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