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-