for a few davs, and also the introduction of the bougie. The
bowels are regularly moved, and the child is in perfect
health.

"The removed extremities of the rectum appeared to be
connected bv a short band of fibrous membrane. I have be-



THE FOUKTII SPKCIKS OF MALFORMATION. 189

fore Hi'c'ii cases ul' iiiu)L'rli)riite iuius, I)iif, not of iiii[)crvi()us roc-
timi." {London Lancet^ Vol. 7., Maij: 1S50. 2>. 510.)

Cask XC. — Von Sclileiss, of Muiiicli, iv])()rt.s the (^iise of ii
male infant in whom the rectum was imperforate about one
inch above a well-formed anus. JJeyoiid the point of im])er-
foration, the rectum was absent, and the colon terminated in
a cul-dc-sac. Schleiss, by a very lucky phuii^o with a trocar,
readied and penetrated the blind end of the inferit)r extremity
of the colon, without wounding the Ijladder or any of the pel-
vic viscera. Success, under numerous difficulties, finally
attended the operation.

On the 11th of October, 1850, Mrs. J. St , a healthy

wonuin of Munich, aged twenty-two years, was delivered of
her second child, a boy, like her first still living, healthy and
well-formed ; no appearance extermdly whatever of any de-
formit}'. The child seemed quiet, had passed urine, but had
taken no nourishment, neither had it evacuated any meconiuui
for twenty-four hours. The midwife in charge of the case ad-
ministered an enema, but it iinn)ediately returned without
producing any effect. Late in the evening of tlie 12th of Oc-
tober, Von S'chleiss was called, and the midwife made him
acquainted with all the circumstances of the case, so far as
she knew. He observed that the child made strange move-
ments with its mouth and tongue, being between those of
licking and those which precede vomiting. Upon examina-
tion of the perinseal region, he found the aims normal, but on
introducing his little finger he found the canal completely ob
structed about an inch above the anal orifice. The cavity of
this portion of the rectum was empty, and no trace of mecn-
nium could be perceived, he therefore became assured that its
continuity was interrupted, and that it ended in a blind sac;
and that there was actually before him a case o^ atresia recti.
In consequence of the lateness of the hour in which he made
this discovery, he postponed further proceedings till next
morning, remindful of the advice of Diefi'enbach, to defer op-
eratino; in such cases till the second day. The child remained
quiet during the night, except the movements of its mouth and
tongue, which were increased in violence, without, however,
resulting in real vomiting ; but then it had taken no w\ater
nor any nourishment, and had passed no meconium. On the
morning of the 13th of October, he made a more thorough
exploration of the parts, by introducing a small silver cathe-
ter into the bladder, and his little linger as well as a small
probe into the rectum. This examination resulted in the con-
viction, that between the point of obstruction in the rectum.



190 THE FOURTH SPECIES OF MALFORMATION.

and the inferior extremity of the colon, tlie former was defi-
cient, and that no communication whatever existed between
the two ; that the bladder which, in this case, was wide and
deep, had advanced as far as to the sacrum, to the anterior
surface of which it was adherent, was lying between these
two points — that is, between the blind end of the rectum, and
the blind end of the inferior extremity of the colon.

Von Schleiss was of opinion that this was a case sui generis^
and that no method of operating heretofore recommended
was at all applicable to it. He however determined on this
occasion to use the trocar usually employed for paracentesis
abdominis, the child being placed on its right side with its
thighs drawn up and nates separated. Presuming that the
blind sac of the inferior extremity of the colon would be
situated more to the left, as in its normal place, Schleiss
introduced the trocar through the anal orifice into the rectum,
and pressed it to the left of the rectum by the side of the
false vertebra of the sacrum, and between the latter and the
posterior wall of the bladder into the cellular tissue which
united them ; and then pushing the stilette strongly in the
direction indicated, he experienced the sensation of having
traversed five or six lines of cellular tissue, and then having
penetrated a cavity. On witiidrawing the stilette he found
the point soiled with meconium ; and upon pushing the
canula still further upwards through the wound which had
been made, into the cavity, meconium immediately flowed
through it. The child at once improved in every respect, and
for the first time took the breast. The silver canula of the
trocar was allowed to remain in place for nine days, when it
was replaced by elastic tubes of gradually increased sizes ;
and at last after four weeks these were laid aside altogether.
The faecal matter now passed easily through the newly made
canal.

AVhen the child began to pass more solid faecal matter,
occasional difficulties occurred, which increased until it was a
year old. It seemed compelled to make, at different times,
two distinct efforts to accomplish the evacuation of its bowels.
At the first efibrt its uneasiness and cries only ceased after
tlie faecal matter had passed the newly formed passage from
the colon, and had become lodged in the cavity of the rec-
tum. At this effort no fcBcal matter whatever would pass by
the anus. At a subsequent period, however, when to all
aj)pearance no marked efforts were being made to defecate,
manifestly limited to the rectal region, they were nevertheless
followed by evacuation. The child often remained several
days without stooling, and made useless and painful efforts.



THE FOURTH SPECIES OF MALFORMA.TI()N. 191

On examining tlie rectnin with the tinger, tlic rectal cavity
was found to bo lilled with scybala; it was sonieliiiies neces-
sary to exti'act them with the linger. After regular inJectioUH
of cohl water had been used for some time, evacuation became
easier ; however, dithculty of evacuation occurred from time
to time. Twenty-live months after the operation, tiie child
was healthy ; the artilicial caual between the colon and the
rectum, passing behind the bladder, was three or three and a
half lines in diameter. Yon Schleiss hoped tliat it would be-
come yet larger as the child grew older, lie encountered
much trouble and dithculty in the treatment of this case, in
consequence of the occurrence, lirst of und)ilical, then of
inguinal hernia on each side, douhtless the result of the
straining efforts of the child to evacuate its bowels, together
with its constant cries. {ZeltscJirift fiir Rat'ionelle Medicin.
Ncue Folije. Band. III. S.Zm. lleidelberg : 1^^)^.)

Case XCI. — ^The following case was communicated to the
editor of the ^''Boston Medical and Surgical Jouraal^'' by Dr.
A. Bryant Clarke, in a letter dated llolyoke, Mass., February
10th, i852.

"I attended a lady, the mother of several healthy children,
in her coniinement on the 5tli of April last, who was delivered
of a tine, plump-looking boy, and to all apj^earance perfectly
developed. On calling the next day, the mother and child
appeared to be doing well. To my inquiries, however, the
nurse stated that nothing had passed its bowels. A slight
laxative was ordered, with directions to use injections by
evening if nothing passed. The second day, nothing having
passed, and the nurse not being able to inject anything, I was
led to examine the rectum. I could pass my little finger into
the anus without difficulty, but after passing about three-
f )urths of' an inch it met with firm resistance, appearing to
terminate in a cul-de-sac. The nature of the case was now
made known to the mother, and the only means of relief, an
operation, was proposed ; but as her husband was absent, she
declined having it done until his return. Circumstances pre-
vented this until the evening of the seventh day. He at lirst
declined an operation, but seeing how w^ell the child continued
to be, and after consultino- a neio-hborino; surgeon, he consented
to have an operation performed on the morning ot the ninth
day. I made use of a trocar and canula. After passing the
trocar through the canula, I withdrew it, but no meconium
followed. Raving pushed up the canuUx into the opening
made by the trocar, I again inserted the latter and withdrew
it, when the meconium followed in abundance. The child



192 THE FOUKTH SPECIES OF MALFORMATION. '

made no cries, and seemed to be relieved by the operation.
But very little blood was lost. Yet the child died in about,
twenty-tbur hours.

"The parents being very intelligent and well-informed,
kindly consented to an examination, which was had the next
day. On laying open the cavity of the abdomen, the colon
was found adlierent throughout its course uj^on the left side
to the internal walls of the cavity of the abdomen. The
abnormal state of the rectum was now seen to consist of a
fleshy-looking mass, interspersed with fat and cellular sub-
stance, which made it resemble the muscular tissue of other
parts, and to close up the rectum for the space of about an
inch and a half. Upon examination it was found the trocar
had gone directly through the centre of the mass, and was
perfectly successful, so far as the operation was concerned.
It was observed that there was a fetid smell to the urine the
day before, and there is no doubt that the means of relief
were too late." {Boston JSLedical and Surgical Journal. Yol.
XL VL p. 100. Boston : 1853.)

Case XCIL — Groeschler, of Prague, reports the following
interesting case of imperforation of the rectum, the anus, in
the meantime being normal. In this instance the rectum
was obstructed at two points, first, by a membranous septum,
at half an inch above the verge of the anus ; then again at
two inches. Beyond this second obstruction the rectum was
entirely wanting, the colon terminating in a cul-de-sac.

Mrs. A. S , aged thirty-nine years, the wife of a shoe-
maker, was delivered on the 10th of July, 1854, of a vigorous
and to all appearance a healthy and iine conditioned boy.
The child urinated regularly, but could not evacuate its bow-
els. On tlie next day, after giving it some mai'sli-mallow tea,
vomiting ensued, and the midwife in attempting' to adminis-
ter an enema, met an obstruction within the anus, which
induced her to call in the aid of Goeschler.

On the 30th of July, at eleven o'clock, A. M., Goeschler
arrived, and upon percussing the child's abdomen, he discov-
ered a clear full tympanitic sound ; its respiration was hur-
ried ; and its hands and feet were of a violet hue. The local
examination of the perinanim, which he made, resulted in
finding a well formed anus, surrounded ])y a sphincter capa-
ble of contraction ; but an ivory sound which he attempted
to introduce, entered onh' about half an inch, being obstructed
by tlie closure of the intestine at that p(^int. This obstacle
ha\'ing been incised by means of a pointed bistoury, he suc-
ceeded in introducing the sound about two inches ; but at



TIIF, FOUKTir SPECIES OF MAI.FOKMATIOX. 193

this point there was fouii<l a second ocehision as complete as
the first, and allowing neither evacuation of the meconium,
nor li(|ui(l injection, (loesc^lih'r pert'oi-utcd this second obsta-
cle 1)}' means of a trocar, and inunediately two lai'ge spoon-
fuls of meconium ])assed out. The swellino; of the abdomen
at once diminished ; the sound and the l)ipe of the syringe
were easily introduced, and an eiu'iua of cold water was
administered. A large elastic catheter was now placed in the
newly made canal. At the end of two hours the infant grew
pale, the tension of the abdomen returned, the extremities
became l)luo, and respiration was hurried ; the evacuation of
meconium ceased by degrees, and death occurred about six
o'clock P. M.

The autopsy was made by Professor Engel, and gave the
following results— The anus was well formed, but from a short
distance above it to the promontory of the sacrum, the rectum
was com})letely wanting : the bladder was normal. The
blind end of the colon was about the hight of the promontory
and attached to the anterior surface of the sacrum by a con-
tinuation of the peritonaeum. The sound introduced into the
anus, passed into the artificial canal, and thence into the
opening made wdtli the trocar in the closed extermity of the
colon. The canal thus formed passed along the line usually
occupied by the rectum, in this instance filled up with a firm
cellular tissue. The abdominal cavity was filled with licpiid
meconium ; but there was no appearance of peritonitis, nor
was there any trace of internal hemorrhage." ( Yiertel-
jalirseht'ift far die praktlsdie Ilellkunde^ XII. Jahrgang^
1855. ///. Band. &\ IS!. Fracj.)

Case XCIII. — Mr. Bird, translator of M. Bouchut's treatise
on the diseases of children, reports a case as follows : — ■

'' Through the kindness of my friend Mr. Tapson, I have
had the opportunity of witnessing the follovring case ; a
female child was born nearly dead, with feeble respiration,
blue surface, and deformity of the left hand. On the second
day, no meconium having jjassed, an examination was made ;
the anus was well formed, but on introducing the finger an
obstruction was discovered about half an inch from the anus ;
it gave the sensation of a membrane, which, on the feeble
effort of the child became more tense ; the child continuing
in a state of cyanosis, with feeble respiration, any operative
proceeding was deemed useless and cruel ; it died on the fifth
day, having taken only a few teaspoonfuls of nourishment ;
there was no vomiting with the exception of a single effort,

18



194 THE FOUKTH SPECIES OF MALFOKMATIOISr.

on the second day, when a little fluid tinged with bile
escaped ; the abdomen became much distended before death.
" Autopsy. — Lungs free from congestion, collapsed, but
restored by insufllation; it was evident, however, that air had
never entered some portions, which required strong efforts of
insufllation to distend them. Both auricles, espcially the
right, were distended with clots ; the foramen ovale was only
two-thirds closed by a thin membrane, the free edge being
directed anteriorly ; the ductus arteriosus Avas widely open.
The peritoneal cavity contained much gas and faecal matters,
but there was no trace of any inflammatory products. About
three inches from the appendix vermiformis, a long rent in
the peritonseal covering of the colon was observed, showing
the mucous membrane beneath ; this was softened and thin-
ned and presented a circular opening less than half an
inch in diameter, the edges of which were irregular
from small shreds of mucous membrane ; the vessels were
much congested in tlie neighborhood of the rent, but no signs
of inflammation were observed, the rent being apparently the
result of mechanical distention. The rectum terminated in a
perfect cul-de-sac, the distended ha3morrhoidal vessels ramify-
ing over the extremity, all the coats of which were jDcrfect,
and not the slightest trace of any opening was observed ; the
vessels of the mucous membrane were considerably injected ;
the large intestines contained no meconium but a large quan-
tity of Arm bright colored faeces." {Practical Treatise on the
Diseases of Children. By M. Boucliut. Bird's English ver-
sion. Booh X. Chap. I. p. 615. London, 1855.)

Case XCIV. — Mr. Ashton reports a case of this species of
malformation.

" I have," says he, " in my possession a preparation given
me by my friend Dr. Qnain, namely, a case of malformation
of the rectum, in which tlie intestine terminated in a closed
sac. The prepai-ation was presented to the Pathological
Society, and the particuhirs of tlie case are published in the
Society's Transactions. ( Vol 1. p. 280.) The anus was
perfect, throngh which an incision was made by the surgeon
in attendance; but he was unsuccessfnl in opening tlie
bowel, and the child died on the ninth day." {A Treatise on
the Diseases., Lijuries and Mcdformations of the Rectum and
Anus. By T. J. Ashton, M. D. Chap. XIX. p. 333.
London : 1854.)

Case XCY. — S. Parkman, M. D., reported the following
case to the Boston Society for Iledical Lnprovenient, on the
13th of February, 1854.



TUE FOURTH SPECIES OF MALFORMATION. 195

" The patient was fifty-two lioiirs old ; anus ])orfcctly
formed; obstruction of rectuni nearly two inches within the
anus. Dr. Parkuuin waited eighteen hours, until the septum
became distended by collected meconium, and then punctured
the ])ouch with a trocar ; injecting afterwards, and washing
out the bowel. This process was repeated, the opening not
remaining free, a director was passed into the anus and
through the opening made by the trocar, and the sphincter
ani and the septum were divided, from before backwards, l>y
a free incision ; the linger could then be passed, and went
into a large cavity. After the operation the child took the
breast readily, and is now doing well, three months after the
operation. l)r. Parkman directed an attendant to pass a well-
oiled finger wnthin the opened intestine daily. [Records of
the Boston Society for Medical Iraprovement. Vol. W. p.
55. Boston : 185(>.)

Case XCVI. — S. Cabot, M. D., of Boston, Mass., reported
the following case of imperforatioii of the rectum, to the
" Boston Society for Medical Improvement^'' on tlie 28tli ol
September, 1857.

Dr. Cabot saw the patient on the fourth day after birth in
the evening, at which time it was reported that no discharge
had taken place from the bowels. Castor oil had been given,
but was rejected. An injection had also been ordered. The
abdomen was now found distended. On examination per
rectum, the finger passed in about one inch. When the child
strained, the intestine could be felt pushing downward,
the central portion of the part thus pushed down feeling
considerably thicker than membrane. A trocar was thrust
in, and a large quantity of fseces and meconium discharged.

On the following morning, two probes were passed in
through the opening, into the intestine, as was supposed, the
largest being left in, and a piece of gum elastic catheter
pushed down upon it. In the evening it was reported that
nothing had passed through the canula. The child had also
vomited foeculent matter. The opening was now eidarged
by the knife and the intestine punctured ; this being followed
by the discharge of a small quantity of gas and meconium.
Death took place on the following day.

It was found on examination, that the internal and external
cul-de-sac approached to within about a half an inch of each
other, and that the probe and catheter, instead of passing
through the original opening into the intestine had made a
false passage in the cellular substance by the side of the gut.



lOG THK FOURTH SPFXIIiS OF MALFORMATION.

[Bonton Medical and Surgical Journai. Yul. L YII. p. 238.
Boston : 1857.)

Case XCVII. — The following case is reported by Dr. G.
S. Jones. It was read before the Suffolk District Medical
Society, of Mass., on the 31st of October, 1857.

"Tlie subject of this case was a line, phinip, male child,
apparently otherwise in a liealthy condition.

••' The day after its birth, the nnrse directed my attention
to the fact that it had had no discharge from its bowels,
although efforts had evidently been made to effect that object.
I ordered castor oil to be given, and if it failed in producing
an evacuation from the bowels, then injections of warm water,
until tlie object desired was obtained. At my next visit, I
was informed that neither the oil nor injections had acconi-
plislied the purpose for which they were intended, and that
the little patient continued to have a " bearing down," which
seemed to be accompanied with much suffering. A paroxysm
of this effort to unload the bowels coming on Mdiile I was
present, induced me to make a more thorough examination
of his condition, than I had done at my previous visit. The
abdomen was found quite tense and tympanitic ; as he passed
urine immediately after his birth, there was no anxiety or
uncertainty respecting the functions of the bladder. The
anal opening was normal, and freely admitted my oiled
linger, but in attempting to pass it up into the bowel,! found
that it could not penetrate further than to the second joint
(about one and a half inches,) in consequence of some obstruc-
tion. While the linger was in the passage, tlie little fellow
would strain and bear down violently, and I could distinctly
feel the blind or pouched extremity of the bowel distended
with meconium. The case was evidently a clear one, and
after rej)resenting its condition to the parents, they were
exceedingly anxious to have me operate upon the child, if
there was the least chance of saving its life.

"Having decided to operate, I had the child placed upon its
back in the lap of its nurse, with its legs flexed upon tlie
abdomen, I then passed a very small bi-valve speculum,
through the anal opening up to the point of obstruction, when
I dilated the passage to "its fullest extent, and by the aid of
light, I was now able to see, what I had only previously felr,
the termination of the impertbrate bowel. The child now
straining quite hard, forced the gut down very tensely ; I
then, with a spear-pointed stilette, made an opening into it,
and copious discharges of gas and meconium followed the



TIIK FOURTH SPECIES OF MALFORMATION. 197

withdrawal of the iiistrmiicut. The ojxMiiiii;- was riirthcr
C'nlari>:e(l by ;i crucial incision across the end of the pouch,
and i)y the use of gum-elastic bougies ; commencing with
one, one fourth of an inch, and at the terminatifni of six
weeks, leaving off with one, half an inch in diameter. It is
now nearly two and a half years since the operation, and the
child appears well and hearty, and suffers no inconvenience
from the malformation or operation. No dr)ul)t the successful
result of this operation was in part due to the speculum, by
the aid of which a view of the parts could be fully obtained,
and a wrong direction could hardly be given the instrument,
in perfin'ating the bowel ; and also to the persevering use of
the bougies several times during the day and niglit, for a
period of six or seven Aveeks, in dilating the ojiening."
{Boston. Medical and Sargioal Jonrnal. Vol. LVI/.j?. 293.
Boston : 185T.)

Cases XCVIII. — XCIX. — ^The two following cases of im-
perfo ration of the rectum, accompanied by a normal anus, were
reported to the '' Suffolk District Iledical Society,'''' by Doctor
Ayer.

First Case. — The first case was a male child. The anus
was perfectly formed. On introducing the linger a few hours
after birth, its passage was obstructed a short distance from the
anus, but the upp)er portion of the intestine could not be felt
piressing down upon the finger as usuall}' happens in these cases.
The child was left for two or three days, when Dr. H. J. Bige-
low was called in consultation. At this time a distended pouch
could be felt by the finger pressed into the rectum. There
was also feecal discharge through the urethra. It was decided
not to do any operation, and the child died, in eight days from
its birth. — {Boston Medical and Surgical Journal. Vol.
L VII. 2>- 510. Boston : 1S58.)

Second Case. — The second case reported by Dr. Ayer, oc-
curred in a female child, and what was most remarkable, of
the same mother. In this case as in the first, the anus was nor-
mal and there was a passage of meconium through the ure-
thra. Dr. II. J. Bigelow was also called in consultation in this
case. The child was not operated upon and died in a few
days.

Dr. Ilodgcs made the autopsy of this case. On opening
the abdomen, which was greatly distended, the rectum pre-
sented itself and seemed to fill the whole cavity. The pelvis
and contents, with the external organs, were removed toge-
ther. The rectum terminated in a round cid-de-sac, and was



198 THE FOURTH SPECIES OF MALFOEMATION.

•iilated by gas and meconium in a fusiform shape for six
inches or more above its termination, being largest just above
the brim of the pelvis, wliere its diameter was an inch and a
half at least. The anus jjenetrated about half an inch, and
the septum between it and the rectum was three -sixteenths of
an inch in thickness, consisting of loose celluar tissue. There
was no communication between the vagina or uterus and rec-
tum, though before death the color of the urine had led to its
supposed existence. No other malformation than that of the