infants having each an abnormal anus. In one the rectum
opened in the loins, and in the other it opened ujDon the dor-
sum of the penis. {Mott's Velpeau. Vol. Ill j;. 1086. JVev^
York: 1847.)

Cases CX — CXI. — M. De La Faye gives the description
of two children, in both of which there was found an abnor
mal anus in the sacral region, the orifice in each being suffi-
ciently large to admit the little finger. In one of the cases a
portion of the rectum passed through the opening in the
sacrum, and formed a kind of hernia. {Principes de Chirur-
gie, p. 358. Paris : 1811.)

Cask CXII. — M. La Coste mentions the case of an infant
in whom the rectum perforated the sacrum and formed an
aljnormal anus, througli which the fteces passed. (Bulletin
de la Societe Medicale d'' Emulation de Paris. Octohre, 1822,
p. 417.)

Cask CXIII. — Dr. Bushe mentions a case in which two
anal apertures existed at the same time. He says : " About
four years ago, Dr. AVilliam Power very kindly allowed me
to examine a fine healthy child, a few days old, in whom the
rectum terminated by two extremities, one being placed a
little more anterior than natural, while the other, though also
on the median line, was situated nearly an inch further back.



THE Firni species of mai.foumatiox. 211

Tliis last, which was tlie smaller of the two, did not discliar<^o
more than one-third of the fu'ct's, and as nearly as I could
ascertain with a probe, M'as about one inch and a half in
length." {A Treatise on the Mai for mat ions, Injuries and
Diseases of the Rectum and Anits, jp. 44. JSfew York: 1S37.)

Case CXIY. — Dr. W. A. Green reports the following sin-
gular case of extensive congenital deformity :

''I was called to Mrs. L ■ on Monday, January 5th,

1858. She had been in labor with her second child. Nothing
nnusual occnrred during gestation or paturition. She gave
bij'th to a child, over the average size, which cried lustily,
seeming to indicate that every function was regularly and
properly performed. Upon a close examination, the following
deformities were found to exist : The spine began a curvature
at the snperior third of the cervical vertebrte, in a direction
toward the right hypochondrium, to the top of the sacrum.
The concavityof this curvature w^as filled with two or three
sac-like appendages, containing, apparently, a fluid and gas.
moveable and compressible. 'A want of the spinous pro-
cesses of three or four contiguous vertebrae, is not a very
uncommon species of monstrosity.' ' This constitutes spina
lifida^ 'There is usually a soft, fluctuating tumor, in the
malformed bones, caused by water contained within the sheath
of the spinal marrow.' [ Vide Ramshothani' s Obstetric - <.
{Keating.) Appendix J/, p. 622.] Below, upon each side
of the sacrum, were tw^o appendages, resembling the mamma'
of woman. In front, between the point where the umbilicus
was attached, and the symphisis pubis, was a protrusion of
intestines, within the peritoneal sac, reducible by pressure,
but returning wdien removed. Immediately under this
hernia, the urine trickled, continuously, from two or three
small openings, which could not be entered by the smallest
probe. Below this, and hanging pendant from the middle of
the symphisis pubis, were the testicles, perfectly formed.
There was no trace nor any portion of the penis. Behind the
symphisis pubis, in juxta-contact, and at the extreme anterior
portion of the perinseum, was an anus, well formed, through
which the faeces passed. About an inch and a half behind
this, at the point of the os coccygis, was another anus, which,
upon examination, proved to be imperforate — a cul-de-sac.

"The face of the inftrnt, when first born, was perfectly
black, but is changing to a mulberry hue. Numerous marks
are upon its body, such as are frequently seen upon children.
Every other portion of the child seems perfectly and synmiet-
rically developed. Its bowels are regular, it is healthy, and



212 THE FIFTH SPECIES OF MALFORMATION.

rapidly growing. The complete, entire absence of tlie penis,
or any portion of it — the unusual, unheard-of positions of
the anus, testicles, and anomalous passage of the urine, are
extremely remarkable and interesting. The bladder has no
urethra, through which to pass its urine, so these apertures
must come in direct contact with, and even enter the fundus
of the bladder," (Southeni Medical and Surgical Journal.
Augusta, Ga., 1858.)

Case CXY. — M. Bouisson of IVIontpellier, relates a case of
this cono-enital vice of conformation which was observed in
the practice of Delmas.

A child was brought to Delmas, from seven to eight days
old, which was born with an imperforation of the anus, and
with a small corrugated opening, red and excoriated, which
existed about half an inch from the median line on the side of
the right nates. Through this opening the fsecal matters were
constantly oozing, the liquid state of which allowed their
rather easy escape. It constituted a true congenital listula of
the anus, on wdiich Delmas operated, at the same time he
remedied the imperforation by an incision. Tlie obstructing
membrane was cutaneous, mucous, with conservation of the
sphincter. M. Delmas incised it, introduced his linger into
the rectum, when he recoguized, at an inconsiderable height,
the end of a grooved probe introduced into the accidental
opening. The operation was performed as in the adult, and
followed by the rapid recovery of the infant. — {These de Con-
cours de Paris. Annee 1851.)

Case CXYI. — A similar case in every respect to that of
Delmas' was communicated to the Chirurgical Society of
Paris in 1850, by M. Denonvilliers. This surgeon operated suc-
cessfully both on the anal occlusion and the fistulous sinus in
this case. — {Practical Treatise on the Diseases of Children,
1)1/ M. Boiichut. Bird^s English Version, ]). 516. London :
1855.)

Case CXYII. — Dr. Friedberg reports the following highly
interesting case of imperf n-ation of the anus, accomjDanied by
a fistulous prolongation of the rectum opening into the pos-
terior wall of the scrotum.

" Albert M — , the fifth child of a healthy woman, was born
on the fourteenth day of Jnly, 1852, at nine o'clock P. M.,
by natural labor. During the following night and day the
child look the breast with reluctance, even from the first. It
passed urine frequently, but without any mixture of faecal



TIIK MI'JU SI'ECIKS OF MALFORMATION. 213

matter. Three days uWor birtli, the cliild liavuig as yet had
no reii;iihir stool, and excitini^ tlie anxiety of the niotlier l)y
its cries and restlessness, slie examined the perinanim and
found in the posterior wall of the scrotum a small (»peiiiii;;' in
])lace of an anus, and thi'oui;-]i which a little meconiuiri passed
when the child made violent straining ett'orts. The physician
called in on the following day, in-escribed warm cataplasms
upon the abdomen, and syrup of rhubarb internally. From
lime to time the abdomen became distended, "the child
groaned and made efforts to stool, until fsecal matter passed
which soon became yellow. Although frequently put to the
breast, it sucked very little, but slept in a very unquiet man-
ner, and from the fourth week it began to waste away surpris-
ingly. Towards the sixth week after its birth, as the mother
said, there occurred a remarkable attack, during which it be-
came pale as a corpse, very restless, breathed almost imper-
ceptibly, drew lip its knees, and seemed to the mother as if
dying. This attack was repeated several times during the
two following weeks, and especially as the mother was con-
vinced, when the child had had no evacuation for several hours.
" The attending physician sent for me on the nineteenth of
September, 1852, to make a more complete diagnosis. The
examination gave me the following results. The child, for its
age, two months, was very small and reduced to the last de-
gree of emaciation. The saliva was of a yellow color, and so
was the wdiole body, especially the countenance ; the eyes
were sunken and surrounded by a greenish blue circle, the
voice was very feeble, and the cries replaced by feeble groans.
The abdomen was moderately distended, hard and sensitive.
There was a slight malformation of the penis ; in fact the in-
ternal orifice of the canal of the urethra, opened in the form
of a cleft about three lines from the end of the glans penis.
The genital organs w^ere quite in the rear of their normal posi-
tion. Three or four lines below the point where the rectum
terminated, there was found in the posterior wall of the
scrotum, an opening with its border turned inward, only large
enough to admit a small sound. I introduced such an instru-
ment half an inch, and had the sensation as if I had introduced
it into a cutaneous canal which extended no further in that di-
rection ; however, as I had seen a greenish colored matter
pass from the opening, I could not doubt the existence of a
continuation of this canal uniting it with the intestine. I in-
troduced a whalebone sound, at first directly upward, then
more towards the rear, in the direction of the middle of the
pelvis, as much as three inches, without meeting a dilatation of
this canal. At this depth the sound was arrested by an ob-



214 THE FIFTH SPECIES OF MALFORMATION.

strnction sucli as caused it to bend. The tuberosities of the
ischium projected when compared with the remarkably wasted
condition of the child, and seemed to be pressed close to each
other, so that the space which separated them was much nar-
rower than usual. The coccyx was bent quite to the front ; the
perina3al raphe extended as far as the coccyx and was not well
marked ; and not even the slightest trace of an anus was
found. During the efforts made shortly after the use of the
catheter, and whilst the abdominal walls were in full action,
I could not feel any fluctuation in the perinsBal region. The
eftbrts were followed by an evacuation, lasting several minutes
and passing through the fistulous opening, and also by an ex-
cretion of urine of a natural color flowing by the external ori-
fice of the urethra. Whenever with my right fore finger
placed in the normal position of the anus, I pushed the perin-
eum towards the pelvic cavity, and with the left hand pressed
the intestines from the anterior abdominal wall towards my
fore-finger, I could not perceive the slightest fluctuation which
could induce me to suspect the vicinity of the terminal end of
the rectum. Little was discovered by auscultation of the per-
in^eum, during percussion of the walls of the abdomen.

" Some hours later, I undertook the formation of a perinaBal
anus. The child was placed on its back, upon the table, the
legs flexed and held asunder by two assistants, while a third
lield the small silver catheter which I had introduced into the
bladder ; then I introduced a silver sound into the opening to
the depth of half an inch and placed it in the hand of an assis-
tant. Starting at this point, I incised the skin along the per-
inseal raphe, to within three lines of the os coccygis, and then
divided the soft tissues, layer by layer. An artery was cut
and had to be tied. Presently the sound escaped from the
canal which could not again be found. I ceased the attempt
to introduce the sound because I feared I would injure the
bladder, and because the operation seemed to fatigue the child ;
I rather sought to penetrate the pelvic cavity as soon as pos-
sible, and whilst an assistant wnth the hand pressed upon the
abdomen of the child, pushed the intestines downward to-
wards the pelvis, with my finger which was introduced to the
depth of two inches, I discovered a moderately soft body situ-
ated between the bladder and the smooth promontory, its an-
terior portion having a round form, and adhering to the pos-
terior wall of the bladder, whilst its posterior fiice was consid-
erably extended along the promontory. By the touch it could
be slightly brought down, and this made me suppose that it
was the intestine filled with solid fk'cal matter. I seized it by
its inferior wall with artery forceps, and brought it down



THE P^FTir SrKCIKS OF MAI,K(MiMATI()N. 215

C'fii'ofully, whilst with tlie end oi' my fini,^cr, T (lestroyc'd all
the luliiesions uttachin^- it to the nei^h])i»riiii^ parts. fii tVinit
I could not altogether succeed ill doin;^ this ; ])ut elsewiiere I
succeeded so completely that I was able (<• hrin*^ duwn the
])osterior portion into the ])erina'al wound. Contii-iued in niv
suj)position that it was a ])art of the dilated rectum, 1 seized it
tirndy with a pair of forceps and a crochet, and between the
two instruments I made an incision longitudiiuilly, from fiont
to rear, about nine lines in len<i;th. There immediately ])assed,
by the increasing efforts of the child, some yellowish brown
matter, the evacuation of which I aided with a spatula. Yery
shortly, liquid faecal matter passed, of a green color and acid
odor. I then cleansed the wound with injections of cold
water. I divided the anterior wall of the canal, as far as I
could recognize it, and then nnited the edges of the intestine
with the lips of the perinieal wound by frequent points of su-
ture ; then I nnited the edges of the wound in front and rear
of the anterior and posterior angles, by means of suture, and
likewise between the ans-les of the intestinal wound and those
of the perinseal w^ound. The most anterior suture of the per-
inaium was placed in such a manner that it travei-sed the
mouth of the canal. I prescribed ap[)lications of cold water
to the perinaeum, and frequent lotions to the wound. During
tlie night the child slept tranquilly, but the next day it uttered
frequent groans, and drew up its legs as if suffering from pain
in the abdomen. It took the breast but seldom, but drank
cold water with avidity ; respiration was accelerated, and the
pulsations of the heart were unusually frequent. The lips of
the wound as well as the surrounding parts were red and
somewliat swollen ; yellow liquid fajcal matter of very acid
odor, was evacuated in small quantities every five or ten min-
utes through the newly formed anus. I prescribed rhubarb
and syrup of saffron, and caused warm poultices to be placed
on the abdomen, after a restless night ; the next morning,
however, the child was better. The redness and swelling of
the edges of the wound were lessened, and they seemed thor-
oughly united, except at the anterior angle. The condition
of the child improved daily ; suppuration continued in the
vicinity of the fistulous opening, without, however, presenting
any mixture with faecal matter. Evacuations occurred only
every hour, or half hour, and the faeces were yellow in color
and of the consistence of pap.

" The sixth day after the (Operation, the anus took an oval
form ; at the commencement of the excretion I observed dilat-
ing motions of the perinteum, and at the close the contraction
of the anus was made manifest by the gathering up of the su-



216 THE FIFTH SPECIES OF MALFORMATION.

lure. Some of the needle punctures opened into each other,
and discharged a shght quantity of pus ; for this reason I took
away the points of suture in question, and the others, two days
after. The union of the edges of the wound, was eveiTwliere
complete.

" The needle punctures which had been open were now
closed, as was also the anterior angle, still suppurating, near
the scrotum. On the fourteentli day after the operation, tlie
cure was complete, tlie jaundiced discoloration had disap-
peared, and the child prospered in a remarkable manner.
From this time it had three or four healthy stools, during the
twenty-four hours ; the appetite was good,*so that besides the
breast, the child took other food, and none of the preceding
morbid phenomena reappeared.

" When in the month of December, 1852, I again saw the
child, it M'as suffering from dentition, and often carried its
hands to its mouth ; the gums were swollen and sensitive to
the middle of the lower alveolar edges. The child wasted
rapidly, it cried out all night long and began to cough. On
the twenty-third of Decemljer, I found in the upper lobe of
the left lung, and in the upper and middle lobes of the right
side, a rough vesicular murmur, respiration was obscure, as
also was the sound produced by percussion. Nevertheless
the child breathed a little, but with dithculty, and presented
a bluish color of tlie face. The pneumonia resisted treatment
and terminated fatally on the tAventy -fifth of December, 1852.

" The autopsy performed the next day, gave the following
results.^In the cavity of the cranium, there Avas nothing re-
markable ; in the large bronchia, a catarrhal secretion, but the
mucous membrane was not red. The posterior and lower
portion of the inferior right lobe was tilled with blood ; the
middle portion, and the lateral portions at their top on l;)eing
cut allowed a large quantity of sanguinolent and frothy serum
to escape, and the bronchia contained a viscid catarrhal i)ro-
duct. No portion was found to contain air. Tlie left inferior
lobe was studded with apoplectic kernels, from the size of a
lintel seed to that of a pea, and near them the pulmonary tis-
sue was filled with blood, partly extravasated, partly fluid
which the latter especially, was easily expressed. In these
places and around them, the pulmonary tissues contained no
air, and upon pressure gave out a stringy serous exudation.
In the pulmonary vessels, comprising the bronchial tubes, as
far as I could follow them, I found no blood nor any other
morbid matter. The right side of the heart was filled with
black liquid blood, and at the left posterior wall of the ventri-
cle there was found only a soft fibrous cord, passing into the



THE FII'Tir SPECIES OF MALFORMATION. 217

I mlinonary arteries; the left sale of the licjirt coiitnincil no
l)h)od ; the f(i3tal conduits were closed. In tlic ulxloniinal
cavity, as soon as tlu^ oincntuni, luucli cniaciatod, had lici-n
raised up, a dilatation, tilled with i>;as, and conipi-jsini; the
eiul of the ileum, and tlie ui)i)er j)art of the descending;' colon,
jutted out. The rectum appeared very slutrt, and of unecpuil
size, the luirrowest portions, however, were of normal diani-
e'er. Ahout one inch above the anus there proceeded IVom
the anterior wall of the rectum, a cord, the size of a larg-c
knittinsj:; needle, directed towards the vesical triau<j:;lc, and at-
tached to the bottom of the bladdei* by cellular tissue. Thus
fixed and becoming-, smaller and smaller, it at last bent its
way to the middle surface of the prostate, towards the bulb
of the urethra, and having reached its posterior wall, was lost
beneath the fistulous opening. It was entirely filled up,
and it was only at its ui)per aiul larger portion, that the exis-
tence of a canal could be perceived, which had, hoNvever, no
longer any communication with the cavity of the rectum. The
interior of the canal no longer presented the appearance of
mucous membrane. W'here the cord left the rectum the lat-
ter presented on its internal surface a depression of a medul-
lary nature. The large intestine contained a yellow ftecal
nuitter, liquid and semi-fluid; the mucous membrane was
healthy throughout. The artificial anus could not be distin-
guished from a normal anus. At its upper portion the circu-
lar fibres of the rectum were so strongl y developed, that they
represented a real internal sphincter. The cicatrized needle
marks were clearly recognized. The liver was very laro-e, of
a nutmeg shape and poor in blood. The biliary ducts were
flexible, the gall bladder was full of yellowish brow^ii bile ;
the mucous membrane healthy. Several of the mesenteric
glands were much swollen and not free from tubercles. Be-
sides this the abdominal cavity presented nothing remarkable.
The muscles of the perineeum did not seem more feebly de-
veloped than usual." — {Recherches Cliniques et Critiques sur
V Anus Artijiciel. In Archives Generales de Medicine de
Paris. Jidllet., 1857. p. oL)

Case CXYIII. — M. Olinet relates the case of a female
child in whom the rectum opened within two lines of the
vulva, the rectum being prolonged to this point by means of
a canal. Through this abnormal anus the meconium was dis-
chai-ged. {,Tournal Universel des Sciences Medicales. Paris:
Fevrier, 1820.)

Case CXIX. — Burns thus describes the case of a female



218 THE FIFTH SPKCIKS OF MALFORMATION.

child liaving an imperforate anus, accompanied with an ab-
normal anas:

'•The rectnm, instead of terminating at the usual place,
perforated the posterior -wall of the vagina; then occupying
the canal of the vagina, it passed through the vulva, and pro-
jected about an inch beyond the labia pudendi, bearing a
distinct resemblance to an imperfectlj'- formed penis. It was
of considerable size, possessing a writhing motion, and freely
discharged meconium by an orifice at its apex." {Edinburgh
Medical and tSurgical Journal^ Vol. I., 2^- 137.)

Case CXX. — M. Yelpeau says that M. Brachet published
the case of a little girl who had an abnormal anus situated at
the fourchette ^ the normal anus was imperforate. {MoWs
Velpeau, Vol. TIL, p. 1087. JVew Tori: 1847.)

Case CXXI. — The following case of imperforate anus, with
an abnormal opening of the rectum in the posterior part of
the vulva, is reported by M. Caussade. The operation in this
case was followed by com|)lete success:

"The subject of this case was a female infant who, when
two months of age, was in an almost dying condition, taken
to M. Caussade. This infant vomited fcecal matters ; had hic-
cup ; the pulse was small, contracted; the face livid, and
covered with sweat ; the voice almost extinct ; and the abdo-
men much distended. She had been placed out to nurse im-
mediately after her birth ; her clouts were observed to be wet
and slightly soiled, but the nurse never observed any alvine
evacuation as in other children. As the little one was, how-
ever, in gopd health, and even grew fat, the nurse continued
to suckle her without seeking the cause of the absence of
alvine evacuations. On examining the infant, M. C. found
that there was no anus, or trace of one. She passed through
a capillary opening at the posterior part of the vulva, very
iiear to the hymen, a thick and yellowish fluid, which, M'hen
the intant cried and struggled, spouted out as if discharged
from the spent of a small syringe. During the straining of
tlie infant, a tumor projected in the perina^um, and in a part
of the breech. To relieve tlie perforation, M. Caussade made
an incision three or four lines in depth in the place which the
anus ought to have occupied. He found at the bottom of the
incision a mass of hard and yellow faical matters. It was
necessary to break them up, and they were removed by
means of a scoop. Several injections were administered,
which brought away a large quantity of yellow liquid matter.
The wound was kept open by a lint tent. The next day the



TIIK Finn Sl'i:CIK8 OF MALFORMATION. 219

fecal matters were readily (Kscliartiicjd, ;ill the unpleasant
symi)tonis ceased, and the health of the little patient was re-
stored." {Gazette des Il6pitaux de Paris^ Mars 29, 1S34.)

Case CXXII. — George Hay ward, M. D., of Boston, Snrgcon
to the Massachusetts General lIos{)ital, reports the fol lowing
interesting case of imperforate anus, tlie rectum terminating
in the labia pudcndi by a small abnoi-nial opening, which
performed the functions of an anus. The operation in this
case was attended with complete success.

" About eighteen months since, I was desired to examine a
female infant, three or four days old, in consequence of a mal-
formation about the anus. On inspection no external opening
of the bowel could be discovered ; but in separating tlie labia,
it was found that the urethra and vagina were perfect, and at
two or three lines behind the vagina, there was a small ori-
tice, sufficient to admit the large end of a prolje, through
which the faeces were discharged.

"The child did not seem to suffer at all, and I heard noth-
ing of it for more than a year, though I visited frequently the
famil}' to which it belonged. A few days after it was
weaned, which was in January last, I was called to visit it,
and was told, that since the change in its diet, it had appa-
rently suflered very much in its eltbrts to discharge the con-
tents of its bowels. These eftorts were violent, almost con-
stant when tlie child was awake, and afibrded scarcely any
relief. Since it had ceased nursing, it liad become emaciated