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 â– 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
â–º 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,
â– 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,