum entirely wanting. Eighth 
 
 Species. 
 Ford, Edward, Case LXX., p. 170. Imperforate rectum above a normal 
 
 anus. Fourth Species. 
 Forget, C. P., Case XXXVIII., p. 135. Imperforation of the anus and 
 
 rectum. Third Species. Case LXXXIX., p. 180. Imperforate rectum 
 
 above a normal anus. Fourth Species. 
 Fourcart, Case XXXVII., p. 133. Imperforation of the anus and rectum. 
 
 Third Species, 
 Fourcade, vide case, p. 56. 
 Fournier, M., Case CXCIII., p. 267. Rectum terminated in the vagina. 
 
 Sixth Species. 
 Freer, George, Case CCLXVI., p. 316. Imperforation of the anus and 
 
 rectum. Third Species. 
 Friedberg, Hermann, Case XLVII., p. 147. Imperforate anus and rectum. 
 
 Third Species. Case LXXXIV., p. 183. Occlusion of the rectum 
 
 above a normal anus. Fourth Species. Case CXVII., p. 212. Im- 
 perforation of the anus, with an abnormal opening in the scrotum. 
 
 Fifth Species. 
 Fristo, Oases CVIII— CIX., p. 210. Imperforate anus in each case, with 
 
 an abnormal one in the groin of one, and at the dorsum of the penis 
 
 of the other. Fifth Species.
 
 356 INDEX TO ILLUSTRATIVE CASES. 
 
 Fiirst, Case CLXXXIX., p. 266. Rectum terminated in the vagina. Sixtli 
 Species. 
 
 (G.) 
 
 Gay, G. H., Case CXLIX., p. 254. Rectum terminated in the bladder. 
 
 Sixth Species. , 
 
 Giering, Case CCXL., p. 287. Rectum entirely absent Eighth Species. 
 Gilman, Noah, Case CXLYI., p. 252. Rectum terminated in the bladder. 
 
 Sixth Species. 
 Goeschler, Case XCII., p. 192. Occlusion of the rectum above a normal 
 
 anus. Fourth Species. 
 Green, Vf. A., Case CXIV., p. 211. Imperforate anus, with an abnormal 
 
 opening at the anterior part of the perinajum. Fifth Species. 
 Gi-imaud, vide case, p. 198. 
 Gross, Samuel D., Case CL., p. 255. Rectum terminated in the bladder. 
 
 Sixth Species. Case CCLIII., p. 293. Rectum and colon both 
 
 absent. Ninth Species. 
 Guersant, Cases CLXXIV.— CCLXXXIII., pp. 262—327. Rectum termi- 
 nated in the uretha. Sixth Species. 
 
 (H.) 
 
 Haesbert, Case CLXXIX., p. 265. Rectum terminated in the vagina. 
 
 Sixth Species. 
 Hartmann, Phillipus, Case CLXXXIV., p. 266. Rectum terminated in 
 
 tlie vagina. Sixth Species. Vide also case, p. 230. 
 Harward, George, Case CXXIL, p. 219. Occlusion of the anus, with an 
 
 abnormal opening in the labia pudendi. Fifth Species. 
 Heister, Laurence, Cases LV — LVI., p. 156. Imperforation of the anus 
 
 and rectum. Third Species. 
 Henkel, J. F., Case CCXXX., p. 286. Rectum entirely absent. Eighth 
 
 Species.
 
 INDEX TO ILLUSTRATIVE CASES. 357 
 
 Iligginson, F., Case XXXIX., p. 135. Imperforate anus and rectum. 
 Third Species. 
 
 Hill, Thomas P., Case LXTI., p. 150. Imperforate anus and rectum. 
 Third Species. 
 
 Iloehstetter, 0. F., Case CLVI., p. 257. Rectum terminated in the urethra. 
 Sixth Species. 
 
 IIofTman, Richard K., Case LXXXI., p. 181. Imperforate rectum above a 
 normal anus. Fourth Species. 
 
 Iloltzach, Case CXXVI., p. 236. Rectum terminated in the bladder. Sixth 
 Species. 
 
 Houghton, L. W.J Case CXLIII., p. 248. Rectum terminated in the blad- 
 der. Sixth Species. 
 
 Howship, John, Case XVIII., p. 81. Imperforation of the anus. Second 
 Species. Case CXCVI., p. 267. Rectum terminated in the vagina. 
 Sixth Species. 
 
 Huber, A., Case CCXXXIV., p. 286. Rectum entirely wanting. Eighth 
 Species. 
 
 Hutchison, Alexander Copeland, Case V , p. 71. Preternatural narrovping 
 of the anus. First Species. Case XV., p. 80. Occlusion of the anas 
 by a simple membrane. Second Species. Case XXXVI., p. 128. Im- 
 perforation of the anus and rectum. Third Species. Case LXXV., 
 p. 176. Imperforate rectum above a normal anus. Fourth Species. 
 
 (J.) 
 
 Jamieson, James, Case CCXXXVI., p. 286. Rectum entirely wanting. 
 
 Eighth Species. 
 Jacquemin, Case CCXLVII., p. 288. Rectum entirely absent. Eighth 
 
 Species. 
 Jessen, Johan, Case LXIIL, p. 167. Imperforate rectum above a normal 
 
 anus. Fourth Species. 
 Johnson, W. Otis, Case XXV., p. 85. Simple occlusion of the anus Second 
 
 Species.
 
 358 INDEX TO ILLUSTEATIYE CASES. 
 
 Jones, George Stephens, Case XCVII., p. 196. Imperforate rectum above 
 
 a normal anus. Fourth Species. 
 Jones, James, Cases LX — LXI., p. 157. Imperforate anus and rectum. 
 
 Third Species. Case LXXXVII., p. 186. Occlusion of the rectum 
 
 above a normal anus. Fourth Species. 
 " Journal des Savants,^^ Case CCXX., p. 282. Vagina terminated in the 
 
 rectum. Seventh Species. 
 
 (K.) 
 
 Kirsten, Case CXCI., p. 266. Rectum terminated in the vagina. Sixth 
 
 Species. 
 Klein, Christian, Case CCX., p. 280. Ureters terminated in the rectum. 
 
 Seventh Species. 
 Klewitz, Case CCLXXV., p. 318. Rectum terminated in the bladder. 
 
 Sixth Species. 
 Kretschmar, Case CLVII., p. 257. Rectum terminated in the urethra. 
 
 Sixth Species. 
 
 (L.) 
 
 La Coste, Case CXII., p. 210. Imperforate anus, with an abnormal opening 
 
 in the sacral region. Fifth Species. 
 Latta, James, Cases XXXII — XXXIII., p. 126. Imperforation of the anus 
 
 and rectum. Third Species. 
 Lauremberg, Case CLXI., p. 257. Rectum terminated in the urethra. 
 
 Sixth Species. 
 Legris, Case CCLXII., p. 315. Rectum terminated in the urethra. Sixth 
 
 Species. 
 Lenoir, Case CCLXXIX., p. 320. Rectum terminated in the urethra. 
 
 Sixth Species. 
 L^veille, Case CCXXXIX., p. 287. Rectum entirely absent. Eighth 
 
 Species.
 
 I 
 
 i 
 
 INDEX TO ILLUSTKATIVE CASES. 359 
 
 Licetus, Fortunius, Case CLI., p. 25G. Rectum terminated in tlic urethra. 
 
 Sixth .Species. 
 Lieutand, Case XLIX., p. 152. Tmperforation of the anus and rectum. 
 
 Third Species. 
 Littr^, Case C, p. 198. Imperforate rectum above a normal anus. Fourth 
 
 Species. Case CCXLIX., p. 292. Rectum and colon both absent. 
 
 Ninth Species. 
 Lohmann, Case CCLIV., p. 293. Rectum and colon both absent. Ninth 
 
 Species. 
 Louis, Case CCXIV., p. 281. The vagina terminated in the rectum. 
 
 Seventh Species. 
 Lucas, Bennett, Case CXXXVI., p. 239. Rectum terminated in the blad- 
 der. ^ Sixth Species. 
 Ludovicus, Case CCXXXIIL, p. 286. Rectum entirely wanting. Eighth 
 
 Species. 
 
 (M.) 
 
 Man tell, T., Case CXXIY., p. 221. Imperforate anus with an abnormal 
 
 opening near the labia pudendi. Fifth Species. 
 Matani, Ant, Case CCXXXV., p. 286. Rectum entirely wanting. Eighth 
 
 Species. 
 Martin, De Lyon, Case CCXXXVII., p. 287. Rectum entirely absent. 
 
 Eighth Species. 
 Martin, vide case, p. 230. 
 ]McEvoy, Francis, Case XXXIV., p. 226. Imperforation of the aniis and 
 
 rectum. Third Species. 
 Meckel, J. F., Case CCXXXVIII., p. 287. Rectum entirely wanting. 
 
 Eighth Species. 
 " Memoires de Berlin,''^ Case CCXIX., p. 282. The vagina terminated in 
 
 the rectum. Seventh Species. 
 JNfercurialis, Hieronymus, Case CLXXVIL, p. 265. Rectum terminated in 
 
 the vagina. Sixth Species.
 
 360 INDEX TO ILLUSTRATIVE CASES. 
 
 Merriman, Samuel, Case XIX., p. 83. Imperforation of the anus. Second 
 Species. 
 
 Merry, Jean, Cases CCXXVIII— CCXXIX., p. 28G. Rectum entirely 
 absent. Eighth Species. 
 
 Miller, Case CXXXVII., p. 241. Rectum terminated in the bladder. Sixth 
 Species. 
 
 Miriel, St^nieur, Cases CCLXVII— CCLXVIII., p. .31G. Imperforate rec- 
 tum above a normal anus. Fourth Species. Case CCLXIX., p. 316. 
 Imperforate anus and rectum. Third Species. 
 
 Mitchell, S., Case LI., p. 152. Imperforate anus and rectum. Third 
 Species. 
 
 Monad, Case CVII., p. 210. Imperforate anus, with an abnormal opening 
 near the glans penis. Fifth Species. 
 
 Moore, E. B., Case XVI., p. 80. Occlusion of the anus.* Second 
 Species. 
 
 Morgagni, .Joan Bapt, Case CXXIX., p. 237. Rectum terminated in the 
 bladder. Sixth Species. Case CCXXIV., p. 285. Rectum entirely 
 absent. Eighth Species. 
 
 Motais, vide case, p. 87. 
 
 Murray, Adam, Case CXXVIII., p. 236. Rectum terminated in the blad- 
 der. Sixth Species. 
 
 Mutter, T. D., Case CXXV., p. 223. Imperforate anus, with an abnormal 
 opening just within the fourchette. Fifth Species. 
 
 (N.) 
 
 Nagel, Case CXXIII., p. 221. Imperforate anus, with an abnormal open- 
 ing near the lower commissure at the entrance of the vagina. Fifth 
 Species. Case CLXXIII., p. 262. Rectum terminated in the urethra. 
 Sixth Species. 
 
 Nekton, M.J Case CCLXXVIII., p. 319. Imperforate anus and rectum. 
 Third Species.
 
 INDEX TO ILLUSTRATIVE OASES. 361 
 
 (0.) 
 
 Qlinet, Case CXVIII., j).. 217. Imperforate amis, with an abnormal open- 
 ing near the vulva. Fifth Species. 
 
 Orfila, M. P., Case CCXVIL, p. 281. The vagina terminated in the rec- 
 tum. Seventh Species. 
 
 Osiander, Case CXXVIL, p. 23G. Kectum terminated in the bladder. 
 "Sixth Species. 
 
 Oosterdykc, Case CCXLIII., p. 288. Rectum entirely absent. Eighth 
 Species. 
 
 Otto, Case CCXLV., p. 288. Rectum entirely absent. Eighth Species. 
 
 Ouvrard, Case CCLXXIY., p. 318. Imperforate anus and rectum. Third 
 Species. 
 
 (P-) 
 
 Palmer, Case CCXLVI., p. 288. Rectum entirely absent. Eighth 
 Species. 
 
 Papendorf, Case CLXXXYI., p. 2G6. Rectum terminated in the vagina. 
 Sixth Species. 
 
 Parkman, S., Case XCV., p, 194. Imperforation of the rectum above a 
 normal anus. Fourth Species. 
 
 Parrish, Joseph, Case CXCVIII., p. 2G9. Rectum terminated in the vagina. 
 Sixth Species. 
 
 Petermann, And., Case CLXXXIII., p. 2G6. Rectum terminated in the 
 vagina. Sixth Species. 
 
 Petit, Jean Louis, Cases XXII. — XXIII., pp. 84 — 85. Simple Imperfora- 
 tion of the anus. Second Species. Case LIII., p. 155. Imperforate 
 anus and rectum. Third Species. Case LXV., p. 167. Imperforate 
 rectum above a normal anus. Fourth Species. Case CCL., p. 292. 
 The rectum and colon both absent. Ninth Species. 
 
 Pikcop, .John, Case LXXXIX., p. 188. Imperforate rectum above a no r- 
 mal anus. Fourth Species.
 
 362 INDEX TO ILLUSTRATIVE CASES. 
 
 Pineo, P., Case XL., p. 136. Imperforate anus and rectum. Third 
 
 Species. 
 Pinkstan, Case LXIX., p. 109. Imperforate rectum above a normal anus. 
 
 Fourth Species. 
 Portal, M., Case CCXV., p. 281. The vagina terminated in the rectum. 
 
 Seventh Species. 
 Poulletier, Case CLVIII., p. 257. Rectum terminated in the urethra. 
 
 Sixth Species. 
 
 (R.) 
 
 Randolphe, Case CXLIY., p. 258. Rectum terminated in the urethra. 
 
 Sixth Species. 
 Richardson, Case CCXI., p. 280. Ureters terminated in the rectum. 
 
 Seventh Species. 
 Ricord, Philip, Case CCL, p. 273. Rectum terminated in the vagina. 
 
 Sixth Species. 
 Rochard, Case CXCII., p. 2G7. Rectum terminated in the vagina. Sixth 
 
 Species. 
 Roonhuysen, Henry Van, Case III., p. 70. Abnormal narrowing of the 
 
 anus. First Species. 
 Rossi, Case CCXVIIL, p. 281. The vagina terminated in the rectum. 
 
 Seventh Species. 
 Roux, J. N., Case CLXVII., p. 258. Rectum terminated in the bladder. 
 
 Sixth Species. Case CCLXXVI., p. 319. Imperforate anus and 
 
 rectum. Third Species. 
 Ruysch, IL, Case XXVI., p. 86. Occlusion of the anus by a simple mem- 
 brane. Second Species. Cases CCXXV.— CCXXVL, p. 285. Rectum 
 
 entirely absent. Eighth Species. 
 
 (S.) 
 Sandan, Van, Case CXXXI., p. 237. Rectum terminated in the bladder. 
 Sixth Species.
 
 INDEX TO ILLUSTRATIVE C\SE3. 363 
 
 Samlras, Case LXXVIII., p. 179. Imperforate rectum above a normal 
 
 anus. Fourth Species. 
 Saviard, Bartholomew, Case XXIV., p. 85. Simple imperforation of the anus. 
 Second Species. Case LIV., p. 156. Imperforate anus and rectum. 
 
 Third Species. Case CCIV., p. 275. The rectum, together with the 
 
 urethra and vagina, terminated in a cloaca in the perinajum. Sixth 
 
 Species. 
 Schenckius, John, Case LIX., p. 257. llectum terminated in the urethra. 
 
 Sixth Species. Case CLXXXII., p. 265. Rectum terminated in the 
 
 vagina. Sixth Species. 
 Schlagintweit, Wilh Aug Joseph, Case CCLXXL, p. 317. Imperforate 
 
 anus and rectum. Third Species. 
 Schleiss, Von, Case XC, p. 189. Imperforate rectum above a normal anus. 
 
 Fourth Species. 
 Shultz, Case XLVIII., p. 151. Imperforate anus and rectum. Third 
 
 Species. 
 Scultetus, Joannes, Case IV., p. 70. Abnormal contraction of the anus. 
 
 First Species. 
 Seaverns, Case X., p. 72. Preternatural narrowing of the anus. First 
 
 Species. 
 Serrand, De St. Malo, Case CCLXIIL, p. 315. Imperforate rectum above 
 
 a normal anus. Fourth Species. 
 Shipman, A. B., Case XXIX., p. 124. Imperforate anus and rectum. Third 
 
 Species. 
 Smellie, William, Case LXVIII., p. 168. Imperforate rectum above a 
 
 normal anus. Fourth Species. 
 Smith, Ashbell, Case CC, p. 272. Rectum terminated in the vagina. 
 
 Sixth Species. 
 Smith, J. A., Case CXLII., p. 247. Rectum terminated in the bladder. 
 
 Sixth Species. 
 Smith, W. G., Case XLIV., p. 144. Imperforate anus and rectum. Third 
 
 Species.
 
 3G-i INDhX TO ILLUSTRATIVE CASES. 
 
 Sommering, Samuel Tliom, Case CXL., p. 257. Rectum terminated in the 
 
 urethra. Sixth Species. 
 South, J. F., Case CVI., p. 208. Imperforate anus, with an abnormal 
 
 opening near the scrotum. Fifth Species. 
 Steel, John H., Case CXXXIX., p. 245. Rectum terminated in the neck 
 
 of the bladder. Sixth Species. 
 Surgeon of Brest, Case CCLXV., p. 315. Imperforate anus and rectum. 
 
 Third Species. 
 Surgeon of Lyons, Case CCLXIV., p. 315. Imperforate anus and rectum. 
 
 Third Species. 
 Svvitzer, Erico, Case CCII., p. 274. Rectum terminated in the vagina. 
 
 Sixth Species. 
 
 (T.) 
 
 Textor, K., Case CCLXX., p. 317. Imperforate anus and rectum. Third 
 
 Species. 
 Townsend, Case IX., p. 72. Abnormal narrowing of the anal orifice. First 
 
 Species. 
 Trioen, Cornel, Case LXVII., p. 108. Imperforate rectum above a 
 
 normal anus. Fourth Species. 
 
 Vallesnieri, Ant, Case CCXXI., p. 282. The uterus terminated in the 
 
 rectum. Seventh Species. 
 Van Meeckren, Jobi a, vide case, p. 87. 
 Van Swieten, Ger F. B., Case CLXXVI., p. 264. Rectum terminated in 
 
 the vagina. Sixth Species. 
 Velpeau, Alf A. L. M., Case CXX., p. 218. Imperforate anus, with an 
 
 abnormal opening in the fourchette. Fifth Species. Cases CXL VII. — 
 
 CXLVIIL, p. 254. Rectum terminated in the bladder. Sixth Species. 
 
 Cases CLXVIIL— CLXIX.— CLXX., p. 260. Rectum terminated in 
 
 the urethra. Sixth Species.
 
 INDEX TO ILLUSTRATIVE CASES. 305 
 
 Vuisiii, F., Caac CCLYIU,, p. 3K'). linpcrruratc aims and icctiiiii. Tliird 
 
 Species. Case CCLX., p. 314. Ilectum and colon ))i»tli absent. Nintli 
 
 Species. 
 Voilleniici-, Case LXXXIIT., p. 183. Imperforate rectum above a normal 
 
 anus. Fourth Species. 
 Vollgnad, Case CXXX., p. 237. Rectum terminated in the bhicUlcr. 
 
 Sixth Species. 
 
 (W.) 
 
 Wagner, Peter Christopher, Case LXIV., p. 167. Imperforate rectum 
 
 above a normal anus. Fourth Species. 
 AVaters, Case XLIIL, p. 143. Imperforate anus and rectum. Third 
 
 Species. 
 Wandermonde, Case CLXXXVII., p. 2G6. Rectum terminated in the vagina. 
 
 Sixth Species. 
 Wayte, John, Case LXXIV., p. 17G. Imperforate rectum above a normal 
 
 anus. Fourth Species. 
 Willaume, Case CLXIII., p. 258. Rectum terminated in the urethra. 
 
 Sixth Species. 
 "Williams, Case CLXVI., p. 258. Rectum terminated in the urethra. 
 
 Sixth Species. 
 Wolf, C. F., Case LIX., p. 156. Imperforate anus and rectum. Third 
 
 Species. 
 Wreisberg, Henry Aug., Case CXXXIV., p. 239. Rectum terminated in 
 
 the bladder. Sixth Species. 
 
 t 
 
 (Y.) 
 
 York, J. H , Case CLXXI., p. 260. Rectum terminated in the urethra. 
 Sixth Species. 
 
 (Z.) 
 
 Zacutus, Lusitanus, Case CLV., p. 257. Rectum terminated in the urethra. 
 Sixth Species.
 
 INDEX. 
 
 (A) 
 
 Abdominal Artificial Anus 295 
 
 General Remarks on 295 
 
 History of the Operation for 304 
 
 Littre's Operation for 309 
 
 Pillore's Operation for 323 
 
 Callisen's Operation for 324 
 
 Amussat's Operation for 328 
 
 Cases of Littre's Operation for. . . 311 
 Cases of Pillore's Operation for. . 3'23 
 Cases of Callisen's Operation for. 320 
 Cases of Amussat's Operation for, 334 
 Appreciation of Operation for.. . 345 
 Abnormal or Preternatural Anus — 200 290 
 
 Abnormal Position of the Rectum 102 
 
 Accoucheur, The Duty of the 38 
 
 Etiology 4l 
 
 MM. Saiiit-Hiloire, Eoux, Serres, 
 
 &c,onthe 42 
 
 Anus Abnormal, Or Preternatural, 200, 290 
 
 Abdominal, Artificial 295 
 
 Coccygeal , Artificial 113 
 
 Perina;al, Artificial 96 
 
 Absence of 88 
 
 Membranous, Occlusion of 75 
 
 Congenital, Malformations of — 51 
 
 Congenital, Narrowing of 61 
 
 Syphilitic. Contraction of 62 
 
 Arrested Development, Theory of 43 
 
 Various authors on the 44 
 
 Atresia Ani — 37 
 
 Atresia Orificii Ani 75 
 
 Atresia Ani et Intestini Recti 88 
 
 Atresia Ani Vesicalis, Urethralis and 
 
 Vaginalis 201 
 
 Auscultation and Percussion 90 
 
 (B) 
 
 Barton's Operation for Atresia Ani 
 
 Vaginalis 234 
 
 Bertin's Proposition to open the Blad- 
 der 238 
 
 Bibliography 17 
 
 Bigelow's Objections to Proctoplasty 
 
 and Colotomy 92, 298 
 
 Bougies, The Character and Use of 64 
 
 Bladder, Rectum Terminating in the.. 225 
 Cases of 236 
 
 [366] 
 
 (C) 
 
 PAGK. 
 
 Caectfm. Artificial Anus in 323 
 
 Cases, The first species of 68 
 
 The second Species of 78 
 
 The third species of 123 
 
 The fourth species of 167 
 
 The fifth species of 206 
 
 The sixth species of 236 
 
 The seventh species of 280 
 
 The eighth species of 285 
 
 The ninth species of 292 
 
 Recapitulation of 294 
 
 Littre's operation on 311 
 
 Compendium of 321 
 
 Pillore's Operation on 323 
 
 Callisen's Operation on 326 
 
 Amussat's Operation on 334 
 
 Classification, Anal and Rectal Malfor- 
 mations of 52 
 
 Coccygeal , Artificial Anus 113 
 
 Colon. Absence of 291 
 
 Iliac , Artificial Anus in 309 
 
 Lumbar , Artificial Anus in 324 
 
 Colotomy 295 
 
 Congenital Malformations of, The Rec- 
 tum and Anus 51 
 
 Contraction of the Anus 61 
 
 Liability of Artiflc ial Anus to. . . 108 
 
 (D) 
 
 Description of the first species of Mal- 
 formation 61 
 
 Of the second species 75 
 
 Of the third species 88 
 
 Of the fourth species 163 
 
 Of the fifth species 200 
 
 Of the sixth species 225 
 
 Of the seventh species 278 
 
 Of the eighth species 283 
 
 Of the ninth species 290 
 
 Dilatation, In Abnormal Narrowing of 
 the Anus 63 
 
 Duty of Accoucheurs 38 
 
 (E) 
 
 Eighth Species of Malformation 283 
 
 Description of 283 
 
 1 reatment of 284 
 
 Cases of 285
 
 INDEX. 
 
 3GT 
 
 PAOB. 
 
 Elevations, Or Excrescences of the Skin 
 in Anal Region 00 
 
 (F) 
 
 Fifth Species of Malformation 200 
 
 Description of 200 
 
 Treatment of 2o:i 
 
 Cases of '-00 
 
 First Species of Malformation 61 
 
 Description of 61 
 
 Treatment of 63 
 
 Cases of 6S 
 
 Fourth .Species of JIalformation 162 
 
 Description of 162 
 
 Prognosis of 165 
 
 Treatment of 165 
 
 Cases of 107 
 
 (G) 
 
 General Remarks on Anal and Rectal 
 
 Malformations 37 
 
 On Abdominal Artificial Anus. . . 295 
 
 General Symptoms 54 
 
 Gross's Objections to Colotomy 298 
 
 (H) 
 
 History of the Operation of Abdominal 
 
 Artificial Anus 304 
 
 The Development of the Rectum 
 and Auus 49 
 
 (I) 
 
 Iliac Artificial Anus 309 
 
 Imperforate Anus 75 
 
 Rectum 162 
 
 Index to Illustrative Cases 349 
 
 Incision Circular, Levret on 77 
 
 Incisions in Proctoplasty 99 
 
 Form of 99 
 
 Infant Pelvis, Average DimeHsions of. . 98 
 
 Deep Incisions in 98 
 
 Contractions of 284 
 
 Intrauterine Disease, A Cause of Malfor- 
 mations 44 
 
 Introduction 17 
 
 Introduction of the Sound in the Ure- 
 thra and Vagina 99 
 
 (L) 
 
 Liability to Closure of Artificial Anus. 108 
 Lumbar Artificial Anus 324 
 
 (M) 
 
 Malformations , Anal and Rectal 37 
 
 General Remarks on 37 
 
 Terms used to designate 37 
 
 Etiology of 41 
 
 Anatomy and Pathology of 46 
 
 Classification of 52 
 
 General Symptoms of 54 
 
 Prognosis of 57 
 
 Muscles Sphincter Ani 100 
 
 Tlie presence and absence of ... 100 
 Different opinion of autliorson.. 101 
 
 Maternal Imagination, as a cause of de- 
 formities 41 
 
 (N) 
 
 Ninth Species of Malformation 290 
 
 Description of 2.*0 
 
 Treatment of 291 
 
 Casesof 292 
 
 (O) 
 
 Operation for Abdominal Artificial 
 
 Auus 295 
 
 1 he Process of Littre 309 
 
 The Process of Pillore 323 
 
 Tlie Process of Callisen 3'24 
 
 The Process of Amussat 3'28 
 
 Operation for Perinicai Artificial Anus. 103 
 
 Ordinary method of 105 
 
 Amussat 's metliod of ll'i 
 
 Hells metliod of 95 
 
 Hutcliison's method of 120 
 
 Roux' method of 258 
 
 Friedbergs metliod Of 203 
 
 Operation for Coccygeal Artificial Anus 1 13 
 
 (P) 
 
 Pathognomonic Sign, How obtained.. 52 
 Pelvis, Infant's, Admeasurements of. . 98 
 
 Deep incisions in 98 
 
 Perinaeal Artificial Anus 96 
 
 PeriuEeal Puncture 118 
 
 The common method of perform- 
 ing it 119 
 
 The author's objections to it 119 
 
 Hutchisons modification of it 120 
 
 Dieffenbach's modification of it.. 1'20 
 Perinaeal Raphe, Continuance and Pro- 
 minence of 88 
 
 Physical Exploration 89 
 
 Physical Signs 127 
 
 Pipe-like Prolongations of the Rectum. 200 
 Preternatural Anus, A mere Faeal Fis- 
 tula 295 
 
 Primary Cause of Malformations, not 
 
 known 43 
 
 Prognosis, General 57 
 
 Of the third species 91 
 
 Of the fourth species 165 
 
 Of the fifth species 201 
 
 Of the sixth species 230 
 
 Proctoplasty , 96 
 
 Longitudinal incision in 99 
 
 Transverse incision in 99 
 
 Crucial incision in 100 
 
 T— incision in 100 
 
 Purging New-born Children , Pernicious 
 Practice of 38 
 
 (R) 
 
 Recapitulation of Cases 294 
 
 Region, Perinaeal, Artificial Anus in... 96 
 
 Coccygeal, Artificial Anus in 113 
 
 Iliac, Artificial Anus in 309 
 
 Lumbar, Artificial Anus in 3'24 
 
 Rectum, Abnormal Position of 102 
 
 Malformations of 51 
 
 Prolongations of 200 
 
 Membranous occlusion of 162 
 
 Preternatural terminations of 51 
 
 Preternatural terminations of 
 
 other organs in 278 
 
 Adventitious Canals of 200 
 
 Obliteration of 51
 
 368 
 
 INDEX. 
 
 PAGE. 
 
 Rectum, Absence of 283 
 
 Early formation of 49 
 
 (S) 
 
 Second Species of Malformation 61 
 
 Description of 61 
 
 Treatment of 63 
 
 Cases of 68 
 
 Seventh Species of Malformation 278 
 
 I 'escription of 278 
 
 Treatment of 279 
 
 Cases of 280 
 
 Sixth Species of Malformation 225 
 
 Description of 225 
 
 Physical Signs of 227 
 
 Diagnosis of 227 
 
 Prognosis of 227 
 
 Treatment of 231 
 
 Casesof 236 
 
 Speculum Ani, Use of 164 
 
 Sound, Introduction of 99 
 
 Syphilitic Contraction of the Anus 62 
 
 Synopsis of the Anal and Rectal Malfor- 
 mations 51 
 
 (T) 
 
 Terms, designating the Anal and Rectal 
 
 Malformations 37 
 
 Term, Artificial Anus misapplied 295 
 
 Its strict meaning 2^5 
 
 Termination of the Rectum, Abnormal. 51 
 
 In the bladder 225 
 
 Intheurethra 226 
 
 Termination of the Rectum in the vagina 226 
 
 In a cloaca in the perinseum 2'-5 
 
 Third Species of Malformation f8 
 
 Description of S8 
 
 Physical Exploration of S9 
 
 Diagnosis of 89 
 
 Prognosis of 91 
 
 Treatment of 96 
 
 Cases of V:3 
 
 Treatment of the first species 63 
 
 Of the second species 76 
 
 Of the third species f 6 
 
 Of the fourth species 165 
 
 Of the fifth species 202 
 
 Of the sixth species 231 
 
 Of the seventh species 279 
 
 Of the eighth species 284 
 
 Of the ninth species 291 
 
 (U) 
 
 Ureters, terminating in the Rectum 278 
 
 Cases of 280 
 
 Urethra, Rectum terminating in the .... 226 
 
 Cases of 25(5 
 
 Uterus, terminating in the Rectum 279 
 
 Case of 282 
 
 (V) 
 
 Vagina, terminating in the Rectum 278 
 
 Cases of 2S0 
 
 Vagina, Rectum terminating in the '^26 
 
 Cases of 2 4
 
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