" 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., â– :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